At least 37 children may be part of the outbreak of Mycobacterium abscessus infections associated with having pulpotomy procedures at the Children’s Dental Group office at 2156 E. Lincoln Avenue in Anaheim, California, according to the Orange County Department of Health (OCDH). During a pulpotomy, tooth decay and the diseased pulp are removed to preserve a primary tooth.
Of the 37 cases of bacterial infection, 12 are confirmed and 25 are probable. All 37 children, ranging in age from 3 to 9, have been hospitalized at some point. The pulpotomy date range for all cases is 3/14/16 – 7/28/16.
What is Mycobacterium Abscessus?
Mycobacterium abscessus is bacterium distantly related to the ones that cause tuberculosis and leprosy. The symptoms of this infection can surface weeks to months after a pulpotomy procedure. Symptoms include swelling, redness, and pain around the infected tooth, often coming slowly over days to weeks.
“The source of bacterial infections can be pinpointed using genetic testing called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS),” says Ryan Osterholm, an attorney at our law firm who helps children sickened in outbreaks of infection get compensation. “When bacteria is found in water that has the same genetic fingerprint as bacteria that sickened outbreak victims, that is clear evidence that water at that location is the source of the outbreak. We have used this kind of evidence to hold businesses accountable for devastating illness.”
Our experience is that a lawsuit can provide needed financial help to the family, compensation to the child for pain and suffering, a means of holding a business accountable.
How Does Dental Water Give a Child an Infection?
Dental water can give a child an infection when biofilm, a slimy film of bacteria, sticks to the inside of dental unit waterlines.
“Biofilm occurs in dental unit waterlines because of the long, small-diameter tubing and low flow rates used in dentistry, the frequent periods of stagnation, and the potential for retraction of oral fluids. As a result, high numbers of common water bacteria can be found in untreated dental unit water systems.” – CDC
Dangerous pathogens that can be found in untreated dental unit water include Mycobacterium abscessus, Legionella, and Pseudomonas aeruginosa. This is why it is imperative that dental waterlines be treated and monitored.
Dental offices should follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product. There are also commercial, self-contained test kits or water-testing laboratories available.
In addition to this outbreak of Mycobacterium abscessus infections:
- in 2011, an 82-year-old woman in Italy was diagnosed with legionellosis and died 2 days later; and
- in 2015, an outbreak of Mycobacterium abscessus odontogenic infections was reported in children receiving pulpotomy treatment from a pediatric dental clinic in Georgia.
2015 Outbreak in Georgia
The 2015 outbreak involved 20 children, ages 3 to 11, who developed Mycobacterium abscessus tooth infections after havin a pulpotomy at a pediatric dentistry practice in Georgia. Onset of infection symptoms ranged from July 23, 2014–September 4, 2015, according to an article in MMWR, a CDC publication. Symptoms and complications included pain, osteomyelitis (bone infection), facial swelling, lymphadenopathy (lymph node disease), pulmonary nodules (growth in the lung) and fever. Of the 20 children harmed, 17 of them needed surgery (surgical excision).
Confirmed cases were those in which Mycobacterium abscessus was isolated by laboratory culture. The incubation period (time between pulpotomy and symptoms) ranged from 18 to 164 days (yes, over 5 months).
The Georgia dental practice had used tap water for pulpotomies without water quality monitoring or bleaching of waterlines at the end of each day, as recommended in the manufacturer guidelines. Water samples were collected for microbiologic analysis, and patient and water sample isolates were sent to CDC for molecular characterization by PFGE (see attorney Ryan Osterholm’s quote about PFGE above).
“All water samples from the seven dental stations had bacterial counts above the American Dental Association recommended ≤500 colony-forming units (CFU)/mL (average = 91,333 CFU/mL); M. abscessus was isolated from all water samples. All water and patient isolates were indistinguishable by PFGE, indicating a common source.”
Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the Field. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016;65:355–356.