Open access peer-reviewed chapter

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

Written By

Livia Barenghi, Alberto Barenghi and Alberto Di Blasio

Submitted: September 3rd, 2018 Reviewed: September 13th, 2018 Published: November 5th, 2018

DOI: 10.5772/intechopen.81494

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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.


  • 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, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26]. Here, we have focused mainly on hand hygiene, PPE use, environment decontamination, and instrument reconditioning [19, 20, 27, 28, 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, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 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 vivobiosensors 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, 44, 45, 46, 47].


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, 49, 50, 51, 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) 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, 17, 18, 19, 20, 27, 28, 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, 6, 7, 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, 13, 14, 15, 60, 61, 62, 63, 64, 65, 66, 67, 68].

Study (publication date, country) [reference]Dental settingHand hygiene (%)Use of protective eyewear (%)Use of gloves (%)Wearing/use of mask (%)Instrument reprocessing (%)Autoclave quality control (%)Handpieces reprocessing after every patients (%)Other violations or noncompliances (%)
Hübner et al. (Germany) [60]35 dental practices1115–236 (autoclave class N)8067
Mutters et al. (Germany) [61]58 invasive dental cares in university dental clinic95 (N)
61–65 (D) (after glove removal)
14.3 (D♀)
28.6 (N)
16 (N)Presence of jewelry during DP in N (80.7%)
Copello et al. (review) (Italy) [62]76 different dental practices (dentist males (78%), professionals aged 50 years or above (59%)40 (goggles)2 (lack of steam autoclave class B)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; 40%: not regular stocking of waste materials
Balcheva et al. (Bulgaria) [63]94 dental students35.5 (prewash); 8.5 (postwash)79.8 (goggles); 95.7 (shield)8.533.0 (use); 51.1 (mask change)
Anders et al. (USA) [64]214 dental students (third-fourth year)56.8 (during the preoperative phase); 23.3 (postoperative phase after removing gloves)53.735.712%: overall noncompliance with infection control parameters in dental students
Dagher et al. (Lebanon) [65]1150 private dental clinics9.954.37.610.921 (automatic washing of used instruments); 35 (steam autoclave) ; 34.7 (dry heat sterilized burs and 39.7 (dry heat sterilized endodontic files; 29.6 (wrapping barrier for instrument sterilization)72.319 (wiping with disinfectant on CCSs); 44.9 (use of surface barriers); 61.6% (impression disinfection
Mandourh et al. (Saudi Arabia) [66]107 dentists working in 34 private dental clinics in ten districts
(♂: 66.4%; ♀: 33.6%)
65.4 (after glove removal (D) with the daily workload (>10 patients/day): the 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%)♂:8.5;
♀: 5.6 (nonawareness of wearing protective eyewear)
54.211.2Keeping sterile instruments in pouches (3.8%)4.670%: 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 contaminated gloved hands was done by 81.3% of the dentists with daily workloads of more than 10 patients.
Yadav et al. (India) [67]30 dental surgeons working in a private dental hospital50 (hand sanitizer)93.45 (disposable gloves)
80 (sterile gloves)
2066 (autoclave); ∼70 (use of irritant disinfectants for instruments; 10 (bur reconditioning); 30 (endodontic files reconditioning)10100% (use of rubber dam); 90% (use of high speed evacuator); 100% (use of surface barriers)
da Costa et al. (Brazil) [68]641 undergraduate dentistry students, 20 Ph.D. students, 15 oral radiology professorsMany factors in oral radiology, mainly associated with: plastic barriers, performance of infection control procedures; use of overgloves

Table 1.

Violations or noncompliances (%) concerning selected infection control procedures.

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

4.1 Hand and glove contamination of DHCP

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:

  • when hands are not visibly soiled

  • before donning gloves and after glove removal

  • following instruction for use (IFU) (product amount, time) by the manufacturer since are efficacious on MRSA even when gloves were not used for routine clinical care [70]

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

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

Concerning gloves, the physical properties of different materials influence bacterial passage in case of glove puncture due to sharp injuries [27, 28, 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, 28, 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 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 Enterococcushand 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. Staphylococcusand Enterococcusspecies 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 Pseudomonasssp. 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, 14, 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 Enterococcusspp., including VRE, can survive from 5 days to 4 months on dry inanimate surfaces [86, 87, 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, 41, 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 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 surfaces were MRSA positive [92],

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

  • 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 [21, 95],

  • the contamination of S. aureusand MRSA on the gloved-dominant hand and the tray are similar, being 5 and 1.5% respectively [69],

  • 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 isolates were resistant to penicillin [96],

  • a high contamination of SA and MRSA species have been reported from materials used in radiographic processing, mainly on the lids of the portable dark rooms [97],

  • in dental settings, the phone contamination is very high and is by S. aureus, E. coli, Enterococcus, and Pseudomonas(see Ref. in [13, 14, 15, 98]),

  • 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. aureusand E. faecaliswas, 20 and 10%, respectively [93], and

  • widespread microbial contamination of air, surface, and dental unit water samples and violations concerning environmental cleaning have been reported in dental surgeries [17, 18].

Recommendations for assessing the effectiveness of disinfection and cleaning practices indicate that the suitable levels of total bacterial numbers in the health care setting are in the range of 2.5–5 CFU/cm2 [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. aureusand E. faeciummay 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. aureusand Enterococcusspp. [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, 14, 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 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, 24, 25, 26, 38, 111, 112, 113, 114, 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, 24, 25, 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 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 (Des-check, 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, 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 vivobiosensors 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, 44, 45, 46, 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:

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

  • increased training and skill-based behavior

  • high proactivity & interaction & communication among DHCP

  • appropriated human and economic resources

  • proper time for IC prevention (hand hygiene, gloves and mask use/change, etc.)

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

  • 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%, 27 respectively) [123, 124]

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

  • acceptable workload-occupational stress to avoid DHCP distraction

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

For future safe and patient-centered dental cares, it is crucial that we increase the professional harmonization and ergonomics of the highly complex “human-technical 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 (, neither of which gave any input or financial support to the writing of this article. There is no other conflict of interest to report.



AEadverse event
ARIAantibiotic-resistant infectious agents
AQLaccepted quality assurance level
CDCcenters for disease control and prevention
CCSsclinical contact surfaces
DDdental device
DHCPdental healthcare personnel
DIdental implant
DUWLdental unit water line
ECeuropean community
HPCheterotrophic plate count
ICinfection control
IFUinstruction for use
MRSAmethicillin-resistant Staphylococcus aureus
PCRpolymerase chain reaction
VREvancomycin-resistant Enterococcus


  1. 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. 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. 3. Summary of Infection Prevention Practices in Dental Settings. USA: Centers for Disease Control and Prevention; 2016. Available[Accessed: 06-12-2018]
  4. 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
  5. 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. 6. Arduino M, Miller J, Shannon M. Safe Water, Safe Dentistry, Safe Kids. Webinar: Organization for Safety Asepsis and Prevention; 2017. Available from: [Accessed: 27-05-2017]
  7. 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)60074-9
  8. 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: 10.1016/j.adaj.2017.10.002
  9. 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. 10. Petti S, Polimeni A. Risk of methicillin-resistantStaphylococcus aureustransmission in the dental healthcare setting: A narrative review. Infection Control and Hospital Epidemiology. 2011;32(11):1109-1115. DOI: 10.1086/662184
  11. 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):858-861. DOI: 10.1016/j.adaj.2017.08.026
  12. 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. DOI: 10.1111/idj.12134
  13. 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: 10.5812/ijo.10201
  14. 14. Barenghi L. Clean, Disinfect and Cover: Top Activities for Clinical Contact Surfaces in Dentistry [Internet]; 2015. Available[Accessed: 06-12-2018]
  15. 15. Barenghi L. The Daily Fight to Limit Cross-Infection in a Dental Office [Internet]. Webinar; 2017. Available from:[Accessed: 06-12-2018]
  16. 16. Jakubovics N, Greenwood M, Meechan JG. General medicine and surgery for dental practitioners: Part 4. Infections and infection control. British Dental Journal. 2014;217(2):73-77. DOI: 10.1038/sj.bdj.2014.593
  17. 17. Monarca S, Grottolo M, Renzi D, Paganelli C, Sapelli P, Zerbini I, et al. Evaluation of environmental bacterial contamination and procedures to control cross infection in a sample of Italian dental surgeries. Occupational and Environmental Medicine. 2000;57:721-726. DOI: 10.1136/oem.57.11.721
  18. 18. Schaefer MK, Michael J, Marilyn Dahl M, et al. Infection control assessment of ambulatory surgical centers. Journal of the American Medical Association. 2010;303(22):2273-2279. DOI: 10.1001/jama.2010.744
  19. 19. Rutala WA, Weber DJ; the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for infection control in dental health-care settings 2003. MMVR. 2003;52:1-61. Available[Accessed: 06-12-2018]
  20. 20. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities; 2008. Available[Accessed: 15-02-2017]
  21. 21. Kharialla AS, Wasfi R, Ashour HM. Carriage frequency, phenotypic and genomic characteristics of methicillin-resistantStaphylococcus aureusisolated from dental health care personnel, patients and environment. Scientific Reports. 2017;7:7390. DOI: 10.1038/s41598-017-07713-8
  22. 22. Cheng VCCC, Wong SCY, Sridhar S, Chan JFW, Lai-Ming M, Lau SKP, et al. Management of an incident of failed sterilization of surgical instruments in a dental clinic in Hong Kong. Journal of the Formosan Medical Association. 2013;112:666-675. DOI: 10.1016/j.jfma.2013.07.020
  23. 23. Hogg NJV, Morrison AD. Resterilization of instruments used in a hospital-based oral and maxillofacial surgery clinic. Journal of the Canadian Dental Association. 2005;71:179-182. ISSN: 1488-2159. Available[Accessed: 29-07-2017]
  24. 24. Wu G, Yu X. Influence of usage history, instrument complexity, and different cleaning procedures on the cleanliness of blood-contaminated dental surgical instruments. Infection Control and Hospital Epidemiology. 2009;30(7):702-704. DOI: 10.1086/598241
  25. 25. Takamoto M, Takechi M, Ohta K, Ninomiya Y, Ono S, Shigeishi H, et al. Risk of bacterial contamination of bone harvesting devices used for autogenous bone graft in implant surgery. Head and Face Medicine. 2013;9(3):1-5 10.1186/1746-160X-9-3
  26. 26. Vassey M, Budge C, Poolman T, Jones P, Perrett D, Nayuni N, et al. A quantitative assessment of residual protein levels on dental instruments reprocessed by manual, ultrasonic and automated cleaning methods. British Dental Journal. 2011;210(9):E14. DOI: 10.1038/sj.bdj.2011.144
  27. 27. Ehrlich T, Dietz B. Modern Dental Assisting. 5th ed. Chapter 30. USA: W.B Sounders Company; 1995. ISBN 0-7216-5053-8
  28. 28. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 4th ed. Chaps. 8, 10–14, 17. Evolve. USA: Mosby Elsevier; 2010. ISBN 978-0-323-05631-1
  29. 29. Pankhurst CL, Coulter WA. Basic Guide to Infection Prevention and Control in Dentistry. 2nd ed. Chapters 2, 4-9. UK: Wiley Blackwell; 2017. ISBN 9781119164982
  30. 30. Centers for Disease Control and Prevention. Office of Infectious Disease. Antibiotic Resistance Threats in the United States. 2013. Available from: [Accessed: 24-07-2018]
  31. 31. Elias CN, Meirelles L. Improving osseointegration of dental implants. Expert Review of Medical Devices. 2010;7(2):241-256. DOI: 10.1586/ERD.09.74
  32. 32. Duraccio D, Mussano F, Faga MG. Biomaterials for dental implants: Current and future trends. Journal of Materials Science. 2015;50:4779-4812. DOI: 10.1007/s10853-015-9056-3
  33. 33. Pokrowiecki R, Mielczarek A, Zaręba T, Tyski S. Oral microbiome and peri-implant diseases: Where are we now? Therapeutics and Clinical Risk Management. 2017;13:1529-1542. DOI: 10.2147/TCRM.S139795
  34. 34. Rasouli R, Barhoum A, Uludag H. A review of nanostructured surfaces and materials for dental implants: Surface coating, patterning and functionalization for improved performance. Biomaterials Science. 2018;6:1312-1338. DOI: 10.1039/c8bm00021b
  35. 35. Miranda-Rius J, Lahor-Soler E, Brunet-Llobet L, de Dios D, Gil FX. Treatments to optimize dental implant surface topography and enhance cell bioactivity. In: Almasri MA, editor. Dental Implantology and Biomaterial Dental Implantology and Biomaterial. Rijeka: InTech; 2016. pp. 110-127. DOI: 10.5772/62682
  36. 36. Toledo-Arana A, Valle J, Solano C, Arrizubieta MJ, Cucarella C, Lamata M, et al. The enterococcal surface protein, Esp, is involved inEnterococcus faecalisbiofilm formation. Applied and Environmental Microbiology. 2001;67(10):4538-4545. DOI: 10.1128/AEM.67.10.4538–4545.2001
  37. 37. Komiyama EY, Lepesqueur LSS, Yassuda CG, Samaranayake LP, Parahitiyawa NB, Balducci I, et al. Enterococcus species in the oral cavity: Prevalence, virulence factors and antimicrobial susceptibility. PLoS One. 2016;11(9):e0163001. DOI: 10.1371/journal.pone.0163001
  38. 38. Dancer SJ. Controlling hospital-acquired infection: Focus on the role of the environment and new technologies for decontamination. Clinical Microbiology Reviews. 2014;27(4):665-690. DOI: 10.1128/CMR.00020-14
  39. 39. Petti S, Polimeni A, Dancer SJ. Effect of disposable barriers, disinfection, and cleaning on controlling methicillin-resistantStaphylococcus aureusenvironmental contamination. American Journal of Infection Control. 2013;41(9):836-840. DOI: 10.1016/j.ajic.2012.09.0
  40. 40. Reifsteck F, Wee S, Wllklnson BJ. Hydrophobicity-hydrophilicity of staphylococci. Journal of Medical Microbiology. 1987;24:65-73. DOI: 10.1099/00222615-24-1-65
  41. 41. Hsu LC, Fang J, Borca-Tasciuc DA, Worobo RW, Moraru CI. Effect of micro-and nanoscale topography on the adhesion of bacterial cells to solid surfaces. Applied and Environmental Microbiology. 2013;79(8):2703-2712. DOI: 10.1128/AEM.03436-12
  42. 42. Krasowska A, Sigler K. How microorganisms use hydrophobicity and what does this mean for human needs? Frontiers in Cellular and Infection Microbiology. 2014;4(112):1-7. DOI: 10.3389/fcimb.2014.00112
  43. 43. Siqueira JF, Fouad AF, Rocas IN. Pyrosequencing as a tool for better understanding of human microbiomes. Journal of Oral Microbiology. 2012;4:10743. DOI: 10.3402/jom.v4i0.10743
  44. 44. Tsunemine H, Yoshioka Y, Nagao M, Tomaru Y, Saitoh T, Adachi S, et al. Multiplex polymerase chain reaction assay for early diagnosis of viral infection. In: Samadikuchaksaraei A, editor. Polymerase Chain Reaction for Biomedical Applications. Rijeka: InTech; 2016. pp. 69-82. DOI: 10.5772/65771
  45. 45. Rozman U, Turk SŠ. PCR technique for the microbial analysis of inanimate hospital environment. In: Samadikuchaksaraei A, editor. Polymerase Chain Reaction for Biomedical Applications. Rijeka: InTech; 2016. pp. 119-134. DOI: 10.5772/65742
  46. 46. Valeriani F, Protano C, Gianfranceschi G, Cozza P, Campanella V, Liguori G, et al. Infection control in healthcare settings: Perspectives for mfDNA analysis in monitoring sanitation procedures. BMC Infectious Diseases. 2016;16:394. DOI: 10.1186/s12879-016-1714-9
  47. 47. Ibacache-Quiroga C, Romo N, Díaz-Viciedo R, Dinamarca MA. Detection and control of indoor airborne pathogenic bacteria by biosensors based on quorum sensing chemical language: Bio-tools, connectivity apps and intelligent buildings. In: Rinken T, editor. Biosensing Technologies for the Detection of Pathogens—A Prospective Way for Rapid Analysis. Rijeka: InTech; 2018. pp. 73-87. DOI: 10.5772/intechopen.72390
  48. 48. Hiivala N. Patient safety incidents, their contributing, and mitigating factors in dentistry [thesis]. Universitatis Helsinkiensis; 2016
  49. 49. Chang WJ, Chang YH. Patient satisfaction analysis: Identifying key drivers and enhancing service quality of dental care. Journal of Dental Sciences. 2013;8:239-247. DOI: 10.1016/j.jds.2012.10.006
  50. 50. Shyagali TR, Bhayya DP. Patient’s attitude and knowledge towards the usage of barrier technique by orthodontists. International Journal of Infection Control. 2012;8(3):1-8. DOI: 10.3396/ijic.v8i3.9667
  51. 51. Alagil NA, Mubayrik AB. Dental patients’ knowledge, awareness, and attitude regarding infection control procedures. The Australasian Medical Journal. 2017;10(9):789-799. DOI: 10.21767/AMJ.2017.3123
  52. 52. Luo JYN, Liu PP, Wong MCM. Patients’ satisfaction with dental care: A qualitative study to develop a satisfaction instrument. BMC Oral Health. 2018;18(15):1-10. DOI: 10.1186/s12903-018-0477-7
  53. 53. 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
  54. 54. 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
  55. 55. Chen YC, Sheng WH, Wang JT, Chang SC, Lin HC, Tien KL, et al. Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections. PLoS One. 2011;6(11):e27163. DOI: 10.1371/journal.pone.0027163
  56. 56. Bradley KK. Dental Healthcare-Associated Transmission of Hepatitis C. Final Report of Public Health Investigation and Response. 2013. Available[Accessed: 17-06-2018]
  57. 57. Manjunath N, Banu F, Chopra A, Kumar P, Nishana F. Management of MRSA patients on the dental chair. International Journal of Research in Medical Science. 2017;5(8):3729-3733. DOI: 10.18203/2320-6012.ijrms20173595
  58. 58. Clayton JL, Miller KJ. Professional and regulatory infection control guidelines: Collaboration to promote patient safety. AORN Journal. 2017;106:201-210. DOI: 10.1016/j.aorn.2017.07.005
  59. 59. Antonucci A. Risk Management in Complex Organizations. In: Svalova V, editor. Risk Assessment. Rijeka: InTech; 2018. pp. 337-369. DOI: 10.5772/intechopen.70762
  60. 60. Hübner NO, Handrup S, Meyer G, Kramer A. Impact of the Guidelines for infection prevention in dentistry (2006) by the Commission of Hospital Hygiene and Infection Prevention at the Robert Koch-Institute (KRINKO) on hygiene management in dental practices – analysis of a survey from 2009. GMS Krankenhaushygiene Interdisziplinär. 2012;7(1):1-6. DOI: 10.3205/dgkh000198
  61. 61. Mutters NT, Hagele U, Hagenfeld D, Hellwig E, Frank U. Compliance with infection control practices in an university hospital dental clinic. GMS Hygiene and Infection Control. 2014;9(3):1-5. DOI: 10.3205/dgkh000238
  62. 62. Copello F, Garbarino S, Messineo A, Campagna M, Durando P, Collaborators. Occupational medicine and hygiene: Applied research in Italy. Journal of Preventive Medicine and Hygiene. 2015;56(2):E102-E110. PMCID: PMC4718353 and PMID: 26789987. Available [Accessed: 12-06-2018]
  63. 63. Balcheva M, Panov VE, Madjova C, Balcheva G. Occupational infectious risk in dentistry-awareness and protection. Journal of IMAB. 2015;21(4):995-999. DOI: 10.5272/jimab.2015214.995
  64. 64. Anders PL, Townsend NE, Davis EL, McCall WDJ. Observed infection control compliance in a dental school: A natural experiment. American Journal of Infection Control. 2016;44(9):e153-e156. DOI: 10.1016/j.ajic.2016.01.036
  65. 65. Dagher J, Sfeir C, Abdallah A, Majzoub Z. Infection control measures in private dental clinics in Lebanon. International Journal of Dentistry. 2017;2017, 11 pages. DOI: 10.1155/2017/5057248
  66. 66. Mandourh MS, Alhomaidhi NR, Fatani NH, Alsharif AS, Ujaimi GK, Khan GM, et al. Awareness and implementation of infection control measures in private dental clinics, Makkah, Saudi Arabia. International Journal of Infection control. 2017;13(1):1-14. DOI: 10.3396/IJIC.v13i1.004.17
  67. 67. Yadav BK, Rai AK, Agarwal S, Yadav B. Assessment of infection control practice in private dental hospital. International Journal of Research in Medical Sciences. 2017;5(11):4737-4742. DOI: 10.18203/2320-6012.ijrms20174687
  68. 68. da Costa E, Pinelli C, da Silva Tagliaferro EP, Corrente JE, Ambrosano GMB. Development and validation of a questionnaire to evaluate infection control in oral radiology. Dento Maxillo Facial Radiology. 2017;46:20160338. DOI: 10.1259/dmfr.20160338
  69. 69. Messano GA, De Bono V, Architrave R, Petti S. Environmental and gloves’ contamination by staphylococci in dental healthcare settings. Acta Stomatologica Naissi. 2013;29:1255-1259. DOI: 10.5937/asn1367255M
  70. 70. Jain S, Clezy K, McLaws M-L. Safe removal of gloves from contact precautions: The role of hand hygiene. American Journal of Infection Control. 2018;xxx:xxx-xxx. DOI: 10.1016/j.ajic.2018.01.013
  71. 71. Pires D, Bellissimo-Rodrigues F, Pittet D. Ethanol-based handrubs: Safe for patients and health care workers. American Journal of Infection Control. 2016;44(8):858-859. DOI: 10.1016/j.ajic.2016.02.016
  72. 72. Bardorf MH, Jäger B, Boeckmans E, Kramer A, Assadian O. Influence of material properties on gloves’ bacterial barrier efficacy in the presence of microperforation. American Journal of Infection Control. 2016;44:1645-1649. DOI: 10.1016/j.ajic.2016.03.070
  73. 73. Patel B. Infection control in the endodontic office. In: Patel B, editor. Endodontic Diagnosis, Pathology, and Treatment Planning: Mastering Clinical Practice. Switzerland: Springer International Publishing; 2015. pp. 87-101. DOI: 10.1007/978-3-319-15591-3_7
  74. 74. Tlili MA, Belgacem A, Sridi H, Akouri M, Aouicha W, Soussi S, et al. Evaluation of surgical glove integrity and factors associated with glove defect. American Journal of Infection Control. 2018;46(1):30-33. DOI: 10.1016/j.ajic.2017.07.016
  75. 75. Florman S, Burgdorf M, Finigan K, Slakey D, Hewitt R, Nichols RL. Efficacy of double gloving with an intrinsic indicator system. Surgical Infections (Larchmt). 2005;6(4):385-395. DOI: 10.1089/sur.2005.6.385
  76. 76. Kramer A, Assadian O. Indication and requirements for single–Use medical gloves. GMS Hygiene and Infection Control. 2016;11:1-6. DOI: 10.3205/dgkh000261
  77. 77. Al-Swuailem AS. Prevalence of manufacturing defects in latex examination gloves used in selected dental practices in central Saudi Arabia. Saudi Medical Journal. 2014;35(7):729-733. PMID: 25028231
  78. 78. Bandlish LK. Infection control: Removing the sensation. British Dental Journal. 2015;219:469. DOI: 10.1038/sj.bdj.2015.864
  79. 79. Hayden MK. Insights into the epidemiology and control of infection with Vancomycin Resistant Enterococci. Clinical Infectious Diseases. 2000;31(4):1058-1065. DOI: 10.1086/318126
  80. 80. Fully TLCS, de Souza Lucena EE, de Souza Dias TG, Barbalho JCM, Lucena VCF, de Araújo Morais HH. Glove perforations after dental care. Revista Gaúcha de Odontologia, Porto Alegre. 2015;63(2):175-180. DOI: 10.1590/1981-863720150002000062823
  81. 81. Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcare associated Infections. Current Opinion in Infectious Diseases. 2013;26(4):338-344. DOI: 10.1097/QCO.0b013e3283630f04
  82. 82. Raghunath N, Meenakshi S, Sreeshyla HS, Priyanka N. Aerosols in dental practice-A neglected infectious vector. British Microbiology Research Journal. 2016;14(2):1-8. DOI: 10.9734/BMRJ/2016/24101
  83. 83. Szymańska J, Sitkowska J. Bacterial hazards in a dental office: An update review. African Journal of Microbiology Research. 2012;6(8):1642-1650. DOI: 10.5897/AJMR11.1002
  84. 84. Omogbai OC, Ehizele AO, Sede MA. Prevalence and antimicrobial susceptibility profile of Pseudomonas spp isolated from water specimen in a Nigerian dental practice. Nigerian Journal of Restorative Dentistry. 2017;2(1):16-20. Available from:[Accessed: 23-06-2018]
  85. 85. Hall DL. Methicillin-resistantStaphylococcus aureusand infection control for restorative dental treatment in nursing homes. Special Care in Dentistry. 2003;23(3):100-107. PMID:14650558
  86. 86. Mertz D, Frei R, Jaussi B, Tietz A, Stebler C, Fluckiger U, et al. Throat swabs are necessary to reliably detect carriers ofStaphylococcus aureus. Clinical Infectious Diseses. 2007;45(4):475-477. DOI: 10.1086/520016
  87. 87. Siani H, Maillard JY. Best practice in healthcare environment decontamination. European Journal of Clinical Microbiology and Infectious Diseases. 2015;34:1-11. DOI: 10.1007/S10096-014-2205-9
  88. 88. Esteves DC, Pereira VC, Souza JM, Keller R, Simões RD, Winkelstroter Eller LK, et al. Influence of biological fluids in bacterial viability on different hospital surfaces and fomites. American Journal of Infection Control. 2016;44:311-314. DOI: 10.1016/j.ajic.2015.09.033
  89. 89. Kurita H, Kurashina K, Honda T. Nosocomial transmission of MRSA via the surfaces of the dental operatory. British Dental Journal. 2006;201(5):297-300. DOI: 10.1038/sj.bdj.4813974
  90. 90. Petti S, De Giusti M, Moroni C, Polimeni A. Long-term survival curve of methicillin-resistantStaphylococcus aureuson clinical contact surfaces in natural-like conditions. American Journal of Infection Control. 2012;40:1010-1012. DOI: 10.1016/j.ajic.2011.11.020
  91. 91. Lax S, Sangwan N, Smith D, Larsen P, Handley KM, Richardson M, et al. Bacterial colonization and succession in a newly opened hospital. Science Translational Medicine. 2017;9(24):1-11. DOI: 10.1126/scitranslmed.aah6500
  92. 92. Roberts MC, Soge OO, Horst JA, Ly KA, Milgrom P. Methicillin-resistantStaphylococcus aureusfrom dental school clinic surfaces and students. American Journal of Infection Control. 2011;39:628-632. DOI: 10.1016/j.ajic.2010.11.007
  93. 93. Decraene V, Ready D, Pratten J, Wilson M. Air-borne microbial contamination of surfaces in a UK dental clinic. The Journal of General and Applied Microbiology. 2008;54(4):195-203. PMID:18802318
  94. 94. Faden A. Methicillin-resistantStaphylococcus aureus(MRSA) screening of hospital dental clinic surfacesStaphylococcus aureus(MRSA) screening. Saudi Journal of Biological Sciences. 2018;xxx:xxx-xxx. DOI: 10.1016/j.sjbs.2018.03.006
  95. 95. Korkut E, Uncu AT, Sener Y. Biofilm formation byStaphylococcus aureusisolates from a dental clinic in Konya, Turkey. Journal of Infection and Public Health. 2017;10:809-813. DOI: 10.1016/j.jiph.2017.01.004
  96. 96. Trochesset DA, Walker SG. Isolation ofStaphylococcus aureusfrom environmental surfaces in an academic dental clinic. The Journal of the American Dental Association. 2012;143(2):164-169. PMID:22298558
  97. 97. Dos Santos RM, Dos Santos FLM, Ramacciato JC, Junqueira JLC. Evaluation of antimicrobial contamination and resistance toStaphylococcus aureuscollected from radiographic materials used in dentistry. Revista Gaúcha de Odontologia. 2012;60(4):467-477. ISSN 1981-8637
  98. 98. Fard RH, Fard RH, Moradi M, Hashemipour MA. Evaluation of the cell phone microbial contamination in dental and engineering schools: Effect of antibacterial spray. Journal of Epidemiology and Global Health. 2017;xxx:xxx-xxx. DOI: 10.1016/j.jegh.2017.10.004
  99. 99. Gerba CP, Lopez GU, Ikner LA. Distribution of bacteria in dental offices and the impact of hydrogen peroxide disinfecting wipes. The Journal of Dental Hygiene. 2016;90(6):354-361. PMID: 29118156
  100. 100. Heller LC, Edelblute CM. Long-term metabolic persistence of gram-positive bacteria on health care-relevant plastic. American Journal of Infection Control. 2018;46:50-53. DOI: 10.1016/j.ajic.2017.07.027
  101. 101. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabric and plastic. Journal of Clinical Microbiology. 2000;38:724-726. PMID: 10655374
  102. 102. Poole K. Mechanisms of bacterial biocide and antibiotic resistance. Journal of Applied Microbiology. 2002;92:55S-64S. PMID: 12000613
  103. 103. Gebel J, Exner M, French G, Chartier Y, Christiansen B, Gemein S, et al. The role of surface disinfection in infection prevention. GMS Hygiene and Infection Control. 2013;8(1):1-12. DOI: 10.3205/dgkh000210
  104. 104. Meade E, Garve M. Efficacy testing of novel chemical disinfectants on clinically relevant microbial pathogens. American Journal of Infection Control. 2018;46:44-49. DOI: 10.1016/j.ajic.2017.07.001
  105. 105. Kenters N, Huijskens EGW, de Wit SCJ, van Rosmalen J, Voss A. Effectiveness of cleaning-disinfection wipes and sprays against multidrug-resistant outbreak strains. American Journal of Infection Control. 2017;45:e69-e73. DOI: 10.1016/j.ajic.2017.04.290
  106. 106. Vidana R, Sillerström E, Ahlquist M, Lund B. Potential for nosocomial transmission of Enterococcus faecalis from surfaces in dental operatories. International Endodontic Journal. 2015;48(6):518-527. DOI: 10.1111/iej.12342
  107. 107. Multiple-Use Dental Dispenser Devices [Internet]. 2017. Available[Accessed: 17-06-2018]
  108. 108. Perçin D. Sterilization practices and hospital infections: Is there a relationship? International Journal of Antisepsis Disinfection Sterilization. 2016;1(1):19-22. DOI: 10.14744/ijads.2016.76476
  109. 109. Motamedi MHK, Navi F, Valai N, Ghaffari K, Ardalan A. Can oral debris on dental instruments harbor organisms from disinfection? Journal of Oral Hygiene and Health. 2016;4:1. DOI: 10.4172/2332-0702.1000195
  110. 110. Li XL, Ji GY. Evaluation of the direct relationship between bacterial load on contaminated stainless steel surgical instruments and the holding time prior to disinfection and also to analyse the efficacy of different disinfecting solutions. Biomedical Research. 2017;28(10):4680-4687. ISSN 0970-938X
  111. 111. Dietze B, Rath A, Wendt C, Martiny H. Survival of MRSA on sterile goods packaging. The Journal of Hospital Infection. 2001;49(4):255-261. DOI: 10.1053/jhin.2001.1094
  112. 112. Campbell C, Barton A, Boyle R, Tully V. Improving the inspection and manual cleaning of dental instruments in a dental hospital. BMJ Quality Improvement Reports. 2016;5(1):u205075.w2305. DOI: 10.1136/bmjquality.u205075.w2305
  113. 113. Cuny E. The use of a process challenge device in dental office gravity displacement tabletop sterilizers. American Journal of Infection Control. 2015;43(10):1131-1133. DOI: 10.1016/j.ajic.2015.05.044
  114. 114. Sonntag D, Martin E, Raab WHM. Representative survey on the reprocessing of endodontic instruments in Germany. British Dental Journal. 2016;220:465-469. DOI: 10.1038/sj.bdj.2016.333
  115. 115. Wadhwani C, Schonnenbaum TR, Audia F, Chung KH. In-vitro study of the contamination remaining on used healing abutments after cleaning and sterilizing in dental practice. Clinical Implant Dentistry and Related Research. 2016;18(6):1069-1074. DOI: 10.1111/cid.12385
  116. 116. Barenghi L. Strumenti Danneggiati? Cause, Conseguenze e Consigli Operativi [Internet]. Available from:[Accessed: 17-06-2018]
  117. 117. Di Blasio A, Barenghi L. Pitfalls of cleaning controls in ultrasonic washers. American Journal of Infection Control. 2015;43:1372-1381. Available from:
  118. 118. Surgical cassette [Internet]. Available from:[Accessed: 17-06-2018]
  119. 119. Surgical-cassette [Internet]. Available from:[Accessed: 17-06-2018]
  120. 120. NobelActive/NobelParallel CC PureSet Tray [Internet]. Available from:[Accessed: 17-06-2018]
  121. 121. 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
  122. 122. Zeng X, Wang G, Liua Y, Zhang X. Graphene-based antimicrobial nanomaterials: Rational design and applications for water disinfection and microbial control. Environmental Science: Nano. 2017;12:2248-2266. DOI: 10.1039/c7en00583k
  123. 123. Egusa H, Watamoto T, Abe K, Kobayashi M, Kaneda Y, Ashida S, et al. An analysis of the persistent presence of opportunistic pathogens on patient-derived dental impressions and gypsum casts. The International Journal of Prosthodontics. 2008;21(1):62-68. PMID: 18350950
  124. 124. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. British Dental Journal. 2015;219(11):521-529. DOI: 10.1038/sj.bdj.2015.914
  125. 125. Mokdad M, Abdel-Moniem T. New paradigms in ergonomics: The positive ergonomics. In: Korhan O, editor. Occupational Health. Rejika: InTech; 2017. pp. 1-22. DOI: 10.5772/66393

Written By

Livia Barenghi, Alberto Barenghi and Alberto Di Blasio

Submitted: September 3rd, 2018 Reviewed: September 13th, 2018 Published: November 5th, 2018