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MRSA and MSSA in the Dental Setting

By Noel Brandon Kelsch, RDHAP

When we hear people's stories, it sometimes inspires us to take a stand, to make a change, and to do what we knew was right in the first place. When it comes to methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA), taking a stand in infection control is paramount.

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Other articles by Kelsch:

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So, what is this disease? Staphylococcus aureus is a gram-positive coccus bacterium that loves to hang out in many areas of the body, but especially on the nose and skin, even in healthy people. The problem is it can lead to a variety of localized and invasive syndromes, ranging from superficial skin infections to life-threatening pneumonia and bloodstream infections.1 Twenty-five to 30% of the general population is colonized with MSSA and 2% with MRSA.2

MSSA is sensitive to methicillin and is frequently on the body. It is not always pathogenic. It is commonly known to cause skin infections, respiratory disease, and even food poisoning.

MRSA is a type of Staphylococcus aureus that is resistant to the usual antibiotics that are available in -lactam antimicrobial agents, including antistaphylococcal penicillins (methicillin, oxacillin, nafcillin) and cephalosporins. This is nothing new. It was discovered only two years after the introduction of methicillin way back in 1961. The problem with this disease is that it can be very invasive very quickly, and it is difficult to treat. Problems with MRSA do not end there. There are 94,360 invasive MRSA infections annually in the U.S., which lead to 18,650 deaths each year. Eighty-six percent of all invasive MRSA infections are health care associated.

Can it happen in dentistry?

MSSA and MRSA infections can be contracted by the public if we simply share towels, touch infected skin, or are in close contact in such places as schools and gyms. Person-to-person contact is the prevalent mode of transmission.

The transmission of MRSA in the dental setting is a possibility, though there have been very few documented cases. An example of the possibility is the documented transmission of MRSA from a British dental practitioner to patients.3 The two patients were seen within three weeks of each other, and both developed the same type of MRSA. The dentist had the same MRSA isolated from his fingernails. He did not wear gloves. He had undergone emergency surgery prior to the events, at a hospital that was dealing with an outbreak of MRSA. The dentist received treatment for the disease, and infection control was increased in his dental setting, including the use of gloves and handwashing. At an evaluation of his office setting nine weeks later, no MRSA was detected.

It is important to stay informed of all infection-control measures to prevent disease from occurring. One important area is clinical-contact surface and the housekeeping surfaces. S. aureus is a virulent bacterium that has the ability to survive on abiotic surfaces for up to 12 days! This can be a reservoir for transmission.4 Studies have found the bacteria present on clinical-contact surfaces post-treatment and on housekeeping surfaces. One study showed a shocking rate of the pathogen on a treasure chest for prizes in a pediatric clinic. Simply cleaning the box with a household cleaner eliminated the risk. Using a hospital-grade disinfectant for clinical-contact surfaces and keeping housekeeping surfaces clean is vital. Using FDA-approved barrier protection in these areas can help limit exposure. This is especially important on any area that has difficult-to-clean components, such as switch plates and light handles.

As with any disease, there are conditions that must be present in order for the disease to be transmitted. These conditions are called the chain of infection. The chart reviews MSSA and MRSA, and shows you how to break the links in the chain and thus prevent the disease.

MSSA: A lesson for us all

Jenna Lucas is the mother of two, a wife, and a registered dental hygienist. She is constantly going, going, going from her job to activities for her children, and the list and never ends. Her immune system started to react to her lifestyle; she had mastitis, and then a yeast infection two weeks after that. Jenna was like many of us – very busy taking care of everyone else and not always taking care of herself.

One Friday night was no different, when after a very long week filled with meetings, work, kids, and life, she noticed a pimple on her nose where her loupes rested under her eye. It wasn't anything special, just a little pimple. On Saturday she had no fever, but the lesion had increased and was slightly red and tender, so she called her doctor and emailed him a picture. He put her on Bactrim without seeing her or culturing the lesion.

Sunday the swelling was worse and invaded her forehead, right eye, and nose. She decided to go to the emergency room. They immediately put her on the intravenous antibiotic vancomycin, and discharged her with Keflex and Bactrim. They labeled the problem "cellulitis."

Jenna Lucas

By Monday the swelling had traveled down her nose. At her follow-up appointment with her doctor, he tried to drain the area but was not able to get much out. He thought it looked better than the previous day and told her that if it was not better on Tuesday, he would change the antibiotic. Jenna did not think it was getting better, and she became her own advocate, sending another picture to the doctor as the swelling increased. He told her to apply moist teabags to bring down the swelling.

She discussed the case with her dentist, who recommended she see an infectious disease specialist. After insurance red tape and no help from her primary care office, she decided to go back to the emergency room so she could get the help she needed. This gut instinct may have saved her life. The ER ordered a CAT scan and blood and wound cultures. Jenna's cellulitis was caused by MSSA, and it had come very close to her eye. A plastic surgeon and an infectious-disease doctor immediately drained the wound and placed a drain. Jenna spent two days in the hospital on IV antibiotics specific for the bacteria that were present.

She remained on antibiotics for another week, and stayed away from work for four weeks. Her infectious-disease doctor explained that she was covered with bacteria in the area of the wound, and she was not to have contact with anyone until the area was completely healed. Colonized people can transmit the disease to others they have close contact with. Patients with active infections are at a greater risk of transmission. It took three months for Jenna's swelling to go away.

Jenna shared how "crazy fast" all of this happened to her. "It was terrifying, especially being so close to the eye, the perfect portal to the brain. It could have gone really bad, REALLY fast!" She never ran a fever, and though she knew her immune system was very run-down and depleted, she never put it together with infection control. Her infection-control practices in the dental setting were model. She wore eye protection and all other required personal protection. She will now take it a step higher by adding a shield over her protective eyewear. Her advice to everyone is, "Take your health into your own hands. We try to trust our doctors, but your gut always knows the right thing to do."

MRSA: A lesson for us all

Debbie Edgar was a busy hygienist. She dealt with work and patients each day, and at the end of her long days she cared for her father, who was in nursing care. Add to that a lack of sleep, and you have a susceptible-host disease waiting to happen.

One day Debbie noticed a rash on the base of her left index finger at the palm of her hand. She managed to take some time to visit a dermatologist, who gave her an ointment to treat the rash. The ointment dried up the skin and created an area that became overdried, and may have become a portal to bacteria.

As days went by, Debbie noticed a joint soreness, but this was not enough to keep her away from work. Like most hygienists, minor pain did not keep her down. But then she noticed she had a little swelling. She went back to the dermatologist, who diagnosed her with arthritis. She was not able to see the rheumatologist for four weeks.

The tenderness and swelling increased, and she saw her family doctor, who agreed with the dermatologist's diagnosis. At night, Debbie could not even touch the area on her hand because it was so painful. Her husband finally took her to the emergency room. There they quickly eliminated arthritis, but in error gave her prednisone (not recommended for MRSA, and it can exacerbate the issues). The next day she took matters into her own hands and got an appointment with the rheumatologist, who immediately contacted an infectious disease specialist. Debbie had surgery that day. Four days after surgery, MRSA was identified.

Debbie Edgar

Debbie was hospitalized for five days after surgery and quarantined. She soon learned she had to become her own advocate in the hospital setting. Protocols were not followed, and she frequently had to ask providers to don gloves and wash their hands.

"You have to be your own advocate, and you have to insist on infection control procedures," she said. Debbie was on a PIC line IV system for six weeks, with vancomycin two times a day. She could not work for eight weeks, and she had to limit her scaling when she did return to work. Debbie wants to remind all of us how important it is to cover any open wounds and apply antibiotic ointment. Contact dermatitis should be resolved before working on patients.

What are MSSA/MRSA symptoms? According to CDC,5 people often initially think the affected area is a spider bite; however, unless a spider is actually seen, the irritation is likely not a bite. Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that might be:

  • Red
  • Swollen
  • Painful
  • Warm to the touch
  • Full of pus or other drainage
  • Accompanied by a fever

The solution to the challenges in the dental setting surrounding MSSA and MRSA is simple and achievable. It requires a few simple infection-control measures that we all know we should be doing. When we do what we know is right, we can prevent this disease in the dental setting.  

NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists' Association.

References

1. Lowy FD. Staphylococcus aureus infections. New Engl J Med 1998;339(8):520-532.
2. Huang R, Mehta S, Weed D, Price CS. Methicillin-resistant Staphylococcus aureus survival on hospital fomites (published online ahead of print Sept. 28, 2006). Infect Control Hosp Epidemiol 2006;27(11):1267-1269. doi:10.1086/507965.
3. Martin MV, Hardy P. Two cases of oral infection by methicillin-resistant Staphylococcus aureus. Br Dent J 1991;170(2):63-64.
4. Johnston CP, Cooper L, Ruby W, et al. Epidemiology of community-acquired methicillin-resistant Staphylococcus aureus skin infections among healthcare workers in an outpatient clinic (published online ahead of print Aug. 31, 2006). Infect Control Hosp Epidemiol 2006;27(10):1133-1136. doi:10.1086/507970
5. http://www.cdc.gov/mrsa/community/
6. Roberts MC, Soge OO, Horst JA, Ly KA, Milgrom P. Methicillin-resistant Staphylococcus aureus from dental school clinic surfaces and students, AJIC: American Journal of Infection Control 2011; 39(8): 628-632.

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