7 Ways to Reduce Infectious Aerosols in Your Office Now

Aerosols, splatter, droplets and other airborne contaminates are not a new issue in dentistry – dental clinicians have been filling the air with potentially infectious particles for over 200 years. However, in light of recent events, we’re being forced as a profession and as its supporting industries to reevaluate the way we handle aerosols. That means taking steps to minimize the spread of microbes in our office spaces. In our research we have found that control at the source, the patient’s oral cavity, is critical.

Why Should You Reduce Aerosols?

We aren’t talking about the visible spray of cooling water, but rather the tiny particles of soft and hard tissue, oral debris, saliva, blood and microbes – that are propelled into the air from the oral cavity during use of powered instruments during dental treatments.

Any time you introduce powered instruments or an air/water syringe into the oral cavity, you propel the patients’ microbes into the environment. This includes use of rotary high or low speed handpieces, sonic and ultrasonic scalers, air polishing or conventional prophy cup polishing – and even lasers, which incorporate microbes within the plumes. Unfortunately, we don’t have the technology today to treat hard or soft tissue pathologies without using these instruments.

Aerosols are emitted whenever we speak, sneeze, cough, or breathe. While often taken for granted, these everyday particles are now also included in our dental aerosol reduction plan.

Why are Aerosols a Problem?

First and foremost, aerosols are incredibly difficult to control. Not only because of their small size (3 microns or less), but because they’re often produced in large quantities that can travel further and linger longer than larger splatter particles.^1,2 Humans have to breathe, and if these tiny particles are in the air, they will make their way into human bodies. Because they’re invisible to the naked eye, it’s that much harder to stop their spread. And unfortunately, it is also harder to be fully aware of a danger when you can’t see it.

Why COVID-19 Creates an Issue

Infectious microbes are always floating about in the air—any air, but COVID-19 has been unique and dangerous because:

• In addition to there being no anti-viral drugs or vaccines as of yet, the virus is easily transmitted and can present asymptomatically, attach to tissues that are part of a number of vital organs and can cause death or lifechanging after affects for those who survive the infection.
• The risk of transmission has led to patients staying away from their regular dental procedures, which can be detrimental to their dental health, and to the life of the dental practice itself.
• With so many unknowns and rapid changes, it’s tempting for patients and clinicians to want to “wait and see what happens”. But clinicians don’t have to wait for new technologies in order to take action now. There are measures you can take today that will help reduce the threat of potentially infectious aerosols in your practice.

7 Ways You Can Help Reduce Infectious Aerosols Now

While we wait for treatments for COVID-19 and ultimately its prevention, avoidance and control are key. Until we have a vaccine or anti-viral drugs, we have to work with what we have on hand – and that means controlling aerosols at the site of the formation—the oral cavity.

1. 1. Screen everyone who comes into your office
      Screening is not just for patients, but everyone who steps through the door – including the clinicians, receptionist, delivery people, cleaning and maintenance people—EVERYONE!Our culture has taught us to “power through” and work, even when we don’t feel well. It has also taught us to keep our appointments and respect time set aside for us. However, COVID-19 has changed those “rules”. You must establish a system to identify those with possible symptoms before they enter. Those screened out can be reappointed after checking with their physician who can prescribe further testing.
   2. Evaluate carefully the value of pre-treatment rinses
      Mouth rinses are used for a number of different reasons in dentistry, but in this case, they have been suggested to reduce the microbial load and potential presence of the virus before treatment.
      • The ADA and Centers for Disease Control and Prevention (CDC) recommend rinsing with a 1% hydrogen peroxide solution, before treatment.^3,4
      • Research is still ongoing, but there is in vitro laboratory evidence that COVID-19 is vulnerable to oxidation. Rinsing with oxidative agents such as 1% hydrogen peroxide or 0.2% povidone iodine may reduce the oral microbes that carry COVID-19.⁵ Unfortunately, evidence is still lacking on the activity of the proposed rinses in the presence of relevant loads of relevant human proteins such as human saliva which can neutralize oxidative reagents.

      Keep in mind that rinses won’t solve the whole problem, but it is one more step you can take to help lower risk of exposure.

   3. Choose efficacious PPE
      Dental professionals have been using face masks, operating gloves, and protective attire for a long time, but the designs chosen often have not been the most effective ones, and/or were not always used effectively.
      • Wear PPE appropriate for the task at hand – including gloves, safety glasses, gowns or coats, and the correct face mask, worn correctly.
      • Surgical face masks that fit properly and provide high filtration of small particles are required in healthcare settings while patient treatment is being performed. Once in place, face masks should not be touched. Particles collect on the outside of the mask, and touching can negate efficacy and contaminate the hands.
      • A face shield worn over a face mask can offer protection of the entire face from splatter, but the face shield does not provide protection from inhalation of infectious microbes due to its total lack of peripheral fit. Face Shields must always be used in addition to an effective face mask.
      • Clinical attire should cover the clinician’s body and be machine washable or disposable. Polypropylene disposables should tolerate steam sterilization and can be re-used. Styles selected should have a high-neck, long-sleeve, full-cover designs.
      • Launder or discard your clinical attire in the office. Don’t carry the particulates, saliva, blood and bodily fluids from every patient to your home.
   4. Isolate the oral area to be treated from saliva
      Saliva is teeming with viable microbes and can carry the SARS CoV-2 virus. Make sure to get the lips, tongue and cheeks out of the way and isolate the operating area from constantly secreted saliva, using isolation products, along with the saliva ejector, high velocity evacuation, and absorbent products.
   5. Always use high-velocity evacuation (HVE) and position it correctly
      HVE during dental treatment should be held very close (1-2 mm) to the operating instrument to control saliva and oral debris spread beyond the oral cavity. The saliva ejector is designed to control pooling saliva and does not have the same capacity to control splatter at the site of operation.
      • Every practice has intraoral high-velocity evacuation. To be effective, it should be constantly moved as the operator moves so it is within 1-2 mm of the active instrument. Hygienists may have to work double-handed, or could consider hiring an assistant to work with them.
   6. Maintain dental unit waterlines and test regularly
      Many practices have been lax about dental unit waterline microbe control, but this water is what supplies coolant water for handpieces and oral hygiene scalers and polishers, and the air/water syringe. It can become highly colonized if not monitored and treated regularly.
      • Control is easiest if you have an independent water bottle system for every unit, but this is not always possible. Central filtration systems can also be used effectively. Make sure you know how to keep your lines clean and contamination free. The Internet lists many products and laboratory services to allow choices that best suit your office.
      • Per the CDC, dental unit water used in nonsurgical procedures should meet the Environmental Protection Agency’s (EPA) standards for drinking water, which is presence of less than or equal to 500 colony forming units of heterotrophic bacteria per milliliter.⁶
      • The CDC, ADA and FDA recommend flushing water and air lines for several minutes at the start of the day, as well as a minimum of 20-30 seconds after each patient.^7,8,9
   7. Study carefully ambient air purification research to determine how it could apply to your practice environment
      Over 100 years ago chlorination of public water supplies was instituted due to widespread death from cholera, dysentery, and typhoid. Today ambient air has become a similar issue due to widespread COVID-19 infections and high death rates.
      • Our research is indicating that purification of dental treatment air requires real effort and thought and showing that decontamination must be considered as a two-stage process.
      • First, we must protect the clinicians during actual treatment from both splatter and aerosols.
      • Second, we must purify the operatory air as rapidly as possible after treatments in preparation to receive the next patient into the space.
      • As yet, we have found no one product that solves both challenges easily, economically, and effectively—but we are continuing our worldwide search.

Conclusion

Aerosol generation during dental treatment is not a new issue. With COVID-19, however, we are seeing aerosols in a new light, since infection with this airborne virus can kill, or leave aftereffects in those who survive. Now is the time to ramp up our aerosol reduction efforts. By implementing the seven practical measures outlined, you can help control aerosol emissions to produce and maintain cleaner, safer ambient air by controlling the oral emissions at their source.