In the dental surgery, the dental team and patients can be exposed to a wide variety of microorganisms that are transmitted via blood, saliva, respiratory secretions or from the skin. The use of surface decontaminants to reduce the potential spread of viruses and control bacteria within a surgery setting, is well-known and laid down in regulations and guidance.
Although the principles that underpin the need for infection control measures remain unchanged, the emergence of new diseases and the increase in incidence of others necessitate the need for continuous evaluation of current infection-control protocols. Dentists and managers must remain vigilant about the effectiveness of the infection control products they are using and a regular audit of materials should be regarded as general good practice.
One such disease increasing in prevalence is tuberculosis (TB); a respiratory disease that now affects an estimated 14m people worldwide. Once considered a disease in decline, TB has re-emerged as a significant public health problem in the UK being particularly prevalent in London and the West Midlands. The incidence of TB infections has been steadily rising over the past two decades (reaching a high of almost 9,000 in 2011)and poses a significant threat to public health.
In the UK tuberculosis has been classed as a notifiable disease since 1913 and infections are monitored by the Health Protection Agency. Following a decade in which incidents of the disease increased sharply, ‘Enhanced Tuberculosis Surveillance’ in England and Wales was commissioned in 1999 and in 2004 a dedicated action plan ‘Stopping Tuberculosis in England’ was launched by the chief medical officer. The immediate aims of the action plan were threefold;
- To reduce the risk of new infections.
- To provide high quality treatment and care for people with tuberculosis.
- To maintain low levels of drug resistance.
The long-term goal of the plan was to reduce and ultimately eliminate TB in England and it set out clear steps that should be taken by the NHS, wider government and health communities to tackle TB, however since its launch in 2004, cases have continued to increase.
Migration has been identified as a key factor in the increase of TB in the UK over the last three decades as individuals are at higher risk of carrying the disease if they have lived in parts of the world where TB is most common. For example populations from sub-Saharan African and the Indian subcontinent often have very high rates of TB relative to the UK, so the need to take precautionary measures against the spread of the disease is a top priority.
Tuberculosis is caused when an individual becomes infected with mycobacterium tuberculosis. Infection is transmitted in the main by airborne particles from an infected person, but hand to surface contact also plays a role in the spread of the disease.
Symptoms of tuberculosis include:
- A persistent cough of more than three weeks that brings up phlegm, which may be bloody
- Breathlessness, which is usually mild to begin with and gradually gets worse
- Lack of appetite and weight loss
- High temperature of 38C or above
- Night sweats
- Extreme tiredness or fatigue
- Unexplained pain for more than three weeks
However one of the key problems in identifying TB is that the infection is not always symptomatic. Symptoms may develop months or years after infection, or never. Thus an infected individual may have no reason to seek treatment and cannot be readily identified.
Mycobacteria can also cause infections in other parts of the body (skin, lymphatic system, soft tissues or non-specific (intracellular). Mycobacteria are a bacteria with particularly thick cell walls, making them difficult to attack with disinfectants and antibiotics. They can survive in water and on surfaces, making elimination even more difficult, and the identification of a new strain of TB ‘extensively drug-resistant’ (XDR) tuberculosis, currently found in 77 countries worldwide, is further accelerating the need for action.
All of these factors combined make the use of surface cleaners and disinfectants that have proven efficacy against TB important in primary care environments, including the dental surgery.
Rigorous surface cleaning is a cornerstone of effective infection control within a dental practice, and protocols that cover both treatment and non-treatment areas are necessary in view of the potential for spread of many pathogens.
Standard precautions that apply to all patients should be enforced to ensure that the potential spread of disease is limited, and this includes assessing patients’ medical history, and cleaning and disinfection of all surfaces that may have come into contact with body fluids, secretions, including saliva and excretions, whether or not they contain blood.
When selecting a surface cleaner it is recommended that a disinfectant capable of inactivating mycobacteria is used. A wide spectrum, all-in-one microbiocidal wipe or trigger spray is easy to use and should be checked for efficacy against mycobacteria, bacteria, fungi, yeast and enveloped viruses (HIV, HBV, HCV, H1N1, H5N1). Products used for this purpose should also conform to the requirements of the Medical Device Directive 93/42/EEC.
Surface cleaners and disinfectants will not eradicate tuberculosis alone, however, in the face of rising cases of the disease it is the duty of all healthcare professionals to be alert to the possibility of infected individuals attending the practice. Taking adequate measures to reduce the potential for the spread of all disease in the dental surgery is a pre-requisite for owners and managers, is relatively simple to achieve by selecting an appropriate, commercially available product, and will help safeguard practices workers and patients alike.
References available on request.