JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES

Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan. a menace for the dental healthcarers. Journal of pharmaceutical and biomedical sciences (J Pharm Biomed Sci.) May(Supplement 1); 30(30):S58-S64.

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ISSN NO- 2230 – 7885 CODEN JPBSCT NLM Title: J Pharm Biomed Sci.

Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan

Review article Aerosols a menace for the dental healthcarers

Ravleen Kaur1, Inderjot Singh2, Gina Singh3, Anushi Mahajan4

Affiliation:- 1Assistant Professor, Department of Periodontics, control by emphasizing seven major areas; aseptic Christian Dental College, Ludhiana, Punjab, India. technique, patient screening and evaluation, 2Associate Professor, Department of Oral & personal protection, instrument sterilization, Maxillofacial surgery, Christian Dental College, environmental surface disinfection, equipment Ludhiana, Punjab, India. asepsis and laboratory asepsis. Each 3Professor and Head, Department of Periodontics, control component contributes to minimizing the Christian Dental College, Ludhiana, Punjab, India. potential for cross-infection during provision of 4Assistant Professor, Department of Periodontics, dental treatment. Dental patients fall into several Christian Dental College, Ludhiana, Punjab, India. risk categories concerning the transmission of infection. Some patients will only suffer from *Correspondence to:- dental or oral , others are infected, some Dr Ravleen Kaur are healthy carriers, and yet others are Assistant Professor, Department of Periodontics, symptomatic or asymptomatic carriers of a Christian Dental College, Ludhiana, Punjab, India transmissible at a contagious or Phone no:- +91-09781108811 noncontiguous stage.

Abstract: Key words: Periodontal ; dental aerosol; Dental professionals have addressed the increased . challenge of infectious disease and infection

Article citation:- Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan. Aerosols a menace for the dental healthcarers. Journal of pharmaceutical and biomedical sciences (J Pharm Biomed Sci.) May(Supplement 1); 30(30):S58-S62. Available at http: //www.jpbms.info

INTRODUCTION he increase in scientific data and the consideration for infection control and awareness of the problems concerning occupational health, since infectious agents could “indoor pollution” have led to many studies be transmitted via aerosols to patients or staff in T 2 aimed at identifying and measuring the different the confines of the dental unit . There is concern factors that can alter the quality of air in an that aerosols from dental procedures may be enclosed environment. The dental office must deal regulated by the Occupational Safety and Health with the inherent or specialized pollution Administration, or OSHA, as part of standards for produced by the daily professional activities indoor air quality3. performed. The various procedures performed Dental professionals have addressed the increased with aerosol-creating instruments, such as air- challenge of infectious disease and infection turbine handpieces, low-speed hand-pieces, control by emphasizing seven major areas; aseptic ultrasonic instruments, bicarbonate polishers, technique, patient screening and evaluation, polishing cups, and air-sprays, inside the oral personal protection, instrument sterilization, cavity, which is highly contaminated with wide and environmental surface disinfection, equipment still partially known range of bacterial flora1. asepsis and laboratory asepsis. Each infection Bioaerosols have been implicated in contributing control component contributes to minimizing the to indoor air-pollution and gained notoriety in potential for cross-infection during provision of association with various conditions, such as dental treatment4. Legionnaires’ disease and Sick building syndrome. Several studies document the dispersion of In the dental clinic, bioaerosols are an important infectious agents in aerosols and splatter during

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Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan dental treatments, especially when the water spray years, the theory of airborne infection has received is used5. Waterlines for the air-water syringe and much attention from all the areas of biomedical handpiece can become contaminated with activity10. Miller et al. 11 and Lorato et al.12 have bacteria6. Infectious agents also can be introduced documented the risks of airborne infection by into the handpiece water-supply from the previous dental aerosols. or current patient and can be aspirated into the waterline from the patient’s mouth when the water Defining aerosols is shut off, even when the hand piece is equipped There is concern that aerosols from dental with anti-retraction valves7. procedures may be regulated by the Occupational The patient’s mouth is also a source of infectious Safety and Health Administration, or OSHA, as part agents that can be dispersed by splatter from the of standards for indoor air quality. OSHA’s water spray5. The oral cavity provides a unique proposed indoor air-quality rule does not specify a ecosystem of moist environment, temperature, and size range in describing bioaerosols13. the existence of endogenous and exogenous There has been some confusion about the metabolic substrates, which makes it an ideal definition of an aerosol, which varies widely medium for bacterial growth8. About 150 billion according to the discipline describing it13. Micik are found in 1g of material of the and colleagues defined dental aerosols as being gingival crevice of a patient with poor oral hygiene, particles smaller than 50 micrometers, with any and over 6 billion are present in 1ml of saliva9. particles larger than 50 µm being described as Modes of microbial transmission in the dental splatter14. Aerosols and splatters are generated by environment may be classified into three general the use of high speed hand-pieces, sonic and categories4: ultrasonic scalers etc15. The particle concentration was 10,000 colony-forming units (CFU)/sq ft up to Direct contact with infectious lesions, blood or 2 ft away, 1000 CFU/sq ft up to 4 ft away, and 100 saliva. CFU/sq ft upto 7 ft away. The results from a  Indirect transmission via transfer of patient’s sneeze and from dental procedures were microorganisms by a contaminated comparable11. So, while dental healthcare workers intermediate object. may lean back to be out of the way as the patient  Aerosolization via the airborne transfer of sneezes, resuming work at close quarters exposes infected blood, saliva or nasopharyngeal them to the same hazard15. secretion droplets, or all three. Aerosols generated by dentists in their work may contain solid particles and chemicals or gases, as Oral microflora and occupational risks: well as and . One cannot easily The human mouth is an ideal incubator for a many separate gases and chemical from the aerosols, as potential microbial pathogens, offering multiple the gases and chemicals in the oral cavity may microenvironments, appropriate temperature and become dissolved in the droplets16. An air turbine an abundance of nutrients. Most adults have been high speed dental handpiece can generate nearly infected with herpes viruses (that is, herpes simplex 27 million particles of dental enamel <5 µm in virus, cytomegalovirus, Epstein-Barr ), and diameter17. Air samples recovered after use of certain respiratory viruses such as Enteroviruses lubricated high speed handpieces contained 0.62 and Rhinoviruses4. mg/m3 oil, presenting some risk for Because of the particular features of the oral cavity oleogranuloma, , or paraffinoma18. and the diagnostic and therapeutic procedures used in , dental surgeons are at high risk for developing infectious diseases. During the past

Splatter 11 Aerosol 16 Squames15 Travel in a ballistic fashion, with a Droplet nuclei are those expelled from the Released from the skin of the surgical curved trajectory similar to that of an nose or mouth, which evaporate and team become airborne, adding to the air artillery shell, landing on the faces and become smaller. Nose and throat droplets hygiene burden and posing a risk to the clothing of the operator and assistant of mucous and saliva do not evaporate as patient. and on nearby surfaces. fast as water. They become droplet nuclei, buoyant in the air and called aerosols.

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Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan

Aerosol particles, nominally under 50 m The human body produces an estimated 7 diameter, may contain one or more million skin squames per minute. microorganisms and may drift in the air for some time. The friction of clothes and bedding They do not settle readily on open agar increases their sloughing, and bodily are >50 µm diameter and may be visible plates, so they are sampled by vacuum movement crease a bellows effect, forcing devices that draw them into liquid culture squames out of the garment neck, sleeves, media or onto agar plates. and trouser cuffs.

They do not settle readily on open agar Body heat creates convection currents, plates, so they are sampled by vacuum further lifting the squames into the air. devices that draw them into liquid culture media or onto agar plates.

They settle quickly (owing to gravity) within the normal working distance from the patient’s mouth and have been considered a type of direct contact.

Splatter from the patient’s mouth can be generated by breathing, speaking, sneezing, coughing, toothbrushing, gargling, high-speed drilling (dry or with water spray), polishing with a rubber cup of Robinson bristle brush air-water syringe spray, and an ultrasonic scaler.

Risk of aerosols and splatter for the dentists and  The removal of composite following completion the patient of fixed orthodontic appliance treatment Particles produced during any dental procedure  Endodontic therapy can have either direct or indirect effects. An example of a direct effect is where a small particle The risk to dentists, dental assistants and patients is inhaled, deposited on or within the lining, and of infectious diseases through aerosols has long then directly invokes an inflammatory response been recognized20. Bennett et al. using within the tissues. An indirect effect occurs when microbiological air samplers assessed the bacterial the particulates are contaminated with airborne concentration within aerosols produced during pathogens either within or on the surface of the routine dental treatment in general practice21. particulate matter. Bacterial cells, with diameters of approximately 0.2 to 2.0 µm, or viruses with Aerosol generation by ultrasonics diameters of between 20 to 400 nanometers, might Ultrasonic scalers generate aerosols with bacteria be found in aerosols arising from an operative peaking over 300 CFU/cu ft of dental operato ry22. procedure or from subsequently altered splatter. Face-shields worn during periodontal surgeries in Within a general dental practice numerous which ultrasonic scalers or air-polishers were used procedures are performed on a daily basis that received an average of 3 splatters/mm square9. In results in the production of aerosols and splatter19. a lab trial, ultrasonic scalers spread splatters of fluorescein dye up to 25 inch away from a dental These procedures include: model13. Aerosols and splatter generated during  The preparation of intracoronal cavities ultrasonic scaling procedures may increase more  Crown preparations, trimming new than threefold over background levels1. restorations  Removal of old restorations Significance of aerosols  Sonic and ultrasonic scaling Airborne were first shown by Koch in  Air polishing 1848, and demonstrated that the animals  Any procedure that requires acid etching breathing air sprayed with tubercle bacilli got followed by rinsing and drying pulmonary . Other airborne infections attributing to contact spread are Psittacosis, Q

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Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan fever, coccidiomycosis, pneumonia, pulmonary sprays or rotary instruments generated aerosols tuberculosis, rhinovirus, adenovirus, influenza, with significantly greater numbers of bacteria14. measles and chicken pox. Dentists have a higher Grenier demonstrated dental treatment in general respiratory risk than the general population15. significantly increased the level of bacteria air The risk to any individual from contaminated contamination and ultrasonic scaling produced aerosol is related to the19 three times contamination than operative dental 1. Virulence of the bacteria treatment27. Bentley et al. also found higher 2. Susceptibility of the individual aerosolized bacterial counts of alpha hemolytic 3. Microbiological load inhaled streptococci during ultrasonic scaling therapy than during tooth preparation28. It is known that the use of mechanical instrumentation within the oral cavity may result Factors: aerosols spread. in blood or saliva being splattered on to the Little is known about the risk of acquiring operator’s mask or glasses23. Blood has certainly tuberculosis through bacterial aerosols in the been detected within the aerosol produced during dental clinic, although there is a risk of acquiring ultrasonic scaling24. the disease from infected individuals in the indoor This of concern to the clinician as it opens up the environment, particularly if there is prolonged possibility of the transmission of blood-borne exposure2. Bentley also demonstrated that aerosol pathogens, even from apparently asymptomatic remain detectable in air for at least 10 minutes patients. Fortunately, the risk of Hepatitis B or HIV following the completion of dental treatment and infection from aerosols generated during dental were detected at 2 feet or more from dental chair28. treatment is estimated to be extremely small21. The length of time that aerosol droplets remain However, HBsAg and HBV-DNA have been detected suspended in the air was investigated by Lorato et in the aerosol of a known Hepatitis B carrier al. and noticed that the count fell immediately in 35 undergoing orthodontic appliance debond and minutes after treatment but was still 230% more enamel clean-up25. Also, the potential for the than it was before ultrasonic scaling29. transmission of the SARS (Severe acute respirato ry There are no international standards giving syndrome) virus has been postulated26. maximum values of bacterial aerosols allowable for infection control in dental clinics. However, Composition of bacterial aerosols: maximum values have been suggested for an Dental procedures have shown to generate ultraclean operating room2. bacterial aerosols pre-dominantly Streptococcus and Staphylococcus spp. Other infective bacteria  In filtered air supplies, the air passing through could also be generated during dental procedures the final filters should contain no more than 0.5 and M tuberculosis has been found in aerosol bacteria carrying particles per cubic meter of particles generated by high speed hand-piece used air. during simulated dental procedures on patients  During an operation, the air within 30cm of the with active tuberculosis20. wound should, on average, contain no more Although oral cavity is a probably the major source than 10 bacteria carrying particles per cubic of bacterial contamination in dental procedures, meter of air. dental unit waterlines have also been implicated as potential reservoir of bacteria, including In the remainder of the working area of the clean Legionella, pneumophila, and M tuberculosis2. air system, since contamination of instruments and S. aureus produces many toxins which can cause materials within the sterile field will lead to cross skin infection, especially post operative wound contamination of wounds, the air within the infection in hospitals. Methicillin-resistant S.aureus working area (3m by 3m) at table height, should (MRSA) can sometimes be found in hospitals and not exceed 20 bacteria- carrying articles per cubic other medical facilities, particularly in ulcers and meter of air2. the long term bedridden patients in hospital. Cross-contamination of MRSA in a hospital based Measuring bacterial aerosols: dental clinic or operating theatre could be a cause A number of methods have been employed to for particular concern and may warrant further assess and measure bacterial aerosols. The various investigation2. Micik et al. demonstrated that other methods used for collecting the air samples, dental procedures incorporating the use of water by various authors were SAS (Automated Surface

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Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan

Air System) sampler1, RODAC plates8, TSA manner within the breathing zone of the dental (Tryticase Soy Agar)15, TYC (Typtone-yeast extract- staff or the patients or both, depending on what the Cystine) Agar21, Columbia blood agar21, Casella Slit target group is. Many previous studies were sampler21, Adersen Sampler21, Vacuum Air limited by the small sample size or by employing Sampling device with Filters31, Reynier’s Slit procedures which did not allow accurate Sampler31. quantification of bacteria. Some also used an The concentration of bacterial aerosols can be experimental design, which may not have measured quantitatively by using the slit-to-agar represented the real situation in most dental air sampler, the technique of vacuum aspiration clinics2. Blood agar plate is a general purpose, non- impaction, which can quantitatively estimate the selective, enriched medium that promotes the number of bacteria in a certain volume of growth of micro-organisms8. According to Legnani air,usually expressed as colony forming units et al, plate method gives a precise indication of the (CFU) per m3. Agar plates are attached containing possible contamination over time by measuring different agar media, which can measure total dental particulate and aerosol precipitation on bacteria count and specific bacterial organisms2. different exposed surfaces in the operatory room1. Single air sampling has limitations as the Cochran et al. 32 and Bentley et al.28 observed the environment may change from time-to-time; larger salivary droplets generated during dental however bacterial aerosols can be serially procedures settle rapidly from the air with heavy monitored and should be undertaken in consistent contamination on the patient’s chest.

Figure 1. Growth of microorganisms on blood agar plate before (1a) and after (1b) exposure to aerosols. Need for good aerosol control: root planing, the bacterial count in the air Dental patients fall into several risk categories increased 30 fold29. This is also true of use of other concerning the transmission of infection. Some instruments, such as high-speed headpieces, patients will only suffer from dental or oral compressed air cleaners, and air/water syringes. diseases, others are infected, some are healthy These devices spread the organic fluid found in the carriers, and yet others are symptomatic or oral cavity, such as saliva, blood, and pus, and their asymptomatic carriers of a transmissible disease at own cooling liquids. These fluids may actually a contagious or noncontiguous stage. All this provide culture media for environmental makes it extremely difficult for dental surgeons to pathogens. All this results in a considerable establish the amount of risk involved. According to increase in the airborne microbial charge9. an investigation conducted in 1987 in the United States, a dental team treating, on the average, 20 Protective measures against bacterial aerosols: patients a day for 7 workdays is likely to encounter Most modern dental clinics are closed systems with two patients with herpetic stomatitis, one carrier air conditioning, which needs regular maintenance. of hepatitis B, and one patient who has tested Bacterial aerosols can also be reduced by using air positive for HIV in every 400 patients operated on. filters, and ultraviolet (UV) light. The use of UV The different kinds of dental procedures should lamps or portable filters for particle removal may also be carefully evaluated9. In 1967 Larato et al. increase equivalent room air changes, but does not demonstrated that during ultrasonic scaling and satisfy fresh air requirements. Laminar air flow

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Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan may further reduce exposure. Specific measures to Personal protective measures, such as the use of prevent the spread of M.tuberculosis may also be surgical masks, prescription or safety glasses worn needed when treating those with active with lateral protection, gowns, and gloves, can tuberculosis. These may include measures to decrease the penetration of or reduce contact with prevent circulation of air which could contain bacteria aerosols and splatter2. Micik et al. studied M.tuberculosis-containing aerosols from the dental the efficacy of surgical masks in protecting dental clinic to other parts of the building2. personnel from air borne bacterial particles and American Dental Association published its initial tested filtering efficiency of mask varying infection control recommendations in 1978, it is from14%-99%. Aerosols or airborne particles of important to realize that basic principles of disease less than 1 m can, however, readily penetrate transmission and prevention were considered surgical masks although 15-83% of aerosols of many years earlier. With the seven major infection 0.06 to 2.5 µm have been shown experimentally to control areas mentioned earlier as a framework, pass through the filter media of various makes of this procedure would seem to fit best under the surgical masks34. heading of aseptic technique4. Spirited debate continues, however, as to the CONCLUSION efficacy of pre-procedural antimicrobial Aerosols are omnipresent in most of the dental mouthrinses in this capacity. A large volume of departments. Unfortunately, the information on literature has demonstrated the effectiveness of aerosol is least dealt. If every dentist would pay certain antiseptic mouth rinses in helping to attention to this topic, the chances of transmission reduce development of gingivitis and of dangerous diseases can be minimized. Clinical periodontitis4. Use of an antiseptic mouthwash by implications that could be drawn from this review, the patient prior to ultrasonic scaling has also been 1. The innocent dental personnel, the operator & shown to be effective in reducing bacterial aerosols the patient could be well protected by during treatment25. Chlorhexidine gluconate has understanding the topic of aerobiology. been found to be more effective than other 2. Factors governing aerosol production & its solutions in reducing bacterial aerosols33. spread should be paid maximum attention & care King et al. suggested the use of aerosol reduction should be taken to control them systematically. device as an effective method in reducing the Further, a chapter on aerosols should be number of microorganisms generated during mandatory in clinical dentistry text books. The ultrasonic scaling, therefore reducing the risk of Studies based on aerosol microbial profile, have disease transmission8. several methodological variations that affects the Suction and preoperative oral hygiene procedures aerosol contamination. The operatory may not be effective in reducing contamination measurement is not similar in aerosol studies as from bacterial splatters11. High-volume evacuation the dimension of the room influences the may however reduce bacterial aerosols and distribution of aerosol; the information regarding splatter during dental procedures, such as with the the operatory preparation for aerosol study is not use of ultrasonic scaling13. mentioned in all the published articles; different The use of a rubber dam may also assist in air-sampling methods are used; the distance and reducing the bacterial contamination generated the location at which the aerosol samples were during the operative treatment. Additional collected are dissimilar in various studies; the measures may include flushing water lines daily duration of aerosol sampling are different; the before use, since residual water is likely to become position of the operator (mask level) and the contaminated overnight2. treatment area in the oral cavity differs which Routine immunizations of dental staff in the dental definitely influences the aerosol contamination. clinic should be up-to-date according to the Furthermore, standardized methodology has not relevant national immunization schedule. Many of been employed and the results have not been these immunizations cover bacterial and viral reported in a comprehensive form. This has made infections which could be transmitted through comparative interpretation of new data difficult bacterial aerosols in the dental clinic. Dental staff and has hampered the further use of aerosol should also consider Mantoux testing for collection measurements in a clinical setting. tuberculosis and BCG immunization, especially for those working in endemic areas2.

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Conflict of interest: - Author has not declared any conflict of interest.

Source of funding: - Not declared.

Copyright © 2013 Ravleen Kaur, Inderjot Singh, Gina Singh, Anushi Mahajan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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