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MRSA in the Dental Office Laura A. Stokowski, RN, MS Posted: 04/01/2011 Drug-Resistant Pathogens in the Dental Office Most people are aware of the risk for infection associated with hospitals, ambulatory settings, and long-term care. But what about the dental office? Patients who seek dental healthcare could easily, and even unknowingly, be carriers of methicillin-resistant Staphylococcus aureus (MRSA) or another multiple drug-resistant organism (MDRO). When taking clinical history prior to treating dental patients, staff rarely ask about infectious diseases, and many patients who are colonized with MDROs are asymptomatic, leaving dental staff in the dark with respect to the exposure risk to themselves or to other patients. The risk to immunocompromised patients could be even greater. Amy Collins, MPH, an epidemiologist in the US Centers for Disease Control and Prevention's (CDC) Division of Oral Health, dental infection control, highlights the differences between acute-care settings and dental offices with respect to the risk for transmission of infectious agents. "In dental outpatient settings, the opportunity for transmission is different: shorter time of patient contact, consistent use of gloves (minimal skin-to-skin contact), minimally invasive procedures that interrupt the protective skin barrier, more frequent environmental cleaning, and so forth, should reduce the transmission risks. This setting is unlikely to require the same level of procedures/contact precautions as acute-care or longterm care settings." Do MDROs Lurk in the Dental Office? In recognition of a potential risk for transmission of infectious agents in ambulatory healthcare settings, a few recent studies have focused on the dental clinic. One such study investigated the possibility that droplets of the patient's saliva, generated by high-speed rotating instruments used in restorative dentistry, could be laden with bacteria that contaminate surfaces, instruments, and personnel. Rautemaa and coworkers[1] gauged the environmental contamination by measuring the distance that airborne droplets could travel and the types of viable pathogens contained in those droplets. They were alarmed to discover that bacterial droplets dispersed by rotating and ultrasonic devices used during dental treatments contaminated surfaces up to 2 meters (7 feet) from the patient in various directions. In another study, MRSA was recovered from numerous surfaces of a hospital-based dental operatory, including the air-water syringe and the patient's chair. Kurita and colleagues[2] cultured 140 consecutive patients and 8 were found to be colonized or infected with isolates identical to the strains found on surfaces in this dental care setting. Horiba and coworkers[3] found that isolates of methicillin-resistant staphylococci recovered from dental surfaces were identical to strains cultured from the oral cavities of dental office staff. Prospero and associates[4] showed that aerosolization can deposit microbes not only on dental surfaces but also on the faces of dental healthcare workers. The generalizability of the findings of these few studies conducted in dental clinics to other settings is unclear. Although these studies demonstrate that MRSA can be isolated from environmental surfaces in dental healthcare settings, it is believed that contaminated surfaces play a minor role in MRSA transmission. [5] More important is the potential for transmission of infectious agents directly from the hands of healthcare workers. In 1991, Martin and Hardy[6]described 2 patients with MRSA dental infections that were found to have resulted from a practitioner who did not routinely wear gloves when treating patients. These infections were believed to be transmitted directly by the dentist. Unlike hospitals and other large healthcare facilities, dental offices typically have no epidemiologists or formally trained/certified infection control experts conducting surveillance and monitoring compliance with infection control practices. The dental team is responsible for taking precautions to protect patients and themselves from infectious exposure. In 2003, the Centers for Disease Control and Prevention (CDC)[7] issued guidelines for infection control in dental health settings that provide the evidence-based rationale for each recommendation. Implementation of these guidelines should prevent or reduce the potential for disease transmission from patient to dental healthcare provider, from dental healthcare provider to patient, and from patient to patient.[7] Raymond Martin, DDS, a dentist in Mansfield, Massachusetts, and member of the Academy of General Dentistry, acknowledges that "the overall role of the environment in infection transmission is recognized as being more important than we previously thought." At the same time, however, he believes that most dental healthcare professionals are fairly consistent about hand washing and wearing gloves, masks, and goggles because of awareness about the risk for blood-borne viral infection in dental care. An Overview of Potential Pathogens Potential sources of infection in the dental healthcare setting include blood-borne pathogens (cytomegalovirus, hepatitis B virus, hepatitis C virus, HIV), herpes simplex, Mycobacterium tuberculosis, staphylococci, streptococci, and other viruses and bacteria that colonize or infect the oral cavity and respiratory tract.[5] Some of these bacteria are drug resistant, with the most well known of these being MRSA. Now endemic in hospitals, MRSA is resistant to all currently available beta-lactam antimicrobial agents. MRSA emerged more than 40 years ago as a source of infections in hospitals and long-term care facilities, hence the label "healthcare-associated MRSA" (HA-MRSA), a cause of surgical site and bloodstream infections in hospitalized patients. [8] Recently, microbiologically distinct strains of MRSA, known as community-associated MRSA (CA-MRSA) have arisen, which cause primarily skin and soft tissue infections among previously healthy persons living in the community. Colonization refers to the presence of microorganisms in or on a host with growth and multiplication but without tissue invasion or damage. In the case of MRSA, the body site most commonly colonized is the anterior nares, but colonization of the oral cavity with MRSA has also been described.[9,10] MRSA has also been found on dentures.[11] Other body sites that may be colonized with MRSA include open wounds, the respiratory tract, the perineum, the upper extremities, the umbilicus (in infants), the urinary tract, and the axilla. Colonized patients are also known as asymptomatic carriers. Infection is the entry and multiplication of microorganisms in the tissues of the host leading to local or systemic signs and symptoms of infection. Most CA-MRSA infections are found in skin abscesses, boils, or pustules (Figure 1). Figure 1. MRSA skin infection. From CDC/Bruno Coignard, MD, Jeff Hageman, MHS, 2005. Individuals who are colonized with MRSA, just as those who are infected with MRSA, can serve as reservoirs for MRSA and transmit the bacteria to others. The prevalence of MRSA is increasing in the United States.[12] In hospitals, the overall MRSA prevalence rate is 46.3 per 1000 inpatients (34 infections and 12 colonizations per 1000). The latest figures indicate that the prevalence of colonization with S aureus is 28.6% of the general population, whereas the prevalence of colonization with MRSA is 1.5%.[13] High-Risk Patients Although anyone can be colonized or infected with MRSA, epidemiologic evidence indicates that there are a few high-risk groups, including: Persons with frequent contact with the healthcare system, especially those on dialysis; Athletes; Children who go to daycare; Inmates of correctional facilities; and Elderly or other patients who reside in long-term care facilities. Most patients with simple MRSA skin or soft tissue infections are treated with incision and drainage, often without antibiotics. Patients with invasive MRSA disease (pneumonia, sepsis/bacteremia, severe bone/joint infection) must be treated in the acute-care setting because these conditions can be fatal. Neither the American Dental Association nor the CDC makes a recommendation about avoiding dental treatment for patients with invasive MRSA disease.[7,14] Modes of Transmission of Infection-Causing Organisms In dental healthcare settings, modes of transmission of infection-causing organisms (including but not limited to MRSA) are both direct and indirect: Blood, saliva, or other body fluids from an infected patient; Contaminated objects (instruments, equipment, environmental surfaces) or contaminated hands of dental healthcare personnel if hand hygiene is not performed before touching another patient; Spray/droplets of contaminated body fluid generated by dental procedures or by coughing or sneezing; and Inhalation of airborne organisms. The "chain of infection" requires a pathogenic organism of sufficient virulence and in adequate numbers, a reservoir that allows the pathogen to survive and multiply, a mode of transmission, and a portal of entry to a susceptible host (Figure 2).[7] Infection control measures are effective when they interrupt the links in this chain.[7] Figure 2. Conditions that must be met to complete the "chain of infection." Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain of infection. From Kohn WG, et al. MMWR Recomm Rep. 2003;52:1-61.[7] Aerosols and Droplets Dental procedures that use mechanical instruments produce airborne particles from the oral cavity. [15] Aerosols (particles < 50 µm in diameter) are small enough to remain airborne for an extended period of time before being inhaled or settling on environmental surfaces.[15] Spatter, on the other hand, is believed to contain larger particles (> 50 µm in diameter) known as droplets of water, blood, and/or saliva. Typically too large to remain suspended, droplets are airborne only briefly before settling on surrounding surfaces. Aerosols pose a threat because of their ability to remain airborne and because they are small enough to reach the lower respiratory tract.[15] Droplet nuclei, however, have been associated with transmission of organisms such as Mycobacterium tuberculosis (TB) and the virus that causes severe acute respiratory syndrome (SARS). Patients known to have these infections should not receive routine dental care in the dental office because a higher level of respiratory protection is required.[16] In treating the patient with active TB, among other precautions, staff must participate in a respiratory protection program, receive annual training, and wear fit-tested N95 respirators because standard surgical face masks do not protect against TB transmission. Infection Control in Dentistry Measures to prevent transmission of MRSA and other MDROs (and blood-borne pathogens) are outlined in CDC's Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings and Guidelines for Infection Control in Dental Health Care Settings - 2003. [7] "The American Dental Association urges all dentists, dental auxiliaries, and dental laboratories to employ appropriate infection control procedures as described in these guidelines, and to keep up-todate as scientific information leads to improvements in infection control, risk assessment and disease management in oral health care."[14] Standard Precautions in Dental Healthcare Dr. Martin emphasizes that because dental staff are rarely aware of what pathogens a patient might be colonized with, "infection prevention must be aimed at everyone, not just those known to be infected. Dentist don't, nor should they, try to ascertain whether patients are carriers of MRSA. Procedures and processes should protect staff and patients, in both directions." This idea -- that any patient could be potentially colonized or infected -- is the basis for standard precautions (formerly known as "universal precautions"). Standard precautions are the primary and most important strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel[17] and are applied to the care of all patients, regardless of the suspected or confirmed presence of an infectious agent. Standard precautions protect staff and patients from transmissible infectious agents found in blood, excretions, or secretions (except sweat), and apply to all body fluids (regardless of whether they contain blood). Routes of transmission include body fluid exposure to healthcare personnels' nonintact skin, mucous membranes, or through percutaneous/sharp injuries. Although MRSA is recognized primarily as an organism that colonizes the anterior nares, in dentistry saliva is considered a potentially infectious material and often contains blood.[7] Ms. Collins of the CDC emphasizes that: "In ambulatory care settings, including outpatient dental offices, strict enforcement of standard precautions, including making sure personal protective equipment (PPE) is used for anticipated contact with uncontrolled secretions and other potentially infectious body fluids, is considered adequate in most circumstances to prevent the transmission of MRSA and other MDROs. In addition to wearing PPE, safe work practices protect the mucous membranes and non-intact skin of dental healthcare personnel from contact with potentially infectious material. These practices include keeping contaminated gloved and ungloved hands from touching the wearer's mouth, nose, eyes, or face, a practice that creates self-inoculation. Proper placement of PPE before patient contact will help avoid the necessity of making PPE adjustments (with possible face or mucous membrane contamination) during use. These are some key strategies to prevent indirect contact transmission of pathogens." The fundamentals of standard precautions are hand hygiene; use of PPE, including gloves, protective outer cover (jacket, lab coat, or gown), mask, eye protection/face shield, respiratory hygiene, and cough etiquette; and safe injection practices. Hand hygiene and gloves should be part of every patient interaction in dental care. Application of other elements of PPE depends on the nature of the interaction and the extent of anticipated exposure. Hand Washing Essentials In healthcare settings, transmission of infectious agents from patient to patient occurs most often by means of the hands of healthcare professionals. The rules for hand washing are straightforward: hands should be washed when visibly soiled, after touching any surface likely to be contaminated, before and after touching patients, before donning gloves, and immediately after removing gloves. Do staff members wash their hands properly? We all like to think we know how to wash our hands, but in fact, hand washing is often performed incorrectly. Staff members, whether in the hospital, ambulatory clinic, or dental office, tend to resist the idea that they need education on hand washing, so "reminders" on how to perform this basic function should be strategically placed. The World Health Organization has 2 very useful posters to give staff a visual reminder about how to wash hands (soap and water) or rub hands (alcohol-based hand rub) correctly (Figures 3 and 4). (Click to enlarge) (Click to enlarge) Personal Protective Equipment PPE protects the dental professional from exposure to body fluids generated during dental procedures, a not uncommon occurrence in this setting. Many routine dental instruments (handpieces, ultrasonic scalers, air-water syringes) create spatter. PPE typically used in dental healthcare settings includes gloves, masks, protective eyewear, face shields, and protective clothing. An important point is that PPE is used not only to protect the clinician, but also the patient. As such, one of the most important practices is to avoid wandering from one operatory to the next while wearing PPE. This can be challenging in dental offices where patient treatment areas are often contiguous. Gloves. Awareness of the risk for transmission of blood-borne pathogens is usually enough incentive for dental healthcare personnel to wear gloves during patient contact. Another value of glove use is to reduce contact transmission of drug-resistant bacteria. Yet, glove-wearing mistakes are common. One of these is the failure to wash hands after removing gloves. Another infraction (one that occurs with all types of PPE) is touching and contaminating equipment (such as computer keyboards) or moving from room to room while wearing the same pair of gloves, effectively carrying transient organisms from one patient area to another. Gloves should not be washed and should be changed if torn or cut. Of greatest importance: wearing gloves does not eliminate the need for hand washing. Staphylococci are spread mainly from person to person, usually on the hands of healthcare personnel. Surgical masks. Surgical masks and protective eyewear protect the patient from organisms generated by the wearer, and protect the wearer from large-particle droplet spatter and to a certain extent from inhalation of smaller particles. Disposable single-use masks should be changed between patients or even during patient care if the mask becomes wet.[7] Goggles/face shields. Protective eyewear, like the mask, is extremely important for protecting the dental professional from contaminated aerosols or spatter. A face shield with side protectors protects the mucous membranes of the eyes, nose, and mouth. Patients should also wear goggles or protective eyewear when aerosol or spatter is generated. Reusable goggles or shields must be cleaned and stored appropriately after use. Protective clothing. Ms. Collins explains the role of protective clothing for dental healthcare professionals. "Protective clothing should be worn during most dental procedures to protect street clothes from contamination and possible cross-contamination to other patients. Clothing, scrubs, uniforms, or laboratory coats used as PPE may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent, (eg, MRSA). Although contaminated clothing has not been implicated directly in transmission, studies have measured the presence of MRSA on these garments." What About the Known MRSA Carrier? In the rare circumstance that a patient is known to be an MRSA carrier or to have an MRSA infection (a long-term care resident or a recently hospitalized patient), should the dental office staff do anything different? "If you are following standard precautions and doing appropriate cleaning of devices, equipment, and the environment, you should be protected," answers Dr. Martin. "You should be equally concerned about the pathogens you don't know about." Dr. Martin goes on to say that if a patient has a boil, a draining abscess, or reddened skin lesion that looks like a spider bite, (such as the wound shown in Figure 1) it should be covered with a clean, dry dressing when the patient presents for dental care. Dental Office Policies and Procedures Evidence-based infection control policies and procedures for the dental office should be detailed in writing, and a staff member should be assigned responsibility for coordinating the office's infection control program. Infection control policies and procedures should cover not only occupational health and safety requirements, but also standard precautions, disinfection, sterilization, and safe handling of patientcare items; handling, disposal, and transporting of contaminated materials (such as extracted teeth) and laundry; cleaning of environmental surfaces; and ensuring dental unit water quality. Special circumstances such as oral surgery, aseptic parenteral injection technique, dental radiology, and optional use of preprocedural chlorhexidine mouth rinses should also be addressed. A few highlights of the CDC recommendations are presented here; for complete details, refer to the 2003 guidelines.[7] Sterilization and disinfection. According to Ms. Collins, "Dental instruments have not been implicated in MDRO transmission to date, although viruses and other infectious organisms can be transmitted from improper processing." The CDC's recommendations for sterilization and disinfection of patient care items such as dental instruments are specific to the potential risk for infection associated with their use. [7] CDC recommends using sterile single-use disposable items whenever possible. Items used to penetrate soft tissue or bone must be heat sterilized because they present the highest transmission risk (items such as scalpel blades, periodontal scalers, and surgical dental burs). Items that come into contact with mucous membranes should be heat sterilized if they are heat tolerant; otherwise they should be processed with a high-level disinfectant. Other items should be cleaned with a US Environmental Protection Agencyregistered hospital disinfectant. Staff members should wear PPE as well to prevent exposure to contaminated materials during cleaning procedures.[18] Environmental surfaces. Surfaces such as floors, walls, and sinks ("housekeeping surfaces"), although not shown to be direct vectors of infection to patients in dental offices, should be regularly cleaned with detergent or a US Environmental Protection Agency-registered hospital disinfectant. Blood and body substances can hinder disinfection. Physical removal of microorganisms and soil by wiping or scrubbing is probably as critical, if not more so, than any antimicrobial effect provided by the agent used (Figure 4). Dental chairs, trays, and other equipment in the patient's immediate environment (clinical contact surfaces) must be cleaned with an appropriate disinfectant between patients (Figure 5). Surface barriers should be used whenever possible. Figure 5. Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows). From Kohn WG, et al. MMWR Recomm Rep. 2003;52:1-61.[6] Figure 6. Clinical contact surfaces in dental treatment, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows). From Kohn WG, et al. MMWR Recomm Rep. 2003;52:1-61. Dental devices. Many of the devices used in dental care (high- and low-speed handpieces, prophylaxis angles, ultrasonic scaling tips, air and water syringe tips) come into contact with mucous membranes. Moreover, high- and low-speed handpieces can retract the patient's oral fluids into the internal compartments of the device.[7] Retained patient material can then be expelled intraorally during subsequent uses of the device. Contaminated backflow has also been demonstrated in saliva ejectors, especially when the patient closes his or her lips, forming a tight seal around the saliva ejector. Patient oral fluids may remain in the tubing, and even if the tip is changed, pressure differentials can cause the fluids to backflow to or be aspirated by the next patient. Devices that can be removed from the waterline should be cleaned and heat sterilized. To properly flush devices that are connected to the dental air/water system, CDC recommends that they be run to discharge water and/or air for at least 20-30 seconds after each patient to physically remove any patient material that might have entered turbine and air and waterlines. Minimizing aerosols and spatter. Harrel and Molinari[15] advocate controlling aerosols and spatter generated during dental procedures and they supply a list of measures to achieve this end: Standard barrier precautions; Preprocedural antiseptic oral rinses; Use of a rubber dam for procedures; and Use of a high-volume evacuator. Staff education, health, and monitoring. Dental office policies should address the timing and extent of staff education about infection control procedures throughout the dental office. This should include training about potentially infectious occupational exposure, work restrictions related to employee health, and the staff member's specific responsibilities with respect to infection control, including the use of PPE. A question often asked about infection control in ambulatory settings such as the dental office is whether routine surveillance or culturing for MRSA and other MDROs (multidrug-resistant Streptococcus pneumonia, vancomycin-resistant enterococcus, carbapenem-resistant Klebsiella pneumonia, Clostridium difficile, etc.) is warranted? Unlike hospitals, dental offices don't need to do routine surveillance cultures, according to Dr. Martin, nor should staff routinely be cultured to ascertain carrier status. "If you have an outbreak, one strategy would be to look for a carrier and potentially refer that person for decolonization." Consultation with an infectious disease physician or the state health department would provide additional strategies in management of an outbreak. More information about work restrictions for dental healthcare personnel infected with or occupationally exposed to infectious diseases can be found in the CDC guidelines.[7] The Challenge to Dental Healthcare Professionals Infection control has greatly improved in dental offices,[18] and the scientific evidence base for improved practices is increasing. MDROs are transmitted by the same routes as antimicrobial-susceptible infectious agents, although the resulting MDRO infection may be more complicated or severe. Patientto-patient transmission in healthcare settings, usually through the hands of healthcare workers, is a major factor accounting for the increase in MDRO incidence and prevalence in acute care settings. Ms. Collins sums up the challenge to dental healthcare professionals. "Preventing the emergence and transmission of these pathogens in the dental office requires a comprehensive approach that includes administrative involvement and measures (eg, performance improvement processes to ensure adherence to recommended infection control measures), education and training of dental healthcare personnel, judicious antibiotic use, and environmental measures (eg, cleaning and disinfection of the patient care environment and equipment)." Because of concerns about the increasing prevalence of MDROs, dental healthcare facilities must prioritize these effective strategies for prevention of MDRO transmission. Summary of Recommendations Educate staff about the "chain of infection" and potential modes of transmission in the dental office, with an emphasis on standard precautions for all patient encounters; Post written information/reminders about correct hand-washing and hand-rubbing techniques; Ensure the availability and correct use of PPE; Establish and monitor compliance with policies and procedures (consistent with CDC guidelines) for infection control practices throughout the dental office, including environmental cleaning, sterilization and disinfection, and other practices outlined by the CDC specifically for the dental healthcare setting.[7] A comprehensive checklist to evaluate your practice according to the CDC guidelines is available from the Organization for Safety, Asepsis and Prevention.[19] Web Resources Medscape MRSA Resource Center CDC MRSA Infections Guidelines for Infection Control in Dental Healthcare Settings. American Dental Association ADA Statement on Infection Control in Dentistry Organization for Safety, Asepsis and Prevention MRSA in the Dental Office Toolkit 2003 CDC Guidelines Checklist Infectious Diseases Society of America Antimicrobial Agent Use References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Rautemaa R, Nordberg A, Wuolijoki-Saaristo K, Meurman JH. Bacterial aerosols in dental practice - a potential hospital infection problem. J Hosp Infect. 2006;64:76-81. Abstract Kurita H, Kurashina K, Honda T. Nosocomial transmission of methicillin-resistant Staphylococcus aureus via the surfaces of the dental operatory. Br Dent J. 2006;201:297-300. Abstract Horiba N, Yoshida T, Suzuki K, et al. Isolation of methicillin-resistant staphylococci in the dental operatory. J Endod. 1995;21:21-25. Abstract Prospero E, Savini S, Annino I. Microbial aerosol contamination of dental healthcare workers' faces and other surfaces in dental practice. Infect Control Hosp Epidemiol. 2003;24:139-141. Abstract Klevens RM, Gorwitz RJ, Collins AS. Methicillin-resistant Staphylococcus aureus: a primer for dentists. J Am Dent Assoc. 2008;139:1328-1337. Abstract Martin MV, Hardy P. Two cases of oral infection by methicillin-resistant Staphylococcus aureus. Br Dent J. 1991;170:63-64. Abstract Kohn WG, Collins AC, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM; Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings -- 2003. MMWR Recomm Rep. 2003;52:1-61. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed March 24, 2011. Kallen AJ, Mu Y, Bulens S, et al. Healthcare associated invasive MRSA infections, 20052008. JAMA. 2010;304:641-648. Abstract Smith AJ, Robertson D, Tang MK, Jackson MS, MacKenzie D, Bagg J. Staphylococcus aureus in the oral cavity: a three-year retrospective analysis of clinical laboratory data. Br Dent J. 2003;195:701-703. Abstract Buonavoglia A, Latronico F, Greco MF. Methicillin-resistant staphylococci carriage in the oral cavity: a study conducted in Bari (Italy). Oral Dis. 2010;16:465-468. Abstract Rossi T, Peltonen R, Laine J, Eerola E, Vuopio-Varkila J, Kotilainen P. Eradication of the longterm carriage of methicillin-resistant Staphylococcus aureus in patients wearing dentures: a follow-up of 10 patients. J Hosp Infect. 1996;34:311-320. Abstract Jarvis WR, Schlosser J, Chinn RY, Tweeten S, Jackson M. National prevalence of methicillinresistant Staphylococcus aureus in inpatients at US health facilities in 2006. Am J Infect Control. 2007;35:631-637. Abstract Gorwitz R, Kruszon-Moran D, McAllister SK, et al. Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001-2004. J Infect Dis. 2008;197:1226-1234. Abstract American Dental Association. Methicillin resistant Staphylococcus aureus. Available at: http://www.ada.org/3080.aspx?currentTab=1#top. Accessed March 14, 2011. Harrell SK, Molinari J. Aerosols and splatter in dentistry. J Am Dent Assoc. 2004;135:429-437. Abstract American Dental Association. Dental treatment and TB. Available at: http://www.ada.org/2949.aspx#top Accessed March 14, 2011. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html Accessed February 16, 2011 Eisen S, Eisen S, Farmelant J. Evaluation of spatter generation and contamination during instrument cleaning prior to sterilization. J Mass Dent Soc. 2006;55:26-29. Abstract 19. Infection Control in Practice. OSAP Check-up: 2003 CDC Guidelines. 2004;3:1-9. Available at: http://www.osap.org/resource/resmgr/Publications/OSAP_CheckUp_2003_CDC_Guidel.pdf Accessed March 13, 2011. 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