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Asian Journal of Oral and Maxillofacial Surgery 22 (2010) 12–16

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Asian Journal of Oral and Maxillofacial Surgery


journal homepage: www.elsevier.com/locate/ajoms

Original Research

Blood contamination of environmental surfaces in outpatient oral surgery


operatory
Takenobu Wada, Kohji Ishihama ∗ , Koji Yonemitsu, Satoshi Sumioka,
Chiaki Yamada, Masataka Higuchi, Mikihiko Kogo
First Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan

a r t i c l e i n f o a b s t r a c t

Article history: High-speed instruments potentially produce large amounts of contaminated splatters and aerosols during
Received 22 May 2009 dental procedures. To evaluate the dissemination of blood and distribution of frequent contaminations,
Accepted 2 July 2009 we investigated blood contamination on environmental surfaces of equipment in an outpatient procedure
Available online 8 June 2010
room. Test samples were collected with disposable alcohol cotton from 443 portions on the surfaces of
medical equipment, and a leucomalachite green blood detection test was then applied. Positive results
Keywords:
were common for dental chair equipment requiring frequent hand contact, such as the controller of the
Aerosols
electric coagulator (46.2%, 6/13) and armrest (36.4%, 4/11). On the surfaces with minimal hand contact,
Nosocomial infection
Dental settings
positive results were observed on the surface of the light arm (35.7%, 5/14) and bracket table arm (12.5%,
Blood-borne infection 2/16). Housekeeping surfaces with frequent hand contact such as the sliding door knob (22.2%, 4/18) and
Hand hygiene towel case (33.3%, 1/3) also showed positive results. Another 36 samples were collected from surfaces
of the PC system. Positive reactions were observed on the keyboard (14.3%, 1/7) and display (33.3%,
2/6), although no blood was detected on the mouse controller, PC body or desk. Possible routes of blood
contamination seemed to be blood-contaminated splatters and medical staff-associated hand contact. As
blood stains were all invisible on the surfaces of frequent hand-contact equipment, these results appear
useful for cleaning and disinfection protocols.
© 2010 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd.
All rights reserved.

1. Introduction lead surgeons during third molar extraction [9] was higher than
that of any other medical specialties, including orthopedic surgery
Hospital infection occurs via percutaneous injury, mucous (86%) [7], cardiovascular surgery (75%) [10], and obstetrics (63%)
membrane contact, and from contaminated environmental sur- [11].
faces. Percutaneous injuries with sharp instruments among In addition to direct exposure via events such as needlestick
healthcare workers represent a risk of occupational transmission injury and splash exposure, transfer of microorganisms from con-
of blood-borne pathogens from infected patients [1,2]. Regarding taminated environmental surfaces to medical staff and patients
human immunodeficiency virus (HIV) infection, the average risk of occurs indirectly, primarily through hand contact [12,13]. Cer-
HIV infection has been indicated to be 0.1–0.3% after percutaneous tain surfaces with reservoirs of microbial contamination have the
injury [3–5]. Dental instruments consist of various sharp, unique potential for nosocomial infection. For example, HBV has been
instruments, such as files, bars, explorers, and scaler tips. Most den- demonstrated to survive in dried blood on environmental surfaces
tal professionals (94%) have experienced accidental puncturing of for up to 1 week [14]. HBV transmission through environmental
the skin by instruments used in treating patient [6]. surfaces has been demonstrated in investigations of HBV outbreaks
Furthermore, splatters and aerosols are frequently produced [15–17], and strategies for cleaning and disinfecting surfaces in
when using power instruments in a surgical operating theatre, patient-care areas are important and well-documented [18].
resulting in a risk of occupational infection through conjunctival Splatters produced during dental procedures include oral fluid
contact with infected blood [7]. Transmission of HIV can occur and tissue debris, exposing operating personnel to potentially haz-
due to exposure of mucous membranes in the eye, nose, or mouth ardous pathogens [19–23]. Additionally, aerosolized oral bacteria
[3,8]. In dental settings, the blood exposure ratio of 88% among were detected as far as 2 m from procedure field [24]. However,
little has elucidated the dissemination of blood and distribution
of frequent contaminations. We conducted a series of surveil-
∗ Corresponding author. Tel.: +81 6 6879 2936; fax: +81 6 6876 5298. lances around the dental chair unit using the leukomalachite green
E-mail address: kohji ishi@hotmail.com (K. Ishihama). blood presumptive test to evaluate distributions of dissemina-

0915-6992/$ – see front matter. © 2010 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ajoms.2009.07.001
T. Wada et al. / Asian Journal of Oral and Maxillofacial Surgery 22 (2010) 12–16 13

Fig. 1. The dental chair unit. (A) An overview of the dental chair unit. The arrowhead and arrow indicate the light arm and bracket arm, respectively. (B) The light. Arrows
indicate the light handle, which is categorized as a site of frequent hand contact. Invisible blood stains were detected from one sample. (C) The bracket table. The arrow and
arrowhead indicate the bracket table handle and the syringe holder, respectively. Panel switches are shown in the dashed circle.

tion. The results provide novel information for the prevention frequent hand-contact group included cabinet handles, the key-
cross-infection at dental settings and oral surgery operatories. board and mouse controller of personal computers, and telephones.
The minimal hand-contact group contained the surfaces of cabinet
2. Materials and methods sliding doors, wagon frames, and most house keeping surfaces, such
as walls and the floor.
This study was designed as a prospective, single center trial to
survey imperceptible blood contamination on the surfaces of dental 2.3. Contamination of walls
chair units and nearby equipment in an outpatient oral surgery
environment. All samples were collected in the outpatient clinic Drawing paper (Japanese calligraphic drawing paper,
room of the Oral Surgery Department at Osaka University Dental 95 cm × 180 cm, three sheets) was affixed to the wall 1.5 m
Hospital, Japan. from the dental chair unit for the detection of contaminated
splatters on the wall as a housekeeping surface. This paper was
2.1. Contamination of dental chair unit surfaces applied for 5 consecutive days. The presumptive test solution was
then sprayed directly onto each paper.
At the end of clinic hours, surfaces of the various parts of the
dental chair unit were wiped with ethanol sterile absorbent cot- 2.4. Contamination of the dental chair unit in third molar surgery
ton (4 cm × 4 cm, STERI COTTO alpha; Kawamoto, Osaka, Japan)
to collect well-diluted invisible blood contamination. For detailed Before each surgery, surfaces of the dental chair light arm
analysis, the ethanol sterile cotton was used with one sheet by one (Fig. 1A, arrowhead) and bracket table arm (Fig. 1A, arrow) were
limited portion; for example, one sterile cotton sheet for the hand cleaned with ethanol disinfection cloths (Alwety disinfection cloth,
piece of the air turbine and one sheet for the light handle of the #72100; Osaki Medical, Nagoya, Japan). These parts are minimal
dental chair unit. The blood presumptive test was then applied for hand-contact surfaces. Impacted mandibular third molar extrac-
each test cotton sheet. Cotton sheets displaying positive reactions tions were then performed under our standard procedure, as
on the blood detection test were considered as positive results. described previously [9]. After surgery, surfaces of the light arm
Environmental surfaces comprised clinical contact surfaces and and bracket table arm were carefully wiped with the ethanol sterile
housekeeping surfaces [25]. Equipment was further divided into absorbent cotton. The blood detection test was then performed.
two groups according to the frequency of hand and finger contact
by clinicians [26]. The frequent hand-contact group included con- 2.5. Leucomalachite green presumptive test for blood
troller panel switches, and built-in instruments of the dental chair
unit. The minimal hand-contact group contained the surfaces of Cottons used in both surveillances were dried naturally, and
light arms, and chair covers. then leucomalachite green solution was applied according to a
method previously established for presumptive testing for blood
2.2. Contamination of equipment and environmental surfaces [9]. We recorded chemical reactions on the sterile cotton and
grouped the results as positive or negative. The leucomalachite
With same procedure, surfaces of the various parts of nearby green solution comprised 0.1 g of leucomalachite green (#125660;
equipment were wiped with ethanol sterile absorbent cotton. The Sigma–Aldrich, MO, USA), 10 ml of acetic acid (#017-00251; Wako
14 T. Wada et al. / Asian Journal of Oral and Maxillofacial Surgery 22 (2010) 12–16

Table 1 Table 2
Results of blood detection testing of the dental chair unit. Results of blood detection testing of equipment and environmental surfaces.

Sample site Number of Total number Positive Sample site Number of Total Positive
positive result of sample ratio (%) positive number of ratio (%)
result sample
Frequent hand contact
Light handle 1 13 7.7 Frequent hand contact
Head rest 0 12 0.0 Writing desk board 0 9 0.0
Back rest 3 12 25.0 Sliding door knob 4 18 22.2
Arm rest 4 11 36.4 Rack board 0 20 0.0
Sheet 1 3 33.3 Gauze can 0 5 0.0
Bracket table 5 14 35.7 Mobile extra-oral vacuum 1 3 33.3
Bracket table handle 3 14 21.4 Printer 0 6 0.0
Syringe holder 4 17 23.5 Phone 0 6 0.0
Hand piece, 3 way syringe 1 8 12.5 Air conditioner switch 0 3 0.0
Panel switch Dr side 6 24 25.0 Door knob 0 3 0.0
Controller for electric coagulator 6 13 46.2 Paper towel case 1 3 33.3
Panel switch Assist side 3 20 15.0
Total 6 76 7.9
Syringe holder Assist side 0 7 0.0
Vacuum 2 8 25.0
3 way syringe Assist side 0 6 0.0 Minimal hand contact
Xp panel screen 0 7 0.0 Sliding door of shelf 1 11 9.1
Frame of shelf 0 4 0.0
Total 39 189 20.6 Rack frame 0 12 0.0
Gauze can base 2 3 66.7
Minimal hand contact Disposal basket for sharp instrument 2 4 50.0
Light arm 5 14 35.7 Wall 0 10 0.0
Bracket table arm 2 16 12.5 Door 0 3 0.0
Xp panel screen arm 0 6 0.0 Frame of hand washing cabinet 3 15 20.0
Spittoon base 7 25 28.0
Total 8 62 12.9
Chair cover 8 15 53.3
Foot switch 1 4 25.0

Total 23 80 28.8 with minimal hand contact, such as the rack frame, walls, and doors,
62 samples were examined (Table 2). Results were negative for the
walls, door, and rack frame.
Pure Chemical Industries, Osaka, Japan), 0.5 ml of 30% hydro- A total of 36 samples were collected from PC surfaces (Table 3).
gen peroxide (#081-04215; Wako Pure Chemical Industries), and Positive reactions were most often observed for the keyboard
19.5 ml of distilled water. (14.3%, 1/7; Fig. 2D) and display (33.3%, 2/6), and no blood was
detected from the mouse controller, PC body, or desk.
3. Results
3.3. Contamination of walls
3.1. Contamination of dental chair unit surfaces (Table 1)
Drawing papers affixed to the walls for 5 consecutive days 1.5 m
From the surfaces of frequent hand-contact equipment of the from the unit showed no blood-contaminated splatters in any cases.
dental chair unit, such as the light handle (Fig. 1B, arrowhead), panel
switches (Fig. 1C, dashed circle), syringe holder (Fig. 1C, arrow- 3.4. Contamination of the dental chair unit in third molar surgery
head), and bracket table handle (Fig. 1C, arrow), 189 samples were
examined (Table 1). A total of 39 samples showed positive results Forty samples from the light arm and bracket table arm were
for the blood detection test. Positive results were most frequently collected from 20 cases. Of the 20 samples from the light arm, 16
seen for doctor-side panel switches (25%, 6/24), the controller for (80%) showed positive results for the blood presumptive test. In
the electric coagulator (46.2%, 6/13), the arm rest (36.4%, 4/11), and addition, of the 20 samples from the bracket table arm, 15 (75%)
the bracket table (35.7%, 5/14). were positive. Only three cases displayed no positive reactions to
From the surfaces of minimal hand-contact equipment of the the blood detection test on either surface.
dental chair unit, such as the light arm, spittoon base, and foot
controller, 80 samples were tested (Table 1). Overall, 23 samples 4. Discussion
showed positive results. The chair cover and foot controller were
not usually cleaned, so positive ratios for these surfaces were rel- This represents the first study to methodically investigate blood
atively high, at 53.3% (8/15) and 25% (1/4), respectively. However, contamination of the surfaces of environmental equipment in out-
positive reactions were also observed on the surface of the light patient oral surgery using a presumptive test for imperceptible
arm (35.7%, 5/14) and bracket table arm (12.5%, 2/16), which were well-diluted blood.
close to the reclining patient in the dental chair (Fig. 1A).
Table 3
3.2. Contamination of equipment and environmental surfaces Results of blood detection testing of PC systems.
(Tables 2 and 3)
Sample site Number of Total number Positive
positive result of sample ratio (%)
From housekeeping surfaces with frequent hand contact, such
Keyboard 1 7 14.3
as sliding door knobs (Fig. 2A), air conditioning switches, and tele- Display 2 6 33.3
phones, a total of 76 samples were examined (Table 2). Positive Mouse controller 0 7 0.0
results were detected on the sliding door/cabinet knob (22.2%, 4/18; PC body 0 9 0.0
Fig. 2A and B), the mobile extra-oral evacuator system (33.3%, 1/3), Desk 0 7 0.0
Total 3 36 8.3
and towel case (33.3%, 1/3, Fig. 2C). From housekeeping surfaces
T. Wada et al. / Asian Journal of Oral and Maxillofacial Surgery 22 (2010) 12–16 15

Fig. 2. Equipment and environmental surfaces. (A) The sliding door knob. (B) The cabinet door knob. Invisible blood contamination was collected from these knobs, but no
blood contamination was seen on the surfaces of these doors. (C) The paper towel case. Blood detection testing revealed contamination on the lateral surface of the case
frame. The frame does not receive frequent hand contact. However, this portion should be kept clean. (D) The keyboard. Blood contamination was detected from the frame,
but not on the keys.

Environmental surfaces around the dental chair unit seem likely using less rigorous methods than those used on dental patient-care
to be exposed to contaminated particles and aerosols during patient items and clinical contact surfaces [28]. Strategies for cleaning and
care [24,27]. In the present study, positive results were observed disinfecting surfaces in patient-care areas are documented in the
from frequent hand-contact surfaces, such as light handles, panel 2003 guidelines for dental settings by the CDC [18] as follows: (1)
switches, syringes and syringe holders. All of these surfaces are potential for direct patient contact; (2) degree and frequency of
both within the range of contaminated splattering during the use of hand contact; and (3) potential contamination of the surface with
high-speed instruments and receive frequent hand contact. These body substances or environmental sources of microorganisms. Our
surfaces are strictly cleaned and disinfected with every patient, investigation aimed to evaluate the range and frequency of poten-
so visible contaminations should be excluded. Although no visi- tial blood contamination in line with strategy 3.
ble blood stains were seen on surfaces with frequent hand contact We have previously investigated contaminated splatters [9]
during the study period, the blood detection test revealed contami- and aerosols [27] during oral surgery, and have revealed the high
nation with imperceptible blood stains diluted up to 4000-fold [9]. incidence of blood exposure among oral surgeons. The direction
Understanding the range and frequency of dissemination seems of splatter appears to be up-forward rather than lateral, as the
crucial for designing routine cleaning and disinfection processes, light arm (1 m up-forward) and the bracket arm (1.5 m forward)
and our results provide information on the distribution of fre- were frequently contaminated after third molar extraction, at
quently contaminated surfaces. frequencies of 80% and 75%, respectively. In contrast, no blood con-
Housekeeping surfaces with frequent hand contact such as the tamination was observed from paper affixed to the wall 1.5 m from
sliding door knob, mobile extra-oral evacuator, and towel case the chair unit. The precise risk of transmission after skin exposure
commonly showed positive results in the present study. These remains unknown, but is believed to be even smaller than that for
surfaces are far from where dental procedures and oral surgery mucous membrane exposure. To date, at least two cases of HCV
are performed using high-speed rotating instruments, which pro- transmission from a blood splash to the conjunctiva [3,29] and one
duce contaminated splatters and particle mists in the surgical case of simultaneous transmission of HCV and HIV after non-intact
field. Contamination of these surfaces would thus seem to be skin exposure have been reported [8]. The CDC guidelines for den-
caused by contaminated hand contact and medical staff-associated tal settings state that the risk of HIV transmission in dental settings
contamination. Transfer of microorganisms from contaminated is extremely low [18], because HIV occupational seroconversion
environmental surfaces to patients occurs primarily through hand had been identified among healthcare workers, but not among
contact [12,13]. When these surfaces are touched, microbial agents dental personal [30,31]. To prevent the advent of novel infectious
can be transferred to instruments, other environmental surfaces, pathogens with strong infectious potential, however, minimization
or the nose, mouth, or eyes of workers or patients [18]. Certain of the dissemination of even trivial amounts of pathogens seems
surfaces can serve as reservoirs of microbial contamination, thus important.
carrying a potential for outbreaks in the hospital. Hand hygiene
plays a crucial role in minimizing the transfer of pathogens, and Acknowledgements
should be well-known by all healthcare workers, including stu-
dents and assistants. The authors wish to express their appreciation to Dr. Koichi
Housekeeping surfaces such as floors, walls and sinks have lim- Sakurada from the National Research Institute of Police Science,
ited risk of disease transmission, and thus can be decontaminated Japan, for helpful advice and discussions during the preparation of
16 T. Wada et al. / Asian Journal of Oral and Maxillofacial Surgery 22 (2010) 12–16

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