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1 ORIGINAL ARTICLE Korean J Clin Lab Sci. 2015, 47(4): pissn eissn Korean J Clin Lab Sci. Vol. 47, No. 4, Dec A Study Regarding Bacterial Contamination of Surfaces in Dental Offices Kyoung-Ok Yun 1 and Hye-Young Kim 2 1 Department of Dental Hygienics, Shinsung University, Dangjin 31801, Korea 2 Department of Clinical Laboratory Science, Shinsung University, Dangjin 31801, Korea 치과진료실내표면세균오염에관한연구 윤경옥 1, 김혜영 2 신성대학교 1 치위생과, 2 임상병리과 This study studied samples taken off surfaces at three sites (Unit chairs, light handles, cuspidors) of 19 dental hospitals and 28 clinics located in Gyeonggi-do and Incheon, South Korea. The bacterial contamination levels of surfaces were CFU/mL in cuspidors, higher than in unit chairs ( CFU/mL) and light handles ( CFU/mL). The values were statistically higher at dental hospitals than at dental clinics, the greater number of patients being associated with the higher bacterial cell count in the cuspidors. The results of identifying the strains isolated purely from surfaces at dental clinic showed Gram positive 47.3% and Gram negative 52.7%. Among Gram positive, the most numberous bacteria were Micrococcus luteus (10.9%), Bacillus pumilus (3.6%), and Staphylococcus aureus (3.6%). Among Gram negative, the most numberous bacteria were Acinetobacter ursingii (5.5%), Brevundimonas diminuta (4.5%), Chryseobacterium (Flavo.) indologenes (CDC IIb) (4.5%), and Methylobacterium sp. (4.5%). This study measures the level of bacterial contamination and identifies the strains isolated in dental clinics. It recognizes the importance of infection control, and the results of the study may be considered as the basis for establishing specific plans for prevention of infection. Keywords: Bacterial contamination, Cuspidors, Dental clinics, Dental hospitals, Unit chairs Corresponding author: Hye-Young Kim Department of Clinical Laboratory Science, Shinsung University, Dangjin 31801, Korea Tel: khy@shinsung.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2015 The Korean Society for Clinical Laboratory Science. All rights reserved. Received: October 16, 2015 Revised 1 st : November 2, 2015 Revised 2 nd : November 5, 2015 Revised 3 rd : November 6, 2015 Revised 4 th : November 8, 2015 Accepted: November 8, 2015 서론최근원내감염에대한인식이높아지면서의료기관의병원감염관리시스템의중요성과문제점에대한관심이집중되고있다. 또한의료기관의인증평가나임상질지표평가기준에서도감염관리에대한비중이높아지고있다. 하지만이러한노력에도면역기능저하환자와노인ㆍ장기이식환자의증가, 항생제내성균주의증가및침습적시술의보편화등으로인하여의료관련감염이계속발 생되고있다 (Yun, 2014). 특히, 치과진료실의환경은치료시날카로운기구로조직을뚫고들어가구강내출혈을발생시키고, 이때환자의혈액과세균및바이러스를포함하고있는타액이침투하여감염성질환을발생시킨다는보고가있다 (Eom과 Kim, 2012). 그리고핸드피스나초음파스케일러등의사용으로감염인자와독소물질을포함한에어로졸이발생되어제한된공간을계속순환하며떠다니다가낙하되어진료실을오염시키기때문에치과의료진뿐만아니라환자에게도

2 280 Kyoung-Ok Yun and Hye-Young Kim. A Study about the Bacterial Contamination of Surface in Dental Office 감염증을일으키게된다. 또한의료진과환자의감염은진료환자나가족등에게도수평적, 수직적감염을일으키는매개체또는감염경로의역할을한다는부분에서중요시되고있다 (Leggat 등, 2007). 치과진료실에서교차감염의위험이있는감염성질환으로는 B 형ㆍC 형간염, 결핵, 포진, 구강과상기도감염질환이며, 최근에는 HIV 바이러스출현으로인한후천성면역결핍증의감염경로가된다는보고가강조되고있다 (Centers for Disease Control and Prevention, 2003; Jamshid 등, 2012). 이에 2006년 7월보건복지부에서는치과진료실의 치과진료감염방지기준 을제정하여실천함으로써진료실의위생수준향상과교차감염을방지하는감염예방에노력하기시작하였으며 (Lee, 2013), 한국보건사회연구원과보건복지가족부주관으로 2007년부터 2009년까지치과의료기관평가시범사업에 감염관리 항목을포함시키게되었다 (Shin, 2008). 하지만이러한노력에도불구하고치과의료종사자들의감염관리에대한인식도가낮고, 실천부족으로감염의위험성은더욱증가되고있으며, 특히치과진료실내세균오염도에대한연구와감염질환원인균에대한조사가부족한실정이다. 이에본연구는병원ㆍ의원치과진료실내세균오염도를측정하고, 감염질환의원인이될수있는세균을확인함으로써적극적인감염관리의중요성을인식시키고, 감염방지를위한구체적인방법을계획수립하기위한기초자료를제시하고자한다. 대상및방법 1. 연구대상 2013년 6월부터 9월까지경기도와인천지역 47곳의치과병원급 19개기관, 의원급 28개기관진료실에서감염되기쉬운유닛체어등받이, 라이트손잡이, 타구대표면에서멸균된면봉을이용하여검체를채취하였다. 2. 연구방법 1) 실험균채취치과병원ㆍ의원진료실의유닛체어등받이, 라이트손잡이, 타구대표면에서실험균을얻기위해 10 cm 10 cm로정한부분을멸균면봉을사용하여검체를채취한후멸균생리식염수 10 ml에넣은다음, 4 o C를유지한상태로실험실로옮겼다 (Chung, 2015). 2) 실험균배양과세균수측정표면의세균수를측정하기위하여채취한검체는 10-1, 10-2, 10-3 으로희석하여준비하였다. 그리고각각시료 100 ul를 nutrient agar (Difco Co., Le Pont de Claix, France) 배지에분주하여멸균유리봉으로고르게펴바른후 35 o C에서 48시간배양하였다. 배양한후형성된집락수로생균수를측정한다음희석배수를곱하여 CFU/mL (CFU; colony forming unit) 로표시였다. 그리고순수분리배양하기위해 2회평판획선배양법으로계대배양하였다. 3) 실험균의동정실험균을동정하기위하여 Bergey s Manual (Holt 등, 1994) 에따라순수분리배양된균주의형태와색소생성능, 점조성등을확인하였으며, 그람염색법으로그람양성균, 그람음성균분리와형태를구분하였다. 그리고 blood agar (Oxoid Co., Bashingstoke, UK) 배지에접종한후 VITEK 2-compact 자동화동정기 (biomérieux Co., Marcy l'etoile, France) 를사용하여그람양성세균동정용카드 (GPI), 그람음성간균동정용카드 (GNI), 그람양성막대균동정용카드 (BAC), 효모동정용카드 (YBC) 로동정하였으며 (Cho 등, 2006), 동정이어려운균주는 BBL Crystal 검사법으로재검사하여동정하였다. 4) 통계분석자료의분석은 SPSS 18.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 표면의세균오염도분석을위해분산분석 (one way ANOVA) 및 t-test을실시하였다. 결과 1. 치과진료실내표면의세균수 치과진료실내표면의세균수는유닛체어의평균균체수는 CFU/mL, 라이트손잡이에서 CFU/mL, 타구대에서 CFU/mL로측정되었으며, 환자가치료한구강내물을헹구는타구대가가장높게나타났다 (Table 1). Table 1. Bacterial contamination levels in dental office (Unit: CFU 10 3 /ml) Division Minimum Maximum Unit chair 5.47± Light handle 16.28± Cuspidor 44.82±

3 Korean J Clin Lab Sci. Vol. 47, No. 4, Dec 의료기관의규모에따른표면세균수의료기관의규모에따른표면세균수를알아보기위해병원ㆍ의원급으로나누어비교분석한결과유닛체어의평균균체수는병원급 CFU/mL, 의원급 CFU/mL 로의원급이높게나타났다. 그리고라이트손잡이는병원급이 CFU/mL, 의원급 CFU/mL로나타났으며, 타구대는병원급 CFU/mL, 의원급 CFU/mL 로병원급이높게검출되었다 (Table 2). 3. 환자수에따른표면세균수환자수에따른표면세균수를비교한결과유닛체어의평균균체수는 명일때 CFU/mL, 라이트손잡이는 100 명이상일때 CFU/mL, 타구대도 100명이상일때 CFU/mL로가장높게나타났다 (Table 3). 4. 의료기관의표면관리에따른세균오염도표면의유닛체어의세균오염도는표면소독을할경우 CFU/mL, 소독하지않을경우 CFU/mL 로표면소독을하는경우가높게나타났으며, 라이트손잡이, 타구대표면은표면소독을하지않는경우에세균오염도가높게확인되었다 (Table 4). 5. 치과진료실내표면세균동정치과진료실의유닛체어, 라이트손잡이, 타구대표면에서순수분리한총균수는 110균주이며, 이중 Gram positive 균주는 47.3%, Gram negative 균주는 52.7% 로 Gram negative 균주가조금높게분포하고있음을알수있었다. Gram positive 균주중 39.2% 가알균, 60.8% 막대균으로나타났으며, Gram negative 균주는 1.7% 알막대균, 98.3% 가막대균으로확인되었다. Gram positive 균주로는 Bacillus cereus, Bacillus licheniformis, Bacillus pumilus, Bacillus subtilis, Brevibacillus brevis, Corynebacterium bovis, Corynebacterium propinquum, Corynebacterium kutscheri, Leifsonia aquatica, Micrococcus luteus, Kocuria varians, Paenibacilllus macerans, Staphylococcus aureus, Staphylococcus cohnii, Staphylococcus lentus, Staphylococcus warneri로동정되었으며, 이중 Micrococcus luteus 10.9% 로가장많이검출되었으며, 다음으로 Bacillus pumilus, Staphylococcus aureus 균주가각각 3.6% 로확인되었다. Gram negative 균주로는 Acinetobacter baumannii, Acinetobacter lwoffii, Acinetobacter ursingii, Brevundimonas diminuta, Burkholderia cepacia, Chryseobacterium (Flavo.) indologenes (CDC IIb), Comamonas (Pseudo.) testosteroni, Cupriavidus pauculus, Delftia acidovorans, Elizabethkingia meningoseptica, Methylobacterium sp., Ochrobactrum anthropi (CDC Vd-1, Vd-2), Rhizobium radiobacter, Roseomonas gilardii, Shewanella putrefaciens (Alteromonas putrefaciens), Sphin- Table 2. Bacterial contamination levels of surfaces depending on the size of dental office (Unit: CFU 10 3 /ml) Division Dental hospitals (n=19) Dental clinics (n=28) Unit chair 4.25± ± Light handle 17.21± ± * Cuspidor 68.95± ± * *p<0.05. F p Table 4. Bacterial contamination levels of surface according to the number of patients visiting dental office (Unit: CFU 10 3 /ml) Division YES (n=12) NO (n=35) Unit chair 3.43± ± Light handle 6.60± ± Cuspidor 39.94± ± *p<0.05. t p Table 3. Bacterial contamination levels of surface according to the number of patients visiting dental office (Unit: CFU 10 3 /ml) Division <50 (n=9) (n=12) 100 (n=26) F p Unit chair 4.27± ± ± Light handle 4.54± ± ± Cuspidor 22.15± ± ± *p<0.05.

4 282 Kyoung-Ok Yun and Hye-Young Kim. A Study about the Bacterial Contamination of Surface in Dental Office Table 5. Genus/species of bacteria identified in the dental office Bacteria A* B C Total N (%) Gram positive cocci Micrococcus luteus (10.9) Staphylococcus aureus (3.6) Staphylococcus cohnii 1 1 (0.9) Staphylococcus lentus (1.8) Staphylococcus warneri 1 1 (0.9) Gram positive rods Bacillus cereus 1 1 (0.9) Bacillus licheniformis 1 1 (0.9) Bacillus pumilus (3.6) Bacillus subtilis 1 1 (0.9) Brevibacillus brevis 1 1 (0.9) Corynebacterium bovis 1 1 (0.9) Corynebacterium propinquum 2 2 (1.8) Corynebacterium kutscheri 1 1 (0.9) Leifsonia aquatica 1 1 (0.9) Kocuria varians 1 1 (0.9) Paenibacilllus macerans 1 1 (0.9) Gram positive rods (15.5) Gram negative rods Acinetobacter baumannii 1 1 (0.9) Acinetobacter lwoffii 1 1 (0.9) Acinetobacter ursingii (5.5) Brevundimonas diminuta (4.5) Burkholderia cepacia 2 2 (1.8) Chryseobacterium (Flavo.) indologenes (CDC IIb) 5 5 (4.5) Comamonas (Pseudo.) testosteroni 1 1 (0.9) Cupriavidus pauculus 1 1 (0.9) Delftia acidovorans 1 1 (0.9) Elizabethkingia meningoseptica 1 1 (0.9) Methylobacterium sp (4.5) Ochrobactrum anthropi (CDC Vd-1, Vd-2) 1 1 (0.9) Roseomonas gilardii 1 1 (0.9) Shewanella putrefaciens (Alteromonas putrefaciens) 1 1 (0.9) Sphingomonas (Pseudo.) paucimobilis (IIk-1) 4 4 (3.6) Stenotrophomonas maltophilia 2 2 (1.8) Gram negative rods (17.2) Gram negative coccobacillus Rhizobium radiobacter 1 1 (0.9) *Unit chair, Light handle, Cuspidor. gomonas (Pseudo.) paucimobilis (IIk-1), Stenotrophomonas maltophilia로동정되었다. 이중 Acinetobacter ursingii 5.5% 로가장높게검출되었으며, Brevundimonas diminuta, Chryseobacterium (Flavo.) indologenes (CDC IIb), Methylobacterium sp. 가각각 4.5% 로나타났다 (Table 5). 고찰최근병원감염에대한중요성이부각되고있으며, 특히치과진료실내에는환자혈액과다양한미생물이증식하고있는타액이 진료시압축공기의분사력을사용하는시술을통하여병원체들이직경 50마이크로보다작은입자인에어로졸의형태로공기중에떠있다가낙하되어의료인, 환자, 도구표면을오염시킴으로감염률을증가시킨다는보고가있다 (Anuradha 와 Shikha, 2015). 이에본연구는치과진료실표면에존재하는세균수와순수분리된세균을동정하여원내감염을일으킬수있는세균을확인함으로서감염경로차단과감염관리의중요성을인식시키기위한목적으로진행하였다. 치과진료실내표면세균수는타구대가 CFU/mL 로가장높게측정되었으며, 라이트손잡이, 유닛체어순으로확인되

5 Korean J Clin Lab Sci. Vol. 47, No. 4, Dec 었다. 유닛체어의각부위별소독전의세균량을측정한결과타구대가가장높게나타났다. 이결과는무영등손잡이, 기구선반, 머리받침순으로관찰된 Park(2012) 의선행연구와같았으며, 타구대의세균수가높게나온이유는환자치료후에구강내를물로헹구면서나오는타액과혈액이묻어세균이증식했기때문이라고판단된다. 의료기관의규모에따른표면세균수를알아본결과는병원급이의원급보다높게측정되었으며, 환자수가많을수록높게나타났다. 이는짧은시간내에많은환자가같은진료용의자를사용함으로써소독및청결상태를준비할시간적여유가없기때문에감염의위험성이커졌을것이며, 진료시사용되는기구의사용빈도가많아질수록다양한병원체에어로졸의수가증가하기때문인것으로사료된다. 의료기관의표면관리에따른세균오염도는라이트손잡이와타구대의표면소독을하지않는경우에세균오염도가높았으며, 유닛체어는표면소독한경우에더높게나타났다. 이와같은결과는세균의아포까지멸균할수있는소독제라도올바른방법으로사용하지않을경우에는일반세균도사멸되지않고오히려오염이확산될수있다는 Jeong 등 (2014) 의연구결과가본실험에서도확인되었다. 따라서치과진료실표면세균의오염도를줄이기위해서는소독방법및횟수등세균수에영향을줄수있는감염관리요인등에대하여연구할필요가있다고판단된다. 치과진료실에서치과치료시 hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, Pseudomonas, Acinetobacter, Diphteroids, Lactobacilli, Staphylococci, Streptococci, Mycobacterium 등과같은병원체가간접ㆍ직접적으로감염균으로검출되어치과의료진과환자사이에서발생되는교차감염의심각한문제를발생시키고있으며 (Kugel 등, 2000), 특히보철물연마하는동안오염된에어로졸입자가장기간공기에남아감염율을증가시켜면역저하환자, 심내막염, 호흡기질환자에게위험하다는연구보고가있다 (Al-Saadi 등, 2011). 본연구에서치과진료실의유닛체어, 라이트손잡이, 타구대표면에서검출된세균의종류를확인한결과순수분리된총 110균주에서 Gram positive 균주는 47.3%, Gram negative 균주는 52.7% 로 Gram negative 균주가조금높게분포하고있음을알수있었다. Gram positive 균주중 39.2% 가알균, 60.8% 막대균으로나타났으며, Gram negative 균주는 1.7% 알막대균, 98.3% 가막대균으로확인되었다. 그리고타구대에서 50.5%, 유닛체어 32.1%, 라이트손잡이 18.3% 순으로타구대에서더많은균주와다양한균주가검출되었다. 순수분리동정된 Gram positive 균주중 Micrococcus luteus 10.9% 로가장많이검출되었으며, 다음으로 Bacillus pumilus, Staphylococcus aureus 균주가각각 3.6% 로나타났다. 치과수관과유닛체어에서분리된균주들중가장빈번한균주가 Micrococcus luteus와 Sphingomonas spp. 라는 O Donnell 등 (2006) 의실험결과와같이본연구결과에서도두균주의검출이높게확인되었으며, 개인치과진료실핸드피스, 머리받침대및타구통에서 Staphylococcus aureus, Bacillus pumilus 균주가분리된 Han과 Chun(2004) 의연구결과와같은균주가검출되었음을확인할수있었다. Staphylococcus aureus는병원내감염의가장큰원인세균으로교차감염을야기하는매개역할을하며, 치과치료후의병원내감염을유발하는주요원인균으로골수염, 복막염등균혈증으로발생되는심장판막조직의감염은매우치명적이라는보고가있다 (Min 등, 2007). 또한서울소재치과병원ㆍ의원의치주염으로진단받은환자의타액으로부터채취한임상검체에서 Staphylococcus aureus의분리율이 41.9% 로나타났다는결과와연관되며 (Kim, 2012), Staphylococcus species가물분무와함께고속치과드릴사용시치과실내공기에서발견되었다는연구보고가치과치료시감염윈인균임을입증할수있었다 (Mansour 등, 2008). Staphylococcus cohnii ss. urealyticus, Staphylococcus lentus, Staphylococcus warneri 균주는건강인에게질병을일르키는원인균으로는낮은비율이지만면역저하환자에게감염이되면패혈증, 골수염을일으키며, 균혈증이발생한환자의혈액배양에서분리되는원내감염균으로보고되고있다 (Min 등, 2007). Micrococcus luteus는비강, 상기도호흡기, 구강점막에서상재하는균주로뇌막염, 균혈증을일으킨다고알려져있다 (Miltiadous 와 Elisaf, 2011). 또한 Bacillus속은 Atlase (1988) 에의하면정상적으로대기중에 35% 로존재하는세균으로, 치과진료실에서도자주검출되는균주로알려져있으며 (Kedjarune 등, 2000), 기회주의감염균주이다. Gram negative 균주에서는 Acinetobacter ursingii 5.5% 로가장많이검출되었으며, Brevundimonas diminuta, Chryseobacterium (Flavo.) indologenes (CDC IIb), Methylobacterium sp. 가각각 4.5% 로확인되었다. Gram negative 균주는세포외막에내독소를함유하는 lipopolysaccharide (LPS) 가존재하고있으며, 치과유닛체어의물에의해옮겨지는가장중요한건강위험요인이라는연구보고 (Szymańskra 등, 2008; Coleman 등, 2009) 를바탕으로본실험에서도 Gram negative 세균수가더많이측정되었고, 세균의종류도다양하게검출된결과는치과진료실의세균오염의심각성과감염관리의시급함을입증한결과라고판단된다. Acinetobacter baumannii, Acinetobacter lwoffii, Acineto-

6 284 Kyoung-Ok Yun and Hye-Young Kim. A Study about the Bacterial Contamination of Surface in Dental Office bacter ursingii는병원내에오랫동안서식하다가면역력이저하된환자에게결막염, 피부염, 폐렴, 뇌수막염, 패혈증, 심내막염, 복강내감염, 수술부위감염, 요로감염등의합병증을일으키는전형적인병원감염균이며, 공기와액체경계면에서 biofilm 형성하여의료장비에부착되어있다가감염되기때문에문제가된다는연구보고가있다 (Loubinoux 등, 2003; Marti 등, 2011; Horii 등, 2011). Brevundimonas diminuta, Burkholderia cepacia, Cupriavidus pauculus, Delftia acidovorans 세균들은대부분이물에서분리되는균주들이며, 치과치료시상처부위로전이감염되면면역력이저하된환자에게균혈증, 패혈증을일으키는중요한감염균으로알려져있으며, 화학소독에저항성이강하고 (Peters 와 McGaw, 1996), 항생제내성확산에중요한역할을하기때문에특히주의가필요한균주로보고되고있다 (Costerton 등, 2005). Delftia acidovorans는 Pseudomonas 로분류되는균으로치과유닛의수관으로들어오는물에서발견되며, 잔류염소에저항성이강하고, biofilm을형성하는균주로치과수술을받는환자에게침투하여감염증을일으킬가능성이높은세균이다 (Stampi 등, 1999). Chryseobacterium indologenes는자연환경에널리분포되어있으며, 염소소독에도생존하기때문에병원소독제에도존재할수있어혈관카테터, 유치장치를통하여감염되어각막염, 패혈증, 폐렴등을일으킨다고보고되고있다 (Hseuh 등, 1997). Methylobacterium sp., Sphingomonas paucimobilis 등도원내감염균으로면역력이저하된환자에게감염되어균혈증, 패혈증을일으키는원인균주이며 (Ryan와 Adley, 2010; Lai 등, 2011), Shewanella putrefaciens균주는표면부착력이있어의료기기에부착하여오염시키거나금속표면을부식시키는원인균으로임상적으로는궤양과외상과같이피부파괴로인한피부와연조직감염을일으키고, 뼈, 관절염. 수막염, 심내막염을일으킨다는보고도있다 (Khashe와 Janda, 1998). 본연구결과치과진료실표면에서확인된미생물들이스켈링, 잇몸수술, 근관치료, 발치등의치료과정중상처가났을때감염의위험성이극대화될수있음을알수있었다. 이에치과진료실표면세균으로인한감염을예방하기위해서는체계적인감염관리시스템과감염을차단하기위한방법을모색할필요가있다고판단된다. 요약본연구는경기도와인천지역의치과병원급 19개기관, 의원급 28개기관진료실의유닛체어등받이, 라이트손잡이, 타구대표면의검체를채취하여실험하였다. 우선치과진료실내표면의세균수는타구대 CFU/mL, 라이트손잡이 CFU/mL, 유닛체어 CFU/mL로타구대가높게측정되었으며, 의료기관의규모로는병원급이높게나타났고, 환자수가많을수록타구대에서세균수가높게측정되었다. 표면세균동정결과는 Gram positive 균주는 47.3%, Gram negative 균주는 52.7% 였으며, Gram positive 균주중 Micrococcus luteus 10.9%, Bacillus pumilus, Staphylococcus aureus 균주가각각 3.6% 로확인되었다. Gram negative 균주로는 Acinetobacter ursingii 5.5% 로가장많이검출되었으며, Brevundimonas diminuta, Chryseobacterium (Flavo.) indologenes (CDC IIb), Methylobacterium sp. 가각각 4.5% 로나타났다. 이에본연구는치과진료실내표면세균오염도를측정하고, 세균의종류를확인함으로써진료실내감염관리의중요성을인식시키고, 감염방지에대한구체적인계획수립의기초자료가될것으로사료된다. Acknowledgements: None Funding: None Conflict of interest: None References 1. Al-Saadi AK. Bacterial cross-contamination between clinic & dental laboratory during polishing procedure of complete denture. Mustansiria Dent J. 2011, 8: Anuradha P. Shikha S. Aerosols and oral health. Uni J Med Dent Sci. 2015, 3: Atlase RM. Microbioloty 2nd ed p357. Maxwell Macmillan New York. 4. Centers for Disease Control and Prevention. Guidelines for infection control in dental healthcare settings. Recommendations and reports December , 52: Cho SS, Cheun JW, Jeun CB, Park SM, Jang SJ, Moon DS, et al. A case of Ochrobactrum anthrop infection after using medicinal plants. Korean J Clin Lab Sci. 2006, 38: Chung JH. Control of Microbes. Korea Health Industry Development Institute last visited on 2015 June Coleman DC, O'Donnell MJ, Shore AC, Russell RJ. Biofilm problems in dental unit water systems and its practical control. J Appl Microbiol. 2009, 106: Costerton JW, Montanaro L, Arciola CR. Biofilm in implant infections: its production and regulation. Int J Artif Organs. 2005, 28: Eom S, Kim GW. Infection control realities and relevant factors in dental hygienists. J Korean Soc Dent Hyg. 2012, 12: Han JS, Chun GS. A study about the contamination of micro-

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386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon