Freitas CVS et al.

ASSESSMENT OF MICROBIOLOGICAL CONTAMINATION OF RADIOGRAPHIC DEVICES IN SCHOOL OF DENTISTRY

doi: 10.14295/bds.2012.v15i1.716

Assessment of microbiological contamination of radiographic

devices in School of Dentistry

Avaliação da contaminação microbiológica em equipamentos

radiog gia

Claudio Vanucci Silva de FREITAS

Ms in Dentistry- Federal University of Maranhão - São Luís - MA - Brazil.

Laércio Santos DIAS

PhD Student in Orthodontics – UNESP - Univ Estadual Paulista - Araçatuba - SP - Brazil.

Camilla Silva de ARAUJO

Ms in Public Health - Federal University of Maranhão - São Luís - MA - Brazil.

Vanessa Camila DA SILVA

Associate Professor of Anesthesiology And Oral Surgery - Department of Dentistry II - Federal
University of Maranhão - São Luís - MA - Brazil.

Valério MONTEIRO - NETO

Associate Professor of Microbiology - Departament of Pathology - Federal University of Maranhão -
São Luís - MA - Brazil.

João Inácio Lima de SOUZA

Associate Professor of Endodontics - Department of Dentistry II - Federal University of Maranhão -
São Luís - MA - Brazil.

A BSTR A CT

Although dental radiology is not directly involved in either invasive procedures or in the use of piercing-cutting material,
the high-touch areas of dental x-ray device, including radiographic are a potential source of infection. The purpose
of this study was to assess the amount of cross infection present in the dental x-ray devices of the School of Dentistry of the
Federal University of Maranhão by investigating the presence of pathogenic microorganisms in high-touch areas of dental
x-ray devices (tube head, timer button, portable processing box and lead apron). Twenty surfaces of 4 dental radiology
clinics were cultured in different media. The results showed that 70 percent of the surfaces had contamination. All the
dental x-ray devices assessed were contaminated (tube head, timers or both) as well as all the lead aprons. The portable
processing boxes showed 75 percent of contamination. The groups found no statistical between the different
surfaces assessed and the microorganisms. The highest frequent microorganisms found were from Staphylococcus genus.
The authors concluded that because of the high incidence of contamination found, the x-ray devices used in the dental
clinics could be at potential risk of cross infection, demonstrating the necessity for applying biosecurity practices when
taking radiographic and during radiographic processing.

K EYWORDS
Radiology; biological contamination; equipment contamination; dental infection control.

I NTRODUCT ION susceptible to bacterial, viral and fungal infections.

This makes the dental clinical environment a possible
Oral cavity represents the site of most concentration source of exposure of the dentist, the team, and
of microorganisms in dental environment, being the patients to the risk of cross infection. With the

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ASSESSMENT OF MICROBIOLOGICAL CONTAMINATION OF RADIOGRAPHIC DEVICES IN SCHOOL OF DENTISTRY

discovery of the antibiotics and vaccines after World number of bacterias on the films, the potential of cross
War II, the humanity obtained the wrong idea of safe, contamination was still present [5].
imagining that infectious diseases did not represent a The amount of the contamination provoked by
danger anymore [1]. However, the appearance of AIDS performing intra-oral radiographic technique was
in Brazil, at the end of the 70s, and its outbreak in the demonstrated by the use of a dental manikin. To
80s, together with the increasing in the incidence of the simulate the presence of saliva, a dye was placed on oral
cases of hepatitis B and C, decreased this wrong idea of cavity floor of the manikin. This solution was detected
safe and the Dentistry professionals started to use more only under the incidence of ultraviolet light, causing
efficient methods to control cross infection [2]. fluorescence. After the execution of 20 radiographic
The transmission of infectious disease is commonly shots through periapical technique was possible to
associated to piercing-cutting material and blood/ observe, by applying the ultraviolet light, the presence
saliva drops; however, these diseases may also be of the dye in the x-ray tube head, cylinder and timer
transmitted by contaminated surfaces and materials. buttons, auxiliary table and dental x-ray positioners as
Therefore, the devices, accessories, and films used well as in the automatic processing device [6].
during the radiographic shooting and processing are The microbiological contamination of the
potentially contaminants and, thus, liable to transmit automatic processing device of dental radiographs
infectious diseases [3]. and the portable processing box was evaluated during
Most of the scientific studies on the infection one week of simulated clinical use. The contaminated
control in dental practice report the standard films and control group films (decontaminated)
procedures applicable to all Dentistry areas. Studies were processed and, posteriorly analyzed
conducted in Radiology have been performed aiming microbiologically. After processing, the films kept
to demonstrate that the radiologic environment can the initial contaminant, were contaminated with other
also be a vector of cross infection, and also to educate experimental microorganism, or both. The portable
the professional on the importance of the application processing box was contaminated by three of four
of biosecurity measurements during the radiographic experimental microorganisms. The contamination was
shooting and processing. in the automatic processing device and in the portable
Aiming to evaluate the possibility of cross processing box even after 48 hours of inactivity [7].
contamination among patients submitted to intra-oral A study was performed aiming to verify the
radiographic shots, samples of oral microbiota were contamination in areas of most contact between the
collected from 60 adult subjects before and after the operators and dental radiographic devices of the School
radiographic examination. The disinfection of x-rays of Dentistry of Taubaté. The samples were collected
was only performed between the treatment of pairs after the procedures of the attendance of the patients
of patients and not between each patient. The results of the clinical disciplines of the aforementioned
revealed the cross contamination among subjects school and plated onto five different culture media.
belonging to the same pairs, and the transference The results proved that the radiographic devices were
of microorganisms occurred in 77% of the patients. equally contaminated, presenting mean rates of 50% of
The vectors of transference included the operator’s microbiological contamination; also, the contamination
hands and the surface of the x-ray device. When the was different among the groups of microorganisms. The
disinfection of the x-rays device was executed cross highest rate of contamination was by Staphylococcus
contamination did not occur [4]. (50%), and the smallest by Gram negative bacilli (6%).
A study evaluated the presence of microorganisms Yeasts (Candida) and Streptococcus mutans showed
in samples of air, surfaces, and processing solutions similar contaminations (30%) [8].
(developer, fixer and water) of a radiographic The detectors used in digital radiographs (both
processing room during periods of high and low sensors and phosphor storage plates) are not
clinical activity. The radiographic films were autoclavable, therefore, being susceptible to cross
intentionally contaminated to evaluate the effect contamination. A study evaluated whether the
of the processing solutions on the microorganisms. phosphor plates used in a School of Dentistry showed
The results showed bacterial contamination in the microbiological contamination. Forty-five plates were
processing solutions, but at least degree in relation to randomly selected for analysis and pushed onto blood
the surfaces. Bacterias survived in the films after the agar plates which were incubated at 37ºC for 72 hours.
radiographic processing. Although the procedures of The authors observed the number, size, distribution and
radiographic processing had significantly reduced the variety of the colonies. There was bacterial growth in

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ASSESSMENT OF MICROBIOLOGICAL CONTAMINATION OF RADIOGRAPHIC DEVICES IN SCHOOL OF DENTISTRY

57.8% of the plates analyzed. Considering the results, broth (BHI - MERCK) with 5% of defibrinated sheep
the authors reinforced the necessity of continuous blood used for the growth of microorganisms in general;
training of the undergraduates and the periodical 2. Bacitracin Sucrose Agar Mitis Salivarius,
sterilization of the plates by ethylene oxide gas [9]. composed by Agar Mitis Salivarius (DIFCO) with 3.3
Because of the aforementioned studies, we note mg/ml of Bacitracin (INLAB), 15% of sucrose and 1
the increasing concern in Dental Radiology regarding ml/l of 1% potassium tellurite used for the growth of
to the biosecurity guidelines to prevent that the Streptococcus mutans;
microorganisms present in the radiographic procedures 3. Standard Agar with chloramphenicol,
may infect the dentistry professionals and patients [10]. composed by Agar Tryptone Glucose Extract
The aim of this study was to evaluate the (DIFCO) with 10 mg/ml of chloramphenicol used for
microbiological contamination in x-ray devices of the growth of fungi and yeasts;
the Dentistry Course of the Federal University of 4. MacConkey Agar (MICROMED): used for
Maranhão by investigating the presence of pathogenic the growth of enteric gram-negative bacterias..
microorganisms in areas of frequent contact with The plates containing Blood Agar (BA) and
the operator, to compare the contamination in the MacConkey Agar (MC) were incubated at 37°C
difference surfaces evaluated, and to identify the for 48 hours. Those containing Bacitracin Sucrose
contaminating microorganisms. Mitis Salivarius Agar (BSMS) were incubated in
anaerobiosis at 37°C for 48 hours, through the
Material and Method Anaerocult system (Merck) composed by pots that
enabled an atmosphere rich in carbon dioxide for
Sample the growth of anaerobe microorganisms. The plates
containing Standard Agar with chloramphenicol
Four rooms of the Dentistry Course of the Federal (SAC) were incubated at environmental temperature
University of Maranhão were assessed, in which for 5 days. One plate of each one of the media was
routine radiographic examinations are performed. incubated without inoculation (negative control) to
In each one of the rooms, five surfaces frequently assure that the media were sterile prior to inoculation.
touched by the operator during radiographic shooting
and processing were selected: tube and timer button Identification of the Microorganisms
of the x-ray device; access sleeve and lid of the
portable processing box; upper surface of the lead After incubation, the macroscopic reading of
apron, totaling 20 surfaces. the plates was performed to verify the presence of
the microorganisms. The results were expressed as
Collection positive cases of contaminated plates.
The colonies growing in BSMS medium were
The samples were always gathered by the same presumptively identified as Streptococcus mutans,
operator after the ending of the day. For this purpose, considering that this is a selective medium for this
a sterile swab moistened with sterile saline solution type of microorganism and observing the macroscopic
was rubbed onto each one of the surfaces selected and characteristics of the colonies. The microorganisms
the material collected was kept in test tubes containing growing in SAC were submitted to microcultivation, that
0.5 ml of brain heart infusion broth (MERCK). is, part of the fungus colonies were plated onto sterile
Following, the samples were immediately taken to laminas containing the medium, covered by coverslips,
the laboratory of Microbiology of the Department of and again incubated for 5 days at environmental
Pathology of the Federal University of Maranhão for temperature. After showing visible growth, they were
inoculation and incubation. observed in laminas by using the lactophenol cotton
blue dye for macroscopic identification of the fungus
Inoculation and Incubation genus. The colonies that grown onto the plates BA
and MC were subcultured into test tubes containing
Each one of the samples kept in the test tubes was Nutrient Agar (BIOLIFE) tilted for later identification.
homogenized in a Vortex agitator for one minute. The These tubes were incubated at the aforementioned
homogenized samples were plated onto four different media conditions. After isolation, the microorganisms were
to investigate the growth of different types of microorganisms: submitted to Gram staining for identification by their
1. Blood Agar, composed by brain-heart infusion tinctorial and morphological characteristics. The Gram

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ASSESSMENT OF MICROBIOLOGICAL CONTAMINATION OF RADIOGRAPHIC DEVICES IN SCHOOL OF DENTISTRY

staining method guided the biochemical scheme to be Among the surfaces evaluated, the timer button
followed for the bacterial identification. Gram-positive of the x-ray device and the upper surface of the lead
bacilli were evaluated regarding their morphological apron showed the highest percentage of contamination
characteristics as well as their capacity of spore (100%), followed by the lid of the processing box
formation. Gram-positive cocci were submitted to (75%), the tube of the x-ray device (50%) and the
catalase test by depositing a drop of 3% hydrogen access sleeve of the processing box (25%). However,
peroxidase onto a sterile lamina and mixing it to the the statistical analysis by Kruskal-Wallis test did not
colony to differentiate the microorganisms between show statistically significant difference (p = 0.11)
catalase-positive (Staphylococcus) and catalase-negative among these contamination rates.
(Streptococcus); Staphylococcus were still submitted to All x-ray devices evaluated presented
the plasmocoagulase test, in which a drop of plasma was contamination (tube, timer, or both), as well as all
deposited onto the colony subcultured in sterile lamina lead aprons. Concerning to the portable processing
to observe whether there is or there is not the formation boxes (including the access sleeve and the lid), three
of small aggregates resulting from coagulation to out of four showed contamination.
differentiate the microorganisms between coagulase- The microorganisms presenting the highest
positive and coagulase-negative. Streptococcus colonies percentage of growth were fungi (65%); genus
were evaluated by their macroscopic characteristics. Rhizopus and Aspergillus was present in 45% and 30%
of the surfaces evaluated in this study, respectively.
Statistical analysis Fungi of other genera as Mucor, Alternaria and
Curvularia, as well as yeasts of genus Candida, were
The results obtained were tabulated and submitted also identified at small frequency (5%).
to statistical analysis by non-parametric Kruskal- Concerning to genus, the most frequent microorganisms
Wallis test, through BioEstat software, version 5.0. found in the samples collected were Staphylococcus,
(55%); in one surface (5%), it was possible to identify
Results also the specie: Staphylococcus aureus.
It was identified, yet at small frequency, several other
The macroscopic analysis of the negative control genera of microorganisms. Table 2 shows the percentage
plates showed that there was no microbial growth of occurrence of the microorganisms on the surfaces
in any of the media used in this study, which meant analyzed. Statistically analyzing the contamination by
that the plates were not contaminated prior to the the different genera of microorganisms through Kruskal
inoculation of the collected samples. The surfaces Wallis test, it was observed a statistically significant
that provided the microbiological growth in any of (p = 0.03) predominance of microorganisms of genus
the four media where the samples were plated were Staphylococcus.
considered as contaminated. Of the 20 surfaces
analyzed, 14 showed microbiological contamination, Table 2- Percentage of the occurrence of
which corresponds to a total percentage of 70% of microorganisms on the surfaces analyzed
contamination. Table 1 displays the general data on MICROORGANISMS FREQUENCY
the amount of contaminated surfaces. Staphylococcus spp. 50%
aureus 5%
Table 1- General data of the number of Rhizopus spp. 45%
contaminated and uncontaminated surfaces Aspergillus spp. 30%

DEVICE ANALYZED AMOUNT CONTA- UNCONTA- Lactobacillus spp. 30%

SURFACE MINATED MINATED Bacillus sp. 15%
X-ray Tube 4 2 2 Streptococcus mutans 5%
Timer 4 4 0 beta-hemolytic 5%
button
Actinomyces spp. 5%
processing Access 4 1 3
Gram-negative short bacilli 5%
box sleeve
Candida spp. 5%
Lid 4 3 1
Alternaria spp. 5%
Lead Upper 4 4 0
apron surface Mucor spp. 5%
TOTAL 20 14 6 Curvularia spp. 5%

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ASSESSMENT OF MICROBIOLOGICAL CONTAMINATION OF RADIOGRAPHIC DEVICES IN SCHOOL OF DENTISTRY

Discussion of opportunistic character. The coagulase-negative

species of Staphylococcus (found in 50% of the
The sample involving four rooms of radiographic surfaces assessed) have been currently considered
examinations correspond to 100% of the x-ray devices as important causes of infection, particularly in
operating during the execution of the research. The hospital environment, mainly in patients with
choice for the five surfaces in which the collection their organic defenses compromised. Additionally,
was randomly performed was because it has been Staphylococcus aureus may be still involved in
demonstrated that the surfaces of the devices are processes of bacteremia, endocarditis, pneumonia
contaminated at the same proportion [8]. and, occasionally, meningitis and bacterial arthritis
The surfaces of the radiographic devices analyzed [13]. This microorganisms represent the most
presented a relevant percentage of contamination of common agent of pyogenic infections and it can
70%, a rate similar to that found by Silva et al. [8], in be isolated in cases of dental abscesses, facial
2003, when evaluating the radiographic devices of the osteomyelitis, pharyngitis, tonsillitis, and sinusitis
School of Dentistry of Taubaté, which corresponded [14].
to 64%. Also agreeing with these authors, there It is also a concerning the high percentage of fungi
was no statistically significant difference in the identified by the study. Great part of the species of
contamination among the surfaces assessed. These the genera found are environmental fungi, of low
high rates may be explained by the fact that schools virulence, which coexists peacefully with the host,
of Dentistry, in general, teach the undergraduates the but when they found favorable conditions as disturbs
necessary theoretical knowledge on infection control, of the immunodefensive system, they develop their
but they did not provide enough training and structure pathogenic power, invading the tissues. Because of
for its practice, which depreciate the theory taught [1]. this, they are considered as opportunistic fungi [13].
The results obtained in this study confirmed the The presence of microorganisms frequently found
risk of contamination by microorganisms through the in the oral microbiota as Streptococcus mutans (5%)
surfaces of the radiographic devices, as already had and beta-hemolytics (5%), Lactobacillus (30%),
been shown in other studies [4 - 9]. Actinomyces (5%) and Candida (5%) suggest than
The microorganisms that grown in the sample microorganisms coming from oral cavity may be
collected generally belong to the normal environment taken to the surface of the radiographic devices by
and microbial flora of human beings and are found in the contaminated gloves of the operator. This proves
the skin, oral cavity, upper air way, gastrointestinal the possibility of the cross contamination during the
and urogenital tracts; however, they may account execution of the radiographic examinations, as it was
for several diseases. The infections may develop also demonstrated in other studies [4, 8].
when these microorganisms are taken to sites were Considering the results of this study and other
they are not usually found and the host’s defense previous studies [4 - 9], it is clear the necessity of
control mechanisms are not capable of restraining the use of measurements of infection control which
them. The constituents of the normal flora may may either eliminate or reduce the transmission
not be pathogenic to the host, however, they may of the microorganisms during dental radiographic
be capable of developing pathological processes procedures. Because the clinical routine of
in other organisms, mainly debilitated and treatment varies greatly from one school to another
immunocompromised organisms [11]. and consequently there is not a protocol which
The high percentage of contamination by can be used by them, it is necessary that each
Staphylococcus (55%) suggests the human presence school develop an individual protocol based on the
by the fact that they generally colonize all surface of Universal Precautions, according to its particularities,
the human beings [12]. This may explain why all lead necessities, and possibilities [15].
aprons evaluated showed the growth of this genus of Not always a carefully structured health
microorganisms, because there is the direct contact questionnaire is effective in discovering all patients
between this protection device and the patient. with infectious disease. Considering this problem, the
However, the fact of this type of microorganism Center of Disease Control (CDC) recommends that
is largely found in nature and is part of the normal all patients be treated as potentially infected [16].
microbiota of the human beings does not make the The area of performance of Dental Radiology
rate found here less worrying. Some species are comprises semi-critic items (are in contact with the
frequently associated to a large variety of infections mucous membrane but not penetrate into it), for

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example: hands of the operator, intra-oral films, infection transmission. The two methods of prevention
radiographic positioners and digital image receptors; and removal of the contamination are the immersion
and non-critic items (are not in direct contact with of the film in a disinfectant solution and the use of
the mucous membrane, but they may be in contact protector barriers [22].
with skin), for example: dental chair, surface of the The use of protector barriers significantly reduces
x-ray devices, lead apron and thyroid guard. Each one the risk of cross contamination, but it not completely
of these categories must receive the necessary care prevents its occurrence. This may be attributed to
regarding to biosecurity [17]. the difficulty in removing and discarding the barrier
The contaminated surfaces seem to be the most without the contamination of the film [23, 24, 25].
difficult problem to solve for controlling the infection A simple stage of disinfection performed after
in radiographic procedures, because they are difficult the shooting and before the processing of the films
to identify readily and cannot be properly sterilized reduces the risk of contamination of both the film and
such as a dental mirror or explorer [16]. The the operator to a negligible level [23]. Solutions such
solution for this problem is the use of disinfectant as 2% glutharaldeyde, 70% alcohol and 2% sodium
solutions and barriers on all surfaces [18]. The hypochlorite have been effective in disinfecting
surfaces which are neither covered by barriers nor the films when the technique of immersion in the
properly decontaminated may be as a reservoir for solution for 5 minutes was used [26]. However, the
infectious microorganisms of saliva resulting in cross most practical disinfection technique seems to be
contamination [19]. the immersion in 5.25% sodium hypochlorite for 30
The use of surface disinfectants approved by the seconds. This disinfection procedure is in agreement
American Dental Association (ADA) is recommended with the asepsis guidelines established both by ADA
inasmuch as they show proved activity against bacteria, and CDC and provides a simpler and more effective
virus and tuberculosis [20]. The best products to be disinfection without any risk to the diagnostic value
used for surface disinfection are sodium hypochlorite, of the films [21].
iodophors and synthetic [2]. Although 70% ethyl The radiographic positioners are devices which
alcohol is not a surface disinfectant approved by ADA may also transmit the contamination among patients
and CDC, it showed statistically significant bacterial when proper care is not taken. Therefore, preference
reduction [12]. should be given to autoclavable or disposable
The portable processing box is a device very positioners [27].
convenient for use in private office because it takes The use of intra-oral digital radiograph has brought
up little space and enables a practical processing new challenges regarding to the controlling of cross
of the radiographic films [21]. However, its access contamination. The sensors and phosphor storage
sleeves may be a source of cross contamination if plates cannot be autoclaved and need special care [25].
the operator is using contaminated gloves during the It is recommended the use of plastic barriers [27] and
processing or if the films are contaminated; therefore, the periodical sterilization with ethylene oxide [9].
the box can become easily a reservoir for potential The American Academy of Oral and Maxillofacial
pathogens [20]. Radiology [28] suggest that each School of Dentistry
The difficulty in disinfecting this access sleeves develop a written method of control of cross
is the main problem of the use of the portable infection. The use of an adequate protocol of infection
processing box regarding to control infection [7]. control may significantly reduce the number of
Several conducts have been suggested to maintain microorganisms on the surfaces and in the processing
the asepsis of the portable box, however, some are solutions [29].
complex and not practical [3]. Therefore, we believe Additionally, it is proposed the creation of an
that the ideal conduct is to keep the contamination interdisciplinary committee for infection control
away from the processing box by maintaining it in the Schools of Dentistry composed by the
far from the aerosols generated in the operative professors, undergraduates, and employees [1],
field, processing decontaminated films, using to avoid the most severe iatrogeny that can occur
decontaminated gloves or over gloves or not use within the dental office - the cross infection [8] -,
gloves. and to enable that the Dentistry can fulfill its legal
To prevent that the films be contaminated by oral and moral obligation of assuring that the patients
fluids and to remove these fluids before the film is receive a quality treatment and be protected by a
taken to the processing box minimizes the risk of proper infection control [30].

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Conclusion 2. There was no significant difference among the

contamination rates of the different surfaces evaluated;
1. The radiographic devices evaluated showed, 3. The microorganisms most frequently found
mostly, microbiological contamination; were of genus Staphylococcus.

Resumo
Embora a Radiologia odontológica não envolva a realização de procedimentos invasivos e o uso de instrumentos
perfurocortantes, os equipamentos, acessórios e filmes utilizados durante os procedimentos radiográficos podem transmitir
doenças infecciosas. O objetivo deste estudo foi avaliar a contaminação microbiológica em equipamentos radiográficos
do Curso de Odontologia da Universidade Federal do Maranhão, investigando a presença de microrganismos patogênicos
em áreas de contato frequente com o operador (cabeçote e disparador do aparelho de raios X; manga de acesso e tampa
da câmara escura portátil e borda superior do avental de chumbo). Vinte superfícies de quatro salas de exame radiográfico
foram avaliadas com a utilização de diferentes meios de cultura. Os resultados revelaram um percentual de contaminação
de 70%. Todos os aparelhos de raios X avaliados apresentaram contaminação (no cabeçote, no disparador, ou em ambos),
assim como todos os aventais de chumbo. Em relação às câmaras escuras, 75% mostraram contaminação. Não houve
diferença estatisticamente significante entre a contaminação nas diferentes superfícies analisadas, e os microrganismos
encontrados com maior frequência (55%) pertencem ao gênero Staphylococcus. Diante do alto índice de contaminação
encontrado, conclui-se que as superfícies dos equipamentos utilizados na Radiologia odontológica podem servir como
vetores de infecção cruzada, demonstrando a necessidade do emprego rotineiro de medidas de biossegurança durante a
realização das incidências e processamento radiográficos.

Palavras-chave
Radiologia; contaminação biológica; contaminação de equipamentos; controle de infecções dentárias.

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