Tuberculosis Epidemiology, Diagnosis and

Infection Control Recommendations for

Dental Settings: An Update on the Centers for
Disease Control and Prevention Guidelines
Jennifer L. Cleveland, Valerie A. Robison and
Adelisa L. Panlilio
J Am Dent Assoc 2009;140;1092-1099

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C O V E R S T O R Y

Tuberculosis epidemiology, diagnosis

and infection control recommendations
for dental settings
An update on the Centers for Disease Control
and Prevention guidelines
Jennifer L. Cleveland, DDS, MPH; Valerie A. Robison, DDS, PhD; Adelisa L. Panlilio, MD, MPH

n 1990, the Centers for Dis-

I ease Control published guide-

lines for preventing the trans-
ABSTRACT J
A D
A

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Background. Although rates of tuberculosis (TB) in ✷✷
®
mission of Mycobacterium
the United States have decreased in recent years, dis-

N
CON
tuberculosis (M. tuberculosis)

IO
parities in TB incidence still exist between U.S.-born
in health care settings, specifically

T
T

A
and foreign-born people (people living in the United N

I
U C
focusing on issues related to A IN
G ED
U

States but born outside it) and between white people and RT 1
human immunodeficiency virus ICLE
nonwhite people. In addition, the number of TB outbreaks
(HIV).1 In 1994, the renamed Cen-
among health care personnel and patients has decreased since the imple-
ters for Disease Control and Pre-
mentation of the 1994 Centers for Disease Control and Prevention (CDC)
vention (CDC) revised those guide-
guidelines to prevent transmission of Mycobacterium tuberculosis. In this
lines to address an increase in the
article, the authors provide updates on the epidemiology of TB, advances in
number of tuberculosis (TB) out-
TB diagnostic methods and TB infection control guidelines for dental
breaks, most of which involved the
settings.
transmission of multidrug-
Results. In 2008, 83 percent of all reported TB cases in the United States
resistant (MDR) TB in health care
occurred in nonwhite people and 17 percent occurred in white people.
settings.2 As a result of wide-spread
Foreign-born people had a TB rate about 10 times higher than that of U.S.-
implementation of these recom-
born people. New blood assays for M. tuberculosis have been developed to
mendations in health care facilities
diagnose TB infection and disease. Changes from the 1994 CDC guidelines
and reductions in community rates
incorporated into CDC’s “Guidelines for Preventing the Transmission of
of TB in the United States, reports
Mycobacterium tuberculosis in Health-Care Settings, 2005” include revised
of health care–associated transmis-
risk classifications, new TB diagnostic methods, decreased frequencies of
sion of M. tuberculosis among
tuberculin skin testing in various settings and changes in terminology.
health care personnel (HCP) and
Clinical Implications. Although the principles of TB infection control
patients have decreased during the
have remained the same, the changing epidemiology of TB and the advent of
past decade.3
new diagnostic methods for TB led to the development of the 2005 update to
Because of the shifts in the epi-
the 1994 guidelines. Dental health care personnel should be aware of the
demiology of TB and the develop-
modifications that are pertinent to dental settings and incorporate them into
ment of new methods of diag-
their overall infection control programs.
nosing TB, the federal Advisory
Key Words. Tuberculosis; epidemiology; diagnosis; dentistry; infection
Council for the Elimination of
control; guidelines.
Tuberculosis asked CDC to con-
JADA 2009;140(9):1092-1099.
sider updating the infection con-
trol guidelines. CDC published a Dr. Cleveland is a dental officer/epidemiologist, Division of Oral Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention, MS F-10, 4770 Buford
revision in 2005.3 Rather than Highway, Atlanta, Ga. 30341, e-mail “JLCleveland@cdc.gov”. Address reprint requests to Dr. Cleveland.
focusing on hospital-based health Dr. Robison is an epidemiologist, Division of Tuberculosis Elimination, National Center for HIV/AIDS,
care settings, the 2005 guidelines Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta.
When this article was written, Dr. Panlilio was a medical officer, Division of Healthcare Quality Promotion,
include inpatient and outpatient National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control
settings, home health care set- and Prevention, Atlanta. She now is a consultant in Atlanta.

1092 JADA, Vol. 140 http://jada.ada.org September 2009


tings, correctional settings and TB clinics. The
term “settings” replaces “facilities” to broaden the
potential places to which these guidelines apply.
Although the risk of transmission of M. tuber-
culosis in dental settings is low,4 it is important
for dental health care personnel (DHCP) to
include protocols for TB infection control in their
offices’ written infection control program. In this
article, we provide an update on CDC’s most
recent TB guidelines, including such topics as the
epidemiology of TB, diagnostic methods and TB
infection control guidelines applicable to dental
settings.
TRANSMISSION AND PATHOGENESIS
Only people with active TB can spread the infec-
tion. M. tuberculosis spreads through airborne
particles, known as droplet nuclei, which can be
generated when people with pulmonary or laryn-
geal TB sneeze, cough, speak or sing. These small
particles (1 to 5 micrometers in diameter) can
stay suspended in the air for hours.5 If a suscep-
tible person inhales droplet nuclei containing M.
tuberculosis, infection may begin if the bacilli
reach the alveoli. Within two to 12 weeks, the
body’s immunological response to M. tuberculosis
usually prevents further multiplication and
spread.
However, some bacilli can remain viable in the
body for many years. This condition is referred to
as “latent tuberculosis infection” (LTBI). People
with LTBI usually have a positive reaction to the
tuberculin skin test (TST) but do not have active
TB disease and cannot infect others. In about 90
percent of Americans infected with TB, the infec-
tion remains latent for life, with no progression to
active TB. Usually, about 5 to 10 percent of
infected people who are not treated for LTBI will
develop active TB disease during their lifetime.2
Signs and symptoms suggestive of active TB dis-
ease include a productive and persistent cough,
bloody sputum, night sweats, weight loss, fever or
anorexia or a combination of these.
EPIDEMIOLOGY
Global. Worldwide, TB remains one of the
leading causes of death resulting from infectious
disease.6 An estimated 2 billion people (one-third
of the world’s population) are thought to be
infected with M. tuberculosis.6 In 2007, approxi-
mately 9.27 million new cases of TB developed,
and 1.78 million people died.6 The advent of the
HIV/AIDS epidemic has accelerated the global
C O V E R S T O R Y
spread of TB. People who have LTBI and HIV
infection are at greater risk than are those with
TB infection alone of progressing to active TB dis-
ease and then transmitting it to others.7
The prevalence of MDR TB—that is, TB that is
resistant to the two most effective first-line thera-
peutic drugs, isoniazid and rifampin—has
increased globally owing to the misuse and mis-
management of anti-TB drugs, incomplete treat-
ment and an inadequate drug supply.6 Findings of
a survey conducted in 2006 among an interna-
tional network of 25 TB laboratories indicated
that, from 2000 through 2004, 20 percent of iso-
lates were MDR TB and 2 percent were resistant
to multiple second-line drugs.8 This almost
untreatable form of MDR TB disease is called
“extensively drug-resistant TB” (XDR TB). CDC9
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noted earlier this year, “Because of the limited
responsiveness of XDR TB to available antibi-
otics, mortality rates among patients with XDR
TB are similar to those of TB patients in the pre-
antibiotic era.”
United States. After an unprecedented resur-
gence of TB between 1985 and 1992,10 the annual
rate of TB in the United States has decreased
steadily.11 However, since 2000, there has been a
slowing in the pace of that decrease, with dispari-
ties in TB rates persisting between U.S.-born and
foreign-born people (people living in the United
States but born outside it) and between white
people and nonwhite people. In 2008, 58 percent
of all TB cases occurred in foreign-born people
and 83 percent of all reported TB cases occurred
in people in racial and ethnic minorities regard-
less of where they were born (29 percent in His-
panics, 26 percent in African Americans, 26 per-
cent in Asian Americans), whereas 17 percent of
ABBREVIATION KEY. AII: Airborne infection isolation.
BAMT: Blood assay for Mycobacterium tuberculosis.
BCG: Bacille Calmette-Guérin. CDC: Centers for
Disease Control and Prevention. DHCP: Dental health
care personnel. EPA: Environmental Protection
Agency. HCP: Health care personnel. HEPA: High-
efficiency particulate air. HIV: Human immuno-
deficiency virus. IGRA: Interferon gamma release
assay. LTBI: Latent tuberculosis infection. MDR TB:
Multidrug-resistant tuberculosis. NIOSH: National
Institute for Occupational Safety and Health.
RP: Respiratory protection. TB: Tuberculosis. TST:
Tuberculin skin test. UVGI: Ultraviolet germicidal
irradiation. XDR TB: Extensively drug-resistant
tuberculosis.
JADA, Vol. 140 http://jada.ada.org September 2009 1093
C O V E R S T O R Y

cases occurred in whites. U.S.-born blacks had TB M. tuberculosis and in immunocompromised

rates seven times higher than those of U.S.-born
whites—the greatest disparity between U.S.-born
whites and U.S.-born members of nonwhite racial
and ethnic groups. Foreign-born people had a TB
rate more than 10 times higher than that of U.S.-
born people (20.2 versus 2.0 cases per 100,000).
People from four countries accounted for one-half
(50.1 percent) of foreign-born people with TB:
Mexico, the Philippines, India and Vietnam.
Among people with TB and a known HIV test
result, 10.5 percent were coinfected with HIV. In
2007, the most recent year for which complete
drug-susceptibility data were available, MDR TB
accounted for 1.2 percent of TB infections, a pro-
portion that has remained stable since 1998. The
proportion of MDR TB cases reported among
people. A diagnosis of LTBI requires that a med-
ical evaluation exclude active TB disease. The
evaluation should include checking for signs and
symptoms suggestive of TB disease, performing
chest radiography and, when indicated, exam-
ining sputum or other clinical samples for the
presence of M. tuberculosis.13 The 2005 revision of
the TB infection control guidelines includes gen-
eral recommendations regarding the use of blood
assays for M. tuberculosis as part of the infection
control program in health care settings.
INFECTION CONTROL GUIDELINES
General recommendations. The 2005 guide-
lines emphasize the importance of maintaining
appropriate infection control measures to prevent

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foreign-born people in the United States in- another resurgence of TB and to eliminate pos-
creased from approximately 25 per- sible occupational transmission to
cent in 1993 to approximately 80 HCP from people with unsuspected
percent in 2007.9 Although the risk All dental settings or undiagnosed infectious TB. The
of developing XDR TB is relatively should conduct an guidelines follow the same general
low in the United States, cases have initial and annual principles of infection control dis-
been reported every year since 1993 assessment of the cussed in the 1994 guidelines; how-
except for 2003.11 risk of tuberculosis ever, some changes and additions
have been made (Table 1). We pro-
DIAGNOSTIC METHODS transmission,
vide an overview of these guide-
New blood assays for M. tubercu- regardless of the lines, with particular emphasis on
losis (BAMTs), called “interferon likelihood of relevant changes for dental outpa-
gamma release assays” (IGRAs), encountering people tient settings.
have been developed for use as an with the disease. References to specific pages of
aid in diagnosing LTBI infection “Guidelines for Preventing the
and TB disease.3 IGRAs can be used Transmission of Mycobacterium
in all circumstances in which the TST is currently tuberculosis in Health-Care Settings, 2005”3 are
used.12,13 These include contact investigations, indicated after the citation number.
evaluation of recent immigrants who have had TB infection control program for dental
bacille Calmette-Guérin (BCG) vaccination for settings. All dental settings, regardless of risk
TB, and TB screening of HCP and others under- category, should develop a written TB infection
going serial evaluation for M. tuberculosis. The control plan as part of their overall infection con-
advantages of the BAMT versus the TST are that trol programs. Specifics of TB infection control
it requires a single patient visit to draw a blood programs will differ, depending on whether
sample; results can be available within 24 hours; patients with suspected or confirmed TB are
it does not boost responses (as measured by likely to seek treatment in each setting.
means of subsequent tests), as can happen with TB risk assessment. All dental settings
the TST; it is not subject to the reader bias that should conduct an initial and annual assessment
can occur with the TST; and it is not affected by of the risk of TB transmission, regardless of the
prior BCG vaccination.3 likelihood of encountering people with TB
In situations involving serial testing for M. disease.3(pp.9-10) This process includes determining
tuberculosis infection, initial two-step testing, the community profile, which can be verified by
which is recommended with the TST, is unneces- using surveillance data from local or state health
sary with an IGRA assay. Limited data exist departments or TB control programs (a list is
regarding the use of IGRAs in children younger available at “www.cdc.gov/tb/links/tboffices.htm”).
than 17 years, among people recently exposed to In the 1994 guidelines, there were five risk cat-

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 C O V E R S T O R Y

TABLE 1

Comparison of selected changes between 1994 and 2005 editions of the

Centers for Disease Control and Prevention’s guidelines for preventing
transmission of Mycobacterium tuberculosis in health care settings.*
ASPECT 1994 GUIDELINES 2005 GUIDELINES

Terminology
Respiratory Hygiene,
Cough Etiquette
“Facilities”: focuses mainly on
hospitals
“Engineering controls”: limited to
ventilation, ultraviolet germicidal
irradiation and room air cleaners
“Negative pressure isolation room”
“Purified protein derivative”
Not included
“Settings”: term encompasses inpatient settings, outpatient
settings (for example, medical, dental), tuberculosis clinics,
health-care settings in correctional facilities, home-based health
care, emergency medical services and laboratories handling
M. tuberculosis specimens
“Environmental controls”: includes not only engineering controls
but also other aspects of the environment, such as building,
setting, facility
“Airborne infection isolation room”
“Tuberculin skin test” (TST)
Included

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Risk Assessment Five categories: minimal, very low, Three categories: low, medium, potential ongoing transmission
low, intermediate and high
Diagnostic Methods TST TST or interferon gamma release assay
Frequently Asked Not addressed Included
Questions
* Sources: Centers for Disease Control and Prevention2 and Jensen and colleagues. 3(pp.2-3)

egories determining the need for TABLE 2

and frequency of TB screening of
HCP: minimal, very low, low,
Tuberculosis (TB) risk categories and
intermediate and high. In the 2005 recommended testing frequency.*
guidelines, there are only three RISK CATEGORY RISK CLASSIFICATION TB TESTING FREQUENCY
risk categories: low, medium and
Low People with TB disease Baseline,† at hiring; further
potential for ongoing transmission unlikely to be seen testing not needed unless
(Table 2).3(pp.9-11,134) As Jensen and Fewer than three patients exposure occurs
with unrecognized TB
colleagues wrote,3 “Because DHCP treated in past year
do not provide initial medical Medium People with TB disease Baseline,† then annually
assessment of patients who may likely to be seen
Three or more patients
have TB, but only conduct a lim- with unrecognized TB
ited screening of patients for symp- treated in past year
toms suggestive of active TB before Potential Ongoing Evidence of ongoing Baseline,† then every eight to
treatment,” most dental settings Transmission person-to-person 10 weeks until evidence of
transmission transmission has ceased
are considered to offer low risk (see
3(pp.9-11, 134)
example F under Hypothetical * Source: Jensen and colleagues.
† Baseline screening should be conducted by a qualified health care professional using a
Risk Classification in the guide- two-step tuberculin skin test or single blood assay interferon gamma release assay.
lines3[p.11]). Even in low-risk set-
tings, however, patients suspected of having TB boosting.3(pp.49-50) In some people who were infected
may seek dental care and should be identified with TB in the past, the body loses its ability to
promptly and referred for medical evaluation.3(pp.8-9) react to the tuberculin antigen. When these
Newly hired HCP working in a low-risk setting people receive a TST many years after the initial
should receive a baseline two-step TST or a single infection, they may have a negative reaction.
BAMT.3(pp.28-29) If a TST is used, two-step testing is However, if they are tested a second time, they
recommended for a health care worker whose ini- may have a positive reaction owing to a boosted
tial test result is negative. If the first test result response to the tuberculin solution. If the second
is negative, a second TST should be administered test is not administered until later—for example,
one to three weeks after the first one to rule out after an exposure to a person with active TB

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C O V E R S T O R Y

BOX 1 the TB screening protocols out-

lined in the guidelines.3(pp.28-32)
Tuberculosis (TB) precautions for outpatient Additional TB screenings are not
dental settings.* recommended for people in the
ADMINISTRATIVE CONTROLS low-risk category, unless they
dAssign responsibility for managing TB infection control program are exposed to M. tuberculosis
dConduct annual risk assessment (Table 2).
dDevelop written TB infection control policies for promptly identifying and
isolating patients with suspected or confirmed TB disease for medical
evaluation or urgent dental treatment TUBERCULOSIS INFECTION
dInstruct patients to cover mouth when coughing and/or wear a surgical mask CONTROL MEASURES FOR
dEnsure that dental health care personnel (DHCP) are educated regarding DENTAL SETTINGS
signs and symptoms of TB
dWhen hiring DHCP, ensure that they are screened for latent TB infection and A dental setting’s TB infection con-
TB disease
trol program should be based on a
dPostpone urgent dental treatment
ENVIRONMENTAL CONTROLS three-level hierarchy of TB infec-
dUse airborne infection isolation room to provide urgent dental treatment to tion control measures: administra-
patients with suspected or confirmed infectious TB
tive controls, environmental con-
dIn settings with high volume of patients with suspected or confirmed TB, use
trols and respiratory protection

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high-efficiency particulate air filters or ultraviolet germicidal irradiation
RESPIRATORY PROTECTION (RP) CONTROLS
dUse RP—at least an N95 filtering face piece (disposable)—for DHCP when
they are providing urgent dental treatment to patients with suspected or
confirmed TB
dInstruct TB patients to cover mouth when coughing and to wear a surgical
mask
* Source: Jensen and colleagues.3(pp.25,126)
BOX 2
Respiratory hygiene and cough
etiquette measures.*
dUse tissues to cover the nose and mouth and to contain
respiratory secretions when coughing or sneezing
dDispose of tissues in no-touch receptacles (such as those
with foot-pedal–operated lids or an open, plastic-lined
wastebasket)
dWhen coughing or sneezing, if tissues are not available,
cover the mouth and nose with the inner surface of the
arm and forearm, to keep pathogenic organisms away
from the hands; although Mycobacterium tuberculosis
cannot be spread by the hands, other respiratory
pathogens such as rhinoviruses can
dPractice hand hygiene (such as hand washing with
nonantimicrobial soap and water, alcohol-based hand
rub or antiseptic hand wash) after having contact with
respiratory secretions or contaminated objects and
materials; hand hygiene is recommended to prevent
transmission of all respiratory illnesses, in general, but
will not affect tuberculosis transmission
* Source: Centers for Disease Control and Prevention.14
disease—a positive TST result may be misread as
a new infection. Therefore, two-step testing can
prevent misinterpretation of a boosted response
as being a new infection. At baseline testing, if
the results of the first and second tests are nega-
tive, the person is considered uninfected. If the
first test result is positive or the first test result is
negative and the second result is positive, the
person should be evaluated by a physician for
latent TB infection or active disease according to
(RP) controls. TB infection control
policies and protocols for imple-
menting these control measures
should be included in the setting’s
overall TB infection control pro-
gram and should be reviewed peri-
odically, preferably no less fre-
quently than annually.
Administrative controls. As was indicated in
the previous CDC guidelines, the most important
measures to prevent transmission of M. tubercu-
losis are administrative controls. Administrative
controls are the first line of defense and should
reduce the risk of exposure of dental staff and
patients to people with active TB (Box 1). Proto-
cols to ensure that patients with suspected or
undiagnosed TB infection are identified promptly
for referral, evaluation and (when necessary)
medical treatment remain the measures most
effective in preventing transmission of M. tuber-
culosis in dental settings. Patients with signs and
symptoms suggestive of TB should be given face
(surgical) masks or tissues (if none is available,
they should be directed to cough into their
sleeves), instructed in respiratory hygiene and
cough etiquette14 (Box 2) and placed in an area
away from other patients and staff members.
For a patient with suspected or confirmed TB,
the CDC recommends that any dental treatment
that is not urgent be postponed until the patient
is determined either not to have TB disease or to
be noninfectious.3(p.25) If urgent treatment is
needed, it should be provided in an airborne infec-
tion isolation (AII) room; DHCP should wear RP—
at least an N95 filtering face piece (disposable)
respirator (see the section below regarding RP

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 C O V E R S T O R Y

controls)—while performing procedures (Box 1).
Protocols for detecting and managing patients
with suspected or confirmed TB, including proto-
cols for medical referrals and urgent dental treat-
ment, should be included in each setting’s written
TB infection control plan.
Environmental controls. The second level of
the hierarchy of TB infection control measures is
the use of environmental controls. These meas-
ures (physical or mechanical) are intended to
remove or inactivate M. tuberculosis by control-
ling the source of infection, diluting and removing
contaminated air and controlling airflow (clean
air to less-clean air). Examples of environmental
controls include general ventilation, air-cleaning
methods such as use of high-effi-
ciency particulate air (HEPA) fil-
There are several differences between dispos-
able respirators and surgical masks in intended
use, fit against the face, wear time, testing and
approval. Particulate respirators, such as those
discussed above, are intended to protect the user
from inhaling particles, including small microor-
ganisms (less than 10 µm in diameter).17 In con-
trast, surgical masks protect against large parti-
cles generated by the user; protect the user’s
mouth and nose from large-particle droplet
splash, spray or spatter that may contain patho-
genic microorganisms; and should be placed on
coughing patients to limit potential dissemination
of infectious respiratory secretions to others (that
is, cough etiquette).18 Surgical masks are not
CDC/NIOSH-certified as respira-
tors and do not protect the user

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ters, ultraviolet germicidal irradia- Determining whether adequately from inhaling airborne
tion (UVGI) and use of AII to disinfect and contaminants, including M. tuber-
rooms.3(pp.60-75) As recommended in sterilize patient-care culosis,15,17,19-22 because they have a
both the 1994 and the 2005 guide- items depends on the looser fit and, often, lower filtration
lines, settings in which DHCP treat efficiency than do N95 respirators.
intended use of the
patients at high risk of having TB The fit of most surgical masks
should have environmental controls item and the potential allows a gap between the edge of
(that is, ventilation systems, risk of transmitting the mask and the face that permits
portable HEPA filters, UGVI) in pathogens because inhaled air to flow around the sides
common areas such as waiting of inadequate of the mask.19-21 If DHCP need a res-
3(p.25)
rooms (Box 1). disinfection between pirator that provides protection
Respiratory protection con- from splashes of blood or body
uses.
trols. The third level in the hier- fluids, they should select a surgical
archy is RP that further reduces N95 (or higher) respirator that is
risk of exposure in situations that pose a high certified by NIOSH and cleared by the U.S. Food
risk. When providing urgent dental treatment to and Drug Administration.3(p.78),15,18,23
patients with suspected or active TB, DHCP
should prevent inhalation of infectious droplet ADDITIONAL INFECTION
CONTROL MEASURES
nuclei by wearing filtering face piece respirators
(such as N95, N99 or N100 respirators), which Cleaning, disinfecting and sterilizing
are certified for this purpose by CDC’s National patient-care items. Medical instruments and
Institute for Occupational Safety and Health devices have not been involved in transmission of
(NIOSH). 3(pp.25,75-77),15,16 An N95 respirator, for M. tuberculosis.3 Nonetheless, DHCP should
example, is at least 95 percent efficient in fil- follow recommendations for cleaning, disinfecting
tering 0.3-μm–diameter particles. (“N” indicates and sterilizing patient-care items (dental instru-
that the filter is not resistant to oil.) RP should be ments, devices and equipment).24,25 Determining
used only in the context of a complete RP pro- whether to disinfect and sterilize patient-care
gram that includes training and fit-testing of items depends on the intended use of the item
DHCP to ensure adequate seal between the face and the potential risk of transmitting pathogens
and the edges of the mask. An RP program is not because of inadequate disinfection between
necessary in settings in which no patients with uses.3(pp.79-80),24,25 Special or additional processing
suspected or confirmed TB are treated, including procedures for critical, semicritical or noncritical
most dental settings. These settings need only patient-care items are not indicated after a
written protocols for recognizing signs and symp- patient with TB receives dental treatment. Rec-
toms of TB and for referring patients to a setting ommendations for cleaning, disinfection and ster-
in which they can be treated. ilization procedures for patient-care items and

JADA, Vol. 140 http://jada.ada.org September 2009 1097

C O V E R S T O R Y
environmental surfaces have been published.24-26
Environmental surface disinfection. A
common misconception about the use of surface
disinfectants in health care settings relates to dis-
infectants labeled as “tuberculocidal.”3(p.80),26 Such
products are not intended to prevent the trans-
mission of M. tuberculosis in health care settings
because TB is not acquired from environmental
surfaces. The U.S. Environmental Protection
Agency (EPA) regulates surface disinfectants,27
and the tuberculocidal claim is an EPA bench-
mark for measuring germicidal potency. Among
the vegetative bacteria, viruses and fungi,
mycobacteria, including M. tuberculosis, have the
highest intrinsic level of resistance to disinfec-
tants. Therefore, any germicide with a tubercu-
locidal claim on the label (that is, a hospital-grade
intermediate-level disinfectant) must be capable
of inactivating a broad spectrum of pathogens,
including much less resistant organisms such as
the blood-borne pathogens (for example, hepatitis
B virus, hepatitis C virus and HIV). It is this
broad-spectrum capability, rather than a
product’s specific potency against mycobacteria,
that is the basis for this designation and the
EPA’s regulation regarding use of tuberculocidal
chemicals for surface disinfection. Between
patients, DHCP should either place barrier pro-
tection on all clinical contact surfaces (that is,
surfaces that are touched frequently during
dental treatment) or clean and disinfect the sur-
faces with an appropriate-level EPA-registered
hospital disinfectant.24,26
SUMMARY
Changes in the epidemiology of TB in the United
States and the advent of new TB diagnostic
methods prompted CDC to revise its infection
control guidelines in 2005 to prevent the trans-
mission of M. tuberculosis during the provision of
medical and dental care. Most of the changes per-
tained to administrative controls, such as simpli-
fying risk classifications for health care settings
and screening for LTBI. DHCP should be aware of
the modifications in this document that are
applicable to dental settings and should incorpo-
rate these changes into the written dental office
infection control manual. ■
Disclosure. None of the authors reported any disclosures.
1. Dooley SW Jr, Castro KG, Hutton MD, Mullan RJ, Polder JA,
Snider DE Jr. Guidelines for preventing the transmission of tubercu-
losis in health-care settings, with special focus on HIV-related issues.
MMWR Recomm Rep 1990;39(RR-17):1-29.
1098 JADA, Vol. 140 http://jada.ada.org September 2009
2. Centers for Disease Control and Prevention. Guidelines for pre-
venting the transmission of Mycobacterium tuberculosis in health-care
facilities, 1994. MMWR Recomm Rep 1994;43(RR-13):1-132.
3. Jensen PA, Lambert LA, Iademarco MF, Ridzon R; Centers for Dis-
ease Control and Prevention. Guidelines for preventing the transmis-
sion of Mycobacterium tuberculosis in health-care settings, 2005.
MMWR Recomm Rep 2005;54(RR-17)1-142.
4. Cleveland JL, Gooch BF, Bolyard EA, Simone PM, Mullan RJ,
Marianos DW. TB infection control recommendations from the CDC,
1994: considerations for dentistry. JADA 1995;126(5):593-599.
5. Wells WF. Aerodynamics of droplet nuclei. In: Wells WF, ed. Air-
borne Contagion and Air Hygiene: An Ecological Study of Droplet Infec-
tions. Cambridge, Mass.: Harvard University Press; 1955:13-19.
6. World Health Organization. Global tuberculosis control: epidemi-
ology, strategy, financing—WHO report 2009. Geneva: World Health
Organization; 2009. Publication WHO/HTM/TB/2009.411. “www.who.
int/tb/publications/global_report/2009/en/index.html”. Accessed July 21,
2009.
7. American Thoracic Society/Centers for Disease Control and Pre-
vention Statement Committee on Latent Tuberculosis Infection Mem-
bership List. Targeted tuberculin testing and treatment of latent tuber-
culosis infection. MMWR Morb Mortal Wkly Rep 2000;49(RR-6):1-151.
8. Centers for Disease Control and Prevention. Emergence of
Mycobacterium tuberculosis with extensive resistance to second-line
drugs—worldwide, 2000-2004. MMWR Morb Mortal Wkly Rep 2006;
Downloaded from jada.ada.org on April 19, 2011
55(11):301-305.
9. Centers for Disease Control and Prevention. Plan to combat exten-
sively drug-resistant tuberculosis: recommendations of the Federal
Tuberculosis Task Force. MMWR Recomm Rep 2009;58(RR-3):1-43.
10. Cantwell MF, Snider DE Jr, Cauthen GM, Onorato IM. Epidemi-
ology of tuberculosis in the United States, 1985 through 1992. JAMA
1994;272(7):535-539.
11. Centers for Disease Control and Prevention. Trends in tubercu-
losis—United States, 2008. MMWR Morb Mortal Wkly Rep 2009;
58(10):249-253.
12. National Tuberculosis Controllers Association; Centers for Dis-
ease Control and Prevention. Guidelines for the investigation of con-
tacts of persons with infectious tuberculosis: recommendations from
the National Tuberculosis Controllers Association and CDC. MMWR
Recomm Rep 2005;54(RR-15):1-47.
13. Mazurek GH, Jereb J, Lobue P, Iademarco MF, Metchock B,
Vernon A; Division of Tuberculosis Elimination, National Center for
HIV, STD, and TB Prevention, Centers for Disease Control and Pre-
vention. Guidelines for using the QuantiFERON-TB Gold test for
detecting Mycobacterium tuberculosis infection, United States (pub-
lished correction appears in MMWR Morb Mortal Wkly Rep
2005;54[50]:1288). MMWR Recomm Rep 2005;54(RR-15):49-55.
14. Centers for Disease Control and Prevention. Seasonal flu: respira-
tory hygiene/cough etiquette in healthcare settings. “www.cdc.gov/
flu/professionals/infectioncontrol/resphygiene.htm”. Accessed Aug. 4,
2009.
15. Centers for Disease Control and Prevention. NIOSH guide to the
selection and use of particulate respirators certified under 42 CFR 84.
Cincinnati: U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health; 1996. DHHS publication
(NIOSH) 96-101.
16. Centers for Disease Control and Prevention. TB respiratory pro-
tection program in health care facilities: administrator’s guide. Cincin-
nati: U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control and Prevention, National Institute
for Occupational Safety and Health; 1999. DHHS publication (NIOSH)
99-143.
17. U.S. Department of Health and Human Services. Interim guid-
ance on planning for the use of surgical masks and respirators in
health care settings during an influenza pandemic. Washington: U.S.
Department of Health and Human Services; 2006.
18. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare
Infection Control Practices Advisory Committee. 2007 guideline for iso-
lation precautions: preventing transmission of infectious agents in
healthcare settings. Atlanta: Public Health Service, U.S. Department
of Health and Human Services, Centers for Disease Control and
Prevention; 2007.
19. Oberg T, Brosseau LM. Surgical mask filter and fit performance.
Am J Infect Control 2008;36(4);276-282.
20. Balazy A, Toivola M, Adhikari A, Sivasubramani SK, Reponen T,
Grinshpun SA. Do N95 respirators provide 95 percent protection level
against airborne viruses, and how adequate are surgical masks? Am J

Infect Control 2006;34(2):51-57.
21. Pippin DJ, Verderame RA, Weber KK. Efficacy of face masks in
preventing inhalation of airborne contaminants. J Oral Maxillofac Surg
1987;45(4):319-323.
22. Centers for Disease Control and Prevention. Understanding res-
piratory protection against SARS. “www.cdc.gov/niosh/npptl/topics/
respirators/factsheets/respsars.html”. Accessed July 22, 2009.
23. U.S. Food and Drug Administration. Masks and N95 respirators.
“www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/Medical
ToolsandSupplies/PersonalProtectiveEquipment/ucm055977.htm”.
Accessed July 22, 2009.
24. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ,
Malvitz DM; Centers for Disease Control and Prevention. Guidelines
for infection control in dental health-care settings—2003. MMWR Morb
Mortal Wkly Rep 2003;52(RR-17):1-61.
C O V E R S T O R Y
25. Rutala WA, Weber DJ; the Healthcare Infection Control Practices
Advisory Committee (HICPAC). Guideline for disinfection and steril-
ization in healthcare facilities, 2008. Atlanta: U.S. Department of
Health and Human Services, Public Health Service, Centers for Dis-
ease Control and Prevention; 2008.
26. Centers for Disease Control and Prevention. Guidelines for envi-
ronmental infection control in health-care facilities: recommendations
of CDC and the Healthcare Infection Control Practices Advisory Com-
mittee (HICPAC) (published correction appears in MMWR Recomm
Rep 2003;52[42]:1025-1026). MMWR Recomm Rep 2003;52(RR-10):
1-42.
27. U.S. Environmental Protection Agency. Selected EPA-registered
disinfectants. “www.epa.gov/oppad001/chemregindex.htm”. Accessed
July 22, 2009.
Downloaded from jada.ada.org on April 19, 2011
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