Infections in Dentistry

*Surgical Infections - Some Facts*

Sciences. 2008;**15**:59-64

of Sabzevar University of Medical

[47] Tai J, Mok E, Ching P, Seto W, Pittet D. Nurses and physicians' perceptions of the importance and impact of healthcare-associated infections and hand hygiene: A multi-center exploratory study in Hong Kong. Infection. 2009;**37**:320-333

[54] Hugonnet S, Harbarth S, Sax H, Duncan RA, Pittet D. Nursing resources: A major determinant of nosocomial infection? Current Opinion in Infectious

Diseases. 2004;**17**:329-333

[48] Kampf G, Löffler H, Gastmeier P. Hand hygiene for the prevention of nosocomial infections. Deutsches Ärzteblatt International. 2009;**106**:649

[49] Helder OK, Brug J, Looman CW, van Goudoever JB, Kornelisse RF. The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: An intervention study with before and after comparison. International Journal of Nursing Studies. 2010;**47**:1245-1252

[50] Picheansathian W, Pearson A, Suchaxaya P. The effectiveness of a promotion programme on hand hygiene compliance and nosocomial infections in a neonatal intensive care unit. International Journal of Nursing

[51] Suchitra J, Devi NL. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections. Indian Journal of Medical

[52] Wisniewski MF, Kim S, Trick WE, Welbel SF, Weinstein RA, Project CAR. Effect of Education on Hand Hygiene Beliefs and Practices A 5-Year Program. Infection Control and Hospital Epidemiology. 2007;**28**:88-91

[53] Voss A, Widmer AF. No time for handwashing!? handwashing versus alcoholic Rub Can We afford 100% compliance? Infection Control and Hospital Epidemiology. 1997;**18**:205-208

Practice. 2008;**14**:315-321

Microbiology. 2007;**25**:181

**32**

**35**

**Chapter 4**

**Abstract**

resistance, biofilm

**1. Introduction**

Infection Control in Dentistry and

Drug-Resistant Infectious Agents:

Using molecular biological methods and retrospective investigations, some outbreaks in dental settings have been proven to be caused by mainly blood-borne viruses and water-borne bacteria. Nowadays, drug-resistant bacteria seem further hazards taking into account the worldwide overuse of antibiotics in dentistry, the limited awareness on infection prevention guidelines, and the lapses and errors during infection prevention (reported in more detail in Part 2). We chose MRSA and VRE as markers since they are considered prioritized bacteria according antibiotic resistance threats. Antibiotic-resistant bacterial infections inside of dental setting are relevant, and we argue about some hazards in dentistry, including dedicated surgeries. MRSA has a key role for its colonization in patients and dental workers, presence on gloves, resistance (days-months on dry inanimate surfaces), the contamination of different clinical contact surfaces in dental settings, the ability of some strains to produce biofilm, and finally its estimated low infective dose. For better dental patient and healthcare personnel safety, we need evidence-based

guidelines to improve education and training initiatives in surgery.

**Keywords:** dentistry, surgery, guidelines, infection control, antibiotic

Dentistry seems to provide safe procedures for oral health care taking into account all adverse events (AEs). Nevertheless, death, injury, and malfunctions due to dental devices (DDs) increased from the MAUDE report in 2000–2012, and the endosseous implants were at the top of the DDs involved in AEs [1]. In the same period, the number of malpractice payments in dentistry increased by 12%, while those in other health professions fell [2]. Dental AEs, complaints, and claims seem to be relatively common in different countries [3]. About 4–17% of AEs are due to infection [4, 5]. The iatrogenic infectious risk in dentistry has not been quantify closely yet [6, 7], but recently, some outbreaks caused by infective agents, mainly blood-borne viruses and water-borne bacteria, have been documented in dental settings based on molecular biological assays and/or retrospective investigations [8–11]. Some evidence exists around the hazard due of antibiotic-resistant infectious agents (ARIAs) in dentistry. Fatal adverse events (FAEs) had been reported within

A Burning Issue. Part 1

*Livia Barenghi, Alberto Barenghi*

*and Alberto Di Blasio*

### **Chapter 4**

## Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1

*Livia Barenghi, Alberto Barenghi and Alberto Di Blasio*

### **Abstract**

Using molecular biological methods and retrospective investigations, some outbreaks in dental settings have been proven to be caused by mainly blood-borne viruses and water-borne bacteria. Nowadays, drug-resistant bacteria seem further hazards taking into account the worldwide overuse of antibiotics in dentistry, the limited awareness on infection prevention guidelines, and the lapses and errors during infection prevention (reported in more detail in Part 2). We chose MRSA and VRE as markers since they are considered prioritized bacteria according antibiotic resistance threats. Antibiotic-resistant bacterial infections inside of dental setting are relevant, and we argue about some hazards in dentistry, including dedicated surgeries. MRSA has a key role for its colonization in patients and dental workers, presence on gloves, resistance (days-months on dry inanimate surfaces), the contamination of different clinical contact surfaces in dental settings, the ability of some strains to produce biofilm, and finally its estimated low infective dose. For better dental patient and healthcare personnel safety, we need evidence-based guidelines to improve education and training initiatives in surgery.

**Keywords:** dentistry, surgery, guidelines, infection control, antibiotic resistance, biofilm

### **1. Introduction**

Dentistry seems to provide safe procedures for oral health care taking into account all adverse events (AEs). Nevertheless, death, injury, and malfunctions due to dental devices (DDs) increased from the MAUDE report in 2000–2012, and the endosseous implants were at the top of the DDs involved in AEs [1]. In the same period, the number of malpractice payments in dentistry increased by 12%, while those in other health professions fell [2]. Dental AEs, complaints, and claims seem to be relatively common in different countries [3]. About 4–17% of AEs are due to infection [4, 5]. The iatrogenic infectious risk in dentistry has not been quantify closely yet [6, 7], but recently, some outbreaks caused by infective agents, mainly blood-borne viruses and water-borne bacteria, have been documented in dental settings based on molecular biological assays and/or retrospective investigations [8–11].

Some evidence exists around the hazard due of antibiotic-resistant infectious agents (ARIAs) in dentistry. Fatal adverse events (FAEs) had been reported within 90 days after different instances of dental care [7]. In the last 50 years, FAEs caused by an infection have (a) increased while respiratory complications and bleeding are steady, and those caused by cardiovascular or related to anesthesia have decreased, (b) significant (12%), (c) mainly associated to dental surgery (implant surgery/placement, extractions (>6 erupted teeth or impacted tooth/teeth), surgical extractions, osseous surgery, sinus lift surgery, bone biopsy, orthognathic surgery), and (d) associated with much longer times until death compared with other causes of death [7]. A study on dental malpractice analyzed 4149 legal claims (both in and out of court) from the years of 2000 to 2010 in Spain [12]. About 2.7% of all AEs resulted in death, and 45% of them were caused by infection. In the absence of specific information reported in both papers [7, 12], we do not exclude the possible involvement or nonrecognition of ARIAs or the failure of proper drug treatment in those FAEs. Recently, in an interview, Davies stated that in 20 years time even minor surgeries could be fatal because of infections [13].

We consider that the following two reviews are important and indicative of the limitedness of data published up to 2011–2012 in dentistry [14, 15]. The first review on methicillin-resistant *Staphylococcus aureus* (MRSA) infection concluded that (1) transmission was ascertained during surgical interventions, particularly in surgical units and among head and neck cancer patients; (2) carriage rates among dental healthcare personnel (DHCP) were lower than those among other healthcare workers (HCWs); (3) carriage rates among adult patients were low, whereas among pedodontic and special care patients rates were higher than those found in the general population; and (4) MRSA had been detected in the environment of emergency, surgical units, and in dental hospitals [14]. In the second review, multiresistant bacteria infections had been included among the main healthcare viral and bacterial infections in dentistry [15], but the transmission of Enterobacteriaceae and/or their resistant strains did not exist yet. The interest on Enterobacteriaceae is warranted since they are susceptible to only a few (if any) antibacterial drugs.

Here, we think it is important to update these conclusions in the light of the global, wide, and long-term abuse and misuse of antibiotics in dentistry and selective pressure on opportunistic bacteria by favoring potentially pathogenic strains [16, 17]. In addition, the limited awareness on infection prevention guidelines and lapses and errors during infection prevention according to Centers for Disease Control and Prevention (CDC) dental guidelines [6, 8–11] sustain the evidence of possible reservoirs of ARIAs in humans (patient, dental staff) and in the environment (clinical contact surfaces (CCSs), dental instruments, and dental unit water lines (DUWLs)) and possible hazards in surgical dental setting. Our approach is in line with the CDC recommendation, in which it states that "*Preventing infections negates the need for antibiotic use in the first place, and scientific evidence shows that reducing antibiotic use in a single facility can reduce resistance in that facility*" [18–20].

In addition, the cluster of above problems is important for risk management, since it is rationally "harmful" that opportunistic species and/or ARIAs were involved in implant failures [21, 22], periodontitis [23, 24], endodontic failures [25] and oral mucosal and deep infections [26].

Here, we discuss briefly main recent evidence and controversy on infections in dedicated dental and mainly in implant surgery, taking into account that many other aspects (i.e. surgery technique, geometry, materials, and surface of dental implants) have already been reviewed extensively [27–30]. Dental implant (DI) complications are a burning issue, since the current demand of DIs is high (20 DIs in Italy and 4 in the USA per year per million of inhabitants), mainly applied in private offices, and the global DI market size was estimated at 3.77 billion USD in 2016 growing at a compound annual growth rate (CAGR) of 7.7% over 2024 [31]. It is important to underline that the incidence of esthetic, technical and infective complications is still high in implantology, and the 5-year infective complication increased from 7.4 to

**37**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

9.4% [32]. In general, the expected implant-associated infections and the outbreaks from opportunistic pathogens (*Staphylococci, Enterococci, Pseudomonas,* etc.) will always be more important. In addition, we have to take into account other factors linked to risk management such as the impact on reputation and finances, the loss of protection of insurance coverings and reimbursements, and shocking advertising rapidly spreading through social networks in the case of outbreaks [8–11, 33–35]. Here (Part 1), we focus on the insufficient compliance with infection control (IC) recommendations in oral healthcare and the difficulties and problems of standard precaution implementation also in ambulatory surgical centers [6, 36–42]. In general, dental surgery and implantology are predominantly done in general dental practice under local anesthesia or sedation [43, 44]. This is a very important aspect since the cross-infection is widespread and more difficult to control compared to surgical rooms. We have divided problems and difficulties for infection prevention into different areas concerning the innovative molecular biology techniques; antibiotic misuse and overuse in dentistry; opportunistic pathogens and antibiotic resistance in dental patients and dental healthcare workers; and surgical infection prevention in dentistry. While in the chapter (Part 2), we have reported infection control implementation, not compliance, lapses and errors during infection prevention according to CDC dental guidelines. We focused on hand hygiene, gloves, environment decontamination, and

The electronic literature search was conducted via the PubMed and Google Scholar databases (from January 2010 up to and including April 2018) using various combinations of the following key indexing terms: (a) patient safety; (b) infection control; (c) implant; (d) endodontia; (e) sterilization; (f) reconditioning; (g) critical items; (h) semicritical items; (i) hand hygiene; (j) DUWL; (k) sharps safety; (l) personal protective equipment (PPE); (m) disinfection; (n) MRSA; (o) VRE; (p) ARIAs; (q) guidelines; and (r) cross-infection. In addition, manual searches were carried out in INTECH books. Then, bibliographic material from the papers has been used in order to find other or older appropriate sources. A total of 179 papers and links were found suitable for inclusion in this chapter (Part 1). Only few papers do not have a DOI or PubMed classification, but the available link by Internet and

Expanded Human Oral Microbiome Database (eHOMD) provides the scientific community with broad and up-to-date information on the bacterial species present in the human aero-digestive tract, including the oral cavity. Genomes for 482 taxa (63% of all taxa, 89% of cultivated taxa) are currently available on eHOMD [48]. Fast and very sensitive molecular biological techniques, classified into nucleic acid-based methods [quantitative real-time polymerase chain reaction (PCR), multiplex PCR, microarray, next-generation sequencing technologies, etc.], are available for the screening, detection, and functional activities of pathogens and antibiotic-resistant bacteria, even those not cultivable by classical microbiological methods and by using both patient biological fluids and samples from inanimate objects (surface, air, DUWL colonization, DDs, and instruments) [49–52]. This is possible because DNA molecules can survive for long time and can be amplified. Current microbiological laboratory approaches based on high-throughput real-time

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

instrument reconditioning in more detail [6, 43–47].

**2. Approach**

accessed date have been added.

**3. Focus on molecular biology techniques**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

9.4% [32]. In general, the expected implant-associated infections and the outbreaks from opportunistic pathogens (*Staphylococci, Enterococci, Pseudomonas,* etc.) will always be more important. In addition, we have to take into account other factors linked to risk management such as the impact on reputation and finances, the loss of protection of insurance coverings and reimbursements, and shocking advertising rapidly spreading through social networks in the case of outbreaks [8–11, 33–35].

Here (Part 1), we focus on the insufficient compliance with infection control (IC) recommendations in oral healthcare and the difficulties and problems of standard precaution implementation also in ambulatory surgical centers [6, 36–42]. In general, dental surgery and implantology are predominantly done in general dental practice under local anesthesia or sedation [43, 44]. This is a very important aspect since the cross-infection is widespread and more difficult to control compared to surgical rooms. We have divided problems and difficulties for infection prevention into different areas concerning the innovative molecular biology techniques; antibiotic misuse and overuse in dentistry; opportunistic pathogens and antibiotic resistance in dental patients and dental healthcare workers; and surgical infection prevention in dentistry. While in the chapter (Part 2), we have reported infection control implementation, not compliance, lapses and errors during infection prevention according to CDC dental guidelines. We focused on hand hygiene, gloves, environment decontamination, and instrument reconditioning in more detail [6, 43–47].

### **2. Approach**

*Surgical Infections - Some Facts*

90 days after different instances of dental care [7]. In the last 50 years, FAEs caused by an infection have (a) increased while respiratory complications and bleeding are steady, and those caused by cardiovascular or related to anesthesia have decreased, (b) significant (12%), (c) mainly associated to dental surgery (implant surgery/placement, extractions (>6 erupted teeth or impacted tooth/teeth), surgical extractions, osseous surgery, sinus lift surgery, bone biopsy, orthognathic surgery), and (d) associated with much longer times until death compared with other causes of death [7]. A study on dental malpractice analyzed 4149 legal claims (both in and out of court) from the years of 2000 to 2010 in Spain [12]. About 2.7% of all AEs resulted in death, and 45% of them were caused by infection. In the absence of specific information reported in both papers [7, 12], we do not exclude the possible involvement or nonrecognition of ARIAs or the failure of proper drug treatment in those FAEs. Recently, in an interview, Davies stated that in 20 years time even minor surgeries could be fatal because of infections [13]. We consider that the following two reviews are important and indicative of the limitedness of data published up to 2011–2012 in dentistry [14, 15]. The first review on methicillin-resistant *Staphylococcus aureus* (MRSA) infection concluded that (1) transmission was ascertained during surgical interventions, particularly in surgical units and among head and neck cancer patients; (2) carriage rates among dental healthcare personnel (DHCP) were lower than those among other healthcare workers (HCWs); (3) carriage rates among adult patients were low, whereas among pedodontic and special care patients rates were higher than those found in the general population; and (4) MRSA had been detected in the environment of emergency, surgical units, and in dental hospitals [14]. In the second review, multiresistant bacteria infections had been included among the main healthcare viral and bacterial infections in dentistry [15], but the transmission of Enterobacteriaceae and/or their resistant strains did not exist yet. The interest on Enterobacteriaceae is warranted since they are susceptible to only a few (if any) antibacterial drugs. Here, we think it is important to update these conclusions in the light of the global, wide, and long-term abuse and misuse of antibiotics in dentistry and selective pressure on opportunistic bacteria by favoring potentially pathogenic strains [16, 17]. In addition, the limited awareness on infection prevention guidelines and lapses and errors during infection prevention according to Centers for Disease Control and Prevention (CDC) dental guidelines [6, 8–11] sustain the evidence of possible reservoirs of ARIAs in humans (patient, dental staff) and in the environment (clinical contact surfaces (CCSs), dental instruments, and dental unit water lines (DUWLs)) and possible hazards in surgical dental setting. Our approach is in line with the CDC recommendation, in which it states that "*Preventing infections negates the need for antibiotic use in the first place, and scientific evidence shows that reducing antibiotic use in a single facility can reduce resistance in that facility*" [18–20]. In addition, the cluster of above problems is important for risk management, since it is rationally "harmful" that opportunistic species and/or ARIAs were involved in implant failures [21, 22], periodontitis [23, 24], endodontic failures [25]

**36**

and oral mucosal and deep infections [26].

Here, we discuss briefly main recent evidence and controversy on infections in dedicated dental and mainly in implant surgery, taking into account that many other aspects (i.e. surgery technique, geometry, materials, and surface of dental implants) have already been reviewed extensively [27–30]. Dental implant (DI) complications are a burning issue, since the current demand of DIs is high (20 DIs in Italy and 4 in the USA per year per million of inhabitants), mainly applied in private offices, and the global DI market size was estimated at 3.77 billion USD in 2016 growing at a compound annual growth rate (CAGR) of 7.7% over 2024 [31]. It is important to underline that the incidence of esthetic, technical and infective complications is still high in implantology, and the 5-year infective complication increased from 7.4 to

The electronic literature search was conducted via the PubMed and Google Scholar databases (from January 2010 up to and including April 2018) using various combinations of the following key indexing terms: (a) patient safety; (b) infection control; (c) implant; (d) endodontia; (e) sterilization; (f) reconditioning; (g) critical items; (h) semicritical items; (i) hand hygiene; (j) DUWL; (k) sharps safety; (l) personal protective equipment (PPE); (m) disinfection; (n) MRSA; (o) VRE; (p) ARIAs; (q) guidelines; and (r) cross-infection. In addition, manual searches were carried out in INTECH books. Then, bibliographic material from the papers has been used in order to find other or older appropriate sources. A total of 179 papers and links were found suitable for inclusion in this chapter (Part 1). Only few papers do not have a DOI or PubMed classification, but the available link by Internet and accessed date have been added.

### **3. Focus on molecular biology techniques**

Expanded Human Oral Microbiome Database (eHOMD) provides the scientific community with broad and up-to-date information on the bacterial species present in the human aero-digestive tract, including the oral cavity. Genomes for 482 taxa (63% of all taxa, 89% of cultivated taxa) are currently available on eHOMD [48]. Fast and very sensitive molecular biological techniques, classified into nucleic acid-based methods [quantitative real-time polymerase chain reaction (PCR), multiplex PCR, microarray, next-generation sequencing technologies, etc.], are available for the screening, detection, and functional activities of pathogens and antibiotic-resistant bacteria, even those not cultivable by classical microbiological methods and by using both patient biological fluids and samples from inanimate objects (surface, air, DUWL colonization, DDs, and instruments) [49–52]. This is possible because DNA molecules can survive for long time and can be amplified. Current microbiological laboratory approaches based on high-throughput real-time PCR allow quick, easy, and cheap detection of the oral microbiome and the antibiotic resistome, throughout 300 antibiotic resistance genes [53] as far as the rapid diagnosis of virulent slime-producing strains associated with dental caries [54]. The specificity of MRSA plus MSSA carriage detected with Xpert MRSA is better than standard culturing techniques, being 37.9 vs. 23.6%, respectively [55]. Concerning microbiological features of peri-implantitis cases, culture methods were able to detect 81.4% of the targeted species of the cases, whereas "checkerboard DNA– DNA hybridization" method 99.3%. In relation to the limited association between the bacterial contamination and the severity of the peri-implantitis [56], it is decisive the sampling procedure, around DIs and during swabs on dental items, and the use of the proper primer sequence for specific genes in different strains (i.e. ica genes for *S. epidermidis and S. aureus*) [57]. PCR is more effective in detecting *E. faecalis* than other analytical tools, such as culturing. *E. faecalis* has been found in root-filled teeth associated with periradicular lesions in a range of 0–70% by culture and 0–90% by PCR [58].

It is important to note that microbiological analysis (by culture or DNA-based methods) is rarely used in dentistry mainly because of the difficulties to delay the antibiotic treatment and for the plethora of infective agents involved in inflammatory diseases in dentistry. In addition, specific sampling procedures are needed since the virulence features of microorganisms and problems to sample deep periodontal and peri-implant pocket and abscesses. Sequencing methods that evaluate the entire microbiome are needed to improve identification of microorganisms (pathogen, opportunistic, noncultivable, drug-resistant ones) associated to peri-implant infective diseases and to develop suitable countermeasures with the expertise of clinical oral microbiologists [59]. In addition, emerging approach based on optical nanoprobes, biosensors, and protein biomarkers suitable for peri-implant crevicular fluids has been proposed to identify the severity and progression of the disease and the response to therapy [60, 61].

### **4. The broad antibiotic misuse or overuse in dentistry**

Globally, antibiotic prescription in dental care has continuously increased over the last 17 years, and a lot of evidence has been published on wide antibiotic misuse or overuse, in industrialized, low- and middle-income countries [62–70]. Dental prescriptions make up 5–11% of all antibiotic prescription among patients in some European countries, Canada, and the USA [19, 20, 65, 71, 72]. The rate of prescription increased the most among dental patients of 60 years or above.

It is important to underline that antibiotic prescription is placed without a microbiological analysis and has mainly prophylactic aim in dentistry. Recently, the prescription of antibiotics in dentistry was reviewed by Holmstrup and Klausen, while the use of antibiotics in odontogenic infections, in addition to the removal of the source of infection, by Martins [73, 74]. A significant percentage (19–37.5%) of microorganisms collected from their patients were penicillin resistant; nevertheless, the relationship between the clinical outcomes and microbial resistance with penicillin is not clear [74].

Recently, to overcome the misuse and abuse of antibiotics in dentistry, different institutions and associations recommended a more restrictive antibiotic policy to improve treatment efficacy and decrease bacterial resistance. Specific guidelines have been published for implantology [17], endodontia [75], oral surgery [17], third molar extraction [76], and medically compromised patients [77] and to prevent infective endocarditis [78, 79] or prosthetic joint infections [80].

**39**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

Here, based on recent and current knowledge, we focus on two well-known bacterial strains, *S. aureus* and *Enterococcus*, and their resistant strains. It is known that *S. aureus* and *Enterococcus faecalis* have been implicated in implant-associated infections [21, 23, 24, 81], endodontic infections [22, 25, 82], and recently in an outbreak of *Enterococcus* endocarditis [11]. We focus on these Gram-positive bacteria for the high innate resistance or ability to become resistant to most antibiotics along with some other virulence factors (hydrophobicity, adherence to abiotic surfaces (including dental implant materials), biofilm formation, ability to growth also in anaerobic conditions) [83]. These features are important in the exploration of standard precaution failures since bacterial adherence on dental implants, collagenbased biomaterials, or many other inanimate objects is known to be linked with the presence of surface components with nonpolar/hydrophobic vs. polar/hydrophilic characteristics. In addition, we focus on Staphylococci and Enterobacteriaceae as markers since they are considered prioritized bacteria according to antibiotic resistance threats, and better knowledge is available on their virulence factors and for dental settings (i.e. contamination on hands and environments, etc.) [6, 43, 45–47].

Single dose of prophylactic antibiotics in healthy volunteers induces a significant selection of resistant strains among the dynamic and complex community of resident oral and gastrointestinal bacterial microflora and causes a large disturbance of oral niches [84, 85]. Approximately, one third of participants gained resistant viridans *Streptococci* against amoxicillin, clindamycin, and penicillin-V, while in *Prevotella* spp., there was approximately a 28% gain in resistance to all antibiotics tested. The disturbance could reduce host colonization resistance, select new

*S. aureus* lives as a commensal primarily in the anterior nares and/or throat of 20–70% of adults [87, 88]. Some of the strains develop multidrug resistance and are well known to be involved in hospital-acquired (HA) infections [89]. The following two reviews are important and indicative of the limitedness of data published up to 2011–2012 in dentistry [14, 15]. *S. aureus* was normally absent or its colonization was very low in oral biofilm and ecological oral niches as reported in older evidence or not considered as a topic [14, 43, 90]. More recent data show that the presence of *S. aureus* in the oral cavity is more frequent and, nowadays, is to be considered a member of the oral microbiota (**Table 1**) [15, 84, 91–105]. Recently, metaproteomic analysis of human salivary supernatant from healthy persons was able to identify peptides from 124 microbial species including *Staphylococcus* [85]. The majority of *S. aureus* strains, isolated from the oral cavity of Tunisian patients, were biofilm/slime producers and exhibited some important genes (i.e. *ica, fnb, cna)* associated to adhesion and virulence factors [106, 107]. *S. pneumoniae* and *S. aureus* are common commensals of the upper respiratory tract in children and adolescents [14, 100, 108]. This fact is relevant since orthodontic patients are mainly children and adolescents and the high genotypic expression of peculiar genes (*ica*A/*ica*D) is important for *S. aureus* in the colonization of orthodontic appliances [109]. Recently, RNA-Seq data permit the analysis of active transcripts, assigned to

supragingival dental plaque biofilm in healthy subjects [110]. The transcripts assigned to Acriflavin resistance complex (*AcrA* and *AcrB* genes) were prevalent,

pathogens, and lead to an overgrowth of resistant bacteria [86].

**5. Focus on opportunistic pathogens and antibiotic resistance in** 

**dental patients and dental healthcare workers**

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

**5.1** *Staphylococcus aureus* **and MRSA**

antibiotics and toxic compounds, of the

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

### **5. Focus on opportunistic pathogens and antibiotic resistance in dental patients and dental healthcare workers**

Here, based on recent and current knowledge, we focus on two well-known bacterial strains, *S. aureus* and *Enterococcus*, and their resistant strains. It is known that *S. aureus* and *Enterococcus faecalis* have been implicated in implant-associated infections [21, 23, 24, 81], endodontic infections [22, 25, 82], and recently in an outbreak of *Enterococcus* endocarditis [11]. We focus on these Gram-positive bacteria for the high innate resistance or ability to become resistant to most antibiotics along with some other virulence factors (hydrophobicity, adherence to abiotic surfaces (including dental implant materials), biofilm formation, ability to growth also in anaerobic conditions) [83]. These features are important in the exploration of standard precaution failures since bacterial adherence on dental implants, collagenbased biomaterials, or many other inanimate objects is known to be linked with the presence of surface components with nonpolar/hydrophobic vs. polar/hydrophilic characteristics. In addition, we focus on Staphylococci and Enterobacteriaceae as markers since they are considered prioritized bacteria according to antibiotic resistance threats, and better knowledge is available on their virulence factors and for dental settings (i.e. contamination on hands and environments, etc.) [6, 43, 45–47].

### **5.1** *Staphylococcus aureus* **and MRSA**

*Surgical Infections - Some Facts*

and 0–90% by PCR [58].

disease and the response to therapy [60, 61].

**4. The broad antibiotic misuse or overuse in dentistry**

tion increased the most among dental patients of 60 years or above.

infective endocarditis [78, 79] or prosthetic joint infections [80].

PCR allow quick, easy, and cheap detection of the oral microbiome and the antibiotic resistome, throughout 300 antibiotic resistance genes [53] as far as the rapid diagnosis of virulent slime-producing strains associated with dental caries [54]. The specificity of MRSA plus MSSA carriage detected with Xpert MRSA is better than standard culturing techniques, being 37.9 vs. 23.6%, respectively [55]. Concerning microbiological features of peri-implantitis cases, culture methods were able to detect 81.4% of the targeted species of the cases, whereas "checkerboard DNA– DNA hybridization" method 99.3%. In relation to the limited association between the bacterial contamination and the severity of the peri-implantitis [56], it is decisive the sampling procedure, around DIs and during swabs on dental items, and the use of the proper primer sequence for specific genes in different strains (i.e. ica genes for *S. epidermidis and S. aureus*) [57]. PCR is more effective in detecting *E. faecalis* than other analytical tools, such as culturing. *E. faecalis* has been found in root-filled teeth associated with periradicular lesions in a range of 0–70% by culture

It is important to note that microbiological analysis (by culture or DNA-based methods) is rarely used in dentistry mainly because of the difficulties to delay the antibiotic treatment and for the plethora of infective agents involved in inflammatory diseases in dentistry. In addition, specific sampling procedures are needed since the virulence features of microorganisms and problems to sample deep periodontal and peri-implant pocket and abscesses. Sequencing methods that evaluate the entire microbiome are needed to improve identification of microorganisms (pathogen, opportunistic, noncultivable, drug-resistant ones) associated to peri-implant infective diseases and to develop suitable countermeasures with the expertise of clinical oral microbiologists [59]. In addition, emerging approach based on optical nanoprobes, biosensors, and protein biomarkers suitable for peri-implant crevicular fluids has been proposed to identify the severity and progression of the

Globally, antibiotic prescription in dental care has continuously increased over the last 17 years, and a lot of evidence has been published on wide antibiotic misuse or overuse, in industrialized, low- and middle-income countries [62–70]. Dental prescriptions make up 5–11% of all antibiotic prescription among patients in some European countries, Canada, and the USA [19, 20, 65, 71, 72]. The rate of prescrip-

It is important to underline that antibiotic prescription is placed without a microbiological analysis and has mainly prophylactic aim in dentistry. Recently, the prescription of antibiotics in dentistry was reviewed by Holmstrup and Klausen, while the use of antibiotics in odontogenic infections, in addition to the removal of the source of infection, by Martins [73, 74]. A significant percentage (19–37.5%) of microorganisms collected from their patients were penicillin resistant; nevertheless, the relationship between the clinical outcomes and microbial resistance with

Recently, to overcome the misuse and abuse of antibiotics in dentistry, different institutions and associations recommended a more restrictive antibiotic policy to improve treatment efficacy and decrease bacterial resistance. Specific guidelines have been published for implantology [17], endodontia [75], oral surgery [17], third molar extraction [76], and medically compromised patients [77] and to prevent

**38**

penicillin is not clear [74].

Single dose of prophylactic antibiotics in healthy volunteers induces a significant selection of resistant strains among the dynamic and complex community of resident oral and gastrointestinal bacterial microflora and causes a large disturbance of oral niches [84, 85]. Approximately, one third of participants gained resistant viridans *Streptococci* against amoxicillin, clindamycin, and penicillin-V, while in *Prevotella* spp., there was approximately a 28% gain in resistance to all antibiotics tested. The disturbance could reduce host colonization resistance, select new pathogens, and lead to an overgrowth of resistant bacteria [86].

*S. aureus* lives as a commensal primarily in the anterior nares and/or throat of 20–70% of adults [87, 88]. Some of the strains develop multidrug resistance and are well known to be involved in hospital-acquired (HA) infections [89]. The following two reviews are important and indicative of the limitedness of data published up to 2011–2012 in dentistry [14, 15]. *S. aureus* was normally absent or its colonization was very low in oral biofilm and ecological oral niches as reported in older evidence or not considered as a topic [14, 43, 90]. More recent data show that the presence of *S. aureus* in the oral cavity is more frequent and, nowadays, is to be considered a member of the oral microbiota (**Table 1**) [15, 84, 91–105]. Recently, metaproteomic analysis of human salivary supernatant from healthy persons was able to identify peptides from 124 microbial species including *Staphylococcus* [85]. The majority of *S. aureus* strains, isolated from the oral cavity of Tunisian patients, were biofilm/slime producers and exhibited some important genes (i.e. *ica, fnb, cna)* associated to adhesion and virulence factors [106, 107]. *S. pneumoniae* and *S. aureus* are common commensals of the upper respiratory tract in children and adolescents [14, 100, 108]. This fact is relevant since orthodontic patients are mainly children and adolescents and the high genotypic expression of peculiar genes (*ica*A/*ica*D) is important for *S. aureus* in the colonization of orthodontic appliances [109]. Recently, RNA-Seq data permit the analysis of active transcripts, assigned to antibiotics and toxic compounds, of the

supragingival dental plaque biofilm in healthy subjects [110]. The transcripts assigned to Acriflavin resistance complex (*AcrA* and *AcrB* genes) were prevalent,


**41**

**Study** Esposito et al. (2015)

Koukos et al.

[101]

Healthy patients

154

2010–2014

Greece

Subgingival samples and

10

#

0

PCR assay

Swab, anterior nares,

8.6

#

11.1

patients;

6.7

nurses; 9.3

dentists

(no. 1300); culture plus

molecular typing

(2015)

Kharialla

[102]

Patient and

#

2013

Egypt

DHCP

et al. (2017)

Yoo et al.

[103]

DHCP *§: using microbiological culture methods; PCR: polymerase chain reaction; #: not indicated.*

139

Korea *Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus (MSSA), and methicillin-resistant Staphylococcus aureus (MRSA) carriage rates among dental students, dental patients, dental* 

Swab, anterior nares; §

#

#

2.9

(2018)

**Table 1.**

*healthcare personnel (DHCP), and healthcare workers (HCWs).*

[100]

Healthy subjects aged 6–17 years

497

2013

Italy

Oropharyngeal and nasal swabs; multiplex real-time PCR

#

49.7 from

3.5 (15–

17 years)

6–9 years.; 54.9

from 10–14 years.;

52.9 from

15–17 years

**References**

**Study population**

**Number of subjects**

**Study carried out (years):**

**Country**

**Sampling, specimen, assay**

*S. aureus* **carriage (%)**

**MSSA carriage (%)**

**MRSA carriage (%)**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

*Surgical Infections - Some Facts*


### **Table 1.**

*Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus (MSSA), and methicillin-resistant Staphylococcus aureus (MRSA) carriage rates among dental students, dental patients, dental healthcare personnel (DHCP), and healthcare workers (HCWs).*

### *Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

*Surgical Infections - Some Facts*

21.3

**40**

**Study** Roberts et al.

[91]

Dental students

61

#

USA

Swab, anterior nose; §

#

21

(2011)

Martınez-Ruız et al.

[92]

Dental students

100

#

Mexico

Paired nasal and throat

#

#

20

swabs; §

(2014)

Petti et al.

[93]

Dental students

157

#

Italy

Dry cotton swabs from

15.3

#

0, any site

(9.7–

20.9), any

site

#

#

3.1

the mouth, nose, and skin

between fingers of the

nondominant hand; §

Nasal samples; §

(2015)

Baek et al.

[94]

Dental students

159

#

Korea

(2016)

Hema et al.

[95]

Dental students

200

#

India

Swab, anterior nares; §

#

#

24.5

(2017)

Zimmerli

[96]

500 dental

500

2006

Switzerland

Swab, anterior nares; §

42

41.6

90

10

0.4

patients >18 years

et al. (2009)

McCormack

[97]

10-year

1429

1998–2007

UK

Perioral clinical

specimens (no. 1986); §

retrospective

analysis of

laboratory data

et al. (2015)

Kabanova

[98]

Patients from

2920

2014

Belarus

Swabbing the area after

15–70

#

5.6–27.8

the incision (no. 162); §

5 maxillofacial

departments

et al. (2017)

Dulon et al.

[99]

HCW in nonoutbreak settings

21,289 subjects

#

#

#

#

1.1–5.4

from high

quality

studies

from 31

studies

(2014),

review

**References**

**Study** 

**Number of** 

**Study** 

**Country**

**Sampling, specimen,** 

*S. aureus*

**MSSA carriage** 

**MRSA** 

**carriage** 

**(%)**

**(%)**

**carriage** 

**(%)**

**assay**

**carried** 

**out** 

**(years):**

**subjects**

**population**

while those encoding for putative macrolide-specific efflux system or proteins involved in acid stress and bacteriocins are less represented. High percentages of *Staphylococcus* species, MRSA, *P. aeruginosa*, and *C. albicans* were detected in the mouths of elderly patients [111, 112]. By PCR, a notable occurrence of MRSA, vancomycin-resistant *S. aureus* (VRSA), and VSSA have been observed in the oral cavity of patients with dental caries [113]. Chronic periodontitis showed extensive antibiotic-resistant subgingival periodontal pathogens in cultivable microbiota, associated with red and orange complex species, and also to Gram-negative enteric rods/Pseudomonads, *E. faecalis*, and *S. aureus* [21, 23, 24, 114].

Here, we report updated data on *S. aureus* and MRSA carriage rates among dental students, dental patients, HCWs, and dental healthcare personnel (DHCP) in **Table 1** [91–103]. Despite the many differences between studies, nowadays there is a probable occupational exposure, from carriage rates, among DHCP and HCWs. This is higher in dental students (**Table 1**), but would seem evident in the last years [14, 91–95]. Nasal MRSA colonization, confirmed by the presence of the *mecA* gene that encodes a low-affinity penicillin-binding protein, occurs in dental students (3.1%), especially those who have clinical experience [94]. MRSA hand and nasal carriage rates in patients, nurses, and dentist are significant in dental settings (**Table 1**) [102]. The majority of MRSA isolates were multidrug resistant, and full resistance was generally higher for personnel than for the environmental isolates.

### *5.1.1 Community- and hospital-acquired MRSA infections and dentistry*

Taking into account MRSA carriage in dental patients and DHCP, the effectiveness of MRSA decolonization, and the violation of IC precautions (see below and in Part 2), MRSA in the oral cavity could potentially be disseminated by carriers (patient and DHCP) to the environment [115]. It is well known that communityacquired MRSA (CA-MRSA) infections often occur in young and healthy individuals, whereas HA-MRSA infections occur predominantly in elder or immunocompromised patients in healthcare settings and vary considerably between different countries [116, 117].

HA-MRSA and CA-MRSA have opposite features concerning competitive fitness, virulence, and antimicrobial resistance [118]. Only rarely HA-MRSAs cause infections in healthy subjects, but at least two CA-MRSAs (USA300 and ST30) cause HA infections. It is not known if these strains acquire multiple resistant genes from HA-MRSA or if they increase bacterial fitness and survival despite the antibiotic resistance. Taking into account that their extracellular proteome seems to be differently involved, we think that this epidemiological change is not soothing for future dental epidemiology. In fact, from a 10-year retrospective analysis of laboratory data, obtained from oral and perioral clinical specimens, most of the MRSA isolates were epidemic MRSA-15 (EMRSA-15) or EMRSA-16 lineage, known to cause both very dangerous HA-MRSA infections [97]. No MRSA isolates belonging to community-acquired recognized lineages were identified. An alarming genetic similarity has been shown between seven MRSAs isolated in dental clinic and the EMRSA-15 clone [102]. In addition, *S. aureus*, MSSA, and EMRSA-15 harbored differently on dentures of in- and outpatients [119].

### **5.2** *Enterococcus faecalis*

It is well known that antibiotic administration causes intestinal overgrowth of *Enterococci* and their translocation across a histologically normal intestinal epithelium; then, they can reach and avidly bind other soft tissues and endocardial tissue matrix components, causing infections, abscess, and endocarditis. There are some

**43**

offices.

**to reality**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

reasons to consider *Enterococci* important for our topic. *E. faecalis* occurs in transient opportunistic infections involving the oral cavity and has been found in common dental diseases (i.e. caries, endodontic infections, periodontitis) and peri-implant infective disease, and its strains are peculiar in comparison to food ones [120]. Recently, public health officials reported an incidence rate of enterococcal endocarditis among the total patient population at the oral surgery practice, more than 200

In addition, *E. faecalis* is so invasive that it is used to test dental materials (composite fillings, endodontic sealers, etc.) and the connection between DI and the abutment [121]. Since it is highly adhesive, has many virulence factors (resistance to extreme conditions (oxygen tension, pH, salts), collagen-binding proteins, gelatinase E, surface proteins), and the ability to form biofilm, *E. faecalis* can reside widely in and around tooth root canals, in the surrounding bone trabeculae, and in heavily infected subgingival sites [122, 123]. It is known that *E. faecalis* resistance to antibiotics has been increasing over time. Then, the oral cavity can constitute a reservoir for virulent E. faecalis strains possessing antibiotic resistance traits, able to transfer vanA resistance genes to MRSA [102] and with biofilm formation capabilities. The latter facilitates the exchange of genetic material (via horizontal gene transfer) important for resistance acquisition [120]. Tetracycline, erythromycin, clindamycin, and metronidazole revealed poor levels of *in vitro* activity against

Nowadays, Enterobacteriaceae and some resistant strains are present in oral cavity of dental patients, and recently, the transmission in dental practice has been proven [11, 120–124]. For dentistry of the future, whole-genome sequencing seems promising to study *Enterobacteriaceae* antimicrobial resistance based on genotype

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

times the expected rate among general population [11].

human subgingival *E. faecalis* clinical isolates [122].

alone [125] and the role in dental implant-associated infections.

**6. Surgical infection prevention in dentistry: from gold standard** 

It is well known that the best choices for dental and implant surgery are a specialized and well-trained dental staff (surgeon, clean nurse, second nurse, anesthetist, etc.) and a specific designed surgical room with proper isolation, clean air system ventilation, instruments for automatic surface decontamination and ISO standards (UNI EN ISO 14644-ISO 5) that allow a very low environmental contamination, and proper antiseptic procedures (including hand washing, wearing, safe instruments passages). Unfortunately, this setting up is used in the case of maxillofacial surgery, and it is commonly present and economically sustainable in hospital surgical dental department. In ambulatory dental offices, there is no isolation and a full separation of the environments used for general dentistry and those used for implant surgery or dental extractions. Only rarely is present a clean air ventilation system according to ISO standards. This difference is very important since in general dental practices the cross-infection is widespread, and the infection prevention is more difficult or less controllable (i.e. absence of the second nurse, environmental contamination) compared to hospital surgical rooms. There are few controls legislated over the operating environment in ambulatory and private dental

Bearing in mind the higher risk of contamination of ambulatory surgical areas, above all during long surgeries (sinus lift, several implant placing, guided bone regeneration (GBR)) and in medically compromised patients, we cannot exclude that a part of implant failures is the result of a chain of personnel latent errors, including some improper antiseptic measures (not surgical hand hygiene, unsterile *Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

reasons to consider *Enterococci* important for our topic. *E. faecalis* occurs in transient opportunistic infections involving the oral cavity and has been found in common dental diseases (i.e. caries, endodontic infections, periodontitis) and peri-implant infective disease, and its strains are peculiar in comparison to food ones [120]. Recently, public health officials reported an incidence rate of enterococcal endocarditis among the total patient population at the oral surgery practice, more than 200 times the expected rate among general population [11].

In addition, *E. faecalis* is so invasive that it is used to test dental materials (composite fillings, endodontic sealers, etc.) and the connection between DI and the abutment [121]. Since it is highly adhesive, has many virulence factors (resistance to extreme conditions (oxygen tension, pH, salts), collagen-binding proteins, gelatinase E, surface proteins), and the ability to form biofilm, *E. faecalis* can reside widely in and around tooth root canals, in the surrounding bone trabeculae, and in heavily infected subgingival sites [122, 123]. It is known that *E. faecalis* resistance to antibiotics has been increasing over time. Then, the oral cavity can constitute a reservoir for virulent E. faecalis strains possessing antibiotic resistance traits, able to transfer vanA resistance genes to MRSA [102] and with biofilm formation capabilities. The latter facilitates the exchange of genetic material (via horizontal gene transfer) important for resistance acquisition [120]. Tetracycline, erythromycin, clindamycin, and metronidazole revealed poor levels of *in vitro* activity against human subgingival *E. faecalis* clinical isolates [122].

Nowadays, Enterobacteriaceae and some resistant strains are present in oral cavity of dental patients, and recently, the transmission in dental practice has been proven [11, 120–124]. For dentistry of the future, whole-genome sequencing seems promising to study *Enterobacteriaceae* antimicrobial resistance based on genotype alone [125] and the role in dental implant-associated infections.

### **6. Surgical infection prevention in dentistry: from gold standard to reality**

It is well known that the best choices for dental and implant surgery are a specialized and well-trained dental staff (surgeon, clean nurse, second nurse, anesthetist, etc.) and a specific designed surgical room with proper isolation, clean air system ventilation, instruments for automatic surface decontamination and ISO standards (UNI EN ISO 14644-ISO 5) that allow a very low environmental contamination, and proper antiseptic procedures (including hand washing, wearing, safe instruments passages). Unfortunately, this setting up is used in the case of maxillofacial surgery, and it is commonly present and economically sustainable in hospital surgical dental department. In ambulatory dental offices, there is no isolation and a full separation of the environments used for general dentistry and those used for implant surgery or dental extractions. Only rarely is present a clean air ventilation system according to ISO standards. This difference is very important since in general dental practices the cross-infection is widespread, and the infection prevention is more difficult or less controllable (i.e. absence of the second nurse, environmental contamination) compared to hospital surgical rooms. There are few controls legislated over the operating environment in ambulatory and private dental offices.

Bearing in mind the higher risk of contamination of ambulatory surgical areas, above all during long surgeries (sinus lift, several implant placing, guided bone regeneration (GBR)) and in medically compromised patients, we cannot exclude that a part of implant failures is the result of a chain of personnel latent errors, including some improper antiseptic measures (not surgical hand hygiene, unsterile

*Surgical Infections - Some Facts*

different countries [116, 117].

**5.2** *Enterococcus faecalis*

differently on dentures of in- and outpatients [119].

while those encoding for putative macrolide-specific efflux system or proteins involved in acid stress and bacteriocins are less represented. High percentages of *Staphylococcus* species, MRSA, *P. aeruginosa*, and *C. albicans* were detected in the mouths of elderly patients [111, 112]. By PCR, a notable occurrence of MRSA, vancomycin-resistant *S. aureus* (VRSA), and VSSA have been observed in the oral cavity of patients with dental caries [113]. Chronic periodontitis showed extensive antibiotic-resistant subgingival periodontal pathogens in cultivable microbiota, associated with red and orange complex species, and also to Gram-negative enteric

Here, we report updated data on *S. aureus* and MRSA carriage rates among dental students, dental patients, HCWs, and dental healthcare personnel (DHCP) in **Table 1** [91–103]. Despite the many differences between studies, nowadays there is a probable occupational exposure, from carriage rates, among DHCP and HCWs. This is higher in dental students (**Table 1**), but would seem evident in the last years [14, 91–95]. Nasal MRSA colonization, confirmed by the presence of the *mecA* gene that encodes a low-affinity penicillin-binding protein, occurs in dental students (3.1%), especially those who have clinical experience [94]. MRSA hand and nasal carriage rates in patients, nurses, and dentist are significant in dental settings (**Table 1**) [102]. The majority of MRSA isolates were multidrug resistant, and full resistance was generally higher for personnel than for the environmental isolates.

rods/Pseudomonads, *E. faecalis*, and *S. aureus* [21, 23, 24, 114].

*5.1.1 Community- and hospital-acquired MRSA infections and dentistry*

Taking into account MRSA carriage in dental patients and DHCP, the effectiveness of MRSA decolonization, and the violation of IC precautions (see below and in Part 2), MRSA in the oral cavity could potentially be disseminated by carriers (patient and DHCP) to the environment [115]. It is well known that communityacquired MRSA (CA-MRSA) infections often occur in young and healthy

individuals, whereas HA-MRSA infections occur predominantly in elder or immunocompromised patients in healthcare settings and vary considerably between

HA-MRSA and CA-MRSA have opposite features concerning competitive fitness, virulence, and antimicrobial resistance [118]. Only rarely HA-MRSAs cause infections in healthy subjects, but at least two CA-MRSAs (USA300 and ST30) cause HA infections. It is not known if these strains acquire multiple resistant genes from HA-MRSA or if they increase bacterial fitness and survival despite the antibiotic resistance. Taking into account that their extracellular proteome seems to be differently involved, we think that this epidemiological change is not soothing for future dental epidemiology. In fact, from a 10-year retrospective analysis of laboratory data, obtained from oral and perioral clinical specimens, most of the MRSA isolates were epidemic MRSA-15 (EMRSA-15) or EMRSA-16 lineage, known to cause both very dangerous HA-MRSA infections [97]. No MRSA isolates belonging to community-acquired recognized lineages were identified. An alarming genetic similarity has been shown between seven MRSAs isolated in dental clinic and the EMRSA-15 clone [102]. In addition, *S. aureus*, MSSA, and EMRSA-15 harbored

It is well known that antibiotic administration causes intestinal overgrowth of *Enterococci* and their translocation across a histologically normal intestinal epithelium; then, they can reach and avidly bind other soft tissues and endocardial tissue matrix components, causing infections, abscess, and endocarditis. There are some

**42**

gloves, improper use of mask, contamination of operating surface or room air, unsterile barrier covering, lack of surgical guide disinfection and mouth rinses, suture contamination by perioral skin bacteria, among others), as far as untrained professional practice [17, 41, 42, 44, 126].

Maintaining sterile conditions during the surgical procedure is of utmost importance. Saliva, perioral skin, unsterile instruments, contaminated gloves, operating room air, or air expired by the patient, all interfere in the surgical procedure leading to contamination of the implant site [43, 45–47]. It has been reported that the prevalence rate of MRSA was the highest in samples from dental surgery compared to other dental environments [102]. MRSA's involvement in surgical infections is in line with the estimated infective dose, which is very low (4 CFU), and surface contamination (<10 CFU/cm2 ) [127, 128]. In ambulatory surgical centers, the main infection control lapses identified were hand hygiene and use of PPE, injection safety and medication handling, equipment reprocessing, and environmental cleaning [41, 42, 129].

The majority of DIs are predominantly placed in general dental practice under local anesthesia. Concerning local anesthesia, hand contact is the main source of the wide contamination reported on anesthetic syringes and anesthetic tubes used in dentistry [130]. Then, DHCP has to follow scrupulously key recommendations for safe injection reported in CDC guidelines [6]. Taking into account the recent outbreaks, the violations seem very hazardous in dentistry [8, 11]. In addition, it is absolutely forbidden and highly risky in the reuse of whatsoever single use sterile medical devices (i.e. irrigation sets) and the use of the water from DUWLs during implant and piezoelectric surgery, etc. [6]. The use of sterile devices and instruments is a need during surgical cares, but even after reconditioning, the contamination of surgical dental instruments and drills is significant even in hospital settings [131–134]. Many other specific failures concerning dental instrument reconditioning will be discussed in Part 2. The importance of hand hygiene, sterile gloves, mask, and eye protection during surgery is well known. Violations are frequent and often surgical videos in dentistry show the surgical mask *under the nose,* that is risky taking into account MRSA nose colonization in dentists and dental nurses. We underline that it is a hazard to touch the barrier membranes during GBR with gloved hands: this is a frequent slip observed in untrained surgeons.

### **6.1 Infections associated to craniofacial skeleton**

The most relevant infections are lateral and apical periodontitis, osteomyelitis, peri-implantitis, and their complications, such as facial cellulitis and other infections involving deep spaces of face and neck [135]. Microbiota associated with infections of the craniofacial skeleton, particularly maxilla and mandible, are polymicrobial in nature and a mix of aerobic-anaerobic genera. In head and neck space odontogenic infections, the most common bacteria isolated were Gram-positive cocci (*Viridans streptococci, Prevotella, Staphylococci, and Peptostreptococcus*), and discordant data have been reported on antibiotic resistance of *Viridans streptococci,* while very few isolates of *Staphylococcus* are now susceptible to penicillin [136, 137].

Taking into account the increasing life expectancy, it is important to underline that older patients, even without systemic diseases, are more prone to development of oral pathology infections because of often lower immunological response [138]. Concerning systemic and local odontogenic infection complications requiring hospital care, an analysis showed that medically compromised patients appear more susceptible to systemic rather than local infection complications with a need for significantly longer hospital stay and with an increased risk for fatal complications [139].

**45**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

The main causative agents of maxillofacial inflammatory diseases are *S. aureus*, *S. epidermidis*, *Streptococcus* spp., *Escherichia coli*, and *Proteus* spp. [85]. Concerning the risk of maxillofacial surgeries, 4% of their patients showed odontogenic infections, and about 2–20% required intensive medical therapy after surgery [140, 141]. These compliances are expected to worse taking into account the current oral carriage of *S. aureus* and MRSA (**Table 1**) and the presence of epidemic MRSA-15 (EMRSA-15) or

Results have been conflicting concerning the occurrence of bacteremia after dental procedures; antimicrobial prophylaxis before an invasive dental procedure does not prevent bacteremia, although it can decrease both its magnitude and its persistence [142]. Delayed-onset infections (DOI) after mandibular third molar extractions are rare complications and usually occur about 30 days after the extraction, but they may also develop much later on [143]. The bacteria identified in DOI are *Fusobacterium, Prevotella, Bacteroides,* and *Peptostreptococcus.* A recent review reported in detail several oral and maxillofacial fungal infections, including mucormycosis, candidiasis, aspergillosis, blastomycosis, histoplasmosis, cryptococcosis,

In general, dental implant procedures are considered clean-contaminated surgeries (graded as class II surgical procedures), since micro-organisms living in the oral mucosa and in saliva contaminate the surgical wound facilitating the infection, with local infection rates of 10–15% and an incidence of infection to 1% or less by the use of both prophylactic antibiotics and proper surgical technique [71]. Despite the statements reported between 1980 and 1990, even in the case of the use of prophylactic antibiotics, the reported prevalence of postoperative infection after implant installation ranges from 0 up to 11.5% and the prevalence of periimplantitis varied from 4.2 to 47% of all implants [21, 56, 69, 71, 84, 114, 145–149]. These data are higher than the annual infection rate for cardiovascular implants and orthopedic implants, that is, 7.4 and 4.3% respectively, in USA hospital settings. Unfortunately, data are not available on the concurrent nasal/throat colonization of

Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry have been recently published [150, 151]. However, despite careful planning, infection is one of the early and late implant complications and iatrogenic actions are regarded as accidents during surgical procedures, complications, or failures caused by a deficient praxis of the professional. Infection is the most common explanation for complications such as swelling, suppuration, fistulas,

Many papers have reported improvements (mainly on the topography and surface features; antimicrobial dental implant functionalization strategies) of DIs and surgery techniques to get better osteointegration and to reduce the infective complications and then to improve long-term success (longevity and function of

Peri-implantitis is a nonspecific, polymicrobial, and heterogeneous diseases of endogenous (caused by commensal oral strains) and iatrogenic nature, with an increased level of pathogenic bacteria from the orange and red complexes and towards a flora with a greater proportion of Gram-negative, motile, anaerobic bacteria [29, 152]. Compared to periodontal disease, the microbial biofilm harbored in peri-implant infective diseases is generally changeable and composed of opportunistic and Gram-negative species. Implant failure can occur at any time during the implant treatment by bacterial infection, but early healing period is quite important due to impaired wound healing.

MRSA as possible patient-implant related factors and DI failure.

and early/late mucosal dehiscence that may point to implant failure.

implants and uploaded prosthesis) [27–30, 32].

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

EMRSA-16 lineage in dental settings.

and coccidioidomycosis [144].

**6.2 Infective agents in dental implantology**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

The main causative agents of maxillofacial inflammatory diseases are *S. aureus*, *S. epidermidis*, *Streptococcus* spp., *Escherichia coli*, and *Proteus* spp. [85]. Concerning the risk of maxillofacial surgeries, 4% of their patients showed odontogenic infections, and about 2–20% required intensive medical therapy after surgery [140, 141]. These compliances are expected to worse taking into account the current oral carriage of *S. aureus* and MRSA (**Table 1**) and the presence of epidemic MRSA-15 (EMRSA-15) or EMRSA-16 lineage in dental settings.

Results have been conflicting concerning the occurrence of bacteremia after dental procedures; antimicrobial prophylaxis before an invasive dental procedure does not prevent bacteremia, although it can decrease both its magnitude and its persistence [142]. Delayed-onset infections (DOI) after mandibular third molar extractions are rare complications and usually occur about 30 days after the extraction, but they may also develop much later on [143]. The bacteria identified in DOI are *Fusobacterium, Prevotella, Bacteroides,* and *Peptostreptococcus.* A recent review reported in detail several oral and maxillofacial fungal infections, including mucormycosis, candidiasis, aspergillosis, blastomycosis, histoplasmosis, cryptococcosis, and coccidioidomycosis [144].

### **6.2 Infective agents in dental implantology**

In general, dental implant procedures are considered clean-contaminated surgeries (graded as class II surgical procedures), since micro-organisms living in the oral mucosa and in saliva contaminate the surgical wound facilitating the infection, with local infection rates of 10–15% and an incidence of infection to 1% or less by the use of both prophylactic antibiotics and proper surgical technique [71]. Despite the statements reported between 1980 and 1990, even in the case of the use of prophylactic antibiotics, the reported prevalence of postoperative infection after implant installation ranges from 0 up to 11.5% and the prevalence of periimplantitis varied from 4.2 to 47% of all implants [21, 56, 69, 71, 84, 114, 145–149]. These data are higher than the annual infection rate for cardiovascular implants and orthopedic implants, that is, 7.4 and 4.3% respectively, in USA hospital settings. Unfortunately, data are not available on the concurrent nasal/throat colonization of MRSA as possible patient-implant related factors and DI failure.

Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry have been recently published [150, 151]. However, despite careful planning, infection is one of the early and late implant complications and iatrogenic actions are regarded as accidents during surgical procedures, complications, or failures caused by a deficient praxis of the professional. Infection is the most common explanation for complications such as swelling, suppuration, fistulas, and early/late mucosal dehiscence that may point to implant failure.

Many papers have reported improvements (mainly on the topography and surface features; antimicrobial dental implant functionalization strategies) of DIs and surgery techniques to get better osteointegration and to reduce the infective complications and then to improve long-term success (longevity and function of implants and uploaded prosthesis) [27–30, 32].

Peri-implantitis is a nonspecific, polymicrobial, and heterogeneous diseases of endogenous (caused by commensal oral strains) and iatrogenic nature, with an increased level of pathogenic bacteria from the orange and red complexes and towards a flora with a greater proportion of Gram-negative, motile, anaerobic bacteria [29, 152]. Compared to periodontal disease, the microbial biofilm harbored in peri-implant infective diseases is generally changeable and composed of opportunistic and Gram-negative species. Implant failure can occur at any time during the implant treatment by bacterial infection, but early healing period is quite important due to impaired wound healing.

*Surgical Infections - Some Facts*

contamination (<10 CFU/cm2

ing [41, 42, 129].

professional practice [17, 41, 42, 44, 126].

gloves, improper use of mask, contamination of operating surface or room air, unsterile barrier covering, lack of surgical guide disinfection and mouth rinses, suture contamination by perioral skin bacteria, among others), as far as untrained

infection control lapses identified were hand hygiene and use of PPE, injection safety and medication handling, equipment reprocessing, and environmental clean-

gloved hands: this is a frequent slip observed in untrained surgeons.

The most relevant infections are lateral and apical periodontitis, osteomyelitis, peri-implantitis, and their complications, such as facial cellulitis and other infections involving deep spaces of face and neck [135]. Microbiota associated with infections of the craniofacial skeleton, particularly maxilla and mandible, are polymicrobial in nature and a mix of aerobic-anaerobic genera. In head and neck space odontogenic infections, the most common bacteria isolated were Gram-positive cocci (*Viridans streptococci, Prevotella, Staphylococci, and Peptostreptococcus*), and discordant data have been reported on antibiotic resistance of *Viridans streptococci,* while very few isolates of *Staphylococcus* are now

Taking into account the increasing life expectancy, it is important to underline that older patients, even without systemic diseases, are more prone to development of oral pathology infections because of often lower immunological response [138]. Concerning systemic and local odontogenic infection complications requiring hospital care, an analysis showed that medically compromised patients appear more susceptible to systemic rather than local infection complications with a need for significantly longer hospital stay and with an increased risk for fatal complications [139].

**6.1 Infections associated to craniofacial skeleton**

susceptible to penicillin [136, 137].

The majority of DIs are predominantly placed in general dental practice under local anesthesia. Concerning local anesthesia, hand contact is the main source of the wide contamination reported on anesthetic syringes and anesthetic tubes used in dentistry [130]. Then, DHCP has to follow scrupulously key recommendations for safe injection reported in CDC guidelines [6]. Taking into account the recent outbreaks, the violations seem very hazardous in dentistry [8, 11]. In addition, it is absolutely forbidden and highly risky in the reuse of whatsoever single use sterile medical devices (i.e. irrigation sets) and the use of the water from DUWLs during implant and piezoelectric surgery, etc. [6]. The use of sterile devices and instruments is a need during surgical cares, but even after reconditioning, the contamination of surgical dental instruments and drills is significant even in hospital settings [131–134]. Many other specific failures concerning dental instrument reconditioning will be discussed in Part 2. The importance of hand hygiene, sterile gloves, mask, and eye protection during surgery is well known. Violations are frequent and often surgical videos in dentistry show the surgical mask *under the nose,* that is risky taking into account MRSA nose colonization in dentists and dental nurses. We underline that it is a hazard to touch the barrier membranes during GBR with

Maintaining sterile conditions during the surgical procedure is of utmost importance. Saliva, perioral skin, unsterile instruments, contaminated gloves, operating room air, or air expired by the patient, all interfere in the surgical procedure leading to contamination of the implant site [43, 45–47]. It has been reported that the prevalence rate of MRSA was the highest in samples from dental surgery compared to other dental environments [102]. MRSA's involvement in surgical infections is in line with the estimated infective dose, which is very low (4 CFU), and surface

) [127, 128]. In ambulatory surgical centers, the main

**44**

These microorganisms have been found differently associated to implant infections: *Porphyromonas gingivalis; endodontalis* and spp.*; Tannerella forsythia and socransky; Prevotella nigrescens, oris,* and *intermedia; Fusobacterium* spp. *and nucleatum; Synergistetes* spp. *HO T*—*360; Pseudoramibacter alactolyticus; Eubacterium* spp.; *Veillonella* spp.*; Enterobacteriaceae; Candida* spp.*; Filifactor alocis; Dialister invisus; Mitsuokella* spp. *HOT 131; Peptococcus* spp. *HO T-168; Clostridiales [F-1] [G-1]* spp. *HO T-093; Catonella morbid; Chloroflexi* spp.*; Tenericutes* spp.*; Aggregatibacter actinomycetemcomitans; Staphylococcus aureus, anaerobius,* and *intermedius; Streptococcus mitis; spirochete including Treponema denticola,* with some differences associated to the type of DI and bacterial infiltration in the internal screw threads of implants [29, 153–155]. Moreover, implants with a peri-implant lesion had a higher frequency of superinfecting bacteria, mainly *Klebsiella pneumoniae* and *Burkholderia cepacia*, which are considered environmental and multidrug-resistant bacteria. Significantly higher bacterial counts (*Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Prevotella intermedia, and Fusobacterium nucleatum*) were found for periodontal pathogenic bacteria within the implant-abutment interface of implants in patients with peri-implantitis compared to those implants surrounded by healthy peri-implant tissues [156]. Using next-generation sequencing methods, recent results indicate that peri-implantitis and periodontitis are both polymicrobial infections with different causative pathogens, and the severity of the peri-implantitis was species-associated, including with *Eubacterium minutum* and an uncultured *Treponema* sp. [157, 158]. Opportunistic microorganisms (enteric rods and *S. aureus*) were found differently in peri-implantitis sites [21, 145].

We underline that some of them (*Enterobacteriaceae, Candida, Staphylococcus, and Streptococcus*) have been indicated as prioritized bacteria in CDC recommendation [18]. Some authors reported that antibiotics do not seem to reduce the incidence of postoperative infections and 2/3 of the infected implants failed before prosthetic loading [21, 146–149]. The majority of bacterial pathogens isolated from peri-implantitis were resistant in vitro to one or more of the tested antibiotics (clindamycin, amoxicillin, doxycycline, or metronidazol) [21].

Nevertheless, microbial investigations seem not contributory to clinician decisions or to be easily applicable nowadays in private practice; the standard procedures (probing, bleeding on probing, probing depth, radiographic assessment, implant mobility) and the visual evaluation of the hyperplastic soft tissues, color changes of the marginal peri-implant tissues, and suppuration are widely used to evaluate the consequences of implant-associated complications [158].

### *6.2.1 Why does the debridement in dentistry?*

Here, we think important to underline some cellular events in relation to implant failures and surgical infections in dentistry. Osseointegration is completed within 3–6 months after implant placement into the dental alveolus, and infection may develop in the early operative period (early infection) or after the process of implant integration (late infection).

At the cellular level, implant-associated infections are the result of two critical phases in the first 6 h post implantation; firstly, the bacterial adhesion to a biomaterial surface by weak and unspecific forces within 1–2 h after implantation, and approximately 2–3 h later, a stronger adhesion with the formation of microcolonies and biofilm, which precedes clinical infection [63]. It is important that *Staphylococcus* species, isolated in dental settings, show high affinity to titanium and good biofilm production [102, 159], which are concurrent detrimental factors for osteogenesis [160, 161]. In addition, during the stationary phase, at least 1% of bacterial cells in biofilms become tolerant to antibiotics [162]. Moreover, the extracellular matrix should provide a

**47**

**7. Conclusion**

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

antibiotic resistance by horizontal gene transfer among *S. aureus* [163].

stable physical environment for cell to-cell contact, which allows the dissemination of

In is well known that smoking is associated with DI failures [159] and that some infective agents (i.e. *Porphyromonas gingivalis*, SA, etc.) showed increased colonization in smokers. Cigarette smoking induces Staphylococcal biofilm formation in an oxidant-dependent manner and enhancement of fibronectin, an important extracellular matrix protein, binding in *S. aureus* [164]. This is relevant for adherence, invasion, and colonization since Staphylococci, in particular *S. aureus*, are the main causes of bone infections [165]. In addition, by molecular mechanisms, *Staphylococci* are able to invade *in vivo* host bone cells (osteoblasts and osteocytes), endothelial cells, and the canaliculi of live cortical bone leading to biofilm formation in osteocyte lacunae [166]. *Staphylococci,* as facultative intracellular pathogens, are shielded from immune response and antibiotics and are expected to induce a highly programmed and regulated cell death of osteogenic cells and then to impair bone formation. *E. faecalis* too is capable of surviving in a vegetative state in healed

Then, it is not surprising that a nightmare and a difficult problem are to eradicate implant infections in present dental practice [149]. For the success of the DI surgery, it seems important a careful debridement of the alveolus from infective agents, frequently drug resistants, above all in the case of immediate DI loading after dental extraction and to defer DI placement after a dental extraction [27, 167].

Infections complications in orthognathic surgery are lower only to those caused by nerve injury [168]. The incidence of surgical site infections was limited to 1% of patients after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery and under antibiotic treatment [162]. No attention is given to ARIAs in orthodontia and orthognathic surgery. To date, there is no gold standard for the treatment of postoperative infections in orthodontic surgery and the use of prophylactic antibiotics before some orthodontic procedures (orthodontic band placement, separator placement, or screw insertion) in patients with a medical history that reveals the presence of diseases affecting the host defense system (aging, patient on corticosteroids or bisphosphonates or anticoagulants, diabetes mellitus, HIV/AIDS) since they are at high risk of developing oral infection [37, 169]. Endocarditic prophylaxis is indicated only during the initial placement of orthodontic bands (not brackets). We previously reviewed the problems related to task-specific evidence-based guidelines for cross-infection control when placing different temporary orthodontic anchorage devices [37]. Infection occurred in 17.3% of the installed miniplates and was caused by predominantly anaerobic, mainly Gram-negative bacteria and associated to immune aging [37, 170, 171]. The failure rate of mini-implants is about threefold to fivefold higher than that of dental implants and mini-plates; nevertheless, the mechanism that leads to mobility and then to their clinical failure is still unknown and more tricky to understand [172]. Recently, interest is arising on the use of antibiotics/antiseptics for some potential beneficial effects on tooth stability after orthodontic treatment, but the advantages should be very carefully balanced

Human infectious diseases will be never-ending [174]. After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections,

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

bone and of reactivation upon DI placement [22].

**6.3 Focus on orthodontia-associated surgery**

in accordance with the risk of antibiotic resistance [173].

### *Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

stable physical environment for cell to-cell contact, which allows the dissemination of antibiotic resistance by horizontal gene transfer among *S. aureus* [163].

In is well known that smoking is associated with DI failures [159] and that some infective agents (i.e. *Porphyromonas gingivalis*, SA, etc.) showed increased colonization in smokers. Cigarette smoking induces Staphylococcal biofilm formation in an oxidant-dependent manner and enhancement of fibronectin, an important extracellular matrix protein, binding in *S. aureus* [164]. This is relevant for adherence, invasion, and colonization since Staphylococci, in particular *S. aureus*, are the main causes of bone infections [165]. In addition, by molecular mechanisms, *Staphylococci* are able to invade *in vivo* host bone cells (osteoblasts and osteocytes), endothelial cells, and the canaliculi of live cortical bone leading to biofilm formation in osteocyte lacunae [166]. *Staphylococci,* as facultative intracellular pathogens, are shielded from immune response and antibiotics and are expected to induce a highly programmed and regulated cell death of osteogenic cells and then to impair bone formation. *E. faecalis* too is capable of surviving in a vegetative state in healed bone and of reactivation upon DI placement [22].

Then, it is not surprising that a nightmare and a difficult problem are to eradicate implant infections in present dental practice [149]. For the success of the DI surgery, it seems important a careful debridement of the alveolus from infective agents, frequently drug resistants, above all in the case of immediate DI loading after dental extraction and to defer DI placement after a dental extraction [27, 167].

### **6.3 Focus on orthodontia-associated surgery**

Infections complications in orthognathic surgery are lower only to those caused by nerve injury [168]. The incidence of surgical site infections was limited to 1% of patients after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery and under antibiotic treatment [162]. No attention is given to ARIAs in orthodontia and orthognathic surgery. To date, there is no gold standard for the treatment of postoperative infections in orthodontic surgery and the use of prophylactic antibiotics before some orthodontic procedures (orthodontic band placement, separator placement, or screw insertion) in patients with a medical history that reveals the presence of diseases affecting the host defense system (aging, patient on corticosteroids or bisphosphonates or anticoagulants, diabetes mellitus, HIV/AIDS) since they are at high risk of developing oral infection [37, 169]. Endocarditic prophylaxis is indicated only during the initial placement of orthodontic bands (not brackets).

We previously reviewed the problems related to task-specific evidence-based guidelines for cross-infection control when placing different temporary orthodontic anchorage devices [37]. Infection occurred in 17.3% of the installed miniplates and was caused by predominantly anaerobic, mainly Gram-negative bacteria and associated to immune aging [37, 170, 171]. The failure rate of mini-implants is about threefold to fivefold higher than that of dental implants and mini-plates; nevertheless, the mechanism that leads to mobility and then to their clinical failure is still unknown and more tricky to understand [172]. Recently, interest is arising on the use of antibiotics/antiseptics for some potential beneficial effects on tooth stability after orthodontic treatment, but the advantages should be very carefully balanced in accordance with the risk of antibiotic resistance [173].

### **7. Conclusion**

Human infectious diseases will be never-ending [174]. After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections,

*Surgical Infections - Some Facts*

These microorganisms have been found differently associated to implant infec-

We underline that some of them (*Enterobacteriaceae, Candida, Staphylococcus,* 

Nevertheless, microbial investigations seem not contributory to clinician decisions or to be easily applicable nowadays in private practice; the standard procedures (probing, bleeding on probing, probing depth, radiographic assessment, implant mobility) and the visual evaluation of the hyperplastic soft tissues, color changes of the marginal peri-implant tissues, and suppuration are widely used to

*and Streptococcus*) have been indicated as prioritized bacteria in CDC recommendation [18]. Some authors reported that antibiotics do not seem to reduce the incidence of postoperative infections and 2/3 of the infected implants failed before prosthetic loading [21, 146–149]. The majority of bacterial pathogens isolated from peri-implantitis were resistant in vitro to one or more of the tested antibiotics

tions: *Porphyromonas gingivalis; endodontalis* and spp.*; Tannerella forsythia and socransky; Prevotella nigrescens, oris,* and *intermedia; Fusobacterium* spp. *and nucleatum; Synergistetes* spp. *HO T*—*360; Pseudoramibacter alactolyticus; Eubacterium* spp.; *Veillonella* spp.*; Enterobacteriaceae; Candida* spp.*; Filifactor alocis; Dialister invisus; Mitsuokella* spp. *HOT 131; Peptococcus* spp. *HO T-168; Clostridiales [F-1] [G-1]* spp. *HO T-093; Catonella morbid; Chloroflexi* spp.*; Tenericutes* spp.*; Aggregatibacter actinomycetemcomitans; Staphylococcus aureus, anaerobius,* and *intermedius; Streptococcus mitis; spirochete including Treponema denticola,* with some differences associated to the type of DI and bacterial infiltration in the internal screw threads of implants [29, 153–155]. Moreover, implants with a peri-implant lesion had a higher frequency of superinfecting bacteria, mainly *Klebsiella pneumoniae* and *Burkholderia cepacia*, which are considered environmental and multidrug-resistant bacteria. Significantly higher bacterial counts (*Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Prevotella intermedia, and Fusobacterium nucleatum*) were found for periodontal pathogenic bacteria within the implant-abutment interface of implants in patients with peri-implantitis compared to those implants surrounded by healthy peri-implant tissues [156]. Using next-generation sequencing methods, recent results indicate that peri-implantitis and periodontitis are both polymicrobial infections with different causative pathogens, and the severity of the peri-implantitis was species-associated, including with *Eubacterium minutum* and an uncultured *Treponema* sp. [157, 158]. Opportunistic microorganisms (enteric rods and *S. aureus*)

were found differently in peri-implantitis sites [21, 145].

(clindamycin, amoxicillin, doxycycline, or metronidazol) [21].

evaluate the consequences of implant-associated complications [158].

Here, we think important to underline some cellular events in relation to implant failures and surgical infections in dentistry. Osseointegration is completed within 3–6 months after implant placement into the dental alveolus, and infection may develop in the early operative period (early infection) or after the process of

At the cellular level, implant-associated infections are the result of two critical phases in the first 6 h post implantation; firstly, the bacterial adhesion to a biomaterial surface by weak and unspecific forces within 1–2 h after implantation, and approximately 2–3 h later, a stronger adhesion with the formation of microcolonies and biofilm, which precedes clinical infection [63]. It is important that *Staphylococcus* species, isolated in dental settings, show high affinity to titanium and good biofilm production [102, 159], which are concurrent detrimental factors for osteogenesis [160, 161]. In addition, during the stationary phase, at least 1% of bacterial cells in biofilms become tolerant to antibiotics [162]. Moreover, the extracellular matrix should provide a

*6.2.1 Why does the debridement in dentistry?*

implant integration (late infection).

**46**

surgical cares increased 100%, and the related healthcare cost skyrockets [175]. The reported data show that opportunistic species and/or ARIA infections are nearby and expected to increase in dental setting [21–26, 29, 81, 82, 85, 91–99, 101–105, 109–114, 120–124, 136–141, 145–149, 153–155, 159, 160, 165] due to the overuse of antibiotics in dentistry and the limited awareness on infection prevention guidelines and the lapses and errors during infection prevention [176]. Moreover, it is considered alarming the genetic connection or similarity between MRSAs isolated in dental clinics and on dentures and the EMRSA-15 or EMRSA-16 clone [97, 102, 119]. In addition, Enterobacteriaceae and some resistant strains are present in oral cavity of dental patients, and recently, the transmission in dental practice has been proven [11, 120–124]. The incidence rate of enterococcal endocarditis among the total patient population at the oral surgery practice has been reported to be more than 200 times the expected rate among general population [11].

Then, dental teams have to face occupational and clinical hazards due to ARIA infections in dental facilities. In the absence of or limited new effective antibiotic discovery, the sustainable use of antibiotics is essential but have delayed significant effects [177] based on many collective actions (people information, professional dental-care providers, policy-maker and regulators, industry stakeholders). On the contrary, the prevention of cross infection by adopting guidelines is easily applicable and has had early significant effects on infection prevention and cost-saving [178, 179]. Moreover, it is basic to safeguard dental team reputation, insurance coverings, and reimbursements [8–11, 33–42, 176] and to limit the nightmares to get rid of current dental implant infections [149].

### **Conflict of interest**

L.B. had a service agreement with KerrHawe and is a consultant for Dental Trey Il Blog (http://blog.dentaltrey.it/), neither of which gave any input or financial support to the writing of this article. There are no other conflicts of interest to report.

**49**

**Author details**

Livia Barenghi1

Parma, Italy

provided the original work is properly cited.

\*, Alberto Barenghi1

1 Integrated Orthodontic Services S.r.l., Lecco, Italy

\*Address all correspondence to: livia.barenghi@libero.it

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Department of Medicine and Surgery, Centro di Odontoiatria, Parma University,

and Alberto Di Blasio2

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1*

MAUDE manufacturer and user facility device experience database

MRSA methicillin-resistant *Staphylococcus aureus*

*DOI: http://dx.doi.org/10.5772/intechopen.80961*

HA-MRSA hospital-acquired MRSA HCW healthcare workers HPC heterotrophic plate count ica *i*nter*c*ellular *a*dhesion HSV herpes simplex virus IFU instruction for use

PCR polymerase chain reaction

VRE vancomycin-resistant *Enterococcus*

### **Abbreviations**


*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*


### **Author details**

*Surgical Infections - Some Facts*

surgical cares increased 100%, and the related healthcare cost skyrockets [175]. The reported data show that opportunistic species and/or ARIA infections are nearby and expected to increase in dental setting [21–26, 29, 81, 82, 85, 91–99, 101–105, 109–114, 120–124, 136–141, 145–149, 153–155, 159, 160, 165] due to the overuse of antibiotics in dentistry and the limited awareness on infection prevention guidelines and the lapses and errors during infection prevention [176]. Moreover, it is considered alarming the genetic connection or similarity between MRSAs isolated in dental clinics and on dentures and the EMRSA-15 or EMRSA-16 clone [97, 102, 119]. In addition, Enterobacteriaceae and some resistant strains are present in oral cavity of dental patients, and recently, the transmission in dental practice has been proven [11, 120–124]. The incidence rate of enterococcal endocarditis among the total patient population at the oral surgery practice has been reported to be more than 200

Then, dental teams have to face occupational and clinical hazards due to ARIA infections in dental facilities. In the absence of or limited new effective antibiotic discovery, the sustainable use of antibiotics is essential but have delayed significant effects [177] based on many collective actions (people information, professional dental-care providers, policy-maker and regulators, industry stakeholders). On the contrary, the prevention of cross infection by adopting guidelines is easily applicable and has had early significant effects on infection prevention and cost-saving [178, 179]. Moreover, it is basic to safeguard dental team reputation, insurance coverings, and reimbursements [8–11, 33–42, 176] and to limit the nightmares to get

L.B. had a service agreement with KerrHawe and is a consultant for Dental Trey Il Blog (http://blog.dentaltrey.it/), neither of which gave any input or financial support to the writing of this article. There are no other conflicts of interest to report.

times the expected rate among general population [11].

rid of current dental implant infections [149].

ARIA antibiotic-resistant infectious agents CAGR compound annual growth rate CA-MRSA community-acquired MRSA

CDC Centers for Disease Control and Prevention

eHOMD expanded human oral microbiome database

**Conflict of interest**

**Abbreviations**

AE adverse event

cna collagen DD dental device

DI dental implant

EMRSA epidemic MRSA

FAE fatal adverse event fnb fibronectin

HA hospital-acquired

CCSs clinical contact surfaces

DHCP dental healthcare personnel

EPS extracellular polysaccharides

GBR guided bone regeneration

DOI delayed-onset infections DUWL dental unit water line

**48**

Livia Barenghi1 \*, Alberto Barenghi1 and Alberto Di Blasio2

1 Integrated Orthodontic Services S.r.l., Lecco, Italy

2 Department of Medicine and Surgery, Centro di Odontoiatria, Parma University, Parma, Italy

\*Address all correspondence to: livia.barenghi@libero.it

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[178] Rennert-May E, Conly J, Lea J, Smith S, Manns B. Economic

evaluations and their use in infection prevention and control: A narrative review. Antimicrobial Resistance and Infection Control. 2018;**7**(31):1-6. DOI:

[179] Gao Q, Sui W. The function of nursing management for stomatology clinic infection. Journal of Nursing and Health Studies. 2017;**2**(1):1-4. DOI:

10.1186/s13756-018-0327-z

10.21767/2574-2825.100008

*Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 1 DOI: http://dx.doi.org/10.5772/intechopen.80961*

[178] Rennert-May E, Conly J, Lea J, Smith S, Manns B. Economic evaluations and their use in infection prevention and control: A narrative review. Antimicrobial Resistance and Infection Control. 2018;**7**(31):1-6. DOI: 10.1186/s13756-018-0327-z

*Surgical Infections - Some Facts*

10.1128/IAI.00689-12

ijmm.2009.10.003

*Staphylococcus aureus* biofilm formation via oxidative stress. Infection and Immunity. 2012;**80**:3804-3811. DOI:

[171] Aly SA, Alyan D, Fayed MS, Alhammadi MS, Mostafa YA. Success rates and factors associated with failure of temporary anchorage devices: A prospective clinical trial. Journal of Investigative and Clinical Dentistry. 2018;**00**:00-00. DOI: 10.1111/

[172] Tortamano A, Dominguez GC, Haddad ACSS, Nunesd FD, Nacaoe M, Morea C. Periodontopathogens around the surface of mini-implants removed from orthodontic patients. Angle Orthodontist. 2012;**82**:591-595. DOI:

[173] Kouskoura T, Katsaros C, von Gunten S. The potential use of pharmacological agents to modulate orthodontic tooth movement (OTM).

[174] Smith KF, Goldberg M, Rosenthal S, Carlson L, Chen J, Chen C, et al. Global rise in human infectious disease outbreaks. Journal of the Royal Society Interface. 2014;**11**:20140950. DOI:

[175] Salomon D, Heidel RE, Kolokythas

restriction of public health care dental benefits affect the volume, severity, or cost of dental-related hospital visits? Journal of Oral Maxillofacial Surgery. 2017;**75**:467-474. DOI: 10.1016/j.

[176] Barenghi L, Barenghi A, Di Blasio A. Infection Control in Dentistry and Drug Resistant Infectious Agents: A Burning Issue. Part 2. UK: InTech; 2018

[177] Degeling C, Johnson J, Iredell J, et al. Assessing the public acceptability of proposed policy interventions to reduce the misuse of antibiotics in Australia: A report on two community juries. Health Expectations. 2018;**21**: 90-99. DOI: 10.1111/hex.12589

Frontiers in Physiology 2017;**8** (Article 67): 1-9. DOI: 10.3389/

jicd.12331

10.2319/081011-506.1

fphys.2017.00067

10.1098/rsif.2014.0950

joms.2016.10.019

A, Miloro M, Schlieve T. Does

[165] Wright JA, Nair SP. Interaction of staphylococci with bone. International Journal of Medical Microbiology. 2010;**300**:193-204. DOI: 10.1016/j.

[166] de Mesy Bentley KL, Trombetta R,

canaliculi of live cortical bone in murine models of osteomyelitis. Journal of Bone and Mineral Research. 2017;**32**(5):985-

Nishitani K, Bello-Irizarry SN, Ninomiya M, Zhang L, et al. Evidence of Staphylococcus aureus deformation,

proliferation, and migration in

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prosdent.2016.09.007

s10006-017-0614-5

jocmr3285w

sodo.2018.01.004

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[170] Faber J, Morum T, Jamilian A, Eslami S, Leal S. Infection predictive factors with orthodontic anchorage miniplates. Seminars in Orthododontics.

2018;**00**:00-00. DOI: 10.1053/j.

[167] de Oliveira-Neto OB, Timbó Barbosa FT, de Sousa-Rodrigues CF, de Lima JC. Quality assessment of systematic reviews regarding immediate placement of dental implants into infected sites: An overview. The Journal of Prosthetic Dentistry. 2017;**117**:601-605. DOI: 10.1016/j.

[168] Friscia M, Sbordone C, Petrocelli M, Vaira LA, Attanasi F, Cassandro FM, et al. Complications after

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**62**

[179] Gao Q, Sui W. The function of nursing management for stomatology clinic infection. Journal of Nursing and Health Studies. 2017;**2**(1):1-4. DOI: 10.21767/2574-2825.100008

Chapter 5

Abstract

survey.

65

1. Introduction

Infection Control in Dentistry and

Drug-Resistant Infectious Agents:

We showed that antibiotic-resistant bacterial infections inside of dental settings are relevant. Here, we have focused on the limited awareness on infection prevention guidelines, and the lapses and errors during infection prevention, which sustain the evidence of possible reservoirs of antibiotic-resistant bacterial infections in humans (dental staff and patients) and on dental items or in the environment. We chose Staphylococci and Enterobacteriaceae as markers since they are considered as prioritized bacteria according to antibiotic resistance pressure, and the data are available on their virulence factors and for dental settings. For better dental patient and healthcare personnel safety, we need to improve knowledge on bioburden and biofouling, based also on molecular biological methods, and education and training initiatives to limit the hazards in surgical dental settings and to sustain accreditation

Livia Barenghi, Alberto Barenghi and Alberto Di Blasio

Keywords: dentistry, surgery, guidelines, infection control, MRSA, biofilm

Antibiotic-resistant bacterial infections inside of dental settings are relevant and

nearby [1] (Part 1). The limited awareness on infection prevention guidelines, lapses, and errors during infection prevention according to Centers for Disease Control and Prevention (CDC) dental guidelines sustains the evidence of possible reservoirs of antibiotic-resistant infectious agents (ARIAs) in humans (patients and dental staff) and in the environment (clinical contact surfaces (CCSs), dental instruments, and dental unit water lines (DUWLs)) and possible hazards mainly in surgical dental settings [2–26]. Here, we have focused mainly on hand hygiene, PPE use, environment decontamination, and instrument reconditioning [19, 20, 27–29]. We focus on Staphylococci and Enterobacteriaceae as markers since they are considered as prioritized bacteria according to antibiotic resistance pressure [30], and better knowledge is available on their virulence factors (adherence to abiotic surfaces, biofilm formation, ability to growth also in anaerobic conditions) and for dental settings (i.e., contamination of hands and environments, etc.). These features are important in the exploration of standard precaution failures since bacterial

adherence to inanimate objects (i.e., many objects in dental settings, dental

of surface components with nonpolar/hydrophobic vs. polar/hydrophilic

implants, collagen-based biomaterials, etc.) is known to be linked with the presence

A Burning Issue. Part 2

### Chapter 5

## Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

Livia Barenghi, Alberto Barenghi and Alberto Di Blasio

### Abstract

We showed that antibiotic-resistant bacterial infections inside of dental settings are relevant. Here, we have focused on the limited awareness on infection prevention guidelines, and the lapses and errors during infection prevention, which sustain the evidence of possible reservoirs of antibiotic-resistant bacterial infections in humans (dental staff and patients) and on dental items or in the environment. We chose Staphylococci and Enterobacteriaceae as markers since they are considered as prioritized bacteria according to antibiotic resistance pressure, and the data are available on their virulence factors and for dental settings. For better dental patient and healthcare personnel safety, we need to improve knowledge on bioburden and biofouling, based also on molecular biological methods, and education and training initiatives to limit the hazards in surgical dental settings and to sustain accreditation survey.

Keywords: dentistry, surgery, guidelines, infection control, MRSA, biofilm

### 1. Introduction

Antibiotic-resistant bacterial infections inside of dental settings are relevant and nearby [1] (Part 1). The limited awareness on infection prevention guidelines, lapses, and errors during infection prevention according to Centers for Disease Control and Prevention (CDC) dental guidelines sustains the evidence of possible reservoirs of antibiotic-resistant infectious agents (ARIAs) in humans (patients and dental staff) and in the environment (clinical contact surfaces (CCSs), dental instruments, and dental unit water lines (DUWLs)) and possible hazards mainly in surgical dental settings [2–26]. Here, we have focused mainly on hand hygiene, PPE use, environment decontamination, and instrument reconditioning [19, 20, 27–29]. We focus on Staphylococci and Enterobacteriaceae as markers since they are considered as prioritized bacteria according to antibiotic resistance pressure [30], and better knowledge is available on their virulence factors (adherence to abiotic surfaces, biofilm formation, ability to growth also in anaerobic conditions) and for dental settings (i.e., contamination of hands and environments, etc.). These features are important in the exploration of standard precaution failures since bacterial adherence to inanimate objects (i.e., many objects in dental settings, dental implants, collagen-based biomaterials, etc.) is known to be linked with the presence of surface components with nonpolar/hydrophobic vs. polar/hydrophilic

characteristics; in particular for methicillin-resistant Staphylococcus aureus (MRSA), its estimated infective dose is very low (4 CFU) [31–42]. Fast and very sensitive molecular biological techniques (quantitative real-time polymerase chain reaction (PCR), multiplex PCR, microarray, next-generation sequencing technologies, etc.) and in vivo biosensors technology seem to be a very promising support to improve the knowledge on bioburden and biofouling, even due to not cultivable infectious agents by classical microbiological methods, and to monitor the effectiveness of item reprocessing [43–47].

or by spray and splash, contaminated items. The spread of ARIAs can be restricted following standard preventions: hand hygiene, clinical contact surface disinfection, and instrument reprocessing are particularly important [16–20, 27–29]. In addition, we must limit the contamination by using premouthwash and surgical aspirators

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

The insufficient compliance of guidelines during infection prevention in dentistry depends on the limited awareness of the infective risk and mainly the fact that the dentist will not share the same fate of the patient in the case of an adverse event (AE), but the financial-occupational consequences can be just as serious as that of an airplane crash [5–8, 56, 58, 59]. Here, we confirm the current significant extent of violations and main noncompliance in IC observed in dental settings (Table 1),

In 1991, MRSA transmission was caused by ungloved hands of a dentist on two patients during dental surgery (see in [10]). Nowadays, this situation is likely to happen due to the violations or noncompliances of hand hygiene and the use of PPE (Table 1) as stated in the key recommendations for hand hygiene and for PPE in dental settings [3]. In addition, MRSA hand carriage rates in dental patients, nurses, and dentist were 9.8, 6.6, and 5% [21]. Staphylococci were detected in 57% samples from gloves S. aureus (5%), CNS (52%), S. epidermidis (44%), MRSA (1.5%),

The rationale of surgical hand washing and the correct gloving is to preserve surgical glove sterility. Since the high turnover of dental patients in private practice and the need for frequent hand hygiene, alcohol-based (95% wt/wt) hand rub is recommended as a speeder alternative to surgical scrub (4–5 minutes) and to apply:

• following instruction for use (IFU) (product amount, time) by the

• since DHCP needs short time procedures and it takes only 20–30″

manufacturer since are efficacious on MRSA even when gloves were not used

Concerning gloves, the physical properties of different materials influence bacterial passage in case of glove puncture due to sharp injuries [27–29, 72]. Glove perforation was 17% in maxillofacial surgery, and occurred significantly more frequently in procedures that exceeded 90 minutes than in those taking less time or during surgical procedure with a high risk of percutaneous injury rate (long procedures: intermaxillary fixation, sinus lift), in surgeon and first assistants. In addition, endodontia and orthognathic surgery are at high risk of glove perforation [13, 73]. Needlestick and sharp injuries occur as a consequence of poor visibility, unexpected patient movements, and during the clearing up of dental instruments at the end of treatments and manual cleaning [27–29, 74]. According to the European Directive n° 32/2010 and National rules, there are a lot of key recommendations for sharps'safety and good practice guides for sharp safe dental treatment [3, 29]. Sharp injuries can be reduced to a degree by behavioral changes, training, and engineering

sadly not different from those previously reported [12–15, 60–68].

MRCNS (2.2%), MRS epidermidis (1.5%), respectively [69].

• before donning gloves and after glove removal

• since it is safe for patients and workers [71].

4.1 Hand and glove contamination of DHCP

DOI: http://dx.doi.org/10.5772/intechopen.81494

• when hands are not visibly soiled

for routine clinical care [70]

67

during clinical activity.

### 2. Approach

The electronic literature search was conducted via the PubMed and Google Scholar databases (from January 2010 up to and including April 2018) using various combinations of the following key indexing terms: (a) patient safety, (b) infection control, (c) implant, (d) endodontia, (e) sterilization, (f) reconditioning, (g) critical items, (h) semicritical items, (i) hand hygiene, (j) DUWL, (k) sharps safety, (l) personal protective equipment (PPE), (m) disinfection, (n) MRSA, (o) VRE, (p) ARIAs, (q) guidelines, and (r) cross infection. In addition, manual searches were carried out in InTech books. Then, bibliographic material from the papers has been used in order to find other or older appropriate sources. A total of 125 papers and links were found suitable for inclusion in this chapter (Part 2). Only few papers do not have a DOI or PubMed classification, but the available links by Internet and accessed date have been added.

### 3. Infection control implementation: a closer look on patient needs and cost/benefit advantages

Marketing and financial strategies are emerging in dentistry. Concerning both, the improvement of infection control (IC) seems to be very important when taking into account dental patient needs and the first economic evaluations. A clean and hygienic appearance of the dental office, the sterilization of the instruments, the hand hygiene, and use of PPE of dental workers are essential requirements for patients, increasingly informed about cross infection in dental settings [48–52].

The first economic evaluations have been published concerning IC implementation [53]. The implementation of IC procedures for 1 year resulted in an infection reduction of 65% at a dental clinic [54]. Chen's group reported that the simple implementation of hand hygiene resulted in a substantial advantage in the cost/ benefit ratio (\$ 1 invested vs. \$ 23.7 saved) for the hospital [55]. The total expenses for the investigation and response, related to the first case of patient to patient transmission for HCV infection in dentistry, totaled at \$ 681,859.01. For every HCV infection that can be avoided with infection prevention, the estimated savings are of \$ 30,000–\$ 40,000 based on treatment costs for HCV infection using antiviral drug [56].

### 4. Noncompliance, lapses, and errors during infection prevention according to CDC dental guidelines

Manjunath recently focused on the management of MRSA patients in the dental chair [57]. MRSA can be transmitted by a carrier state, often asymptomatic, in dental patients and dental healthcare personnel (DHCP) (by contaminated hands)

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

or by spray and splash, contaminated items. The spread of ARIAs can be restricted following standard preventions: hand hygiene, clinical contact surface disinfection, and instrument reprocessing are particularly important [16–20, 27–29]. In addition, we must limit the contamination by using premouthwash and surgical aspirators during clinical activity.

The insufficient compliance of guidelines during infection prevention in dentistry depends on the limited awareness of the infective risk and mainly the fact that the dentist will not share the same fate of the patient in the case of an adverse event (AE), but the financial-occupational consequences can be just as serious as that of an airplane crash [5–8, 56, 58, 59]. Here, we confirm the current significant extent of violations and main noncompliance in IC observed in dental settings (Table 1), sadly not different from those previously reported [12–15, 60–68].

### 4.1 Hand and glove contamination of DHCP

characteristics; in particular for methicillin-resistant Staphylococcus aureus (MRSA), its estimated infective dose is very low (4 CFU) [31–42]. Fast and very sensitive molecular biological techniques (quantitative real-time polymerase chain reaction (PCR), multiplex PCR, microarray, next-generation sequencing technologies, etc.) and in vivo biosensors technology seem to be a very promising support to improve the knowledge on bioburden and biofouling, even due to not cultivable infectious agents by classical microbiological methods, and to monitor the effectiveness of

The electronic literature search was conducted via the PubMed and Google Scholar databases (from January 2010 up to and including April 2018) using various combinations of the following key indexing terms: (a) patient safety, (b) infection control, (c) implant, (d) endodontia, (e) sterilization, (f) reconditioning, (g) critical items, (h) semicritical items, (i) hand hygiene, (j) DUWL, (k) sharps safety, (l) personal protective equipment (PPE), (m) disinfection, (n) MRSA, (o) VRE, (p) ARIAs, (q) guidelines, and (r) cross infection. In addition, manual searches were carried out in InTech books. Then, bibliographic material from the papers has been used in order to find other or older appropriate sources. A total of 125 papers and links were found suitable for inclusion in this chapter (Part 2). Only few papers do not have a DOI or PubMed classification, but the available links by Internet and

3. Infection control implementation: a closer look on patient needs and

Marketing and financial strategies are emerging in dentistry. Concerning both, the improvement of infection control (IC) seems to be very important when taking into account dental patient needs and the first economic evaluations. A clean and hygienic appearance of the dental office, the sterilization of the instruments, the hand hygiene, and use of PPE of dental workers are essential requirements for patients, increasingly informed about cross infection in dental settings [48–52]. The first economic evaluations have been published concerning IC implementation [53]. The implementation of IC procedures for 1 year resulted in an infection reduction of 65% at a dental clinic [54]. Chen's group reported that the simple implementation of hand hygiene resulted in a substantial advantage in the cost/ benefit ratio (\$ 1 invested vs. \$ 23.7 saved) for the hospital [55]. The total expenses for the investigation and response, related to the first case of patient to patient transmission for HCV infection in dentistry, totaled at \$ 681,859.01. For every HCV infection that can be avoided with infection prevention, the estimated savings are of \$ 30,000–\$ 40,000 based on treatment costs for HCV infection

4. Noncompliance, lapses, and errors during infection prevention

chair [57]. MRSA can be transmitted by a carrier state, often asymptomatic, in dental patients and dental healthcare personnel (DHCP) (by contaminated hands)

Manjunath recently focused on the management of MRSA patients in the dental

item reprocessing [43–47].

Surgical Infections - Some Facts

accessed date have been added.

cost/benefit advantages

using antiviral drug [56].

66

according to CDC dental guidelines

2. Approach

In 1991, MRSA transmission was caused by ungloved hands of a dentist on two patients during dental surgery (see in [10]). Nowadays, this situation is likely to happen due to the violations or noncompliances of hand hygiene and the use of PPE (Table 1) as stated in the key recommendations for hand hygiene and for PPE in dental settings [3]. In addition, MRSA hand carriage rates in dental patients, nurses, and dentist were 9.8, 6.6, and 5% [21]. Staphylococci were detected in 57% samples from gloves S. aureus (5%), CNS (52%), S. epidermidis (44%), MRSA (1.5%), MRCNS (2.2%), MRS epidermidis (1.5%), respectively [69].

The rationale of surgical hand washing and the correct gloving is to preserve surgical glove sterility. Since the high turnover of dental patients in private practice and the need for frequent hand hygiene, alcohol-based (95% wt/wt) hand rub is recommended as a speeder alternative to surgical scrub (4–5 minutes) and to apply:


Concerning gloves, the physical properties of different materials influence bacterial passage in case of glove puncture due to sharp injuries [27–29, 72]. Glove perforation was 17% in maxillofacial surgery, and occurred significantly more frequently in procedures that exceeded 90 minutes than in those taking less time or during surgical procedure with a high risk of percutaneous injury rate (long procedures: intermaxillary fixation, sinus lift), in surgeon and first assistants. In addition, endodontia and orthognathic surgery are at high risk of glove perforation [13, 73]. Needlestick and sharp injuries occur as a consequence of poor visibility, unexpected patient movements, and during the clearing up of dental instruments at the end of treatments and manual cleaning [27–29, 74]. According to the European Directive n° 32/2010 and National rules, there are a lot of key recommendations for sharps'safety and good practice guides for sharp safe dental treatment [3, 29]. Sharp injuries can be reduced to a degree by behavioral changes, training, and engineering


Study

69

Dental setting

 Hand hygiene (%)

 Use of

Use of

Wearing/

Instrument

Autoclave

Handpieces

Other violations or

quality

reprocessing

noncompliances

 (%)

control

after every

(%)

patients (%)

12%: overall

noncompliance

infection control

DOI: http://dx.doi.org/10.5772/intechopen.81494

parameters

 in dental

students

72.3

 19 (wiping with

disinfectant

44.9 (use of surface

barriers); 61.6%

(impression

disinfection

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

 on CCSs);

 with

protective

gloves (%)

use of

reprocessing

 (%)

mask

(%)

eyewear (%)

(publication

date,

country)

[reference]

Anders et al.

214 dental students

56.8 (during the

53.7

 35.7

(third-fourth

 year)

preoperative

23.3 phase after removing

gloves)

9.9

54.3

7.6

 10.9

 21 (automatic washing

of used

35 (steam autoclave) ;

34.7 (dry heat sterilized

burs and 39.7 (dry heat

sterilized endodontic files; 29.6 (wrapping barrier for instrument

sterilization)

instruments);

Dagher et al.

1150 private dental

clinics

(Lebanon)

[65]

Mandourh

107 dentists

65.4 (after glove

♂:8.5;

54.2

 11.2

 Keeping sterile

4.6

 70%: unsafe work behavior of bending

needles after use;

12.2%: not disposing

sharps in a safety

container; 2.8%: do not

believe separation of

blood-soaked

 waste is

important.

The incorrect practice

of opening drawers

with gloved hands was done

by 81.3% of the dentists

with daily workloads of

more than 10 patients.

contaminated

instruments

 in pouches

(3.8%)

♀: 5.6

(nonawareness

removal (D) with the

daily workload (>10

patients/day):

 the

of wearing protective

eyewear)

working in 34

private dental

clinics in ten

districts

correct time (66.3%);

correct duration (41.3%) and drying

(18.8%); after

removing the gloves (25%); washing with

soap and water after

contact with saliva (56.3%) or alcohol

hand rub when hand is visibly dirty (80%)

(♂: 66.4%; ♀:

33.6%)

et al. (Saudi Arabia) [66]

(postoperative

 phase);

(USA) [64]


### Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

Study

68

Dental setting

 Hand hygiene (%)

 Use of

Use of

Wearing/

Instrument

Autoclave

Handpieces

Other violations or

quality

reprocessing

noncompliances

 (%)

control

after every

(%)

patients (%)

protective

gloves (%)

use of

reprocessing

 (%)

mask

(%)

eyewear (%)

(publication

date,

country)

[reference]

Hübner et al.

35 dental practices

11

15–23

6 (autoclave class N)

 80

67

Surgical Infections - Some Facts

Presence of jewelry

during DP in N

(80.7%)

DUWL: 10%: lack of

any infection control;

50%: absence of analytical control of the

DUWL water was carried out only in

nearly half of the dental

practices; 77%: absence

of a

microbiological

assessment

 of the work-environment

contamination.

15% of the dental

practices: presence of

expired

pharmaceuticals;

not regular stocking of

waste materials

Balcheva

94 dental students

 35.5 (prewash);

 8.5

79.8 (goggles);

8.5

 33.0 (use);

51.1

(mask

change)

95.7 (shield)

(postwash)

et al. (Bulgaria)

[63]

 40%:

(Germany)

[60]

Mutters et al.

58 invasive dental

95 (N)

14.3 (D♀)

16 (N)

> 28.6 (N)

61–65 (D) (after glove

removal)

40 (goggles)

2 (lack of steam

autoclave class B)

(Germany)

cares in university

dental clinic

[61]

Copello et al.

76 different dental

(review)

practices (dentist

males (78%),

professionals

50 years or above

(59%)

 aged

(Italy) [62]


### Table 1.

Violations or noncompliances (%) concerning selected infection control procedures. innovations. Nevertheless, with the exception of free-standing needle guards, needle burners, blade-safe surgical blade remover, and rigid puncture-proof yellow hidden waste bin, some engineering innovations (i.e., disposable retractable scalpel blade, blunt-tip suture needles) are no longer the methods of choice or it is not proven best protection in dentistry. There is no data on the best protection and early identification of perforation of using double gloving with an indicator in dentistry [75]. Single-use gloves intended for use in nonsterile areas must meet the requirements as reported and an AQL of ≤1.5 in accordance with EN 455–1 [76]. However, Al-Swuailem found gloves with higher defect rates (as high as 20%) than what is considered acceptable (2.5%) according to the international regulations [77]. Then, we suggest extreme caution on the cheapest gloves and at lower quality of sterile gloves available in the market, as these could have unclear or fake AQL, which is crucial for glove perforation. It is not known whether Enterococcus hand carriage is possible in DHCP for prolonged periods [78, 79], but the glove perforation is high in endodontics also using electronic root canal length measurement devices [80].

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

Nowadays, it is widely recognized that environmental surface contamination plays an important role in the transmission of healthcare-associated infections [81]. The aerosols generated by high-speed handpieces, ultrasonic scalers, air polishing, air-water syringe sprays, contaminated water from DUWL [82], patient's saliva and blood, and respiratory secretions from MRSA carriers could cause air and then CCSs and item contamination, above all when dam and surgical high-speed evacuator are not used. Staphylococcus and Enterococcus species are present in DUWL water [83].

Despite the fact that DUWL biofilm is intrinsically resistant to antibiotics, Omogbai's paper showed a wide presence of ARIAs, mainly associated to Pseudo-

of CCSs [13–15]. Here, we report some updated data focused on ARIAs.

5 days to 4 months on dry inanimate surfaces [86–88].

We underline the numerous violations and noncompliance concerning two aspects: (a) the use of standard surgical masks, which is risky in relation to MRSA carriers among DHCP and (b) surface disinfection [1, 21, 65] (Table 1). Barenghi reviewed the microbial contamination of CCSs and analyzed the guidelines, products, and procedures (barrier protective coverings, disinfectants vs. cleaners, impregnated wipes, choice of surface disinfectant and wipes) for the management

There was no indication of a special tendency or heightened ability of MRSA to aerosolize [85]. S. aureus, including MRSA, can remain virulent for 10 days on dry surfaces and survive for 7 days to 9 weeks on dry inanimate surfaces and 2 days on plastic laminate surfaces, while Enterococcus spp., including VRE, can survive from

Since 2006, the dental operatory had to be considered a possible reservoir of MRSA [89]. Before the revision of IC protocols, 6% of patients were infected by HA-MRSA among those hospitalized for oral and maxillofacial diseases. After treating the patients under a revised IC protocols, including single use of barrier covers, MRSA was not detected on the surfaces of the dental operatory, and no HAI occurred during hospitalization. MRSA long-term persistence in a simulation of dental operative conditions up to 4 months suggests that the risk for MRSA diffusion on CCSs is high in the dental office [90]. In fact, hydrophobic microorganisms adhere relatively easily to medical devices and CCSs constructed from hydrophobic materials (rubber, silicon, stainless steel, teflon, etc.); in addition, the bacterial attachment depends on many other factors (material topography at the micro- and nanoscale) [40–42]. The dynamics of microbial colonization among patients, staff, and inanimate surfaces are not known in dental settings [91]. A dental operative room is certainly

4.2 Environmental contamination in dental setting

DOI: http://dx.doi.org/10.5772/intechopen.81494

monas ssp. isolates [84].

71

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

innovations. Nevertheless, with the exception of free-standing needle guards, needle burners, blade-safe surgical blade remover, and rigid puncture-proof yellow hidden waste bin, some engineering innovations (i.e., disposable retractable scalpel blade, blunt-tip suture needles) are no longer the methods of choice or it is not proven best protection in dentistry. There is no data on the best protection and early identification of perforation of using double gloving with an indicator in dentistry [75]. Single-use gloves intended for use in nonsterile areas must meet the requirements as reported and an AQL of ≤1.5 in accordance with EN 455–1 [76]. However, Al-Swuailem found gloves with higher defect rates (as high as 20%) than what is considered acceptable (2.5%) according to the international regulations [77]. Then, we suggest extreme caution on the cheapest gloves and at lower quality of sterile gloves available in the market, as these could have unclear or fake AQL, which is crucial for glove perforation. It is not known whether Enterococcus hand carriage is possible in DHCP for prolonged periods [78, 79], but the glove perforation is high in endodontics also using electronic root canal length measurement devices [80].

### 4.2 Environmental contamination in dental setting

Nowadays, it is widely recognized that environmental surface contamination plays an important role in the transmission of healthcare-associated infections [81]. The aerosols generated by high-speed handpieces, ultrasonic scalers, air polishing, air-water syringe sprays, contaminated water from DUWL [82], patient's saliva and blood, and respiratory secretions from MRSA carriers could cause air and then CCSs and item contamination, above all when dam and surgical high-speed evacuator are not used. Staphylococcus and Enterococcus species are present in DUWL water [83]. Despite the fact that DUWL biofilm is intrinsically resistant to antibiotics, Omogbai's paper showed a wide presence of ARIAs, mainly associated to Pseudomonas ssp. isolates [84].

We underline the numerous violations and noncompliance concerning two aspects: (a) the use of standard surgical masks, which is risky in relation to MRSA carriers among DHCP and (b) surface disinfection [1, 21, 65] (Table 1). Barenghi reviewed the microbial contamination of CCSs and analyzed the guidelines, products, and procedures (barrier protective coverings, disinfectants vs. cleaners, impregnated wipes, choice of surface disinfectant and wipes) for the management of CCSs [13–15]. Here, we report some updated data focused on ARIAs.

There was no indication of a special tendency or heightened ability of MRSA to aerosolize [85]. S. aureus, including MRSA, can remain virulent for 10 days on dry surfaces and survive for 7 days to 9 weeks on dry inanimate surfaces and 2 days on plastic laminate surfaces, while Enterococcus spp., including VRE, can survive from 5 days to 4 months on dry inanimate surfaces [86–88].

Since 2006, the dental operatory had to be considered a possible reservoir of MRSA [89]. Before the revision of IC protocols, 6% of patients were infected by HA-MRSA among those hospitalized for oral and maxillofacial diseases. After treating the patients under a revised IC protocols, including single use of barrier covers, MRSA was not detected on the surfaces of the dental operatory, and no HAI occurred during hospitalization. MRSA long-term persistence in a simulation of dental operative conditions up to 4 months suggests that the risk for MRSA diffusion on CCSs is high in the dental office [90]. In fact, hydrophobic microorganisms adhere relatively easily to medical devices and CCSs constructed from hydrophobic materials (rubber, silicon, stainless steel, teflon, etc.); in addition, the bacterial attachment depends on many other factors (material topography at the micro- and nanoscale) [40–42].

The dynamics of microbial colonization among patients, staff, and inanimate surfaces are not known in dental settings [91]. A dental operative room is certainly

Study

70

Dental setting

 Hand hygiene (%)

 Use of

Use of

Wearing/

Instrument

Autoclave

Handpieces

Other violations or

quality

reprocessing

noncompliances

 (%)

control

after every

(%)

patients (%)

protective

gloves (%)

use of

reprocessing

 (%)

mask

(%)

eyewear (%)

(publication

date,

country)

[reference]

Yadav et al.

30 dental surgeons

50 (hand sanitizer)

 93.4

5

20

 66 (autoclave); (use of irritant

disinfectants

instruments;

 10 (bur

reconditioning);

(endodontic

 files

reconditioning)

 30

 for

70

10

100% (use of rubber

Surgical Infections - Some Facts

dam); 90% (use of high

speed evacuator);

100% (use of surface

barriers)

Many factors in oral

radiology, mainly associated with: plastic

barriers, of infection control

procedures;

 use of

overgloves

performance

(disposable

gloves)

80 (sterile

gloves)

(India) [67]

working in a

private dental

hospital

da Costa et al.

641

undergraduate

(Brazil) [68]

dentistry students,

20 Ph.D. students,

15 oral radiology

professors

D, dentist; N, dental nurse; DP, dental procedure; , female; , male; CCSs, clinical contact surfaces.

Table 1. Violations or

noncompliances

 (%) concerning

 selected infection control procedures. different from a hospital room, but the turnover of patients, relatives, and DHCP could be very high, especially in orthodontic offices. The presence of ARIAs on CCSs in dental setting has been confirmed from the puzzle of different operative theaters:

care setting are in the range of 2.5–5 CFU/cm<sup>2</sup> [99]. It has been shown that the presence of a significant total coliform contamination, as markers of the presence of feces, before surface disinfection or on some dental materials "received from manufacturer" and/or "clinically exposed" (see in Ref. [13]). MRSA contamination has been detected on 2.8% of fomites [99]. Since, we frequently touch multiuse vials containing bonds, cements, pastes, etc. with contaminated gloved hands, it is important to remember that S. aureus and E. faecium may retain viability on plastic for longer than 1 year [100]. Avoiding touching everywhere with contaminated gloved hands (i.e., inside the drawers) or contaminated hands after glove disposal

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

In general, there was no obvious difference in survival to biocides between multiresistant and susceptible strains of S. aureus and Enterococcus spp. [101]. Biocide resistance is rare since the biocides affect multiple cellular components, and this is more of a problem for Gram-negative bacteria (i.e., Pseudomonas), but not for S. aureus [102]. Resistance problems do not emerge when efficacious surface disinfectants are used properly following instruction for use (IFU) [103]. Two tested antibiotic-resistant microorganisms (MRSA, VRE) resisted to intermediate-level disinfectants in off-label conditions [104]. Recently, seven cleaning-disinfecting wipes and sprays, based on different active ingredients, were tested for their efficacy in removal of microbial burden and proteins in hospital settings. Efficacy was tested with known Dutch outbreak strains. In general, a > 5 log10 reduction of CFU for tested wipes and sprays was obtained for all tested bacteria strains, with the

Today, it is important to check the products carefully, including the specific biocidal activity (i.e., spectrum and time of action) at least of the main ARIAs, you use to avoid gray-market products (i.e., without approval in accordance with European Community (EC) product directives and/or FDA requirements, defective or expired) [11]. Nevertheless, inefficient surface decontamination (improper procedures, time below the contact time, insufficient dispersal, etc.) (Table 1) can then allow for the survival and growth of the surviving bacterial population [54, 93, 106]. The use of disposable barrier protective coverings (DBPCs) (transparent food barriers, purpose and medical-grade barriers, adhesive barriers) is recommended in particular for more contaminated zones of instruments (curing lights, intraoral radiographic equipment, computer keyboards, multiple-use dental dispenser devices, etc.), dental chair parts (dental suction units, light arms), buttons, switches, and other materials and accessories [13–15, 107]. In the future, it will be ergonomic to increase the use of the no-touch procedures (vaporization with hydrogen peroxide, HEPA filters, etc.) and rapid systems to control environmental

Poor or bad instrument reconditioning practices for critical dental items are linked to cross infection [108]. Here, we reported the failures concerning dental instrument reconditioning, which includes decontamination, cleaning, wrapping, sterilization and storage. Since many multiresistant and susceptible bacterial strains in dental settings are good biofilm producers and then survive to desiccation, and are more resistant to disinfectants than planktonic communities, afterwards, the inadequate reconditioning of reusable dental instruments can potentially increase cross infection and outbreak [22, 109]. It is very important to avoid the drying of

and obviously before a proper hand hygiene.

DOI: http://dx.doi.org/10.5772/intechopen.81494

4.2.1 Resistant and susceptible strain survival to surface disinfectants

exception of the hydrogen peroxide spray and VRE [105].

cleanliness above all for surgical rooms.

4.3 Dental instrument reconditioning

73


Recommendations for assessing the effectiveness of disinfection and cleaning practices indicate that the suitable levels of total bacterial numbers in the health

### Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

care setting are in the range of 2.5–5 CFU/cm<sup>2</sup> [99]. It has been shown that the presence of a significant total coliform contamination, as markers of the presence of feces, before surface disinfection or on some dental materials "received from manufacturer" and/or "clinically exposed" (see in Ref. [13]). MRSA contamination has been detected on 2.8% of fomites [99]. Since, we frequently touch multiuse vials containing bonds, cements, pastes, etc. with contaminated gloved hands, it is important to remember that S. aureus and E. faecium may retain viability on plastic for longer than 1 year [100]. Avoiding touching everywhere with contaminated gloved hands (i.e., inside the drawers) or contaminated hands after glove disposal and obviously before a proper hand hygiene.

### 4.2.1 Resistant and susceptible strain survival to surface disinfectants

In general, there was no obvious difference in survival to biocides between multiresistant and susceptible strains of S. aureus and Enterococcus spp. [101]. Biocide resistance is rare since the biocides affect multiple cellular components, and this is more of a problem for Gram-negative bacteria (i.e., Pseudomonas), but not for S. aureus [102]. Resistance problems do not emerge when efficacious surface disinfectants are used properly following instruction for use (IFU) [103]. Two tested antibiotic-resistant microorganisms (MRSA, VRE) resisted to intermediate-level disinfectants in off-label conditions [104]. Recently, seven cleaning-disinfecting wipes and sprays, based on different active ingredients, were tested for their efficacy in removal of microbial burden and proteins in hospital settings. Efficacy was tested with known Dutch outbreak strains. In general, a > 5 log10 reduction of CFU for tested wipes and sprays was obtained for all tested bacteria strains, with the exception of the hydrogen peroxide spray and VRE [105].

Today, it is important to check the products carefully, including the specific biocidal activity (i.e., spectrum and time of action) at least of the main ARIAs, you use to avoid gray-market products (i.e., without approval in accordance with European Community (EC) product directives and/or FDA requirements, defective or expired) [11]. Nevertheless, inefficient surface decontamination (improper procedures, time below the contact time, insufficient dispersal, etc.) (Table 1) can then allow for the survival and growth of the surviving bacterial population [54, 93, 106]. The use of disposable barrier protective coverings (DBPCs) (transparent food barriers, purpose and medical-grade barriers, adhesive barriers) is recommended in particular for more contaminated zones of instruments (curing lights, intraoral radiographic equipment, computer keyboards, multiple-use dental dispenser devices, etc.), dental chair parts (dental suction units, light arms), buttons, switches, and other materials and accessories [13–15, 107]. In the future, it will be ergonomic to increase the use of the no-touch procedures (vaporization with hydrogen peroxide, HEPA filters, etc.) and rapid systems to control environmental cleanliness above all for surgical rooms.

### 4.3 Dental instrument reconditioning

Poor or bad instrument reconditioning practices for critical dental items are linked to cross infection [108]. Here, we reported the failures concerning dental instrument reconditioning, which includes decontamination, cleaning, wrapping, sterilization and storage. Since many multiresistant and susceptible bacterial strains in dental settings are good biofilm producers and then survive to desiccation, and are more resistant to disinfectants than planktonic communities, afterwards, the inadequate reconditioning of reusable dental instruments can potentially increase cross infection and outbreak [22, 109]. It is very important to avoid the drying of

different from a hospital room, but the turnover of patients, relatives, and DHCP could be very high, especially in orthodontic offices. The presence of ARIAs on CCSs in dental setting has been confirmed from the puzzle of different operative theaters:

• 21% of dental students and 8.4% frequently touched dental school clinic

• 1.3% of the environmental isolates were MRSA-positive, and there were no statistical differences in biofilm-forming ability between MRSA isolates recovered from DHCP and those recovered from environmental surfaces [21],

• 10-fold increase in viable bacteria during periods of clinical activity vs. the absence of such activity, 73 species selected and 48% of species resistant to at

• greater contamination of surfaces with MRSA colonies was observed after patients were treated in five different departments of a hospital dental clinic. High prevalence of MRSA strains has been observed on various surfaces, especially the paper dental records in the oral medicine department [94],

• MRSA prevalence rate was different in samples from dental surgery (4.3%), prosthetic dentistry (3.9%), operative dentistry (2.9%), periodontics (2.4%), prosthodontic (1%), and endodontic (0.98%). The majority of MRSA and SA isolates recovered from environmental surfaces were biofilm producers

• the contamination of S. aureus and MRSA on the gloved-dominant hand and

• the more frequently contaminated items were panoramic headrest/chin rest, radiation shields, towel dispenser, keyboard, and chair arm inside patient care areas of an academic dental clinic. 4.7% of abiotic surfaces in treatment and nontreatment areas were contaminated with S. aureus (<5 CFUs). Most

• a high contamination of SA and MRSA species have been reported from materials used in radiographic processing, mainly on the lids of the portable

• in dental settings, the phone contamination is very high and is by S. aureus,

• only a few, dental surfaces were positive for E. faecalis (0.9%), but on the other hand, disinfection of surfaces reduced contamination levels by only 10% [54]. After clinical activity, the microbial surface contamination by S. aureus and

• widespread microbial contamination of air, surface, and dental unit water samples and violations concerning environmental cleaning have been reported

Recommendations for assessing the effectiveness of disinfection and cleaning practices indicate that the suitable levels of total bacterial numbers in the health

E. coli, Enterococcus, and Pseudomonas (see Ref. in [13–15, 98]),

E. faecalis was, 20 and 10%, respectively [93], and

the tray are similar, being 5 and 1.5% respectively [69],

isolates were resistant to penicillin [96],

least an antibiotic using 16S ribosomal RNA gene sequencing [93],

surfaces were MRSA positive [92],

Surgical Infections - Some Facts

[21, 95],

dark rooms [97],

in dental surgeries [17, 18].

72

biological fluids on instruments and long delay in reprocessing (better within 6 hr) [110]. Main violations or noncompliances concerning all phases of instrument reconditioning in dental settings (Table 1) are very frequent and can be classified as follows: (a) lack of resources (es steam autoclave class B, unwrapped devices, insufficient drying, autoclave quality controls, etc.); (b) cleaning difficulties, above all for manual procedures, in the case of older, more complex instruments (implant drills, trephine drills, healing abutments, high-speed handpieces, torque wrenches) and dirty instruments with biological fluids, cements, bonding, adhesive, etc.; (c) many difficulties during reprocessing of surgical drills, endodontic instruments and their accessories; (d) use of water of uncertain quality for cleaning and steam autoclave; (e) insufficient training; (f) selection of item design with difficult clean ability; (g) loss of sterility; and (h) reuse of single-use medical devices (i.e., irrigation sets) [5, 12, 13, 23–26, 38, 111–115]. MRSA was demonstrated to survive on sterile item packaging for more than 38 weeks [113]. In general, the operative problems during surgical instrument reconditioning are more frequent since instruments can be single-end sharps (elevators), heavy (forceps), and joint fit (bone chisels, scissors, forceps, suturing forceps, etc.); in addition, they often have a hole and/or a cavity or are very little and sharp (drills, trephine drills). Instruments or surgical drills made with different alloys or old or very used are particularly tricky to recondition; we have to follow IFU to avoid corrosion and discharge them when have been damaged during clinical procedure (i.e., contact between bone drill and dental periosteal elevator) and/or reconditioning (i.e., lack of compatibility, contact in ultrasonic washer) [23–26]. Surgical and dental instruments should be discharged when corrosion stains, signs of milling or grazes [116], etc., are present. Since the reported contamination on surgical drills and instrument, we have to follow IFU and use ultrasonic washer with proper cleaning products using controls [117].

the infective risk is usually estimated in healthy people, while vulnerable patients (children, pregnant women, elderly people, diabetic, immune-deficient, under drug treatments, etc.) are particularly susceptible to infections from opportunistic pathogens and ARIAs. Elderly people are particularly exposed since they are often on antibiotics, situations, which favor antibiotic-resistant pathogens, and frequently require implant surgery and endodontic care. The hazard for our reputation and insurance coverage is increasing with the possibility offered by molecular biology to identify dentally acquired infections [1]. Molecular biology and in vivo biosensors technology, to detect quorum sensing signaling molecules produced by airborne pathogenic bacteria, can prove the violations and noncompliances in dental settings and useful for accreditation surveys [43–47, 58]. Nevertheless, antimicrobial surfaces and graphene-based antimicrobial nanomaterials seem to be promising to

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

Concerning IC, we need to rapidly improve the efficacy and efficiency in IC

• a better knowledge-based and rule-based behavior according to guidelines

• high proactivity & interaction & communication among DHCP

• proper time for IC prevention (hand hygiene, gloves and mask use/

• use of surgical facemasks designed to rapidly inactivate dentistry-associated

• DUWL water quality and the use of sterile solution for surgery [6, 7, 14]

• digital models produced by an intraoral scan to eliminate the problem of impression and high contamination of gypsum casts (i.e., MRSA: 26.7, 15.4%,

• more automation and no-touch procedures for cleaning and disinfection

For future safe and patient-centered dental cares, it is crucial that we increase the professional harmonization and ergonomics of the highly complex "humantechnical dental office system" [125]. For better dental patient and DHCP safety,

L.B. had a service agreement with KerrHawe and is a consultant for Dental Trey

Il Blog (http://blog.dentaltrey.it/), neither of which gave any input or financial support to the writing of this article. There is no other conflict of interest to report.

• acceptable workload-occupational stress to avoid DHCP distraction

• use of proper items with FDA and/or CE mark [11].

we need to improve education and training initiatives.

lower cross infection [122].

DOI: http://dx.doi.org/10.5772/intechopen.81494

• increased training and skill-based behavior

• appropriated human and economic resources

prevention by means of:

change, etc.)

pathogens

Conflict of interest

75

27 respectively) [123, 124]

The use of surgical cassettes with modern hole patterns and washer disinfector allows an optimal cleaning and thermo-disinfection of surgical instruments with little occupational risk and better efficiency and instrument integrity. Surgical cassettes have different sizes, configurations, and can be specialized to meet specific surgical needs [118]. In the case of implantology, the surgical cassette normally holds some hand instruments, drills and screwdrivers, torque ratchet, and accessories for implantology. The correct sorting of the instruments is facilitated by the color-coding markings and pictograms [119, 120]. Manufacturer's electronic information for the processing with EN ISO 17664 is available.

Another advantage of this planning is that the surgical kit is reassembled directly in the operating room, and instruments are fixed in the open position. Using WD, there are advantages of no instrument contact or rubbing, and better automatic cleaning. Routine quality control is possible by inserting appropriate controls for cleaning efficacy (wash-checks WD STF, Browne) and the moist heat process (Descheck, Browne) inside the cassette. Recently, Valeriani proposed a fast simple molecular approach (by microflora DNA analysis) for monitoring the effectiveness of item reprocessing, which seems to be a very promising support for surveillance in dental care settings [46].

### 5. Conclusion

The prevention of cross infection by adopting guidelines is easily applicable and has had early significant effects on infection prevention and cost saving [53, 54] compared to the delayed significant effects due to the sustainable use of antibiotics in dentistry [121]. We reported many concurrent violations and noncompliances in infection prevention, some of which could not necessarily be harmful. Nevertheless, Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

the infective risk is usually estimated in healthy people, while vulnerable patients (children, pregnant women, elderly people, diabetic, immune-deficient, under drug treatments, etc.) are particularly susceptible to infections from opportunistic pathogens and ARIAs. Elderly people are particularly exposed since they are often on antibiotics, situations, which favor antibiotic-resistant pathogens, and frequently require implant surgery and endodontic care. The hazard for our reputation and insurance coverage is increasing with the possibility offered by molecular biology to identify dentally acquired infections [1]. Molecular biology and in vivo biosensors technology, to detect quorum sensing signaling molecules produced by airborne pathogenic bacteria, can prove the violations and noncompliances in dental settings and useful for accreditation surveys [43–47, 58]. Nevertheless, antimicrobial surfaces and graphene-based antimicrobial nanomaterials seem to be promising to lower cross infection [122].

Concerning IC, we need to rapidly improve the efficacy and efficiency in IC prevention by means of:


For future safe and patient-centered dental cares, it is crucial that we increase the professional harmonization and ergonomics of the highly complex "humantechnical dental office system" [125]. For better dental patient and DHCP safety, we need to improve education and training initiatives.

### Conflict of interest

L.B. had a service agreement with KerrHawe and is a consultant for Dental Trey Il Blog (http://blog.dentaltrey.it/), neither of which gave any input or financial support to the writing of this article. There is no other conflict of interest to report.

biological fluids on instruments and long delay in reprocessing (better within 6 hr) [110]. Main violations or noncompliances concerning all phases of instrument reconditioning in dental settings (Table 1) are very frequent and can be classified as follows: (a) lack of resources (es steam autoclave class B, unwrapped devices, insufficient drying, autoclave quality controls, etc.); (b) cleaning difficulties, above all for manual procedures, in the case of older, more complex instruments (implant drills, trephine drills, healing abutments, high-speed handpieces, torque wrenches) and dirty instruments with biological fluids, cements, bonding, adhesive, etc.; (c) many difficulties during reprocessing of surgical drills, endodontic instruments and their accessories; (d) use of water of uncertain quality for cleaning and steam autoclave; (e) insufficient training; (f) selection of item design with difficult clean ability; (g) loss of sterility; and (h) reuse of single-use medical devices (i.e., irrigation sets) [5, 12, 13, 23–26, 38, 111–115]. MRSA was demonstrated to survive on sterile item packaging for more than 38 weeks [113]. In general, the operative problems during surgical instrument reconditioning are more frequent since instruments can be single-end sharps (elevators), heavy (forceps), and joint fit (bone chisels, scissors, forceps, suturing forceps, etc.); in addition, they often have a hole and/or a cavity or are very little and sharp (drills, trephine drills). Instruments or surgical drills made with different alloys or old or very used are particularly tricky to recondition; we have to follow IFU to avoid corrosion and discharge them when have been damaged during clinical procedure (i.e., contact between bone drill and dental periosteal elevator) and/or reconditioning (i.e., lack of compatibility, contact in ultrasonic washer) [23–26]. Surgical and dental instruments should be discharged when corrosion stains, signs of milling or grazes [116], etc., are present. Since the reported contamination on surgical drills and instrument, we have to follow IFU and

use ultrasonic washer with proper cleaning products using controls [117].

mation for the processing with EN ISO 17664 is available.

dental care settings [46].

Surgical Infections - Some Facts

5. Conclusion

74

The use of surgical cassettes with modern hole patterns and washer disinfector allows an optimal cleaning and thermo-disinfection of surgical instruments with little occupational risk and better efficiency and instrument integrity. Surgical cassettes have different sizes, configurations, and can be specialized to meet specific surgical needs [118]. In the case of implantology, the surgical cassette normally holds some hand instruments, drills and screwdrivers, torque ratchet, and accessories for implantology. The correct sorting of the instruments is facilitated by the color-coding markings and pictograms [119, 120]. Manufacturer's electronic infor-

Another advantage of this planning is that the surgical kit is reassembled directly in the operating room, and instruments are fixed in the open position. Using WD, there are advantages of no instrument contact or rubbing, and better automatic cleaning. Routine quality control is possible by inserting appropriate controls for cleaning efficacy (wash-checks WD STF, Browne) and the moist heat process (Descheck, Browne) inside the cassette. Recently, Valeriani proposed a fast simple molecular approach (by microflora DNA analysis) for monitoring the effectiveness of item reprocessing, which seems to be a very promising support for surveillance in

The prevention of cross infection by adopting guidelines is easily applicable and has had early significant effects on infection prevention and cost saving [53, 54] compared to the delayed significant effects due to the sustainable use of antibiotics in dentistry [121]. We reported many concurrent violations and noncompliances in infection prevention, some of which could not necessarily be harmful. Nevertheless,

### Abbreviations


References

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DOI: http://dx.doi.org/10.5772/intechopen.81494

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2

[8] Ross KM, Mehr JS, Greeley RD, Montoya LA, Kulkarni PTA, Frontin S, et al. Outbreak of bacterial endocarditis associated with an oral surgery practice. The Journal of the American Dental Association. 2018;149(3):191-201. DOI:

[9] Perea-Perez B, Labajo-Gonzalez E, Acosta-Gio AE, Yamalik N. Eleven basic procedures/practices for dental patient safety. Journal of Patient Safety. 2015. DOI: 10.1097/PTS.0000000000000234

[10] Petti S, Polimeni A. Risk of methicillin-resistant Staphylococcus aureus transmission in the dental healthcare setting: A narrative review.

Infection Control and Hospital Epidemiology. 2011;32(11):1109-1115.

[11] Collins FM. The significance of the US Food and drug administration for dental professionals and safe patient care. The Journal of the American Dental Association. 2017;148(11):

[12] Oosthuysen J, Potgieter E, Fossey A. Compliance with infection prevention and control in oral health-care facilities: A global perspective. International Dental Journal. 2014;64(6):297-311.

[13] Barenghi L, Barenghi A, Di Blasio A. Implementation of recent infection prevention procedures published by centers for disease control and

prevention: Difficulties and problems in orthodontic offices. Iranian Journal of Orthodontics. 2018;13(1):e10201. DOI:

[14] Barenghi L. Clean, Disinfect and Cover: Top Activities for Clinical Contact Surfaces in Dentistry

[Internet]; 2015. Available from: www.

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858-861. DOI: 10.1016/j.

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10.5812/ijo.10201

adaj.2017.08.026

10.1016/j.adaj.2017.10.002

[2] Kalenderian E, Obadan-Udoh E, Maramaldi P, Etolue J, Yansane A, Stewart D, et al. Classifying adverse events in the dental office. Journal of Patient Safety. 2017;00:00-00. DOI: 10.1097/PTS.0000000000000407

[3] Summary of Infection Prevention Practices in Dental Settings. USA: Centers for Disease Control and Prevention; 2016. Available from:

infectioncontrol/pdf/safe-care2.pdf

[5] Cleveland JL, Gray SK, Harte JA, Robison VA, Moorman AC, Gooch BF. Transmission of blood-borne pathogens in us dental health care settings. 2016 update. The Journal of the American Dental Association. 2016;147(9): 729-738. DOI: 10.1016/j.adaj.2016.03.02

[6] Arduino M, Miller J, Shannon M. Safe Water, Safe Dentistry, Safe Kids. Webinar: Organization for Safety Asepsis and Prevention; 2017. Available from: https://www.osap.org/page/ LecturesWebinarsConf? [Accessed:

[7] Ricci ML, Fontana S, Pinci F, Fiumana E, Pedna MF, Farolfi P, et al. Pneumonia associated with a dental unit water line. The Lancet. 2012;379(9816): 684. DOI: 10.1016/S0140-6736(12)

27-05-2017]

60074-9

77

[4] Reuter NG, Westgate PM, Ingram M, Miller CS. Death related to dental treatment: A systematic review. Oral Surgery Oral Medicine Oral Pathology Oral Radiology. 2016;123(2):194-204. DOI: 10.1016/j.oooo.2016.10.015

www.cdc.gov/oralhealth/

[Accessed: 06-12-2018]

### Author details

Livia Barenghi<sup>1</sup> \*, Alberto Barenghi<sup>1</sup> and Alberto Di Blasio<sup>2</sup>

1 Integrated Orthodontic Services S.r.l., Lecco, Italy

2 Department of Medicine and Surgery, Centro di Odontoiatria, Parma University, Parma, Italy

\*Address all correspondence to: livia.barenghi@libero.it

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Infection Control in Dentistry and Drug-Resistant Infectious Agents: A Burning Issue. Part 2 DOI: http://dx.doi.org/10.5772/intechopen.81494

### References

Abbreviations

AE adverse event

Surgical Infections - Some Facts

DD dental device

DI dental implant DUWL dental unit water line EC european community HPC heterotrophic plate count

IC infection control IFU instruction for use

Author details

Livia Barenghi<sup>1</sup>

Parma, Italy

76

CCSs clinical contact surfaces

DHCP dental healthcare personnel

PCR polymerase chain reaction

VRE vancomycin-resistant Enterococcus

ARIA antibiotic-resistant infectious agents AQL accepted quality assurance level

CDC centers for disease control and prevention

MRSA methicillin-resistant Staphylococcus aureus

\*, Alberto Barenghi<sup>1</sup> and Alberto Di Blasio<sup>2</sup>

2 Department of Medicine and Surgery, Centro di Odontoiatria, Parma University,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Integrated Orthodontic Services S.r.l., Lecco, Italy

\*Address all correspondence to: livia.barenghi@libero.it

provided the original work is properly cited.

[1] Barenghi L, Barenghi A, Di Blasio A. Infection Control in Dentistry and Drug Resistant Infectious Agents: A Burning Issue. Part 1. Rijeka: InTech; 2018

[2] Kalenderian E, Obadan-Udoh E, Maramaldi P, Etolue J, Yansane A, Stewart D, et al. Classifying adverse events in the dental office. Journal of Patient Safety. 2017;00:00-00. DOI: 10.1097/PTS.0000000000000407

[3] Summary of Infection Prevention Practices in Dental Settings. USA: Centers for Disease Control and Prevention; 2016. Available from: www.cdc.gov/oralhealth/ infectioncontrol/pdf/safe-care2.pdf [Accessed: 06-12-2018]

[4] Reuter NG, Westgate PM, Ingram M, Miller CS. Death related to dental treatment: A systematic review. Oral Surgery Oral Medicine Oral Pathology Oral Radiology. 2016;123(2):194-204. DOI: 10.1016/j.oooo.2016.10.015

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### *Edited by Manal Mohammad Baddour*

Skin is a natural barrier to infection. Surgical breakage of skin can lead to surgical site infections (SSIs). SSIs are relatively common and constitute a problematic issue in surgical procedures. Most common organisms include Gram-positive, such as Staphylococcus and Streptococcus, as well as Gram-negative, such as Pseudomonas and others, bacteria. The extent and outcome of SSI can vary widely depending on the procedure, organism, extent, and other factors, and can result in discomfort, severe morbidity, or even life-threatening conditions.It is thus mandatory to be aware of and follow WHO and CDC guidelines for the prevention of SSIs and to reduce risk factors for acquisition. This book sheds light on certain aspects related to SSIs and how to avoid them.

Published in London, UK © 2020 IntechOpen © ktsimage / iStock

Surgical Infections - Some Facts

Surgical Infections

Some Facts

*Edited by Manal Mohammad Baddour*