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http://annalsofrscb.ro 1594 A Review on the Current Trends to Reduce Exposure to Bioaerosols in Operative Dentistry

NISHITHA ARUN1, SINDHU RAMESH2,

1Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals,

Saveetha Institute of Medical and Technical Sciences, Saveetha University,

Chennai, India Corresponding Author

2Professor, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals,

Saveetha Institute of Medical and Technical Sciences , Saveetha University,

162 , PH Road , Chennai 600077, TamilNadu , India

ABSTRACT

Aerosols and dentistry always go hand in hand. Aerosols are particles less than 50 μm in diameter and dentists are at high risk of infectious airborne diseases due to these aerosols. They are produced as a result of dental procedures using high speed handpiece, ultrasonic units, three way syringes etc. Covid -19 pandemic has fabricated new challenges to health care providers and increased their responsibilities towards society. During this time of crisis it is necessary for the dental professionals to safeguard themselves and also offer timely treatment to their patients. The current pandemic has opened a wide arena for additions and changes in the way dentists previously worked.

Physical barriers such rubber dams, specially designed chambers and protective acrylic screens are used to avoid direct contact with aerosols. Air purification, filtration units along with fumigation and ventilation can be used to reduce the microbial load in air circulating within the operatories. This article reviews the current trends that are available to reduce bio aerosols in dental operatories that can be practically employed in day to day practice.

Keywords :Aerosols, COVID -19, rubber dam, physical barriers, filtration, treatment protocol Introduction

Dentistry and aerosols are indivisible from each other. Aerosols are small particles of liquid or solid produced by animals or machines that are suspended in the air(Ahmad 2009). The frequent generation of aerosols in dental operatories has the potential of infection transmission to dental personnel(Belting, Haberfelde, and Juhl 1964; Harrel and Molinari 2004). Patients may harbour pathogenic microorganisms such as viruses or bacteria in their blood or air way. While treating such patients , aerosol generation could be a significant health hazard to the dentists and dental assistants since it may lead to causation of infectious disease such as influenza, tuberculosis, meningitis or severe acute respiratory syndromes(Feres et al. 2010),(Bennett et al. 2000). A study showed that during dental procedures, the inner portion of the eye and regions around the nose were the severely contaminated areas of the face among the dentists and these could be a potential route of cross- infection(Nejatidanesh et al. 2013). According to the World Health Organisation (WHO) healthcare professionals have been strongly impacted by the COVID‐19 pandemic, a disease caused by the coronavirus(Ashrae 2013). Majority of dental procedures require the use of a high speed handpiece or ultrasonics with water sprays. Exposure to blood and saliva along with aerosols produced during usage of high speed air turbines renders the dental professionals at higher risk to contract SARS‐CoV‐2 (Bentley, Burkhart, and Crawford 1994),(Rivera-Hidalgo, Barnes, and Harrel 1999),(Toroğlu, Haytaç, and Köksal 2001).

With the release of bio aerosols the microbial load of air increases leading to contamination of all surfaces in the dental operatory (Zemouri et al. 2020) (Figure 1). According to a recent study, despite having high knowledge, dentists worldwide are in a state of anxiety to work during the COVID-19 pandemic (Ahmed et al. 2020). There is a need to employ additional infection control methods to prevent the disease spread during this time of

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pandemic(Bescos et al. 2020; Meng, Hua, and Bian 2020). Our team has a copious experience in working on various research projects across multiple disciplines (Govindaraju and Gurunathan 2017; A. Christabel et al. 2016; Soh and Narayanan 2013; Mehta et al. 2019; Ezhilarasan, Apoorva, and Ashok Vardhan 2019a; Campeau et al. 2014; Kumar and S 2016; S. L. Christabel 2015; Kumar and Rahman 2017; Sridharan, Ramani, and Patankar 2017; Ramesh et al.

2016; Thamaraiselvan et al. 2015; Thangaraj et al. 2016; Ponnulakshmi et al. 2019; ―Fluoride, Fluoridated Toothpaste Efficacy and Its Safety in Children - Review‖ 2018) Now the growing trend in this area motivated us to pursue this project. Our institution is passionate about high quality evidence based research and has excelled in various fields (JayaseelanVijayashreePriyadharsini 2019; Pc, Marimuthu, and Devadoss 2018; Ramesh et al. 2018;

Ramadurai et al. 2019; Sridharan et al. 2019; Ezhilarasan, Apoorva, and Ashok Vardhan 2019b; Mathew et al. 2020;

Samuel 2021; R et al. 2020; Chandrasekar et al. 2020; J. VijayashreePriyadharsini, SmilineGirija, and Paramasivam 2018). The aim of this article is to review the current trends used to reduce bio- aerosols in operative dentistry.

Figure 1: Different routes of transmission in dental setting (Ge et al. 2020) Physical Barriers To Reduce Splatter of Bio-Aerosols

The center for Disease Control and Prevention (CDC) recommends all the dental health care providers to use Personal Protective Equipment (PPE) such as masks, gloves, goggles and gowns to cover their skin and mucous membrane of nose, mouth and eye and also use physical barriers to cover the clinical surfaces to reduce the exposure to pathological microorganisms(―The Effect of Rubber Dam on Atmospheric Bacterial Aerosols during Restorative Dentistry‖ 2017).

Rubber Dam

In 1864, Dr Sanford C. Barnum introduced rubber dams to the dentistry(Elderton 1971). The rubber dam is made of stretchable latex material and used to isolate the tooth or teeth from the other oral tissues and saliva. Rubber dam usage is considered as a standard practice in operative dentistry and endodontics world wide. The three main advantages of using rubber dams during endodontic treatment are control in cross infection, protection and better treatment efficiency and success rates(Ahmad 2009). Use of rubber dams has shown to reduce the bioaerosols and also microbial contamination of the PPE of the dentists and the assistants such as gloves by 98.5% (Samaranayake, Reid, and Evans 1989; Marshall 2017). There was a significant reduction in microbial load in aerosols generated during dental procedures with the usage of rubber dams (Cochran, Miller, and Sheldrake 1989),(Samaranayake, Reid, and Evans 1989).To reduce the bio aerosols in dental operatories The Center for Disease Control and

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Prevention also recommends the use of rubber dams (―Guidelines for Infection Control in Dental Health-Care Settings - 2003‖ 2003).

The device with the aspiration and filtering system

The main aim of this system is to attenuate the aerosol emission in dental operatories, by isolating the patient in an

‗internal environment‘ and the operator in an ‗external environment‘. The operator can perform the procedures by accessing the oral cavity of the patient through three holes whereas the chamber made of translucent acrylic material acts as a barrier between the operator and the patient. Translucent flexible polyvinyl chloride (PVC) films are used to cover the orifices of the three holes and also the back of the device instead of rigid acrylic so that the patient can lean comfortably on the chair and at the same time the chair is being protected from contamination(Figure 2). This device contains an aspiration system in which the air from the chamber passes through an antiseptic solution (2%

NaOCl) placed in a box externally to reduce the viable microorganisms and toxic particles prior to the return of the air to the external environment (Figure 2). While testing the device it was found that the contamination was restricted to surgical gloves, aprons, interior of the pipe system and internal walls of the acrylic chamber. The contamination was less compared to the treatment done without this device. The disadvantage of using this system was that the movements were confined and the visualization by the dentists were limited during the operative procedures (Teichert‐Filho et al. 2020).

Figure 2: Device with the Aspiration and Filtering System Microscope with Shield

In this setting, a clear polycarbonate disk with two holes, one for the DOM objective lens of microscope and one for the exhaust hose, is used as a barrier between the operator and the patient. There was increased exhaust of air through the vacuum hose inlet hence reducing the dispersion of the contaminated air. This device along with PPE can offer increased protection from the aerosols (Russell 2020).

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Figure 3: Microscope with Polycarbonate Shield and Exhaust

Modifications In Treatment Protocol Preprocedural Mouthrinses

Several researches suggest that usage of antimicrobial oral rinse by patients before dental treatment decreases microbial aerosols.(Stirrups 1987)(Stirrups 1987; Orton 1987). In terms of pre procedural mouth rinses Chlorhexidine(CHX) is considered the gold standard due to its broad‐spectrum antibacterial activity. It was found that 0.05 percent CPC was as effective as CHX in reducing the levels of bio-spatter generated during dental procedures (Feres et al. 2010),(Goyal, n.d.). Povidone-iodine, especially 0.23% for a minimum of 15 seconds is capable of reducing viral load in saliva and is highly recommended in dentistry(Spagnuolo et al. 2020)(Eggers et al.

2018).

Radiographs

Dental professionals can use extraoral dental radiographs namely panoramic radiographs or Cone Beam Computed Tomography(CBCT) during the COVID-19 pandemic instead of intraoral dental radiographs which can stimulate saliva secretion and cough(Parihar et al.2020).

Carious lesions which are asymptomatic without the pulpal involvement can be treated by one of the following ways to reduce aerosols that are produced by the conventional methods.

Chemo Mechanical Caries Removal (CMCR) Agents

Chemico mechanical method of caries removal is considered an effective alternative to conventional caries removal by rotary as it is atraumatic with bactericidal or bacteriostatic properties(Bussadori, Castro, and Galvão 2005) . In previous studies it was shown that Papacarie, a chemical caries removal agent containing papain and chloramine had bactericidal, bacteriostatic and antiinflammatory characteristics and it was also effective in removal of infected dentin while preserving deeper layers of affected dentin (Bussadori et al. 2014), (Hafez et al. 2017). Several clinical trials have been carried out using chemical caries removal agents such as Caridex in all classes of coronal lesions, cervical lesions and root caries in both deciduous and permanent teeth. It has been reported that teeth with complete removal of carious lesions in dentin ranged from 42–100% using chemo mechanical method(Yip, Stevenson, and Beeley 1995).(Figure 4)

Atraumatic Restorative Technique

This method was introduced in mid 1980s to provide dental health care for disadvantaged population in underdeveloped countries(Frencken et al. 1996).This technique utilises spoon excavator to remove the possible soft caries to the required depth for the stable placement of restoration preferably Glass ionomer Cement(GIC) (Lakhani et al. 2020; Bussadori, Castro, and Galvão 2005). ART is a minimally invasive treatment thus producing a minimal amount of aerosol as the use of high speed handpieces are not required (Cagetti and Angelino 2020).

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The carious lesion can be arrested preventing further progression of caries with the application of Silver Diamine Fluoride (SDF) without removing any carious tissue owing to its bactericidal and fluoride releasing property (Horst, Ellenikiotis, and Milgrom 2017). No further restoration is usually required after SDF application. If food lodgment occurs then GIC/ Resin Modified GIC restorative material can be placed over the SDF treated carious dentin. This is referred to as Silver Modified Atraumatic Restorative Technique (SMART) (Nuvvula and Mallineni 2019). In case of restoration with composite resins, self-etch bonds are preferred in order to minimize the use of a three way syringe to wash off excess etchant prior to bonding(Kao 1991).

Caries involving the pulp

Slow speed micromotor handpiece without water spray, chemomechanical caries excavation with a spoon excavator or high speed anti retraction handpiece that reduce the back flow of microbes into handpiece and dental unit can be used until pulp is exposed to minimize aerosols and single visit root canal treatment can be done to reduce the appointments (Casamassimo, Townsend, and Litch 2020)(Hu et al. 2007) .

Post Endodontic Restorations

Endodontically treated, non vital teeth are prone to biomechanical failure compared to vital teeth due to loss of tooth structure owing to carious lesions and/or cavity preparation (Sedgley & Messer 1992)(Tamseet al. 1999). Composite resin monoblocking and Hall‘s technique can be used as an alternative to full coverage crowns made of metal- ceramic which will need high speed handpiece causing aerosol production (Lakhani et al. 2020).

Mechanical Aerosol Reduction And Filtration Systems

Increasing ventilation rates, creating negative pressure isolation rooms, and installation of high-efficiency air filters, will minimize aerosols in the dental operatories, thus preventing cross infection(―Use of Negative Pressure Isolation in the Provision of Dental Care‖ 2020).

Negative pressure Isolation

CDC recommends an isolation room with negative pressure to perform dental treatments(Brian et al.2020). In a negative pressure room the exhausted air must exceed the supplied air with a least pressure difference of 0.01 inch water gauge to sustain a negative pressure room. In this setting the air flow should be channeled from cleaner non operative areas to operative, isolation areas to prevent cross-contamination. Several previous studies have shown airflow directed through a negative pressure isolation room is a preferred model to protect dental professionals from being exposed to infectious respiratory diseases (Chen et al. 2010; Cheong and Phua 2006; Brian et al.2020)(Zhao, Liu, and Chen 2020; Chartier and Pessoa-Silva 2009). The exhausted air is funneled to the outside of the building or the exhaust is driven through HEPA filters before recirculation(Lee 2016).

High Volume Evacuators (HVE)

Suction system with a large opening is attached to an evacuation system that removes a large volume of air around 100 cubic feet of air per minute and reduces the operative site contamination by more than 90% (Kobza, Pastuszka, and Brągoszewska 2018). Currently in dental practice, Extra-Oral Vacuum Aspirator (EOVA) are used for protection against air contaminants splattered from the oral cavity without being dispersed into the environment (Suyama et al. 1995).

Air filtration and purification

Indoor air purification units are used to remove all water mist and splatter from the mouth and to filter and disinfect the aerosols thereby protecting the environment and dental professionals (Zhao, Liu, and Chen 2020).

HEPA filter

High-Efficiency Particulate Air (HEPA) filter is used to entrap ultrafine particles including bacteria and viruses.

These filters can be integrated with the air conditioning unit and used to filter the air prior to recirculation. Apart from HEPA filters Ultra Low Particulate Air (ULPA) Filters can be used for air purification.

(Lakhani et al. 2020)(Liu et al. 2017) .

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Ultraviolet light (UV)

UV light at an intensity of 1210uw/cm2 and wavelength 280 nm is capable of killing viruses by breaking the genome of the virus and inactivating them(Dziedzic, Tanasiewicz, and Tysiąc-Miśta 2020), (Botta et al. 2020). It is recommended to irradiate the treatment chamber and the instruments used using UV for 15 minutes (Parihar et al.2020).

Fumigation

Fumigation is the technique of choice for disinfection of large spaces like dental operatories and in the presence of numerous equipment which are difficult to disinfect individually. Formaldehyde was the most frequently used fumigant for years but recently their use has substantially reduced due to their carcinogenic nature(McDonnell 2006). Recently hydrogen peroxide vapour (HPV) either as vapor or aerosol is used as fumigant to disinfect hospitals and operatories (Beswick et al. 2011)(Kümin et al. 2020). Nebulizer or fogging systems generate fumigant mist which is dispersed through the nozzle.

Ventilation

Indoor ventilation and airflow is of great importance in dental operatories which can be achieved by natural ventilation or a mechanical system. Fresh air continuously supplied to the treatment chamber by opening windows can dilute the virus laden contaminated air. Adequate ventilation in dental clinics especially during the current Covid pandemic plays a very vital role in controlling the spread of infection.

Conclusion

The entire world is coping with the new normal at the present time of Covid pandemic. Dental professionals are at higher risk of air borne infectious diseases due to usage of high speed air turbines and scalers that produce bioaerosols. Hence it is top priority of the dental professionals to safeguard themselves and as well offer uncompromised treatment to their patients. Dentists have to vigorously follow the existing safety measures along with modification in treatment protocols, addition of special filtration and air purification to reduce the aerosols in the dental operatories to face the current challenge and help in preventing the spread of Sars-Cov-2.

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