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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1655-1658  

Evaluation of reduction protocols in managing aerosol generation in caries management in COVID 19 in Riyadh: An original research


1 Ministry of Health, Riyadh, Kingdom of Saudi Arabia
2 Medical University of Lodz, Poland, Europe, Poland
3 Department of Oral and Maxillofacial Surgery, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia

Date of Submission15-May-2021
Date of Decision23-May-2021
Date of Acceptance28-May-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Suhael Ahmed
Department of Oral and Maxillofacial Surgery, Riyadh Elm University, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_390_21

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   Abstract 


Introduction: External high-volume extraction (HVE) devices may offer a way to reduce any aerosol particulate generated. The aim of this study was to measure the particle count during dental aerosol-generating procedures and compare the results with when a HVE device is used. Materials and Methods: Design A comparative clinical study measuring the amount of PM1, PM2.5, and PM10 aerosol particulate with and without the use of an external HVE device was undertaken. Materials and methods in total, ten restorative procedures were monitored with an industrial Trotec PC220 particle counter. The intervention was an external HVE device. Main outcome methods the air sampler was placed at the average working distance of the clinicians involved in the study − 420 mm. Results: In the present study, aerosol particulate was recorded at statistically significantly increased levels during dental procedures without an external HVE device versus with the device. Discussion The null hypothesis was rejected, in that significant differences were found between the results of the amount of aerosol particle count with and without a HVE device. Conclusion: If the results of the present study are repeated in an in vivo setting, an external high-volume suction device may potentially show a lower risk of transmission of viral particulate.

Keywords: Aerosol, caries management, COVID 19


How to cite this article:
Alamri AA, Almutairi AB, Hawsah AM, Aljarullah AH, Almeerabdullah YW, Alenezi MA, Ahmed S. Evaluation of reduction protocols in managing aerosol generation in caries management in COVID 19 in Riyadh: An original research. J Pharm Bioall Sci 2021;13, Suppl S2:1655-8

How to cite this URL:
Alamri AA, Almutairi AB, Hawsah AM, Aljarullah AH, Almeerabdullah YW, Alenezi MA, Ahmed S. Evaluation of reduction protocols in managing aerosol generation in caries management in COVID 19 in Riyadh: An original research. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Aug 13];13, Suppl S2:1655-8. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1655/330123




   Introduction Top


In light of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the United States Occupational Safety and Health Administration have classified dentistry as one of the very high-risk occupations for transmission of the disease because of the aerosols produced.[1] An aerosol is a dispersion system consisting of solid and liquid particles of various sizes which are suspended in a gas medium. The size of the particles that can be potentially suspended in the aerosols produced can range from 0.001 to 100 microns. For human transmission of disease, the infectious dose required is small. Viral and bacterial agents have an affinity for specific components of cells and tissues along with pathogenic factors. Ultra-fine particles, such as the SARS-CoV-2 virus molecule, which are sub-1 micron can potentially enter the circulatory system through this mechanism directly or through being carried on a larger particle.[2],[3],[4],[5]

The exact mechanisms by which SARSCoV-2 virus is spread remain under investigation, but current understanding points to transmission through aerosol droplets. The mechanical action of tools used in the dental clinic can produce suspended particles as aerosols, such as the use of fast and slow dental handpieces, ultrasonic scalers, and air-water syringes. The potential spread of the SARSCoV-2 virus in a dental clinic is characterized through three pathways: direct contact with infected oral fluids; direct contact with contaminated surfaces; and inhalation of infectious particulate aerosols.[6] The aim of this study was to measure the particle count during dental aerosol procedures and compare the results to when a high-volume extraction (HVE) device was used. The null hypothesis was that no differences would be found in the amount of aerosol particle count with or without a HVE device


   Materials and Methods Top


Five different restorative procedures were monitored with an industrial Trotec PC220 particle counter. This sampler is sent with a calibration certificate where the sampler is calibrated with a PC200/220 filter for zero calibration by the manufacturer. The sampler was used to measure the following sized particulate generated in each procedure: PM1 (particulate sized 1 micrometer [μm] or less), PM2.5 (particulate sized 1–2.5 μm), and PM10 (particulate sized 2.5–10 μm). The five different procedures were carried out with/without a HVE device. Specifically, and spatially, the sampler was placed 420 mm directly to the right of the phantom head unit on an adjacent dental unit. The unit used in this study was a VacStation by Eighteeth. The VacStation uses a multi-level filtration system (HEPA, high-fiber cotton filter, activated carbon, KMnO4, ceramsite filter, 2nd HEPA 13) and UV-C light. The VacStation was placed with the circular suction orifice placed 300 mm in front of the phantom head. This position would– in an in vivo setting– be positioned above the patient's chest and in front of their mouth. The VacStation was turned on to the maximum suction setting. The sampling period for the component of the study without the use of a HVE device was recorded from the start of that specific procedure. The procedure duration was of continuous use for 1 min. The sampling measurement then continued for 1 min or until the air particulate levels returned to normal levels.

Procedures tested

  1. Intense (full-blast) three-in-one air-water syringe (mixed air and water): The three-in-one air-water syringe was directed toward the lower anterior region with normal aspirator suction collecting the water produced
  2. Micromotor high-speed handpiece with water: The micromotor high-speed handpiece was used to drill a lower anterior tooth on the dental model as mesial cavities. On the second procedure with the HVE device in place, the same tooth was drilled on the distal surface
  3. Air turbine high-speed handpiece with water: The air turbine high-speed handpiece was used to drill a lower anterior tooth on the dental model as mesial cavities. On the second procedure with the HVE device in place, the same tooth was drilled on the distal surface
  4. Slow-speed handpiece with water: The slow-speed handpiece was used to drill a lower anterior tooth on the dental model as mesial cavities. On the second procedure with the HVE device in place, the same tooth was drilled on the distal surface
  5. Ultrasonic scaling with water: The ultrasonic scaler was used to scale around the gingival margins of the lower anterior teeth on the model.


The ethics approval was not required as this was in vitro study without human involvement.

The statistical analysis was done using appropriate tools and the P < 0.05 was considered as statistically significant.


   Results Top


In [Figure 1] and [Figure 2], the data are shown as a graph of particle count measured for each size of particulate during the procedure for 1 min and for 1 min after the procedure. In the present study, there is a clear difference between the results, as shown in the two graphs displaying the data recorded over time. We can see from statistical analysis in SPSS 26 IBM Corp. Released 2019. (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp) that, with a Tukey comparison of means [Table 1], there is a statistically significant difference in the data samples recorded for every dental procedure when an external HVE device is used. The only exception to this is the PM1 particle count in a three-in-one procedure.
Figure 1: Aerosol generation without high-volume suction used

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Figure 2: Aerosol generation with high-volume suction used

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Table 1: Statistical results of a Tukey comparison of means for each procedure

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   Discussion Top


In the present study, the PM1-sized particulate generated with all procedures appears to remain within the range sampled within the control measurements with no procedure taking place. However, outside of the three-in-one procedure, there was a statistically significant reduction in particle count when an external HVE device was used. There was a clear increase in PM2.[5] particulate generated during the dental procedures. This statistically significant increase was approximately double the normal background sample measurements. With the use of an external HVE device, the samples taken during the five dental procedures were statistically significantly reduced. There was a slight increase in the measured levels toward the end of the air turbine procedure, but this was statistically insignificant (11 μg/m3 with HVE vs. 24 μg/m3 without HVE). The PM10-sized particulate generated in each of the procedures followed a similar, yet amplified, pattern to the PM2.5-sized particulate generated. The maximum levels of particulate generated were approximately three times the background levels of PM10. With the use of an external HVE device, the samples taken during the five dental procedures were statistically significantly reduced. We can therefore interpret these results as meaning no, or very little, PM1 particulate is generated during three-in-one dental procedures as the difference was statistically insignificant. There is a statistically significant increase of between two to three times the background μg/m3 levels of PM2.5-and PM10-sized particulate compared to the results recorded during dental procedures without an external HVE used. One limitation in the interpretation of these results is the biological relevance with regards to the SARS-CoV-2 virus. This virus is new, and relative infectivity and mechanisms of transmission are currently under investigation. In the SARS outbreak in 2003, Kan et al. studied the relationship between particulate levels with mortality. The study showed that particulate matter with aerodynamic diameter 10 μm (PM10) was positively associated with the SARS mortality.[7] While not of dental origin, Feng et al. carried out an ecologic analysis that found a positive relationship between PM2.5 particulate count and viral transmission in Beijing.[8]

In the present study, aerosol particulate was recorded at statistically significantly increased levels during dental procedures without an external HVE device versus with the device. These increased levels were around two dozen μm per cubic meter. We, therefore, have to look at ways to mitigate this risk during the current SARS-CoV-2 crisis.

Pippin et al. also discuss that, in the reduction of dental aerosols, the first layer of defence is personal protection barriers such as masks, gloves, visors, safety goggles, and hairnets.[9] The second layer of defence is the routine use of an antiseptic preprocedural rinse with a mouthwash such as Peroxyl/povidone-iodine or chlorhexidine. The third layer of defense is the regular use of a HVE device either by an assistant or attached to the instrument being used. An additional layer of defence could also be the employment of a tool to scale back aerosol contamination that escapes the operating area, such as a HEPA filter.

These extra layers of defense are either commonly found or easily implemented in most dental practices. It has also been recommended that dental practices install negative-pressure airflow to prevent airborne transmission through aerosols. The correctly placed high-volume vacuum suction and evacuator near the handpiece and the mouth can reduce 90% of the output of aerosol. During conservative practices, the use of the rubber dam barrier is also thought to reduce the risk significantly up to 98.5%. 53 the results of our study confirms that the extraoral HVE unit does not require an assistant to maintain position. To prevent the risk of transmission, especially during the SARS-CoV-2 pandemic, high-risk personal protective equipment has been advised worldwide to varying degrees. In the United Kingdom, there has also been an advisory in place for a fallow time after aerosol-generating procedures.[10],[11] Both the protective equipment and fallow period are a large departure from the clinical norm and could impact the sustainability and running of dental clinics. Reducing the need to depart from the norm could improve patient access through the reduced wait times postprocedure and improve comfort for the operator.[12]

A number of limitations are suggested in our in vitro study, namely the in vivo effects such as saliva, blood, breathing, coughing, and patient interaction which need to be accounted for and may impact the results in an in vivo patient setting.


   Conclusion Top


The results of the present study show potential clinical usefulness of the HVE device in reducing and mitigating some risk of transmission of the SARS-CoV-2 virus. The aerosols and splatter generated during dental procedures have the potential to spread infection However, if further studies show that aerosol particulate is produced in an in vivo clinical setting, it may be possible to effectively reduce and mitigate the associated risk with the use of external HVE devices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
United States Department of Labor Occupational Safety and Health Administration. Dentistry Workers and Employers; 2020. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html. [Last accessed on 2020 Jun 21].  Back to cited text no. 1
    
2.
An N, Yue L, Zhao B. Droplets and aerosols in dental clinics and prevention and control measures of infection. Zhonghua Kou Qiang Yi Xue Za Zhi 2020;55:223-8.  Back to cited text no. 2
    
3.
Zemouri C, Volgenant CM, Buijs MJ, Crielaard W, Rosema NA, Brandt BW, et al. Dental aerosols: Microbial composition and spatial distribution. J Oral Microbiol 2020;12:1762040.  Back to cited text no. 3
    
4.
Wurie F, Le Polain de Waroux O, Brande M, Dehaan W, Holdgate K, Mannan R, et al. Characteristics of exhaled particle production in healthy volunteers: Possible implications for infectious disease transmission. F1000Res 2013;2:14.  Back to cited text no. 4
    
5.
Tang JW, Li Y, Eames I, Chan PK, Ridgway GL. Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. J Hosp Infect 2006;64:100-14.  Back to cited text no. 5
    
6.
WHO. Modes of Transmission of Virus Causing COVID-19: Implications for IPC Precaution Recommendations; 2020. Available from: https://apps.who.int/iris/bitstream/handle/10665/331601/WHO-2019-nCoV-Sci_Brief-Transmission_modes2020.1-eng.pdf?sequence=1 and isAllowed=y. [Last accessed on 2020 Oct 04].  Back to cited text no. 6
    
7.
Kan HD, Chen BH, Fu CW, Yu SZ, Mu LN. Relationship between ambient air pollution and daily mortality of SARS in Bejing. Biomed Environ Sci 2005;18:1-4.  Back to cited text no. 7
    
8.
Feng C, Li J, Sun W, Zhang Y, Wang Q. Impact of ambient fne particulate matter (PM2.5) exposure on the risk of influenza likeillness: A time-series analysis in Beiing, China. Environ Health 2016;15:17.  Back to cited text no. 8
    
9.
Pippin DJ, Verderame RA, Weber KK. Efficacy of face masks in preventing inhalation of airborne contaminants. J Oral Maxillofac Surg 1987;45:319-23.  Back to cited text no. 9
    
10.
Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg 2002;76:202-6.  Back to cited text no. 10
    
11.
Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4.  Back to cited text no. 11
    
12.
OCDO. Standard Operating Procedure: Transition to Recovery; 2020. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-torecovery-SOP-4June.pdf. [Last accessed on 2020 Jun 12].  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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