Centers for Disease Control and Prevention Guidelines for Prevention of Tuberculosis in Dental Settings
The Centers for Disease Control and Prevention published “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994” in Morbidity and Mortality Weekly Report, volume 28,No. RR-13, October 28, 1994. All of the details are in that publication, but the information related to dental setting (which is section II.M.2.E. on page 52 of the article) is presented in this appendix. A link to the original publication can be found on 
. Further information related to tuberculosis prevention in the dental office can be found in the May 1995 issue of the Journal of the American Dental Association.∗
In general the symptoms for which patients seek treatment in a dental care setting are not likely to be caused by infectious tuberculosis. Unless a patient requiring dental care coincidentally has tuberculosis, the dental professional is not likely to encounter infectious tuberculosis in the dental setting. Furthermore, generation of droplet nuclei containing Mycobacterium tuberculosis during dental procedures has not been demonstrated.† Therefore the risk of transmission of M. tuberculosis in most dental settings is probably low. Nevertheless, during dental procedures, patients and dental workers share the same air for varying periods of time. Coughing may be stimulated occasionally by oral manipulations, although no specific dental procedures have been classified as “cough-inducing.”
In some instances, the population served by a dental care facility, or the health care workers in the facility, may be at relatively high risk for tuberculosis. Because the potential exists for transmission of M. tuberculosis in dental settings, the following recommendations should be followed:
• A risk assessment (Table C-1) should be done periodically, and tuberculosis infection control policies for each dental setting should be based on the risk assessment. The policies should include provisions for detection and referral of patients who may have undiagnosed active tuberculosis; management of patients with active tuberculosis, relative to provision of urgent dental care; and employer-sponsored health care worker education, counseling, and screening (Box C-1).
TABLE C-1
Conducting a Tuberculosis Risk Assessment in a Dental Setting
| Assessments and Results | Risk Category |
| Review the community tuberculosis profile from public health records and determine the number of patients with active tuberculosis seen in the office in the last year. If patients with active tuberculosis have been in the office, skin test (PPD∗) office staff. | |
| Patients with active tuberculosis were not treated in office, and none were reported in the community. | Minimal risk |
| Patients with active tuberculosis were not treated in office, but some were reported in the community. Plan to screen and refer known or suspected patients with tuberculosis to a collaborating facility for evaluation and management if treatment is required. | Very low risk |
| Office provided treatment to fewer than six patients with active tuberculosis, and no evidence of PPD skin test conversions was found among office staff. | Low risk |
| Office provided treatment to six or more patients with active tuberculosis, and no evidence of PPD skin test conversions was found among office staff. | Intermediate risk |
| Evidence was found of transmission of tuberculosis in the office based on skin testing data. | High risk |
∗PPD, Purified protein derivative from Mycobacterium used in skin testing.
• While taking patients’ initial medical histories and at periodic updates, dental health care workers routinely should ask all patients whether they have a history of tuberculosis disease and symptoms suggestive of tuberculosis.
• Patients with a medical history or symptoms suggestive of undiagnosed active tuberculosis should be referred promptly for medical evaluation of possible infectiousness. Such patients should not remain in the dental care facility any longer than required to arrange a referral. While in the dental care facility, the patients should wear surgical masks and should be instructed to cover their mouths and noses when coughing or sneezing.
• Elective dental treatment should be deferred until a physician confirms that the patient does not have infectious tuberculosis. If the patient is diagnosed as having active tuberculosis, elective dental treatment should be deferred until the patient is no longer infectious.
• If urgent dental care must be provided for a patient who has or is strongly suspected of having infectious tuberculosis, such care should be provided in facilities that can provide tuberculosis isolation (see Section II, E and G of the original publication for details). Dental health care workers should use respiratory protection while performing procedures on such patients.
• Any dental health care worker who has a persistent cough (i.e., a cough lasting 3 weeks or more), especially in the presence of other signs or symptoms compatible with active tuberculosis (e.g., weight loss, night sweats, bloody sputum, anorexia, and fever), should be evaluated promptly for tuberculosis. The health care worker should not return to the workplace until a diagnosis of tuberculosis is excluded or until the health care worker is on therapy and a determination is made that the health care worker is noninfectious.
• In dental care facilities that provide care to populations at high risk for active tuberculosis, use of engineering controls similar to those used in general-use areas (e.g., waiting rooms) of medical facilities that have a similar risk profile may be appropriate.
GUIDELINES FOR PREVENTING THE TRANSMISSION OF MYCOBACTERIUM TUBERCULOSIS IN HEALTH-CARE SETTINGS, 2005∗
Note: The references and Appendices cited here are given in the original publication. A link to the original publication can be found on .
The generation of droplet nuclei containing M. tuberculosis as a result of dental procedures has not been demonstrated.184 Nonetheless, oral manipulations during dental procedures could stimulate coughing and dispersal of infectious particles. Patients and dental HCWs share the same air space for varying periods, which contributes to the potential for transmission of M. tuberculosis in dental settings.185 For example, during primarily routine dental procedures in a dental setting, MDR TB might have been transmitted between two dental workers. 186
To prevent the transmission of M. tuberculosis in dental-care settings, certain recommendations should be followed.187,188 Infection control policies for each dental health-care setting should be developed, based on the community TB risk assessment (see TB Risk Assessment Worksheet [Appendix B]), and the periodically should be reviewed annually, if possible. The policies should include appropriate screening for LTBI and TB disease for dental HCWs, education on the risk for transmission to the dental HCWs, and provisions for detection and management of patients who have suspected or confirmed TB disease.
When taking a patient's initial medical history and at periodic updates, dental HCWs should routinely document whether the patient has symptoms or signs of TB disease. If urgent dental care must be provided for a patient who has suspected or confirmed infectious TB disease, dental care should be provided in a setting that meets the requirements for an AII room (see Environmental Controls). Respiratory protection (at least N95 disposable respirator) should be used while performing procedures on such patients.
In dental health-care settings that routinely provide care to populations at high risk for TB disease, using engineering controls (e.g., portable HEPA units) similar to those used in waiting rooms or clinic areas of health-care settings with a comparable community-risk profile might be beneficial.
During clinical assessment and evaluation, a patient with suspected or confirmed TB disease should be instructed to observe strict respiratory hygiene and cough etiquette procedures 122. The patient should alsowear a surgical or procedure mask, if possible. Non-urgent dental treatment should be postponed, and these patients should be promptly referred to an appropriate medical setting for evaluation of possible infectiousness. In addition, these patients should be kept in the dental health-care setting no longer than required to arrange a referral.
∗Cleveland JT, Gooch BF, Bolyard EA, et al: TB infection control recommendations from the CDC, 1994: considerations for dentistry, J Am Dent Assoc 126:593-600, 1995.
†Dueli RC, Madden RN: Droplet nuclei produced during dental treatment of tubercular patients, Oral Surg 30:711-716, 1970.
∗Prepared by Paul A. Jensen, PhD, Lauren A. Lambert, MPH, Michael F. Iademarco, MD, Renee Ridzon, MD Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005 MMWR 54(RR17);1-141, 2005.