Prevention is better than cure

In western society there has been a resurgence of certain infectious diseases over the past decade, even those thought to have been relegated to a bygone era.

Falling childhood vaccination rates, changes in behaviours and eating habits, and worsening social and economic conditions are all factors that have contributed to the rise of infectious diseases. Added to this, rapidly emerging resistant bacteria is an increasing threat to the extraordinary health benefits that have been achieved over decades with antibiotics.

Emerging infectious diseases, including COVID-19 and its variants, and the re-emergence of once-common diseases such measles, are serious concerns within the dental setting, as each pose serious risk to the dental team and to patients.

Examples of diseases of concern that have made a resurgence:

Measles
Measles is one of the world’s most contagious diseases, a viral illness that can lead to serious illness, lifelong disability and even death[i]. It is caused by a single-stranded RNA virus of the genus Morbillivirus and the family Paramyxoviridae[ii] and spreads easily by contact with infected nasal or throat secretions (coughing and sneezing). The virus remains active and contagious in the air or on infected surfaces for up to two hours[iii].

Measles cases continue to rise. According to the UK Health Security Agency (UKSHA) there were 1,603 suspected cases of measles in England and Wales in 2023, a sharp rise from 735 cases in 2022 and 360 in 2021[iv].

UKSHA statistics reveal there have been 733 confirmed cases of measles since October 2023, with 112 (15%) of those being In London, making the capital one of England’s worst affected areas. While the majority (63%) of cases were in children under 10, 29.5% (216) were found in young people and adults over the age of 15.

Syphilis
Although a rare disease, cases of syphilis have been rising over the past few years, increasing by 23.8% from 2021 to 2022 to put them at their highest levels for decades[v]. The bacterial organism responsible for syphilis, Treponema pallidum, can be acquired by sexual transmission or injection with needles used by an infected person[vi].

Dental practitioners are well placed for early diagnosis of syphilis due to characteristic oral presentations including oral ulcers and white patches in the mouth.

Tuberculosis
Tuberculosis (TB) is a bacterial infection spread through inhaling small droplets from coughs and sneezes of an infected person. It is caused by the bacterium Mycobacterium tuberculosis that mainly affects the lungs, although it can affect any part of the body, including the glands, bones and nervous system.

While England remains a low incidence country for TB, cases in England rose by 10.7% in 2023 compared to 2022, signalling a rebound of TB cases to above the pre-COVID-19 pandemic numbers[vii].

Antimicrobial and antibiotic resistance

Antimicrobial resistance (AMR) has been identified by the World Health Organisation (WHO) as one of the top global public health and development threats. AMR occurs when disease-causing microorganisms (including bacteria, viruses, fungi and parasites) no longer respond to antimicrobial medicines.

A major factor in the spread of AMR is the exposure of bacteria to antibiotics. The overuse of antibiotics in recent years has led to the emergence of so-called ‘superbugs’, strains of bacteria that have developed resistance to many different types of antibiotics including:

• MRSA (methicillin-resistant Staphylococcus aureus)
• Clostridium difficile (C. diff)
• bacteria that cause multi-drug-resistant tuberculosis[viii]

Antibiotic resistance (ABR) is of particular concern to dental teams as antibiotics are the class of drugs most prescribed by dentists. According to the British Dental Association (BDA), dentists are responsible for 1 in 10 primary care prescriptions for antibiotics in the UK[ix] and states: “reducing unnecessary antibiotic prescribing is vital to minimise the emergence of antimicrobial resistant bacteria. Failure to act could result in ten million deaths, every year, globally by 2050”.

The challenges

According to WHO and public health research institutions, the COVID-19 pandemic proved to be the most contagious and the fastest transmissible disease ever recorded, touching every corner of the globe in less than two years[x].

The dental profession faced unprecedented challenges from the outset of the pandemic in providing care while minimising the risk of transmission. The unique nature of COVID-19 being highly infectious, easily transmissible with the ability to survive for a long time in the environment required modifications to existing and already strict infection control measures to further protect staff, patients and the wider community.

Preventing infectious disease transmission is essential for patient and staff in dental settings. Pathogens like SARS-CoV-2 and antibiotic resistance further highlight the need for vigilant, evidence-based infection control protocols.

Screening

Dental professionals should be aware of current infectious disease risks and be prepared to ask patients appropriate questions when making appointments as required. However, screening patients in advance of attendance, which was an important part of reducing spread during the COVID-19 pandemic, is no longer required. Instead patients should be encouraged to inform the practice of any symptoms which might preclude their attendance as soon as possible and not wait until the day of the appointment.

Prevention

It is the responsibility of dental practices, managers and decon leads to establish a protocol that prevents or limits the spread of infection. This can be accomplished by following the nationally/locally recommended infection control work practice procedures[xi].

Members of the dental team are obliged to keep their knowledge and skills up-to-date regarding the diagnosis and management of infectious diseases that may be transmitted in the dental setting and take appropriate measures to protect patients, staff and themselves against infection.

The main routes of transmission in dental settings include sharps injuries, contact with saliva and respiratory droplets, inhalation of pathogen-containing aerosols, and contact with contaminated equipment or surfaces. Understanding how these transmission routes progress is a crucial part of knowing why procedures are followed and why infection prevention and control in dental practice is a recurring theme in continuing education.

Stopping the spread

Key infection control strategies include diligent hand hygiene, the use of personal protective equipment (PPE), cleaning and sterilisation of dental instruments and scrupulous cleaning and disinfection of clinical and non-clinical surfaces.

As SARS-CoV-2 emerged there was strong messaging about the importance of escalating such infection control measures and the principals behind these messages remain important today.

Preventing and reducing the transmission of infectious disease is essential to ensuring overall health. At the same time, antimicrobial resistance is a global problem that makes infections harder to treat with existing medicines. Only by maintaining the highest standards of infection prevention and control can health care workers reduce the opportunities for infections to spread and for resistance to develop.