Nosocomial transmission of methicillin-resistant Staphylococcus aureus via the surfaces of the dental operatory

OBJECTIVE: We assess the possibility of methicillin-resistant Staphylococcus aureus (MRSA) transmission via the surfaces of the dental operatory. METHODS: A survey of MRSA contamination on the surfaces of the dental operatory, and an analysis of MRSA transmission via the dental operatory between patients was carried out in the department of special dental care and oral surgery. RESULTS: MRSA was observed on the surfaces of dental operatory including the air-water syringe and reclining chair. Nosocomial infection or colonisation of MRSA occurred in eight out of 140 consecutive patients who had no evidence of MRSA at admission. Antibiograms of 30 antibiotics revealed that the isolates from the eight patients were of the same strain as those from the surface of dental operatory. After treating the patients under a revised infection control (IC) protocol including a single use of barrier covers, MRSA was not detected on the surfaces of the dental operatory, and no nosocomial infection or colonisation occurred during hospitalisation (0/117 patients). CONCLUSIONS: These results suggest that MRSA contaminates the surfaces of the dental operatory, and therefore the dental operatory should be considered a possible reservoir of MRSA.     

Methicillin-resistant Staphylococcus aureus: a primer for dentists

BACKGROUND AND OVERVIEW: In 2005 in the United States, an estimated 94,370 new, invasive infections and 18,650 deaths were associated with methicillin-resistant Staphylococcus aureus (MRSA); most of these infections were in people with exposures in health care settings. MRSA also has emerged as a community-based pathogen, causing primarily skin infections that are not life-threatening, but occasionally causing more severe and invasive infections. The authors describe the history of MRSA; identify populations at greatest risk of experiencing MRSA colonization and infection; compare characteristics of MRSA infections occurring in health care and community settings; and summarize strategies, based on U.S. Centers for Disease Control and Prevention recommendations and the literature, to prevent transmission of MRSA in dental offices. CONCLUSIONS AND CLINICAL IMPLICATIONS: Standard infection control precautions should be enforced strictly in all ambulatory care settings, including dental offices, to prevent facility-based transmission of MRSA and other infectious agents.     

Oral health care and status of elderly care home residents in Glasgow

OBJECTIVES: To investigate variations in reported oral health care provision and unmet dental need within a sample of care homes for the elderly in Glasgow. BASIC RESEARCH DESIGN: Two-phase study of a 50% random sample of 120 care homes (n = 60). Phase 1: telephone interviews with care home managers. Phase 2: oral examinations of residents and face-to-face interviews with care staff, in a sub-sample of 10 homes. CLINICAL SETTING: Care homes in Greater Glasgow. PARTICIPANTS: Residents and staff. RESULTS: Phase 1: data were collected from 58 of 60 care home managers approached (response rate: 97%). Oral assessment of residents on admission was reported for 78% of nursing homes and 24% of residential homes, and annual screening by a dentist for 85% and 76% respectively. Only 58% of nursing homes and 8% of residential homes had a formal mouth care policy. Staff training in mouth care was not universal and often carried out "in-house". All managers believed dental support was available when required. Phase 2: 288 oral examinations and 22 staff interviews took place within 10 homes selected. Examinations revealed high levels of oral disease. When interviewed, staff accepted that mouth care was within their remit but failed to document it within patient care plans. Further training on oral health and disease was requested from all levels of staff. CONCLUSIONS: Oral disease is common among elderly care home residents in Glasgow. Increased emphasis on implementation of standard oral care protocols and improved education of staff is essential if the oral health of elderly institutionalised residents is to improve.     

Risk Factors for Methicillin-Resistant Staphylococcus aureus (MRSA) and Use of a Nasal Mupirocin Ointment in Oral Cancer Inpatients.

PURPOSE: Elimination of methicillin-resistant Staphylococcus aureus (MRSA) is of critical importance in oral and maxillofacial surgery because control is very difficult once infection of an oral tumor or oral wound with MRSA is established. PATIENTS AND METHODS: We retrospectively investigated the risk factors for acquiring MRSA in 518 patients with oral cancer among 1,877 inpatients in our department between 1984 and 2005. RESULTS: The patients with oral cancer demonstrated a high rate of MRSA colonization and infection (77.8%) relative to the population as a whole with MRSA isolated percentage in our department after 1991. The risk factors for MRSA in oral cancer patients are also related to systemic diseases and physiological and iatrogenic conditions, including cerebrovascular diseases (77.8%), peripheral arterial catheterization (69.2%), diabetes (50.0%), tracheotomy (50.0%), renal failure (50.0%), long-term broad-spectrum antibiotic use (45.7%), and malnutrition (43.3%). However, the highest risk of MRSA seems to be related to poor hygienic care. CONCLUSIONS: Beginning in 1999, we implemented a strategy for reducing infection by MRSA that included nasal mupirocin ointment for patients at high risk of MRSA; since then, the detection rate has decreased. We suggest that the administration of nasal mupirocin ointment and provision of scrupulous hygienic care for high-risk patients are useful and effective measures for decreasing the incidence of MRSA infection.     

Oral health problems and needs of nursing home residents

Kiyak HA, Grayston MM, Crinean CL: Oral health problems and needs of nursing home residents.
Abstract – The problem of dental neglect and high levels of unmet dental needs among elderly residents of long term care facilities has been widely documented in literature. A survey was conducted of 1063 residents in 31 nursing homes throughout Washington (representing 11% of all facilities in the slate). The greatest single need among dentate elderly was for routine oral hygiene (72%), while for denture wearers adjustment of loose dentures was the primary need (46.4%). Periodontal problems were slightly more prevalent than root caries (43%) and 36% respectively) among dentate elderly. Dry mouth was found in 10% of residents. Oral conditions were worse in larger facilities located in rural and moderate size communities, and those under a proprietary corporation. These results suggest that daily oral hygiene and regular check-ups by a dental professional are most needed by frail elderly, especially in large, proprietary homes in rural and moderate size communities. Education of nursing home staff and the elderly themselves in the importance and methods of home care are also critical needs.     

MRSA: an important consideration for geriatric dentistry practitioners

Methicillin-resistant Staphylococcus aureus (MRSA) can cause life-threatening disease in older populations. MRSA is readily spread by patient to patient or by health care workers to patient contact. Implications for dental practitioners include the fact that they may be passive vectors for the disease and that dental treatment of patients with active MRSA infections must follow effective infection control practices.     

Nurses' dental assessments and subsequent care in Minnesota nursing homes

Concerns about the quality of care in US nursing homes led to 1987 federal regulations mandating a national standardized resident assessment. This assessment, or Minimum Data Set (MDS), is performed by nurses on all residents and includes items to detect oral health problems. As yet, however, there are few data on the utility of these MDS oral health evaluations. In this study, we analyzed data from Minnesota nursing homes to determine the prevalence of oral health problems ("triggers") requiring dental referral from the MDS, version 1 (Items L and M). We also analyzed the relationship between these MDS assessments and subsequent dental care. Data came from a 1994 Minnesota nursing home dental utilization study containing information on 466 residents (dental users and non-users) sampled from 21 nursing homes. Nurses identified 3.2% of residents as having oral debris, 3.0% with broken, loose, or carious teeth, and only four (0.9%) residents with gum inflammation/soft tissue problems. Only one resident (0.2%) was identified with mouth pain. Regression analyses of data from 135 residents admitted since 1992 revealed no relationship between the presence of MDS "triggers" and subsequent utilization measured in visits/year and gross charges/year. Nurses' MDS assessments identified few oral health problems, and those problems identified did not translate into dental treatment, raising questions about the utility of the current approach.     

Attitudes of Irish dental, dental hygiene and dental nursing students and newly qualified practitioners to tobacco use cessation: a national survey

BACKGROUND: Ireland has some of the strictest smoking regulations in the world. Little is known of the attitudes of student Irish dental healthcare workers towards tobacco control and tobacco use cessation. This study aimed at determining the knowledge and attitudes of these students towards the deleterious effects of tobacco in the mouth and towards tobacco use cessation in dental practice. METHOD: A questionnaire survey was distributed to 654 students (including newly qualified) on dentistry, dental hygiene and dental nursing programmes in Irish dental schools. Information sought included college, course, year of study, sex, age, nationality, smoking status, knowledge of effects of tobacco in the mouth and attitudes towards tobacco use cessation in dental practice and towards the Irish smoking bans. MAIN FINDINGS: There was a 90% response rate. In all, 12% of dental students, 25% of dental hygiene students and 31% of dental nursing students were current smokers. Newly qualified dental hygienists were as knowledgeable about tobacco effects in the mouth as newly qualified dentists. Overall, the majority in each student category believed that all three groups could be effective tobacco counsellors and should provide tobacco use cessation counselling to patients, although less than half of evening course dental nursing students felt that dental nurses could be effective counsellors or should provide counselling. There was overwhelming support for the Irish smoking ban. Only a minority of dental students and dental nursing students had received instruction in tobacco use cessation counselling. CONCLUSIONS: There are strong positive attitudes to tobacco use cessation counselling in dental practice among these young dental healthcare students. This is true even amongst those who have not received specific instruction in tobacco use cessation counselling.     

Opinions on the provision of dental care in Iowa nursing homes

Using a stratified random sample, a questionnaire was mailed to 400 practicing dentists and 200 directors of nursing (DONs). Response rates were 58.3% for dentists and 50% for DONs. Dentists were representative of Iowa dentists, with 85% male, mean age 49.1 years, and 22.4 years in practice. All DONs were female, with mean age of 44.9 years. Of the participating dentists, 86% had provided dental care for nursing home residents, but the majority of care was completed in dental offices. Three‐quarters of dentists were somewhat/not interested in nursing home dentistry. Dentists and DONs held common perceptions of the most frequent problems related to care provision at nursing homes: low financial reimbursement, especially for Medicaid patients; no portable dental equipment; no suitable area for dentistry; dentist's preference to treat patients at their dental practice; and transportation of residents to a dental practice. Dentists and DONs had some differing perceptions about oral health care (p < .01). Minimal dental care was provided on‐site at Iowa nursing homes.     

Dental care for institutionalized geriatric patients in Germany

summary This investigation determined the level of dental care for institutionalized geriatric patients residing in nursing home facilities. A total of 364 patients from nine different geriatric care units within the city of Berlin were involved in this study. On average the patients were 84.9 years old. Women represented 87.3% of the patients. A standardized questionnaire and a clinical examination of the mouth were utilized to assess patient satisfaction with geriatric care, their general medical status and their oral health status. The results demonstrated that patients in geriatric care did not undergo routine dental check-ups. Oral hygiene was sufficient in only 12.6% of the patients, and prosthesis hygiene in 45% of the cases. Only 37.6 of the dentures exhibited sufficient retention and stability. In 80% of the patients dental treatment was necessary. Recommendations for improvement of dental care delivery to institutionalized geriatric patients are given. It has to be concluded that dental management of institutionalized geriatric patients is an essential yet presently underfulfilled service.     

Methicillin-resistant Staphylococcus aureus. A continuing infection control challenge

The ability of MRSA and other staphylococci to colonize, persist, and adapt to multiple environmental and tissue conditions has allowed for these bacteria to be virtually ubiquitous in their distribution. The effectiveness of commonly used antibiotics, such as penicillin, has continued to decline against infections caused by MRSA and increasingly resistant strains. The challenge for both dental and medical health professionals is to routinely apply proven, evidence-based infection control precautions. As mentioned earlier in this discussion, when compliance with effective aseptic technique practices improves, the patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and that single-use items are properly discarded. Clean and disinfect clinical contact surfaces that are not barrier-protected by using an environmental protection agency-registered hospital disinfectant with a low- (ie, HIV and HBV label claims) to intermediate-level (ie, tuberculocidal claim) activity after each patient. When the surface is visibly contaminated with blood, an intermediate-incidence of detectable infections can be reduced. Microorganisms will continue to evolve and adapt in order to survive and thrive, sometimes at the expense of susceptible human hosts. The struggle is to constantly remain aware of impending infectious threats which may challenge current precautions, and maintain and improve the quality of infection control to minimize the potential for disease.     

Opinions of dentists and directors of nursing concerning dental care provision for Adelaide nursing homes

BACKGROUND: The complex oral health problems of nursing home residents have been well documented. However, the influences on residents' oral health status, including opinions and experiences of dental professionals and nursing home staff, have not yet been adequately investigated. METHODS: The baseline questionnaire component of this longitudinal study was mailed to all registered dentists practising in Adelaide and Adelaide nursing home directors of nursing (DONs). RESULTS: 413 dentists and 97 DONs indicated that Adelaide dentists' interest and training in nursing home dentistry was low. Dental service provision for nursing home residents was very low and dentists preferred to provide treatment at their dental practices. Few dental hygienists were working in nursing homes and dental professionals provided little educational assistance for nursing home staff. Dentists and DONs held several common and many varying perceptions of the problems associated with dental care provision in nursing homes. Both identified a group of nursing home environmental constraints and a lack of portable dental equipment. DONs further identified a group of resident related problems, and dentists a group of dental practice-related problems. CONCLUSIONS: These study results provide important information concerning problems with nursing home dentistry for dental service providers, educators, policy-makers, administrators and nursing home staff.     

Oral care for successful aging in long-term care

The oral health of frail elders residing in long-term care facilities is very poor, probably because access to dental services is limited and help with daily mouth care is almost nonexistent. Recent concerns and interest have been raised through the cooperation of administrators, nursing staff, and dental personnel to address this apparent neglect. Moreover, evidence shows that caries and periodontal disorders can be managed successfully in geriatric populations. Consequently, there is a basis on which to develop a practical strategy for mouth care that should reduce the morbidity and early mortality in long-term care and to assist an increasingly frail and dependent population to age successfully.     

Prevalence of oral methicillin-resistant Staphy/ococcus aureus in an institutionalized veterans population

Methicillin-resistant Staphylococcus aureus ( MRSA) is a nosocomial pathogen now of great concern in nursing homes and other institutional settings. MRSA has been well-documented to inhabit the nares, skin wounds, and respiratory tract, but little is known about its presence in the oral cavity. In this study, all patients admitted to an 80-bed VA extended care facility were cultured weekly for 12 weeks to detect the presence of MRSA in the nares, wounds, in-dwelling devices, and the oral cavity. Of a total of 107 participating subjects, 20 cultured positive for oral MRSA, yielding a prevalence of 18.7%, compared with 19.6% prevalence in the nares —the traditionally accepted screening site for MRSA. There was a 91.6% agreement between oral and nasal carriage in subjects, but four of 107 subjects (3.7%) cultured positive for oral MRSA without evidence of nasal carriage. These results suggest that oral MRSA may be more common than previously thought in high-risk settings, with a prevalence comparable with that of nasal infection. Further investigation is necessary to characterize the factors associated with the presence of MRSA in the oral cavity     

An analysis of the persistent presence of opportunistic pathogens on patient-derived dental impressions and gypsum casts

PURPOSE: This study aimed to assess the persistent presence of microorganisms on patient-derived dental impressions and gypsum casts, while highlighting important human pathogens such as Candida, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa. MATERIALS AND METHODS: The practices and opinions regarding cross-infection control from 59 general dentists in Japan were obtained via a questionnaire. Alginate impressions were made from 56 patients. Using a brain heart infusion agar medium, impression and imprint cultures were carried out to visualize the microbial contamination on the surfaces of the impressions and gypsum casts, respectively. The colonies on the surfaces of the 30 impression cultures and 26 imprint cultures were collected by swabbing and then inoculated onto selective agar plates to detect streptococci, staphylococci, Candida, MRSA, and P aeruginosa. RESULTS: The questionnaire showed that only 54% of general dentists had a cross-infection policy in their dental clinics, and only 30% to 40% were aware of the possible persistence of MRSA or P aeruginosa on impressions and gypsum casts. The impression/imprint cultures grew a large number of visible bacterial colonies on all of impression/gypsum cast samples investigated. Selective agar cultures demonstrated the presence of streptococci (100, 100%), staphylococci (56.7, 65.4%), Candida (30, 46.2%), MRSA (26.7, 15.4%), and P aeruginosa (6.7, 7.7%) on the impressions and the gypsum casts, respectively. CONCLUSIONS: This investigation showed that patient-derived dental impressions and gypsum casts are contaminated with numerous microbes, including Candida, MRSA, and P aeruginosa, which are known pathogens responsible for nosocomial and/or life-threatening infection in the immunocompromised host.     

Outreach dental service for persons with special needs in Hong Kong

The authors describe the acceptance and efficiency of an outreach dental service, which provided oral health care to persons with special needs in Hong Kong. Portable dental equipment was transported to various institutions. Basic dental care including prevention, scaling, restoration, extraction, and denture repair was provided free of charge. Elderly adults living in institutions were the main service recipients, but other people with special needs, including physically disabled and persons with mental retardation were also reached. One-third of the patients had dental pain or sensitivity, and 70% had not visited a dentist for more than three years. Dental care was provided to 6,867 patients over four years. Feedback from the patients showed that more than 90% of them were satisfied with the service. These findings indicate that patients with special needs in Hong Kong are in great need of dental care. An outreach dental service appears to be both appropriate and efficient in providing care to these persons.     

Dental treatment outcomes among dentate nursing facility residents: an initial study

This investigation used retrospective methodology to examine the outcomes of previous dental treatment and the incidence of developing restorative and extraction needs, including dental caries, among nursing facility residents. Data were taken from treatment records of 48 dentate residents in 10 nursing facilities who received comprehensive dental treatment delivered through the Geriatric Mobile Unit (GMU) program operated by the University of Iowa College of Dentistry and were examined an average of 2.9 years had a mean age of 84 years at the second exam, and 90% were female. About 18% of all previously placed restorations needed to be replaced, and an additional 11% of teeth that received a restoration needed to be extracted at follow-up. At follow-up, nearly 70% (33/48) of residents needed restorative care, while 44% (21/48) needed extractions. The mean incidence of teeth developing new treatment needs between the two visits was 2.7 teeth/person (14.9% of teeth) for restorative need and 1.1 teeth/person (6.6% of teeth) for extraction need. Results suggest that successful treatment outcomes can be achieved for nursing facility residents, but that dental disease and treatment needs develop at a high rate among these residents.     

Individualized mouth prop for dental professionals and carers

Maintaining a high standard of dental health in children with special needs, particularly those who are unable to control mandibular activity, can prove difficult and time consuming for parents, carers and dental professionals. This article describes the construction of an individually made and relatively unobtrusive finger guard mouth prop, designed to facilitate intraoral examination and oral hygiene care for these children. An initial evaluation by a number of users found these mouth props were simple to fit, stable and provided adequate finger protection. All users planned to continue using their mouth prop after the trial period. It is concluded that similar finger mounted mouth props may help facilitate dental care and oral hygiene for children requiring special care.     

Oral health status and treatment needs of Canadian adults aged 85 years and over

In an oral health survey, 1375 adults aged 85 and older were examined in North York, Canada. Only 31% of dentate nursing home residents and 47% of dentate independently living subjects had received dental care in the year previous to examination. The overall prevalence of edentulism was 66%, and about 80% of subjects wore at least one denture. Of the dentate subjects, over 60% had untreated decay, and 47% of nursing home residents had untreated root decay. Regarding clinically defined treatment needs, high levels of unmet need were identified in subjects from both types of residences. Among nursing home residents, about 45% of dentate subjects required tooth extraction, and 56% required prosthodontic treatment. Although only 27% of dentate independently living residents required tooth extraction, over 60% needed restorative treatment. Higher prevalence of both untreated decay and unmet treatment needs was associated with lower utilization of dental care for dentate subjects. For edentulous subjects, prosthetic treatment was required by 70% of nursing home residents and by 51% of independently living subjects. These results indicate that, for both nursing home and independently living residents, dental diseases and treatment needs continue throughout the lifespan.     

Receipt of dental care, dental status and workforce in U.S. nursing homes: 1997 National Nursing Home Survey

The goal of this paper was to report the prevalence of dental care — a Healthy People 2010 objective — for nursing home residents 65 years and older, and to assess the association between receipt of dental care with other oral status and workforce measures. Data from 7,363 residents aged 65 years and older with information in the 1997 National Nursing Home Survey (NNHS) were used.
Overall, 18.2% of elderly nursing home residents had received dental care in the last month. Multivariable modeling found residents were more likely to receive dental care in the past month if they lived in the Northeast (OR=3.32, 95% CI 2.51-4.39); were dentate (OR=1.46, 95% CI 1.26-1.69); had a length of stay 12 months or longer (OR=1.37, 95% CI 1.17-1.62); or resided in facilities with dental professional services (OR=2.05, 95% CI 1.60-2.62).
The results showed that disparities in receipt of dental care existed by region, length of stay, dentate status, and availability of dental services in nursing homes. Additionally, current oral health surveillance measures for nursing homes may have been inadequate.