CDC weighs in on TADs

This letter is in response to a recent guest editorial (Scholz RP, Cook A. Sterilization requirements for the placement of temporary anchorage devices. Am J Orthod Dentofacial Orthop 2009;l35[4 Suppl]:S20-2). The authors presented information on sterilization procedures for the placement of a particular type of temporary anchorage device (TAD), the miniscrew implant (MSI). We believe that several of the editorial's statements regarding the infection control recommendations of the Centers for Disease Control and Prevention (CDC) are inaccurate and might result in inappropriate or unnecessary precautions by dental health care providers.1

CDC has no regulatory authority and does not establish requirements or have oversight over the practice of dentistry. The Occupational Safety and Health Administration (OSHA) and state dental licensing boards are the regulatory authorities for dentistry. CDC's infection control guidelines are based on the best available science, however, and are frequently used as the basis for regulation by state dental boards and OSHA. Contrary to the authors'statements, CDC has made no determination to date on whether the placement of an MSI is an oral “surgical procedure.”

The oral cavity is colonized by numerous microorganisms that can enter the vascular system during oral surgical procedures—“those that require incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity.”l CDC recommends that surgical precautions, including the use of surgical hand antisepsis, sterile surgeon's gloves, and sterile saline solutions or sterile water-irrigating solutions (with a sterile delivery system, such as a bulb syringe or single-use disposable product), be used for surgical procedures. Dental health care providers need to apply CDC's recommendations combined with the principles of infection control and professional judgment when deciding whether surgical precautions are warranted.

MSIs can be anchored into bone with either a predrilling or self-drilling method. In the predrilling method, a punch incision is made in the gingival tissue to expose bone, and a pilot hole is drilled for proper placement of the implant. In the self-drilling method, the MSI has a pointed tip that is directly screwed with a type of ratchet through the gingival tissue into bone. The predrilling method fulfills CDC's criteria for an oral surgical procedure. In contrast, the self-drilling method, similar to an anesthetic injection, is not an oral surgical procedure, unless a punch incision is used. Nonetheless, because of the potential for contaminating a sterile MSI before placement, our professional judgment suggests that it would be prudent to, at a minimum, wear sterile surgical gloves, regardless of the placement technique.

In addition, the authors stated that, for oral surgical procedures, tap water can be used in self-contained water dispensers if a waterline maintenance tablet is placed in the dispenser. Although many products available in the dental market for controlling water contamination can improve water quality, none provide a sterile irrigating solution, as is recommended for surgical procedures.1 Conventional dental units cannot deliver sterile solutions even if they are used in the self-contained water bottle, because the dental unit's tubing cannot be sterilized. Delivery devices (eg, sterile bulb syringe or sterile, single-use disposable products) should be used for sterile water.1 Finally, instruments used for placing MSIs do not need to be quarantined after sterilization until the results of biological monitoring are known; this measure is recommended only for the implant device itself.1, 2

Other recommendations include the following.

CDC staff continues to monitor the current scientific literature and update infection control recommendations when new information is available. We appreciate the opportunity to clarify several points in the editorial.