Incidence alginate with

Marshal Seymour

of viable impressions sputum

mycobacteria in patients

tuberculosis

on

positive

Polan, D.D.S.,* Stanley Roistacher, D.D.S.***

Frommer,

D.D.S.,**

and

Jamaica, N. Y.

patient with tuberculosis presents a health hazard to those who are intimately involved with him. Although the disease is transmitted from individual to individual via droplet infection, many variables influence the actual contraction of tuberculosis as a disease. These include: (A) race-when influences such as dosage, previous infection, and environment are equalized, Negroes are found to have a lower degree of resistance; (B) sex-considerably more men than women over the age of 25 years contract tuberculosis; (C) age-during infancy, tuberculosis has the lowest incidence but the highest death rate; (D) malnutrition; and (E) the state of resistance of the individual seeded with the acid-fast bacil1us.l Since dental care involves manipulation in an area where the tubercle bacillus is most likely to be found and since the instruments, materials, and supplies are introduced directly into the oral cavity with possible contact of infected sputum or contaminated saliva, it is most important for dentists to use all precautions to prevent the transmission of these viable organisms to another person via the above-mentioned vectors. The mycobacterium is readily destroyed by exposure to boiling water for 10 minutes.2 However, not all dental instruments can be so treated. A variety of rotary cutting instruments would be rendered inoperable as a result of boiling, and many of the dental materials would be subject to distortion or destruction by boiling water. These would include plaster casts, impression materials, and methyl methacry*Staff, Department of Dentistry, Long Island Jewish Medical Center. **Assistant Attending, Long Island Jewish Medical Center-Queens Affiliation. ***Director, Hospital Center Department Affiliation. of Dentistry, Long Island Jewish Medical

Hospital

Center

Center-Queens

335

336

Polan,

Frommer,

and Roistachcr

late resin. Many cold stcrilizatioir solutions have becln tlcvisccl but with irtdifftWiil SUCct!SS. This article will describtt thr results of examining alginate jirre\,ersible hydrc~ colloid ) impressions made on known TILpositive patients wllcn the impressions WIW rcmovrd from these patients tno~rths. REVIEW OF THE LITERATURE

Darlington and Salman~ discussed the spread of tuberculosis. They suggest-cd that tllca most common pathway of infection was via the sputurn of active tubcrculal patients. Other authors have suggested additional routes: but the consensus apprars to be that the oral cavity is the most likely pathway. 1)uguid analyzed the positive sputum cultures of 20 patients. He took specimen cultures from the throat and the anterior part of the rnouth, and he instructed thr patients to cough into glass slides which were then swabbed for inoculation of cnltllre plat?s. Half of these slide specimens and mouth specimens contained viable organisms: 75 per cent of those taken frorn the throat were read as positive with TR bacilhls. Dubois-Verliere? suggested that the tubcrcle bacillus would be found in the mouths of tubercular patients. He obtained oral swabbings and washings of 68 tubercular patients. Cultures were prepared at hourly intervals following each patients last expectoration. Results showed that the percentage of positive rulturcd tubercle bacilli decreased frorn 54 per cent in the first hour to 11 per cent positive in the fourth hour. Dubois-Verliere7 found that tubercle bacilli were present in the secretions of the throat of 15 of 20 patients and in the secretions in the anterior part of the mouth of 10 of 20 patients. Abbott and co-workers8 attempted to assess the degree to which mycobscteri:i occur at the site of operative dentistry. They took smears and cultures from samples of water which were syringed over the dental surfaces of 111 TH patients during the performance of 300 dental procedures. Colonies of bacteria that were morphologically similar to human tubrrcle bacilli werr removed from 131 (43.7 per cent I of the 300 specimens. PROCEDURE A sample population for this study was selected from the inpatients of the Queens Hospital Center, Pulmonary Disease Service. All of the patients were rdenttllous in the maxillary arch and sputum positive at the time the impressions were made. The trays were sterile and were handled with sterile rubber gloves. The materials used were taken from packages individually wrapped by the manufacturers. The group consisted of 7 women and 13 men. All were on a regimen of chernotherapeutic agents at the time of testing. These agents included INH, PAS, Strept,omycin, and cycloserine with Ethionamide. Table I shows the distribution of these patients and drugs. The impressions were made when the patient arose and before the intake of an) solid or liquid substance which might alter the salivary content of the mouth. Using a perforated stock metal tray, a single impression was made of each subjects maxil-

z%ite~ 3
Table I. Number of patients
No. of patients 5 7 4 2 1 1

Mycobacteria

tuberculosis

on alginate

impressions

337

and drugs used

Drugs INH, PAS, Streptomycin INH, PAS INH and combinations of cycloserine and/or Ethionamide INH, PAS, and combinations of cycloserine and/cr Ethionamide INH, Streptomycin Cycloserine with Ethionamide

Table II. Incidence known tuberculosis

Medium ATS 7HlO

of positive

cultures

from dental

impressions

in 20 patients

with

Positive

culture 4 20

Negative 16 0

culture

1 Total

no. of fiatients 20 20

lary arch. These impressions were swabbed in 5 areas, and the swabs were dropped into test tubes containing sterile saline solution. Equal parts of this solution were combined with equal parts of a 3 per cent solution of sodium hydroxide, and these were placed in a sterile centrifuge tube. The mixture was thoroughly shaken for 15 minutes. Ten ml. of this liquid was transferred to a second sterile centrifuge tube and was concentrated by centrifugation at 3,000 r.p.m. for 15 minutes. The supernatant liquid was decanted in the presence of phenol red, and the remaining sediment was neutralized to a pH of 7 using 0.1 N to 1 N HCl. Penicillin ( 100,000 units) was then added to the neutralized concentrate to reduce bacterial contamination. For each of the specimens, 2 tubes of Lowenstein-Jensen medium were inoculated and incubated at 37 C. overnight. After 24 hours, one plate of ATS and one plate of 7HlO culture media were inoculated from the Lowenstein-Jensen tubes, and these were incubated for 5 weeks in toto. A drop of the liquid from the Lowenstein-Jensen medium was placed on a slide which was slightly covered with egg albumin for its fixative action. The slide was stained, employing the Ziehl-Nelsen method for demonstration of acid-fast bacilli. RESULTS 1. All initial smears were negative. 2. Two to 4 weeks following the inoculation of the culture media, both test media began to show colony growth. 3. After 5 weeks, each of the 20 cases showed some growth of colonies on one or both of the test media (Table II).

33%

Polan,

Frommer,

and Roistacher

September, 1970

J. Pros.Dent.

CONCLUSIONS
1. Viable tubercle bacilli can be transmitted from the contaminated saliva or the infected sputum of positive TB patients to inert dental impression materials, and these organisms can be recovered from these materials. 2. Smears do not appear to offer any valid demonstration of the presence 01 absence of microorganisms in the mouth. 3. The culture medium 7HlO appears to be far superior to ATS for the growth of tubercle bacilli.

DISCUSSION
This preliminary study must be followed by similar examinations of dental procedures which begin with impression making and then go on through additional steps to produce prosthodontic appliances. The various operational steps must be studied to see ( 1) whether or not materials employed in each step must be differently handled or treated and (2) whether or not the tubercle bacillus can retain its viability through these various steps to emerge at the end of the technical procedure capable of being seeded in another person. The authors would like to express their appreciation to Dr. M. Mollov, Director of Bacteriology at Queens Hospital Center, for her support and cooperation in this study. We would also like to thank Dr. Harry Epstein, Visiting Physician, Division of Pulmonary Medicine at the Queens Hospital Center, for his support and knowledge in the preparation of this study and to express our gratitude to Mrs. Jarmilla Dvorak for her assistance in preparing the research in this field of literature.

References
1. Anderson, W. A. D.: Pathology, ed. 5, St. Louis, 1966, The Cl. V. Mesby Company, p. 735. 2. Pleasure, M. A., Duerr, E. L., and Goldman, M.: Eliminating a Health Hazard in Prosthodontic Treatment of Patients With Pulmonary Tuberculosis, J. PROS. DENT. 9: 818-824, 1959. 3. Simsa, J., and Dozertova, A.: Integral Asepsis in Dental Treatment of Patients With Tuberculosis, D. Abst. 2: 690, 1957. 4. Darlington, C. C., and Salman, I.: Oral Tuberculous Lesions, Am. Rev. Tuberc. 35: 147179, 1937. 5. Anderson, W. A. D.: Pathology, ed. 5, St. Louis, 1966, The C. V. Mosby Company, pp. 732-747. 6. Duguid, J. P.: Expulsion of Pathogenic Organisms From the Respiratory Tract, &it. Med. J. 1: 265-268, 1946. 7. Dubois-Verliere, A.: Permanence du Bacilli de Kock dans la Bouche et la Pharynx Apres Lexpectoration, Rev. de la Tuberc., Series 5, No. 9, p. 447. 8. Abbott, J. N., Briney, A. T., and Denaro, S. A.: Recovery of Tube&e Bacilli From Mouth Washings of Tuberculous Dental Patients, J. A. D. A. 5th 49-52, 1955.
THE LONG ISLAND JEWISH MEDICAL CENTER QUEENS HOSPITAL CENTER APFELIATION 82-68 164~~ ST. JAMAICA, N. Y. 11432