As we collectively let out a sigh of relief that the COVID-19 pandemic is nearing it’s end in May, it may be tempting to think about infection prevention and control as returning to the pre-pandemic practices and levels of awareness about infectious disease outbreaks. If the pandemic has taught us anything, it is that dental professionals are more vulnerable than we previously acknowledged. In the U.S., we are currently experiencing several significant infectious disease outbreaks that should be of concern to dental professionals. This article will explore the three most current infectious disease issues in dentistry and how they affect the field.
On March 7, 2023, the Centers for Disease Control and Prevention issued a health alert regarding a measles outbreak in Kentucky. According to this report, a confirmed case if measles was identified in an unvaccinated individual who attended a large religious gathering at a university in KY, with an estimated 20,000 people in attendance. An undetermined number of people may have been exposed, who attended the gathering from other states in the U.S, as well as other countries.
Measles can cause serious or severe health complications in both children and adults. These can include pneumonia, and encephalitis and even death. Since there are large numbers if individuals who are unvaccinated for measles, or whose immune status may not be adequate to prevent infection, the CDC has issued this alert to inform anyone in attendance that they may be at risk of exposure. Measles is very easily spread through respiratory droplets, and infected individuals may be infectious to others for 2-4 days before the onset of the rash which is most characteristic of measles. Fever and respiratory symptoms and conjunctivitis typically precede the rash, and might be mistaken for other respiratory illness.
Since measles could easily spread in dental practices, it is critical to remember that screening patients for respiratory symptoms and fevers needs to be a continuing infection prevention protocol, even after the end of the COVID-19 pandemic. Additional information about measles infections is available on the CDC website. The CDC lists the measles vaccine (MMR), or Measles, Mumps, and Rubella; as a recommended vaccine for health care workers.
An intraoral sign of measles, known as Koplik Spots, may be present in individuals who are infected, but do not yet present with the typical Measles rash. These tiny white spots in the mouth may appear 2-3 days after respiratory symptoms appear. They may detected in patients during treatment, and clinicians should be aware of the potential for this patient to be infectious for measles. If the patient indicates that they have experienced respiratory symptoms, fever or itchy watery eyes in the 2-3 days prior to their dental visit, clinicians should postpone treatment, especially any treatment that includes aerosol generating procedures (AGPs).
Any members of the dental team who may have been exposed and are experiencing symptoms should not be permitted to work until a diagnosis has been obtained and/or their symptoms have subsided and a medical professional has cleared them to return to work. The CDC has several resources available for healthcare professionals to help guide the decision-making process if a measles exposure is suspected. Fig. 1 is an excerpt from the CDC Infection Control Guidelines for Dental Healthcare Settings 2003, pgs. 8 and 9. This chart lists work restrictions for infectious diseases and current infectious disease issues in dentistry (except COVID-19). It is available from the CDC website: https://www.cdc.gov/mmwr/pdf/rr/rr5217.pdf
Norovirus infections are commonly referred to as “the stomach flu” or a “stomach bug”. The CDC describes it as a very contagious virus that causes vomiting and diarrhea and that people infected with norovirus can shed billions of norovirus particles. It is the leading cause of vomiting and diarrhea from acute gastroenteritis among people of all ages in the U.S. Norovirus can be transmitted through direct contact with an infected person, consuming contaminated food or water, or touching contaminated surfaces and putting unwashed hands in the mouth. The most recent norovirus outbreak is a multi-state outbreak traced to consumption of raw oysters.
A recent study from the National Institutes of Health (NIH) discovered that norovirus and other enteric/gastrointestinal viruses can be spread through saliva. Therefore, contact with an infected patient’s saliva is a potential risk of exposure for dental clinicians. While most patients would not present for treatment when they are in the acute phase of the illness, those patients remain infectious for 2-3 days after their symptoms subside. The study indicates that these viruses can spread from coughing, and sneezing and other activities that include exposure to an infected patient’s saliva. This reinforces the need for always following standard precautions, assuming that all patients are potentially infectious.
Shigella is a bacterium that causes an infection called Shigellosis, causing diarrhea, and which can easily spread from person to person. On Feb. 24, 2023, the CDC issued an alert through its Health Alert Network (HAN) warning that increased reports of extensively drug-resistant (XDR) cases of Shigellosis are occurring in the U.S. According to the CDC, it takes only a small number of bacteria to cause and infection, with symptoms starting 1-2 days after exposure and lasting for 7 days. Infected patients can spread the bacteria through their feces for several weeks after their symptoms are resolved. The infection is caused by swallowing the bacteria. This happens from touching contaminated surfaces with hands and touching the mouth, changing diapers of children with Shigella, eating food prepared by a individual with a Shigella infection, swallowing water when swimming, swallowing contaminated drinking water and it can also be transmitted through exposure to feces through sexual contact.
While a Shigella infection is most likely to occur outside of a dental facility, both patients and team members can be potentially infectious in the office if proper attention is not paid to handwashing, wearing appropriate PPE, and cleaning and disinfecting of restroom facilities in the dental office.
So, what does all this mean for dental practices? First, we need to continue to screen patients for respiratory symptoms and be prepared to reappoint patients for non-emergency treatment. This screening can be easily accomplished electronically when confirming patients. Although the recommendation from the CDC in the height of the pandemic was to take patient temperatures upon arrival at the office, taking temperatures should still take place in the treatment room, as part of routine collection of vital signs. If a patient’s temperature is above 100°F, additional screening should take place prior to treatment, since a low grade fever is often the first sign of an infection.
The risk of exposure to aerosols in dentistry is not going away with the COVID-19 pandemic. Wearing N95 respirators or higher ASTM level masks that have fewer gaps on the face continues to be an important infection prevention protocol for dental clinicians. Cleaning and disinfecting treatment rooms as well as public areas of the facility, such as restrooms, is also of critical importance. An excellent tool for reviewing the amount of cross-contamination that occurs in dental treatment rooms is the newly update video “If Saliva Were Red”, from the Organization for Safety Asepsis and Prevention (OSAP). This video is available to any dental professional at no cost, and can be viewed on YouTube at: https://youtu.be/-nHWMMesi00.
Dental practices must also ensure that all team members are appropriately trained to understand the principles of infection prevention and control, as well as the reasons why certain protocols must be followed. As an increasing number of dental assistants, both clinical and administrative, are being hired into practices with no prior experience in dentistry or healthcare, this becomes more important than ever.
In addition, dental practices must be aware of local and state public health regulations and recommendations, based on diseases that may be spreading in a given area. Since many state dental boards are now requiring compliance with CDC guidelines, every practice needs to be aware of these requirements. OSHA uses CDC guidelines for enforcement of infection control regulations and OSHA is instituting changes to their enforcement guidelines that will “hold employers to greater account for safety, health failures”.
Creating the safest environment for patient care and for employees that deliver the patient care should be a priority in every dental practice, from both a legal and ethical perspective. It should be viewed as a very positive way to attract and retain patients and employees.
CDC Health Alert Network (HAN) Measles Exposure at a Large Gathering in Kentucky February 2023 and Global Measles Outbreaks https://emergency.cdc.gov/han/2023/han00488.asp
CDC Measles (Rubeola) https://www.cdc.gov/measles/index.html
CDC Recommended Vaccines for Healthcare Workers https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html
NIH Scientists Discover Norovirus and Other “Stomach Viruses” Can Spread Through Saliva https://www.nih.gov/news-events/news-releases/nih-scientists-discover-norovirus-other-stomach-viruses-can-spread-through-saliva
CDC Shigella-Shigellosis https://www.cdc.gov/shigella/index.html
CDC HAN Increase in Extensively Drug-Resistant Shigellosis in the United States https://emergency.cdc.gov/han/2023/han00486.asp
OSHA News Release Jan. 26, 2023, https://www.osha.gov/news/newsreleases/national/01262023- 0