MRSA in the Dental Office

Laura A. Stokowski, RN, MS

Disclosures

April 01, 2011

In This Article

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-to-date 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' non-intact 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).

Figure 3.

How to hand wash? World Health Organization, 2009. Available at: http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf

Figure 4.

How to hand rub? World Health Organization, 2009. Available at: http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf

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.

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