MRSA in the Dental Office

Laura A. Stokowski, RN, MS

Disclosures

April 01, 2011

In This Article

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 long-term 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.

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