Now that COVID-19 isn’t dominating the infection control news stories (although it is still present), we turn our attention to some additional news regarding infectious disease transmissions that may affect us in dentistry. Some of the information is good news and of course, some is not so good.
Recently the Food and Drug Administration (FDA) granted approval for two new vaccines for Respiratory Syncytial Virus (RSV)., The vaccines are the first for preventing this serious respiratory virus. According to Gavi The Vaccine Alliance, RSV infects millions of people globally each year with lower respiratory tract infections, with mild symptoms. Young children and older adults are particularly vulnerable, and many are hospitalized for treatment of the infections. RSV infections can also be fatal, especially in patients with underlying medical conditions. These new vaccines, approved for individuals over 60, is reported to reduce the risk of severe RSV-related lower respiratory disease by 94%. RSV is characterized by the Centers for Disease Control and Prevention (CDC) as an infection of the lower respiratory tract that includes symptoms of runny nose, decreased appetite, coughing, sneezing, wheezing and fever. These symptoms are similar to COVID-19 and influenza however, a single nasal swab test (PCR) can detect which of these viruses is occurring in a patient. Some danger signs in children and adults that indicate the need for immediate medical intervention include difficulty breathing, stridor (wheezing, grunting or high-pitched sounds with each breath), coughing or wheezing that does not stop, decreased alertness, bluish skin, tongue or lips, dehydration, and high fever (104°F).
According to the CDC, in the 2022-2023, the overall rate of RSV-associated hospitalizations was 51.9% per 100,000 people. The CDC’s National Respiratory and Enteric Virus Surveillance System (NREVSS) is an excellent resource for dental health care providers to monitor RSV, influenza and other respiratory virus trends in the area where their dental practices or clinics are located. This information is updated weekly by states and regions in the U.S.
If the pandemic taught us anything in dentistry, it is that the threat of respiratory infections can be serious, and that dental health care personnel are at risk of exposure from patients and from each other. Even though the pandemic is over, endemic COVID-19, influenza and RSV infections continue to spread. Reappointing patients who have respiratory symptoms should be a standard protocol in every dental practice, with the exception of patients needing emergency treatment.
The CDC recently reported that cases of malaria were identified in Sarasota County, FL and Cameron County, TX. These four cases, not related, are believed to be locally acquired, which is not as common as cases that are acquired when individuals travel to countries where malaria is common. Malaria is a parasitic infection, transmitted through mosquito bites. If not treated, malaria can be fatal. The CDC, along with state and local health departments are increasing efforts to raise awareness among professionals and the public of the potential risk of malaria and other mosquito-borne infections. Preventive measures include DEET-containing insect repellent, loose-fitting long-sleeved shirts and pants and utilizing screens on doors and windows.
Symptoms of malaria infection include: fever, shaking chills, headache, muscle aches and fatigue. Nausea, vomiting and diarrhea can also occur, along with anemia and jaundice. If not treated promptly, malaria infection can cause kidney failure, seizures, mental confusion, coma, and death.
According to the CDC and the Association for Professionals in Infection Control and Epidemiology (APIC), Candida Auris (C. auris) is an emerging fungus, discovered in Japan in 2009. It is considered to be an urgent antimicrobial resistance threat. The CDC states that it is spreading at an alarming rate in hospitals and long-term care facilities. Of great concern to health care professionals is that C. auris is difficult to identify, often is mistaken as a bacterial infection, and medical laboratories must have specific technology to correctly identify it, which is beyond standard laboratory methods. The most concerning issue is that C. Auris is resistant to the most commonly used antifungal medications. It is easily spread in health care facilities and is especially harmful to individuals who have weakened immune systems. In these individuals the infection may enter the bloodstream, causing what is described as an invasive infection.
Although no cases of C. auris infections have been associated with oral health care, it is possible that an infectious patient may be treated in a dental practice. Patients may be ill from other types of medical conditions, and they may be experiencing fever and chills as the result of a C. auris infection. This reinforces the need to monitor every patient’s vital signs, including temperatures, at the beginning of each visit. During the pandemic, the CDC recommended checking temperatures before patients were admitted to the dental office. While that is no longer necessary, taking a patient’s temperature and blood pressure is considered a good medical practice. And the temperature and blood pressure needs to be recorded in the clinical note. Unless it is an emergency, or the fever is believed to be caused by a dental infection, these patients should be reappointed until they are well enough for oral health care procedures.
In addition, if appropriate disinfecting protocols are not followed with all patients, C. auris could be spread to other patients and dental health care professionals. In most cases the tuberculocidal disinfectants that are used in dentistry will be effective against C. auris, but dental professionals can look up their disinfectants on the Environmental Protection Agency (EPA) list for emerging pathogens to determine if the product they use is effective against C. auris.
Dental Unit Water Quality
Bacterial infections resulting from patient treatment using untreated, contaminated dental unit water continue to be investigated by the CDC. While most of the cases identified have affected pediatric patients who received pulpotomies, adult patients have been infected as well. The CDC states that any dental unit with untreated water is a potential infectious disease threat to patients. It is also a threat to dental health care providers as well, due to the exposure to aerosols created from that water.
Much attention has been directed at how to treat the water, and there are many products on the market that are effective in controlling microbial contamination, but the issue still exists. There are several reasons why this is the case, including a lack of consistency in using the waterline cleaner/disinfectants, not following the manufacturer’s instructions for use of the product, lack of shock/cleaning of the dental unit waterlines according to the equipment manufacturer's instructions and product instructions, and a lack of testing to determine if the products or procedures followed are actually working.
Every dental practice needs to have a waterline protocol in place that includes training for the team to understand the risks of using contaminated water, selecting the appropriate product that is compatible with the dental units in the practice, a testing protocol, and a protocol to follow if a dental unit fails to meet the CDC recommended <500CFU/ml. The CDC has a great deal of information on its website about dental unit water quality that can help guide a dental practice to establish and follow the necessary protocols.
Taking a Broader View of Infection Prevention and Control
As dental professionals, we sometimes view issues in a narrow context – only looking at what directly affects the delivery of oral health care. It is important to recognize, however, that comprehensive oral health care includes recognizing what is occurring in the global context of infectious disease. In many cases dental professionals dismiss some issues as irrelevant because very few or no infections have been documented in dentistry or are unlikely to occur in dentistry. Dentistry is a profession of preventing oral disease and should also be a profession of preventing the spread of infectious diseases.
U.S. Food and Drug Administration: https://www.fda.gov/vaccines-blood-biologics/abrysvo
U.S. Food and Drug Administration: https://www.fda.gov/vaccines-blood-biologics/arexvy
DC RSV-NET: https://www.cdc.gov/rsv/research/rsv-net/dashboard.html#:~:text=In%20the%202022%2D2023%20season,was%2051.0%20per%20100%2C000%20people.
CDC NREVSS: https://www.cdc.gov/surveillance/nrevss/rsv/state.html
CDC FAQ’s About Malaria: https://www.cdc.gov/malaria/about/faqs.html
CDC Increasing Threat of Spread of Antimicrobial-resistant Fungus in Healthcare Facilities: https://www.cdc.gov/media/releases/2023/p0320-cauris.html
CDC Invasive Candidiasis: https://www.cdc.gov/fungal/diseases/candidiasis/invasive/index.html
EPA List P: Antimicrobial Products Registered with EPA for Claims Against Candida Auris: https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-against-candida-auris
CDC Dental Unit Water Quality: https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/dental-unit-water-quality.html