MRSA in the Dental Office

Laura A. Stokowski, RN, MS


April 01, 2011

In This Article

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 patient-care 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 Agency-registered 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]


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