Download MRSA in the Dental Office

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:
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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:
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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:
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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
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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
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