Aerosol concentrations and size distributions during clinical dental procedures

Strategies for preventing aerosol-generated microbial contamination in dental procedures: A systematic review and meta-analysis

BACKGROUND

Aerosol generation in dental practice is a significant concern in infection control. This study aimed to investigate the strategies for controlling and preventing aerosol-generated microbes during dental procedures.

METHODS

A systematic search was performed using PRISMA guidelines through electronic databases (PubMed, ScienceDirect, Cochrane Library, Google Scholar, and Scopus) using specific keywords, like "aerosol generation" AND "dental procedures" AND "prevention" for studies reporting interventions, including mouthwash and suction devices, that were effective against pathogens generated during dental procedures. Eligible studies were included based on predefined criteria. Pooled effectiveness was calculated using a random-effects model in RevMan 5.4 software. Quality assessments were performed using RoB-2.0 and the Robvis web application.

RESULTS

Nineteen studies were included in this systematic review and meta-analysis. Different interventions, including cetylpyridinium chloride, chlorhexidine, chlorine dioxide, hydrogen peroxide, herbal formulated products, and suction devices, have been identified as the most utilized interventions to reduce microbial contamination during dental procedures. Overall, these interventions were found to be effective, with a pooled effectiveness of -46.64 (95% CI: -60.89 to -32.38, I2=100%, p<0.00001).

CONCLUSIONS

This study underscores the importance of a multifaceted approach that integrates antiseptic mouthwash and suction devices to minimize the risk of cross-contamination and infection transmission during aerosol-generated dental procedures, thereby safeguarding the health and safety of both patients and dental healthcare workers.

DATA AVAILABILITY STATEMENT

The data presented in this study are available on request from the corresponding author.

Temporal trends in indoor bioaerosols: implications for dental healthcare environments

Antibiotic resistance, a significant public health hazard, is predicted to cause 10 million deaths worldwide by 2050. The study aimed to identify culturable bioaerosols in the indoor air of dental units in Lahore and assess their antibiotic resistance. Air samples were collected from 10 dental unit locations at different distances, with average concentrations of fungi and bacteria falling within intermediate ranges, per the Global Index of Microbial Contamination (GIMC/m3) index. The study found higher antibiotic-resistant strains in hospital dental units, particularly during winter. The most vigorous strain, S.aureus-NAJIH18, exhibited 70% resistance to ceftazidime. The research highlights the importance of quantifying microbial pollutants for evaluating their source and complexity. It suggests proactive mitigation techniques, such as focused cleaning and air filtration, to improve indoor air quality can mitigate the spread of antibiotic-resistant strains. These insights offer hope in combating the growing public health threat of antibiotic resistance.

A Molecular Approach for Detecting Bacteria and Fungi in Healthcare Environment Aerosols: A Systematic Review

Molecular methods have become integral to microbiological research for microbial identification. This literature review focuses on the application of molecular methods in examining airborne bacteria and fungi in healthcare facilities. In January 2024, a comprehensive electronic search was carried out in esteemed databases including PubMed, Web of Science, and Scopus, employing carefully selected keywords such as ((bacteria) OR (virus) OR (fungi)) AND (aerosol) AND ((hospital) OR (healthcare) OR (dental office)) AND ((molecular) OR (PCR) OR (NGS) OR (RNA) OR (DNA) OR (metagenomic) OR (microarray)), following the PRISMA protocol. The review specifically targets healthcare environments with elevated concentrations of pathogenic bacteria. A total of 487 articles were initially identified, but only 13 met the inclusion criteria and were included in the review. The study disclosed that the prevalent molecular methodology for appraising aerosol quality encompassed the utilization of the PCR method, incorporating either 16S rRNA (bacteria) or 18S rRNA (fungi) amplification techniques. Notably, five diverse molecular techniques, specifically PFGE, DGGE, SBT, LAMP, and DNA hybridization methods, were implemented in five distinct studies. These molecular tests exhibited superior capabilities compared to traditional bacterial and fungal cultures, providing precise strain identification. Additionally, the molecular methods allowed the detection of gene sequences associated with antibiotic resistance. In conclusion, molecular testing offers significant advantages over classical microbiological culture, providing more comprehensive information.

Reduction by air purifier of particulate concentration during orthodontic procedures: a pilot study

BACKGROUND

The SARS-CoV-2 pandemic has raised awareness of the importance of air quality. This pilot study arose from the need to reduce the concentration of particulate matter in the dental office during orthodontic procedures. To evaluate the efficacy of using an air purifier during orthodontic care in the dental office to reduce the concentration of ambient particulate matter.

RESULTS

Significant reductions in particle numbers were obtained for all particle sizes except the largest particles counted (10 μm) through use of the air filter. A marked association between higher humidity levels and higher particle counts was also observed.

CONCLUSIONS

Using an air purifier during dental care achieves a significant reduction in the concentration of ambient particles in the dental office. There is a correlation between higher relative humidity and higher particle concentration. The probability of obtaining a maximum particulate concentration level of 0.3 and 0.5 μm is 1000 times lower when using an air purifier.

Visualization of droplets and aerosols in simulated dental treatments to clarify the effectiveness of oral suction devices

PURPOSE

The hazards of aerosols generated during dental treatments are poorly understood. This study aimed to establish visualization methods, discover conditions for droplets/aerosols generated in simulating dental treatments and identify the conditions for effective suction methods.

METHODS

The spreading area was evaluated via image analysis of the droplets/aerosols generated by a dental air turbine on a mannequin using a light emitting diode (LED) light source and high-speed camera. The effects of different bur types and treatment sites, reduction effect of intra-oral suction (IOS) and extra-oral suction (EOS) devices, and effect of EOS installation conditions were evaluated.

RESULTS

Regarding the bur types, a bud-shaped bur on the air turbine generated the most droplets/aerosols compared with round-shaped, round end-tapered, or needle-tapered burs. Regarding the treatment site, the area of droplets/aerosols produced by an air turbine from the palatal plane of the anterior maxillary teeth was significantly higher. The generated droplet/aerosol area was reduced by 92.1% by using IOS alone and 97.8% by combining IOS and EOS. EOS most effectively aspirated droplets/aerosols when placed close (10 cm) to the mouth in the vertical direction (0°).

CONCLUSIONS

The droplets/aerosols generated by an air turbine could be visualized using an LED light and a high-speed camera in simulating dental treatments. The bur shape and position of the dental air turbine considerably influenced droplet/aerosol diffusion. The combined use of IOS and EOS at a proper position (close and perpendicular to the mouth) facilitated effective diffusion prevention to protect the dental-care environment.

The BioCascade-VIVAS system for collection and delivery of virus-laden size-fractionated airborne particles

The size of virus-laden particles determines whether aerosol or droplet transmission is dominant in the airborne transmission of pathogens. Determining dominant transmission pathways is critical to implementing effective exposure risk mitigation strategies. The aerobiology discipline greatly needs an air sampling system that can collect virus-laden airborne particles, separate them by particle diameter, and deliver them directly onto host cells without inactivating virus or killing cells. We report the use of a testing system that combines a BioAerosol Nebulizing Generator (BANG) to aerosolize Human coronavirus (HCoV)-OC43 (OC43) and an integrated air sampling system comprised of a BioCascade impactor (BC) and Viable Virus Aerosol Sampler (VIVAS), together referred to as BC-VIVAS, to deliver the aerosolized virus directly onto Vero E6 cells. Particles were collected into four stages according to their aerodynamic diameter (Stage 1: >9.43 μm, Stage 2: 3.81-9.43 μm, Stage 3: 1.41-3.81 μm and Stage 4: <1.41 μm). OC43 was detected by reverse-transcription quantitative polymerase chain reaction (RT-qPCR) analyses of samples from all BC-VIVAS stages. The calculated OC43 genome equivalent counts per cm3 of air ranged from 0.34±0.09 to 70.28±12.56, with the highest concentrations in stage 3 (1.41-3.81 μm) and stage 4 (<1.41 μm). Virus-induced cytopathic effects appeared only in cells exposed to particles collected in stages 3 and 4, demonstrating the presence of viable OC43 in particles <3.81 μm. This study demonstrates the dual utility of the BC-VIVAS as particle size-fractionating air sampler and a direct exposure system for aerosolized viruses. Such utility may help minimize conventional post-collection sample processing time required to assess the viability of airborne viruses and increase the understanding about transmission pathways for airborne pathogens.

High-volume evacuation mitigates viral aerosol spread in dental procedures

Dental healthcare personnel (DHCP) are subjected to microbe-containing aerosols and splatters in their everyday work. Safer work conditions must be developed to ensure the functioning of the healthcare system. By simulating dental procedures, we aimed to compare the virus-containing aerosol generation of four common dental instruments, and high-volume evacuation (HVE) in their mitigation. Moreover, we combined the detection of infectious viruses with RT-qPCR to form a fuller view of virus-containing aerosol spread in dental procedures. The air-water syringe produced the highest number of aerosols. HVE greatly reduced aerosol concentrations during procedures. The air-water syringe spread infectious virus-containing aerosols throughout the room, while other instruments only did so to close proximity. Additionally, infectious viruses were detected on the face shields of DHCP. Virus genomes were detected throughout the room with all instruments, indicating that more resilient viruses might remain infectious and pose a health hazard. HVE reduced the spread of both infectious viruses and viral genomes, however, it did not fully prevent them. We recommend meticulous use of HVE, a well-fitting mask and face shields in dental procedures. We advise particular caution when operating with the air-water syringe. Due to limited repetitions, this study should be considered a proof-of-concept report.

Effectiveness of interventions to reduce aerosol generation in dental environments: A systematic review

Certain dental procedures produce high levels of aerosols containing pathogenic microorganisms, posing a risk for the transmission of infections in dental settings. This study aimed to assess the effectiveness of various aerosol mitigation interventions during clinical dental procedures in real-world environments. A systematic literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science, and Embase for English studies up to March 2023 according to the PRISMA guidelines. Only peer-reviewed controlled clinical trials (CCT) or randomized controlled trials (RCT) studies involving human subjects were included. The risk of bias of selected researches were evaluated by two independent authors using the Cochrane Collaboration tool. The literature search yielded 3491 articles, of which 42 studies met the inclusion criteria and were included in this study. Most studies evaluated bacterial contamination in bio-aerosols, while the viral and fungal contamination was assessed in only three studies. Overall, various approaches have been applied in reducing aerosol contamination in clinical scenarios, including high-volume evacuators (HVE), mouse rinses and rubber dams, air cleaning systems, and high-efficiency particulate air (HEPA) filters. The available evidence suggests that various aerosol mitigation strategies could be implemented to decrease the risk of cross-infection during clinical dental procedures in real-world environments. However, further clinical trials are necessary to establish statistical validity in measuring aerosol contamination and mitigation, as well as to evaluate the risk of infection transmission for viral and fungal contamination.

Aerosol in the oral health-care setting: a misty topic

Studies have shown that mouth and respiratory tract microorganisms can be transported in aerosol and spatter. Due to aerosol-generating procedures, there are potentially various infection risks for patients and those working in health care, especially in oral health care. Dental aerosol can contaminate not only the mucous membranes of the oral health-care professional's mouth, respiratory passages, and eyes but also exposed surfaces and materials in the environment. As such, preventing disease transmission within oral health-care offices is important issue. Since the start of the COVID-19 pandemic, an innumerable amount of (mis)information and advice on how to stay safe and prevent the spread of coronavirus has been published. What preventive measures can and have been taken to counteract this, and what have we learned during the pandemic? This review summarizes relevant literature that has addressed the presence and dispersal of aerosol and spatter as a concern in health care. It includes the sources of dental aerosol, their potential health threats, and strategies for controlling and mitigating their impact. It shows that further research is needed to better understand the potential health risks of dental aerosol and to develop effective strategies for mitigating them. CLINICAL RELEVANCE: Using personal protective equipment, high-volume evacuation systems and pre-procedural antimicrobial agents can help to reduce the potential for infection in oral health-care settings and protect the well-being of oral health-care workers and their patients.