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A Clinical Study Measuring Dental Aerosols with and Without a High-Volume Extraction Device

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A Clinical Study Measuring Dental Aerosols with and Without a High-Volume Extraction Device RESEARCH A clinical study measuring dental aerosols with and without a high-volume extraction device Adam Nulty,*1,2 Chris Lefkaditis,3 Patrik Zachrisson,4 Quintus Van Tonder5 and Riaz Yar6 Key points Without the use of an external high-volume With the use of an external HVE device, PM1- The use of an external high-volume suction extraction (HVE) device during aerosol sized particle count, which would pass through device reduced the aerosol particle count of all generating procedures, there is a signifcant an N95 or N99 mask, remained moderately stable sizes signifcantly. increase of PM2.5- and PM10-sized particle throughout the procedures. count from the use of micromotor high-speed, air turbine high-speed, slow-speed and ultrasonic handpieces. Abstract Introduction External high-volume extraction (HVE) devices may ofer a way to reduce any aerosol particulate generated. Aims 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. 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 signifcantly increased levels during dental procedures without an external HVE device versus with the device. Discussion The null hypothesis was rejected, in that signifcant diferences 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. Introduction aerosols produced.1 Before investigating the can range from 0.001–100 microns.5 Tese present study, we must discuss how aerosols particles can be defned according to their Aerosols and the SARS-CoV-2 virus are generated and what sized particles are size: coarse particles are 2.5–10 microns In light of the SARS-CoV-2 pandemic, the present within any potential aerosol that is (PM10 classifcation), fne particles are under United States Occupational Safety and Health generated in a dental procedure, in order to 2.5 microns (PM2.5) and ultra-fne particles Administration have classifed dentistry as understand the signifcance of reducing the are under 0.1 microns (PM1). For human one of the very high-risk occupations for aerosols generated. An aerosol is a dispersion transmission of disease, the infectious dose transmission of the disease because of the system consisting of solid and liquid particles required is small. Viral and bacterial agents of various sizes which are suspended in a gas have an afnity for specifc components of cells medium.2 While using this defnition, and and tissues along with pathogenic factors.6 Te 1Dentist On THE ROCK, 26 The Rock, Bury, BL9 0NT, UK; 2PhD Student, University of Leeds, Woodhouse Lane, Leeds, the three important elements of aerosols, we oral-nasal breathing pathway can channel air LS2 9JT, UK; 3Hellesdon Dental Care, 153 Middleton’s Lane, must consider that it is normal for an aerosol particles over ten microns in size. Tis poses Norwich, NR6 5SF, UK; 4Wensleydale Dental Practice, 11 George Street, Huntingdon, PE29 3BD, UK; 5Zandielle to be suspended in the air only if it is less than risk as particles under ten microns in size can Clinic, Queen’s Square, Attleborough, NR17 2AE, UK; 6The ten microns in size.2,3 Tis is because as these therefore enter the respiratory system and Square Advanced Dental Care, 2 Hollins House, 329 Hale Road, Hale Barns, WA15 8TS, UK. droplets decrease in size, so does their relative smaller particles under 2.5 microns can enter *Correspondence to: Adam Nulty mass. As such, the impact of gravity on these the alveoli sac. Ultra-fne particles, such as the Email address: [email protected] particles reduces and they can be suspended in SARS-CoV-2 virus molecule, which are sub-1 Refereed Paper. the air for much longer.4 micron can potentially enter the circulatory Accepted 25 September 2020 The size of the particles that can be system through this mechanism directly or https://doi.org/10.1038/s41415-020-2274-3 potentially suspended in the aerosols produced through being carried on a larger particle.7,8 BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 12 2020 1 © The Author(s), under exclusive licence to British Dental Association null RESEARCH Te mechanism of breathing in living creatures to the naked eye, and is noticed by the patient surfaces; and inhalation of infectious can also create aerosols in the form of bio- and dental staf.21 particulate aerosols.34 aerosols.9 Tese droplets can be produced in One recent study looked at how ultrasonic Te aim of this study was to measure the large numbers; for example, up to 3,000 in scaling can transmit particulate aerosol for particle count during dental aerosol procedures just a single cough. High-projectile particles up to six feet and, without an air current, and compare the results to when a high-volume can also be generated in larger numbers (over this particulate can remain suspended extraction (HVE) device was used. 40,000) in the action of sneezing.10 from 35 minutes to several hours.22 If the Te null hypothesis was that no diferences suspended particulate is over ten microns, would be found in the amount of aerosol How do airborne infections spread? gravity can cause these particles to settle on particle count with or without a HVE device. Even before specifc infectious agents (such the surrounding surfaces, such as the patient as bacteria and viruses) were discovered, the and the immediate clinical area, for up to two Materials and methodology potential of infection by the airborne route was meters.3,23 During these dental procedures, recognised; for example, the bubonic plague, various dental equipment such as dental Air sampler device also known as the ‘Black Death’, which was handpieces, air-water syringes, ultrasonic In total, fve diferent restorative procedures recorded to be spread via an airborne route. scalers and air-polishing units are known to were monitored with an industrial Trotec Tis is seen as a concern in more recent times produce colony-forming units via the bio- PC220 particle counter. This sampler is in air travel. In one report, the mycobacterium aerosols generated.19,24,25 sent with a calibration certifcate where the Bacillus causing tuberculosis was spread sampler is calibrated with a PC200/220 flter through passengers on an aeroplane.11 Can splatter from dental procedures for zero calibration by the manufacturer. Passengers seated closer to the source of the spread disease? The air sampler therefore does not need infection were more likely to contract the Miller et al. have concluded that bio-aerosols calibrating before use by the user. Tis air disease. can contain millions of bacteria per cubic foot sampler conforms with ISO 21501-4 – which The exact mechanisms by which SARS- of air.26 King et al. have stated that aerosols specifically refers to the light-scattering CoV-2 virus is spread remain under retrieved from six inches away from a patient airborne particle counter – and is accurate to investigation, but current understanding points demonstrated that the colony-forming units within ± 95% with a 5% particle coincidence to transmission through aerosol droplets.12,13,14 were substantially reduced through aerosol loss. Te sampler was used to measure the Many worldwide governments and healthcare reduction systems.27 following sized particulate generated in authorities have therefore advised dental During a conventional dental procedure, each procedure: PM1 (particulate sized 1 practitioners to proceed with only emergency the patient is required to sit with their mouth micrometre [μm] or less), PM2.5 (particulate and essential procedures, and to avoid elective open, exposing naturally occurring fluids sized 1–2.5 μm) and PM10 (particulate sized dental procedures altogether.15,16 such as saliva and blood.28 During a dental 2.5–10 μm). Te fve diferent procedures procedure that uses ultrasonic scalers, air- were carried out without a HVE device in Dental aerosols water syringes or high-speed air turbine or place and then repeated separately with the Te mechanical action of tools used in the micromotor devices, the mechanical action HVE device in place, in order to compare dental clinic can produce suspended particles can spread these bodily fuids through splatter the efect of the HVE on the particle counts as aerosols, such as the use of fast and slow out of the operating site into the surrounding recorded. Te air sampler uses multi-angle, dental handpieces, ultrasonic scalers and air- environment. It is this splatter that can take the laser-scattering detection. Scattered light can water syringes.17 Tese tools use high-powered form of a spray of variously sized droplets.29 be collected at a specifed angle and, according air or fast-turning mechanical micromotors to Te constituents of these droplets and their to the scattering intensity, equivalent particle work, which can create these aerosols through relative size have been given the dental terms diameters and the number of suspended the kinetic energy acting in the process of ‘splatter’ and ‘aerosols’.30 Larger particles that particulate matter with diferent sizes per unit dental instrumentation.18,19 are not suspended can be visible where spread volume can be obtained.
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