DISEASE TRANSMISSION IN HEALTHCARE SETTINGS

Modes of transmission for healthcare workers and patients in healthcare settings include direct contact, indirect contact with contaminated surfaces or objects (fomites), droplets, and bloodborne and airborne routes.^7,8 Disease may occur when a sufficient level of a given pathogen is present to result in an infectious dose.⁷ In hospitals, 1 in 25 patients are impacted by at least one hospital-acquired infection (HAI).⁹ Many HAIs are caused by antibiotic-resistant micro-organisms, often referred to as “superbugs,” and may lead to sepsis or death.¹⁰ In the dental setting, confirmed diagnoses of acquired infections among patients and/or dental healthcare personnel have resulted from water in contaminated dental unit waterlines, failure to adhere to the requirements of the Bloodborne Pathogens Standard, and incorrect/inadequate reprocessing of contaminated instruments.^7,8,11 Other risks include contaminated clinical contact surfaces, direct contact, and airborne transmission. 

AIRBORNE TRANSMISSION

Examples of micro-organisms with airborne transmission include the measles virus and Mycobacterium tuberculosis, which are both highly infectious, and Candida auris.^12-15 Airborne spread of SARS was confirmed more than a decade ago.¹⁶ In air sampling studies of hospital air where infected patients were staying, PCR was used to detect micro-organisms.¹⁷ Collectively in these studies, sampled air had contained the varicella-zoster virus, measles virus, M tuberculosis, influenza viruses, respiratory synctial virus, rhinovirus, adenovirus, Mycoplasma pneumoniae, and other micro-organisms. For many, the particles were <5 μm in size. There was also evidence of airborne transmission during the SARS-CoV outbreak.¹⁸ For some micro-organisms, while one mode of transmission may dominate, other modes of transmission also occur: for example, MRSA (which can be transmitted by direct contact and indirect contact with fomites), varicella-zoster, and Pseudomonas aeruginosa.^19-21 The latest was SARS-CoV-2, which is now generally accepted to mainly involve airborne transmission, with far fewer cases associated with close-contact droplet transmission or contaminated surfaces. 

Particle Size and Behavior

Different understandings exist with respect to airborne transmission. Aerosols contain particles ≤50 μm in a gas—in the current context, in air. Infectious aerosols contain pathogens within particles in the air. Larger particles are generally believed to behave ballistically and to settle out rapidly in close proximity. This includes spatter, which contains particles >50 μm and droplets >20 μm in aerosols.^16,22 However, in a study on respiratory exhalation, it was found that droplets between 60 and 100 μm were carried farther than 6 m away.²³ In addition, when droplets rapidly dehydrate in the air, this creates airborne droplet nuclei, which are largely ≤5 μm but may be as large as 10 μm.¹⁶ Small particles can move with airflow, remain airborne longer, and travel farther than larger particles.²⁴ The time it takes for particles to settle varies based on particle size, airflow, and the height of the area in which settling occurs. Studies use the diameter of unit density spheres to assess settling time that involves the same velocity as for the actual particle being investigated (Figure 1).

Furthermore, while particles passing in turbulent air close to a horizontal surface can settle, other particles will continue to be disturbed and remain airborne for long periods of time.²⁴ In addition, it is possible for particles settled on surfaces to become airborne. Whether or not this occurs depends on particle size, adhesion to a surface, and the energy and airflow reaching the space.²⁴ A recent report noted that micro-organisms on floors in hospital settings could become resuspended into the air, such as when walked on, with a potential for transmission and contamination of surfaces.²⁵ The report also cited earlier studies showing the contamination of floors with Clostridioides difficile, vancomycin-resistant enterococci, and MRSA. Particle size also determines how deep a pathogen can reach in the respiratory tract, with smaller aerosol particles reaching deeper into the lungs. In studies analyzing cough and breath aerosols, M tuberculosis, P aeruginosa, and numerous viruses were found in particles <5 μm in size.¹⁷ Particles <10 μm readily reach below the glottis in the larynx; those <5 μm are readily inhaled into the lower respiratory tract^16,17,26 (Figure 2).

INFECTION CONTROL PROTOCOLS AND GUIDANCE IN THE DENTAL SETTING

The CDC provides recommendations with standard precautions and additional protocols for infection control. CDC guidance for healthcare settings during COVID-19 includes (but is not limited to) triaging patients, social distancing, source control, changes to PPE for protection, and the recommendation to select an EPA-registered hospital-level disinfectant on EPA List N.²⁷ In the dental setting, key guidance includes the use of high-volume evacuation, rubber dams (when possible), and specific recommendations for PPE during aerosol-generating procedures. Other devices, such as extraoral suction, can also mitigate aerosolization through capture while varying in power level, dimensions, configuration, noise level, and how the captured aerosol is then handled.²⁸ A layered approach has been recommended. This approach includes using ventilation and considering the use of adjunctive devices, specifically high-efficiency particulate air (HEPA) filtration and ultraviolet germicidal irradiation (UVGI).²⁹ HEPA filtration and upper-room UVGI¹³ work continuously while rooms are occupied, providing ongoing adjunctive infection control. Newer Food and Drug Administration (FDA)-cleared medical devices are also available in the dental setting, which we will discuss later in this article. 

Of note, ozone generator air purifiers are not recommended. While ozone is a germicide at high levels, it is also toxic. OSHA’s permissible level of ozone is an airborne exposure limit of 0.10 ppm (0.2 mg/m³) for an 8-hour work shift (a day of exposure). The National Institute of Occupational Safety and Health recommends an upper limit of 0.10 ppm, not to be exceeded at any time.^30,31 The California Air Resource Board (CARB), which oversees air pollution control efforts in California to reach and maintain health-based air quality standards, and other governmental organizations advise against the use of such ozone generators in spaces occupied by people or animals.^32,33 Based on the evidence, ozone concentrations within the permissible levels are ineffective in removing micro-organisms, as well as many odor-causing chemicals, and would need to be substantially higher to kill airborne micro-organisms.³¹ 

Air Exchanges and Ventilation

“Air changes per hour” (ACH) denotes how many times the air within a defined space is replaced, provided the air is well-mixed. The CDC defined a minimum of 6 ACH as criteria for an efficient ventilation system in 2003, while for transmission-based precautions, it states that at least 12 ACH should be ensured.³⁴ The minimum of 6 ACH is being reviewed. As reported by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the assumption in the past was that air was ideally mixed and no obstacles to airflow were present, such as a dental chair. It was also noted that it was based on an absence of “re-contamination of the room by the exhaust air.”³⁵ The objective of increasing room ventilation is to supply more clean air, thereby reducing the concentration of contaminants with the goal of keeping this below the threshold that could cause injury/disease. It has also been shown that a relative humidity below 40% can increase the survival rate of some airborne micro-organisms and increase their transmission.³⁵ 

One method to assess ventilation is through the use of carbon dioxide monitors. These determine the concentration of carbon dioxide in an area, with readings below 800 ppm recognized as a target benchmark for good ventilation. Periodic assessment of the level of carbon dioxide in a defined space provides information on the need (or not) to adjust ventilation. It can provide an early warning system when used appropriately.³⁶

In accordance with the CDC guidance, options that include opening windows—even just slightly, when possible—aid ventilation. Fans can be used to increase the flow of outside air into the area. Another option is to consult an HVAC specialist about further opening the HVAC’s outdoor air dampers and to help ensure that the HVAC is working properly and is adjusted for optimal airflow.²⁷ Additional methods of adjusting ventilation can be found on the CDC website. 

Minimum Efficiency Reporting Value (MERV) ratings are provided for filters.³⁷ The higher the MERV rating, the more efficient the filter. For example, the particle size efficiency of a MERV 14 filter is 76% to 84% for 0.3-μm to 1.0-μm particles and 90% or greater for 1.0-μm to 3.0-μm particles. A MERV 12 filter, on the other hand, has a particle size efficiency of 80% to 89.9% for 1-μm to 3-μm particles and 90% or greater for 3-μm to 10-μm particles. Currently, ASHRAE recommends a filter with a MERV 13 rating (at least 85% efficient at capturing particles in the 1- to 3-µm size range) for HVAC systems, while noting that a MERV 14 or better is preferred.³⁸ It also notes that the given HVAC system must be taken into account and that it may not be possible to accommodate a MERV 13 filter. Higher efficiency typically increases the pressure drop, paradoxically, in turn, potentially reducing the airflow through the system and/or increasing energy use.³⁷   

HEPA Filtration (Adjunctive)

The CDC recommends that consideration be given to using portable HEPA filters to decontaminate air, preferably those with powered fans.²⁷ HEPA filters can theoretically capture at least 99.97% of 0.3-μm particles, the most penetrating particle size and, therefore, the most difficult to capture compared to both larger and smaller particles.^39,40 When selecting a HEPA filter, one with a high clean air delivery rate (CADR) is recommended. This defines the cubic feet of air per minute that can be handled by the filter. The device should be positioned so that air is sucked into it directionally away from patients and the clinical team, avoiding sucking contaminated air over room occupants. The room dimensions and capacity must be considered in determining the required capacity of a HEPA filter or whether more than one HEPA filter will be required. 

While some devices on the market may be advertised as “HEPA-Rx,” “true HEPA” or “medical-grade HEPA” filters, these are not recognized HEPA categories.

NEWER ADJUNCTIVE TECHNOLOGIES

Many newer technologies and devices are now being marketed as adjunct devices for air decontamination. These variously offer the capture of micro-organisms and their destruction in the device and/or in the air. There are several considerations to be made before deciding whether to purchase these. First and foremost, do you need one, does it work, and is it safe? Is the device FDA-cleared or being marketed during COVID-19 under the FDA Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers during the COVID-19 public health emergency or neither? Is it CARB-certified (which is needed in California)? Other factors include whether there are independent studies demonstrating efficacy against micro-organisms. Another consideration is the availability of information from studies in healthcare settings supporting efficacy. Does the device operate episodically or continuously, including safely when the room/area is occupied? Other considerations beyond the scope of this article include specifications, size, capacity, performance, ease-of-use, cost, maintenance, and ongoing support.  

ActivePure Medical Guardian: The ActivePure Medical Guardian is cleared by the FDA as a Class II Medical Device and is CARB-certified. This device is portable, and the system is designed to be used in rooms of up to 3,000 ft³. The technology is an advanced form of the one developed and used in the NASA Space Program and included in the Space Foundation Technology Hall of Fame. It offers continuous air and surface decontamination and works in 2 phases using 3 technologies. The first phase utilizes a patented process that includes a UV light source in the device and titanium dioxide as a photocatalyst that is used to produce gaseous hydrogen peroxide and other oxidizers. These then exit the device and enter the air. The oxidizers interact with and disrupt bacterial and fungal cell membranes, as well as the outer shell of viruses. This leads to microbial kill. During phase 2, air is sucked into the device, along with contaminants and oxidizers present in that air. The contaminants are then ionized to become negatively charged, trapped by a positively charged filter media, and filtered by HEPA filters. In addition, the oxidizers present kill the trapped and filtered micro-organisms. 

Testing Results: Studies on the technology have been conducted in laboratory and healthcare settings. Tests resulting in FDA Class II Medical Device Clearance showed a log reduction of 5 (99.999%) for airborne RNA MS2 bacteriophages in 30 minutes. 

At the University of Texas Medical Branch, an independent laboratory study on the first phase of ActivePure, using only the ActivePure technology (no filters or ionizers), was conducted using SARS-CoV-2.⁴¹ The test protocol was designed to deliver 29 ft³ per minute of air movement (the lowest setting). Within 3 minutes, a ≥2.87 to ≥3.38 log reduction was found, which equates to a ≥99.87% to ≥99.96% reduction in the concentration of SARS-CoV-2. It was noted that the actual reduction may have been 99.99% or greater since the level of detection was reached. 

In a second independent study, the efficacy of the ActivePure Medical Guardian against aerosolized vegetative bacteria, viruses, and spores was evaluated using a sealed bioaerosol chamber in a laboratory at approximately 70.6°F and with 36% relative humidity, and inside the chamber at 75°F and 50%, respectively.⁴¹ The bioaerosol was created using a nebulizer filled with approximately 50 mL of biological stock and operated at 50 psi for 20 or 25 minutes (organism dependent). Aerosol samples were collected using 2 impingers and collected at baseline and 15-minute intervals for 90 minutes. The test micro-organisms were Staphylococcus epidermidis, Erwinia herbicola, RNA MS2 and DNA Phi X174 bacteriophages, Aspergillus niger, and Bacillus subtilis. These are proxy/surrogate micro-organisms for known pathogens, among them, respectively, Staphylococcus aureus; Yersinia pestis (black plague); influenza virus and norovirus; HCV, HCB, and HIV; Stachybotrys chartarumand (a toxic black mold); and Bacillus anthracis (anthrax) (Table 1).  

Three test trials were conducted as well as a control trial. The results showed an overall average net log reduction of 4.8 ±0.74, representing a greater than 99.99% reduction. For S epidermidis, less than 1.2% of the aerosolized bacteria were viable at 15 minutes. At 60 minutes, the average net log reduction was 5.95 ±0.34, equivalent to an almost 99.9999% reduction. For E herbicola, the average reduction at 15 minutes was >99.99%, and by 75 minutes, an average net log reduction of 5.36 ±0.37 was obtained. For the MS2 bacteriophage, in 15 minutes, on average, 99.999% was removed, and by 60 minutes, an average log reduction of 5.58 ±0.43 was observed. Testing with the Phi X174 bacteriophage produced an average net log reduction of 4.05 ±0.27 at 60 minutes. For both bacteriophages, reductions reached the limit of detection. For Bacillus subtilis, a 98.91% reduction in spores was found at 15 minutes, and by 90 minutes, a net log reduction of 4.23 ±0.31. was observed. Lastly, the 15-minute reduction for A niger was 99.71%, and by 60 minutes, an average net log reduction of 4.12 ±0.10 was found (Figure 3). At the 60-minute sampling point, the log reductions compared to the samples obtained ranged from a log 4 reduction (99.99% reduction) to a log 6 reduction (99.9999% reduction)⁴¹ (Figure 3).

Brondell Pro Sanitizing Air Purifier with AG+ Technology: This device was FDA-cleared as a medical device in January 2021 and is CARB-certified. It contains a pre-filter, proprietary HEPA filter, and nanocrystalline filter. The HEPA filter is described as antiviral; the nanocrystalline filter removes gases and odors; and a UV light is used inside the device to help sanitize the filter surfaces, the unit, and the air within it. A plasma generator generates negative ions that leave the device together with clean air and are designed to destroy micro-organisms in the room’s air. In one independent laboratory test using a test chamber, a 99.9% reduction in the H1N1 and H3N2 influenza viruses was found at 1 hour. In a second independent laboratory test, a 99.9% reduction in SARS-CoV-2 at 15 minutes was found. At the time of writing, no studies in healthcare settings were found. 

Molekule Air Pro RX air purifier: This is an FDA-cleared medical device and CARB-certified. It contains a pre-filter and a photoelectrochemical oxidation (PECO) filter. The fibers of the PECO filter are coated with a nanocatalyst that is activated by UV light and produces hydroxyl radicals in the closed chamber to destroy micro-organisms trapped in the PECO-filter fibers. In an independent laboratory test using 4 filter samples per time point, the company’s PECO filters were evaluated for reductions in RNA virus MS2, a proxy virus for SARS-CoV-2.⁴² At 1 hour, a 99.95% reduction was observed, and at 24 hours, a 99.9994% reduction was observed.  

Radic8: Radic8 devices were first developed in South Korea during the SARS outbreak and are used extensively there. This air purifier has 2 main phases.⁴³ After the air is sucked in, it passes through a pre-filter, a HEPA filter, and an activated carbon filter. UV-C light and titanium dioxide are used to produce hydroxyl radicals—these remain in the closed chamber and kill micro-organisms there. Treated air is then released into the room. The device has a “single-pass” 99.9999% kill rate against viruses similar to SARS-CoV-2, meaning that this kill rate is achieved based on air going through the device once. This technology is proven in lab testing to kill SARS-CoV-2, bacteria, and fungi in aerosols. While not an FDA-cleared medical device, the Radic8 is currently marketed under the FDA’s Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency.  

CONCLUSION

Collectively, emerging and re-emerging diseases have resulted in a greater focus on infection control and, periodically, in changes to infection control guidance and practices. Of particular concern, we have now entered what is being referred to as the post-antibiotic era in which our ability to combat many infectious diseases is compromised by decreasing the availability of effective antibiotics. Our understanding of airborne transmission has also come into sharper focus, and during COVID-19, a layered approach has been recommended, including ventilation, as well as to consider HEPA filtration and UVGI. Numerous new types of adjunctive devices are on the market. When looking at newer devices, if considering one, a careful review and due diligence are needed to determine their efficacy, safety, and applicability.

REFERENCES

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ABOUT THE AUTHOR

Dr. Collins graduated as a general dentist from the University of Glasgow in Scotland and holds an MBA and an MA from Boston University. She is a published author and international speaker on topics including infection control and OSHA. She is a consultant; an editor for Dental World; a trainer; and a CE contributor, editor, and peer reviewer. She is the ADA representative to the Association for the Advancement of Medical Instrumentation (AAMI), Chicago Dental Society, the Organization for Safety, Asepsis and Prevention (OSAP), a participant in Standards working groups and a Fellow of the Pierre Fauchard Academy. She can be reached via email at drfionacollins@gmail.com.

Disclosure: Dr. Collins reports no disclosures.  

After the tumultuous events of the past year, four companies got together to survey 720 dentists and office managers in North America to assess the profession. Their study, the State of Dentistry Report, looks at how dental practices adjusted to these changes, what obstacles remain, and other issues.

“It’s been my experience that dentistry can be an incredibly isolating profession, especially for private practitioners. There is no debate to be had that dentistry has faced significant challenges over the past year due to the pandemic,” said Greg Tice, director of education at the Seattle Study Club.

“I’ve personally spoken with hundreds of clinicians, in the Seattle Study Club network in particular, who have all stated one of the biggest challenges was and continues to be where to turn for reliable information. This survey is a first step in providing that reliable information,” Tice said.

Benco Dental, Glidewell, Midmark Corporation, and Young Innovations conducted the survey between February 22 and March 22, 2021. It asked dental professionals about the impact of the pandemic on them, what has been working well, and what the next opportunities will be. Topics include business outlook, job satisfaction, procedures and equipment, and patient acquisition and retention.

“Every dental practice should have someone responsible for infection control in the office. I think everybody would agree you would never go to a hospital for a procedure that didn’t have an infection control person in charge,” said Chuck Cohen, managing director at Benco Dental.

RELATED ARTICLES

How the COVID-19 Pandemic Has Affected Dental Practices: One Year Later – CLICK HERE

What Will Dentistry Look Like After COVID-19? – CLICK HERE

Better Oral Hygiene Could Reduce COVID-19 Severity – CLICK HERE

OSAP is pleased to announce the recipient of the 2021 Dr. James A Cottone Award for Excellence in Investigative Research. This award is named for one of the founders of OSAP who exemplified the best in infection control and safety research.

The recipient of the 2021 Cottone Award is Sepehr Makhous, PhD, for his Abstract: Evaluating Aerosol Persistence During Dental Procedures Using a Real-Time Network of Sensor. Eve Cuny, MS, who serves as the Chair of the OSAP Association Board of Directors, says “This abstract provides a new and superior way of measurement of aerosol. Further studies could use this method to build upon the study.”

Dr. Makshous is a postdoctoral researcher at the University of Washington (UW), Seattle. He and his team investigate the integration of real-time aerosol sensors in a dental setting to help evaluate and improve mitigation strategies to eliminate aerosol transmission. He has been working closely with Dr. Schwedhelm, Dr. Huang, and Dr. Chan from UW School of Dentistry to evaluate a sensor network system. They are actively looking for collaborators (research, industrial, and military) to help them with understanding the current limitations in aerosolized viruses and pathogens during dental procedures. If this research direction interests you and you would like to learn more, please contact Dr. Makshous at sosper30@uw.edu.

ABOUT OSAP

The Organization for Safety, Asepsis and Prevention (OSAP) is the only dental membership association solely focused on infection prevention and patient safety education. Our members include individual clinicians, group practices, educators, researchers, consultants, trainers, compliance directors, policymakers, and industry representatives who advocate for safe and infection-free delivery of oral healthcare. OSAP focuses on strategies to improve compliance with safe practices and on building a strong network of recognized infection control experts.

OSAP offers an extensive online collection of resources, publications, FAQs, checklists, and toolkits that help dental professionals deliver the Safest Dental Visit possible for their patients. Plus, online and live courses help advance the level of knowledge and skill for every member of the dental team. For additional information, visit www.osap.org.

FOR ADDITIONAL INFORMATION, PLEASE CONTACT:

Michelle Lee
Executive Director
(800) 298-6727
office@osap.org

RELATED ARTICLES 

NYU Dentistry Names Dr. Leena Palomo Chair of the Ashman Department of Periodontology and Implant Dentistry – CLICK HERE

2021 Recipients Of The Incisal Edge ‘40 Under 40’ Award For Young Dentists – CLICK HERE

McGill University to Lead Study on Oral Health Knowledge in Canada – CLICK HERE

The US Food and Drug Administration (FDA) is revoking the emergency use authorizations (EUAs) of all disposable respirators that have not been approved by the National Institute of Occupational Safety and Health (NIOSH), which include imported disposable respirators such as KN95s, along with EUAs for decontamination and bioburden reduction systems.

The FDA said that its actions are consistent with updated recommendations from the Centers for Disease Control and Prevention (CDC) that healthcare facilities not use crisis capacity strategies and should promptly return to conventional practices.

Also, the FDA said, its actions are consistent with the recently published emergency temporary standard from Occupational Safety and Health Administration (OSHA) to protect healthcare workers requiring healthcare employers to provide NIOSH-approved or FDA-authorized respirators for workers potentially exposed to COVID-19.

“Throughout the pandemic, the FDA has worked closely with our federal partners at the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health, the Occupational Safety and Health Administration, and with manufacturers to protect our frontline workers by facilitating access to the medical supplies they require,” said Suzanne Schwartz, MD, MBA, director of the Office of Strategic Partnerships and Technology Innovation in the FDA’s Center for Devices and Radiological Health.

“As a result of these efforts, our country is now better positioned to provide healthcare workers with access to NIOSH-approved N95s rather than using non-NIOSH-approved respirators or reusing decontaminated disposable respirators,” Schwartz said.

All manufacturers of decontamination and bioburden reduction systems have requested, and the FDA has proceeded with, the revocation of their EUAs, effective June 30, 2021.

“Early in the public health emergency, there was a need to issue emergency use authorizations for non-NIOSH-approved respirators as well as decontamination and bioburden reduction systems to disinfect disposable respirators,” Schwartz said. “Today, those conditions no longer exist. Our national supply of NIOSH-approved N95s is more accessible to our healthcare workers every day.”

Since the beginning of the pandemic, the FDA said, NIOSH has approved more than 875 respirator models or configurations, with some of these manufactured by approximately 20 new, domestic NIOSH-approval holders. Also, there are now more than 6,400 total respirator models or configurations on the NIOSH-certified equipment list that have met NIOSH-approved EUA criteria and thus are FDA authorized. These include

• More than 600 filtering facepiece respirator (FFR) models, of which there are more than 530 N95 FFR models
• More than 5,500 elastomeric respirator configurations, including new elastomeric respirators without an exhalation valve
• More than 360 powered air purifying respirator configurations

The FDA’s EUA revocation of all non-NIOSH-approved disposable FFRs follows earlier actions to limit authorization of imports of non-NIOSH-approved FFR respirators, imports of non-NIOSH-approved FFRs manufactured in China, and decontamination and bioburden reduction systems for disposable respirators, the FDA said.

The FDA said it also has withdrawn two related decontamination and bioburden reduction guidance documents:

• Recommendations for Sponsors Requesting EUAs for Decontamination and Bioburden Reduction Systems for Face Masks and Respirators During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency: Guidance for Industry and Food and Drug Administration Staff
• Enforcement Policy for Bioburden Reduction Systems Using Dry Heat to Support Single-User Reuse of Certain Filtering Facepiece Respirators During the Coronavirus Disease (2019) Public Health Emergency

The FDA recommends that healthcare personnel transition from extended use of disposable respirators to single-use for single-patient interactions as appropriate.

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Many common dental procedures have very low risk for increasing the aerosol spread of COVID-19, according to the University of Bristol, while some procedures such as ultrasonic scaling did not generate any aerosol other than from the clean instrument itself.

Conducted by the University of Bristol, University Hospitals Bristol, the Weston NHS Foundation Trust, and the North Bristol NHS Trust, the study is the largest to date to specifically measure aerosol generation from dental instruments in real-patient clinical scenarios, the researchers said.

As part of the AERosolisation and Transmission of SARS-CoV-2 in Healthcare Settings (AERATOR) study, the research aimed to measure the amount of aerosol produced by a range of dental procedures caried out on patients.

Where aerosol was detected in patient procedures, the researchers compared the size distributions of the aerosol to the aerosol produced by the dental instrument itself when used in a non-patient phantom head control.

The study found that ultrasonic instruments commonly used for dental scaling produced much lower aerosol concentrations than the high-speed dental drill despite both instruments requiring the same precautions.

Also, aerosol produced during ultrasonic scaling was consistent with the clean aerosol produced by the instrument itself and did not show that additional aerosol is produced that could potentially spread COVID-19.

“Our study confirms much of the guidance around dental procedures deemed as low risk of spreading COVID-19 is correct but suggests that the ultrasonic instrument could be seen as lower risk than it currently is,” said joint first author Tom Dudding, BDS, a restorative dentistry specialty trainee at the Bristol Dental School.

“Our findings could allow the expansion of dental, hygiene, and therapy work as it would reduce the need for additional precautions such as additional personal protective equipment and fallow times when using this instrument,” Dudding said.

“Our study provides strong evidence to confirm many of the common dental procedures have very low risk of increasing the aerosol spread of COVID-19,” said Mark Gormley, BDS, consultant senior lecturer at the Bristol Dental School and joint senior author.

“We also found that some other procedures, such as ultrasonic scaling, do not appear to generate additional aerosol above that of the instrument itself and do not increase the risk to dentists relative to the risk of being near the patient,” Gormley said.

For procedures such as the high-speed and slow-speed drilling commonly used for dental fillings, crown preparations, and polishing, the researchers said, the next step would be to repeat these experiments with instruments that can further differentiate between aerosol produced by the dental instrument and aerosol that has been contaminated by bodily fluids such as saliva, the researchers said. If no contaminated aerosol is identified, these instruments also would be safe for use without additional precautions, the researchers said.

The researchers also will consider conducting a non-inferiority, randomized controlled trial of additional precautions such as personal protective equipment and fallow time versus pre-pandemic precautions in dental practices, they said. The study would look at the difference in infection rates in patients and dental staff across the two groups with no difference demonstrating the additional precautions are not needed.

The study, “A Clinical Observational Analysis of Aerosol Emissions from Dental Procedures,” was published by medRxiv.

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OSHA recently issued a 900-page emergency temporary standard for healthcare settings, but the ADA said dental practices are largely exempt from these new guidelines. What are dental practices supposed to do now? Linda Harvey, founder of the Dental Compliance Institute, discusses the new guidelines as well as how to survive an audit if OSHA ever visits your office.

The combined use of a high-volume evacuator (HVE) with an intraoral suction device significantly reduces the amount of microbial aerosols generated during dental cleanings, according to the Loma Linda University (LLU) School of Dentistry, improving safety for patients and dental professionals alike.

Researchers at the school found a threefold reduction in microbial aerosols with the simultaneous use of an HVE plus an additional suction device placed in a patient’s mouth compared to using an HVE only.

The spread of COVID-19 and expanding understanding about its routes of transmission, including airborne respiratory droplets, sparked the researchers’ determination to investigate aerosol dispersion during dental procedures, said Montry S. Suprono, DDS, MSD, director of the LLU Center for Dental Research and the study’s principal investigator.

“Once organizations like the WHO and CDC released reports describing the virus’s modes of transmission, we quickly understood how dentistry would be affected because a number of dental procedures generate aerosols,” said Suprono. “So, we wanted to figure out ways to minimize the risks by decreasing the amount of aerosols that are generated during dental procedures.”

The clinical trial involved more than 90 dental student participants who served as operators and patients at the LLU dental clinic. The researchers collected aerosol samples by placing blood agar plates, which are dishes intended to collect the aerosols, in various zones throughout the clinic such as shelves and patients’ chests for intervals of time before, during, and after dental cleanings.

The procedures were conducted using a split-mouth design. Operators used both the HVE and intraoral suction device on one side of the patient’s mouth during one round of the cleaning and then only the HVE on the other side of the patient’s mouth for the other round. After collecting the aerosols in the various agar plates, samples were incubated for two days, and microbial levels of each sample were measured.

The highest microbial counts came from the plates positioned on patients in the operating zone compared to plates placed on mobile trays and shelves farther away. Also, microbial levels during procedures were highest compared to pre-treatment and post-treatment levels. And compared to using the HVE alone, the combination of the HVE and an intraoral suction device significantly reduced the amount of microbial aerosols generated.

Furthermore, microbial levels before procedures were similar to microbial levels after procedures, meaning that a 30-minute time interval for air change and for the aerosols to settle down on surfaces post-procedure appears to be adequate, the researchers said.

“We now know dental professionals should allow for aerosols to settle for some time before sanitizing the treatment area and that the risk between patients is minimal if time is allowed,” Suprono said.

Suprono hopes the research will inform and guide best clinical practices to enhance safety and hygiene during dental cleanings. There also remains ample opportunity to consider other types of dental procedures or equipment in evaluating aerosol generating, he said. Understanding aerosol dynamics through computerized simulations and modeling constitutes another rapidly developing area of research as well, he added.

The researchers will continue studying personal protective equipment, aerosols, and air quality as it pertains to dental practice, Suprono said.

“These kinds of inquiries and research are critical to evaluate how dentistry currently works now and how it could evolve in the future with the goal of improving the safety for our patients and dental professionals,” said Suprono.’

The study, “A Clinical Investigation of Dental Evacuation Systems in Reducing Aerosols,” was published by the Journal of the American Dental Association.

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Dental practice changed forever last year, distinguishing aerosol-generating procedures (AGPs) from non-AGPs, while adding air quality controls to concerns about our day-to-day operations. It won’t go back, ever!

Now that COVID-19 cases are declining in most areas, determining the right kind of respiratory protection program for you and your patients is essential in your practice. But it takes some sleuthing. We have a few clues and partial answers.

The Centers for Disease Control and Prevention (CDC) issues guidance that includes words such as “must,” “should,” and “may,” based on science. So, I will use these words since I know them so well. 

What exactly is mandated? Nothing yet. Whew!

But we got a clue when the Occupational Safety and Health Administration (OSHA) issued seven violations to a Masschusetts dental practice, including failing to provide fit testing for N95 masks to employees last September, among other infractions. OSHA has largely exempted dentistry from its emergency temporary standard, but not from every office having a written plan.

Best Practices for Masks

N95 masks should be the minimum standard for dental personnel in patient care for most dental procedures until more science definitively states otherwise.

Since OSHA issues its final guidance consistent with the CDC, and the CDC hasn’t updated its infection control guidance for dental settings since December 2020, look for the CDC’s recommendations first, and then OSHA’s. I always hated those unpredictable CDC clearance processes, with last minute (but usually correct) input from infectious disease physicians.

Let’s talk about guidelines for clinicians’ masks:

• When “must” we implement a respiratory protection program? Answer: Always!
• When “should” we use an N95 mask? Answer: Nearly always for all procedures, except exams.
• What about using powered air-purifying respirators or elastomeric masks? Answer: You “may” use them sometimes during AGPs.

The bottom line is that you “must” match your mask to what you are doing. That’s clear.

What about patient mask compliance? Should patients wear masks into the office, even if they are vaccinated? Yes, keep doing that for now, until further word from the CDC. Even though patients are likely to be fully vaccinated, with 45.3% of the United States population fully vaccinated as of this writing, patients “may” opt for masks.

Encourage patients to use masks temporarily. With the B.1.617.2 delta variant of SARS-CoV-2 circulating in the United States, it’s a good idea. While delta variants represent only a tiny fraction of virus in the United States now, partially vaccinated patients and unvaccinated patients “must” be wearing masks since they are likely to be unprotected from it and, possibly, from any other variants that may emerge worldwide.

What’s more, masks “must” be worn by patients with disabilities, compromised immune systems, or allergies to vaccines. And if delta or other emergent variants start to pose greater challenges even for some fully vaccinated people, then perhaps they, too, “may” prudently wear masks temporarily, depending on whether their local health departments say community transmission in their county is high or moderate.  

The Risks of AGPs

How do we characterize AGPs? Well, that is the big question. Without more science, we still don’t know with COVID-19. But we know enough about other respiratory diseases that we “should” have been wearing N95 masks long ago because of measles, tuberculosis, MERS, SARS-1, and seasonal influenza.

Oh well. Coulda, woulda, shoulda. The CDC didn’t let me say it then, but probably will now. For example, in 1986, my CDC colleagues noted that children in a pediatric office transmitted measles at distances of 10 feet or more.

By the way, measles is on the rise in the United States because of the antivax movement over the last 20 years. In the 1990s, tuberculosis transmitted easily among airplane passengers meant that a dental office was vulnerable. If that isn’t enough, SARS and MERS reinforced the need for masks in dental practice for respiratory protection in the 2000s.     

Measurement of AGPs is critical. While a recent article in Lancet suggested getting rid of the term AGPs, I disagree. Rather, like most oral health problems, we need a refined measurement or surveillance system to measure AGPs for different dental procedures and in different offices.

We need our interdisciplinary colleagues in environmental microbiologists, air laboratorians at the National Institute for Occupational Safety and Health (NIOSH), statistical modelers, and trusty heating and air-conditioning personnel as well as lots of proper air samples of different dental procedures.

Dental offices “should”  probably have six room air exchanges per hour in operatories, like a regular hospital or healthcare room at least. Until more science is available. Add to this the need for improved ventilation and air de-densifying.

Why do we need to take these precautions? Because even though the ADA is reporting low rates of infection, there is selection bias by dentists of sampling with wide variability in community transmission, based on variations in reporting from local and state health departments. 

For example, last year, Meng et al. reported from a Chinese dental school that eight of 169 dental personnel were infected, which is about a 5% infection rate, while the community transmission was about twice that.  

Better science about the risks for dentists to be infected with COVID-19 comes from the United Kingdom. The Journal of Dental Research study, as opposed to ADA data, showed higher rates of infection among dental personnel, or three times the general population. This study also found that about 35% of Black and 19% of Asian dental professionals, versus 14.3% of White dental professionals, were infected with COVID-19.

What measures might be important for assessing the output of AGPs? Data shows that the size, speed, measurement, humidity, viral or bacterial load of the patient, centrifugal force of a 200,000-rpm electric or 400,000-rpm air turbine handpiece, how the operators position their evacuation systems, and which quadrant they are working in all matter. However, prior studies have shown that while the virus may be present, the volume of the virus might not be enough to spread disease.  

What should we do now, while the science is emerging? Let’s begin to think about aerosols like “smoke” and droplets like “rain,” and let’s get to a place where we start to measure the output of AGPs of different dental procedures with personal and environmental samples. (Where have you been, NIOSH and National Instititute of Dental and Craniofacial Research?) And then there are models in which aerosols (or smoke) may transmit more infections after masking and social distancing are in place. 

Finally, we need a panel at the CDC for building the bridge between infectious and chronic diseases. Really. We must!

Along with vaccination, pandemic preparedness, and response, dentists “must” be included in infectious disease testing and in health department surveillance. We could with electronic records, and by doing so we could add to known community surveillance tools and studies. Let’s start with pilots now so we aren’t settling back into complacency until the next pandemic. Which is coming. When? We don’t know, but it will. 

Remember, as dentists, we know we are always the first to get those cancelled appointments because of flu in the fall! And don’t forget to include teledentistry in your practice, now, to accommodate the new realities with patients, as well as any other pandemic or infectious disease that “may” come along.

Dr. Scarlett is an infectious and chronic disease prevention specialist, practicing dentist, speaker, author, and consultant. For 30 years, she has provided expert guidance on infectious diseases and infection control as a consultant to the CDC, the World Health Organization, the Pan American Health Organization, the United States Agency for International Development, the American Red Cross, and many consumer health companies. She is a member of the ADA Working Group on Teledentistry and also provides a variety of strategic consulting services for dental companies and associations, including strategic planning, organizational design and development, technical and white papers, new product development and testing, and leadership for dental advisory committees. She can be reached at mscarlett@scarlettconsulting.com and (404) 808-­9980.

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It’s Dentistry Today‘s 40th anniversary, and we’re interviewing 40 of the profession’s most influential leaders. Today we’re speaking with Dr. Manor Haas, one of our most popular and prolific authors. A specialist in private practice in endodontics and microsurgery, Dr. Haas also is a lecturer and clinical instructor with the University of Toronto Faculty of Dentistry Department of Graduate and Undergraduate Endodontics. He provides direct patient care and specialized training in pediatric training at Toronto’s Hospital for Sick Children.

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It has been a year since face-to-face dental care has resumed in England, prompting the British Dental Association (BDA) to ask the four chief dental officers (CDOs) to commission the Scottish Dental Clinical Effectiveness Programme (SDCEP) to develop a roadmap for the safe relaxation of current restrictions currently limiting access to dentistry across the United Kingdom.

UK practices are continuing to operate at a fraction of their pre-pandemic capacity to meet infection prevention and control (IPC) guidance, with an estimated 30 million appointments lost since March 2020 in England alone, the BDA said.

In a message to the CDOs of England, Wales, Scotland, and Northern Ireland, the BDA said that SDCEP is now best placed to review any new scientific literature, assess the wider prevailing conditions, and produce recommendations for IPC de-escalation founded on the best available evidence while accounting for expert views of a safe yet pragmatic way to move forward.

The BDA said this review should include but not be limited to community infection, transmission, and vaccination rates, as well as the threat posed by emerging variants of SARS-CoV-2.

Also, this review should include the relevance of aerosol-generating procedures to COVID-19 transmission. Evidence is accumulating that infective aerosols arise principally from coughing by COVID-19 patients, the BDA said, with medical interventions posting a relatively low risk. This suggests that high-level personal protective equipment might not be necessary in dentistry except for the treatment of patients known or considered likely to be infected with SARS-CoV-2.

The review additionally should consider the range and impact of international dental standard operating procedures (SOPs), the BDA said. Cochrane compared dental guidance from around the world in May 202, but the pandemic has progressed since this publication, and IPC practices will have evolved. More information should now be available on any transmission of COVID-19 linked to dental settings, the BDA said.

The impact on poor oral health and inequalities should be reviewed as well, the BDA said, including the impact of limited access to care, the suspension of dental public health programs, poor lockdown diets, and altered oral hygiene habits. The BDA expects the demand for dental services and the number of high-needs patients to be greater than before March 2020.

Further, the BDA said the review should note missed or delayed diagnoses of oral cancers across all of the nations in the United Kingdom as a result of reduced access to dental services.

Dental antibiotic prescribing also remains elevated relative to 2019 levels, the BDA said. Timely access to urgent dental care, which currently is impeded by IPC requirements, is essential for dentistry to play its part in averting a further global health disaster due to antimicrobial resistance, the BDA said.

Noting the impact of the current IPC requirements on the dental workforce, the BDA noted that 47% of dentists in England are likely to leave the profession in the next year if existing SOPs remain in place, with a similar proportion intending to reduce their National Health Service commitment. Such an exodus would have a devastating and long-lasting impact on already inadequate levels of access, the BDA said.

Finally, the BDA said, the review should consider patient triaging and waiting arrangements, which affect patient flow and capacity.

The BDA said it has underlined the need for clear and consistent guidelines and public communications alongside practical support to underpin a safe de-escalation of IPC requirements across dentistry.

“It’s a year since face-to-face care resumed in England, but the restrictions we work to remain largely unchanged. So today we have asked all four UK chief dental officers to begin work on a roadmap to ease restrictions,” said BDA chair Eddie Crouch.

“The risk we face today from the virus needs to be balanced against the millions unable to access care, and threats to the very sustainability of this service,” said Crouch. “It is time to let the experts weigh up the risk of COVID transmission with the dangers of prolonging the status quo. We know this issue is already high on the official agenda, but patients and the profession deserve clarity on the way ahead.”

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