Creating Clean Air in Dental Offices
Top Strategies To Capture Aerosols and Splatter in Dentistry, Helping Keep the Air Healthy In a Dental Office
This article is written as a part of the Nebraska Family Dentistry Wellness Program with the goal of keeping our team members, dentists and patients safe from the coronavirus and other pathogens. At Nebraska Family Dentistry Locations we have implemented most of the steps described in this article.
Benefits of Reducing Aerosols and Splatter in Dentistry to Create Clean Air Quality in Dental Offices:
Due to the recent health threat and the possibility of contracting a potentially life-threatening virus we all know as COVID-19, many dental professionals are looking at ways they can reduce aerosols and splatter in dentistry and provide clean air quality in dental offices.
Creating clean air quality in dental offices is not possible solely with the use of high suction and a central air conditioning system. Using high suction devices and having a great air conditioning system with good HEPA filters will reduce the amounts of harmful pathogens in the dental office. Due to our unforeseen circumstances, it’s not enough to truly create clean air.
Common pathogens that dental professionals are exposed to include:
- Mercury vapor
- Polishing materials debris
- Cleaning chemicals
What are the top products for reducing aerosols and splatter in dentistry to aid in creating clean air quality in dental offices?
Today, a group of products and tactics can be used together to help minimize the number of aerosols in the dental office and reduce the clinicians’ exposure to aerosols. Although there isn’t just one measure by itself that will fully resolve the problem, all of these precautions used in combination with one another can substantially lower risk levels.
So, what are these tactics that dental clinicians can implement to help improve the management of aerosols in their offices and create clean air quality in dental offices?
10 products and tactics used to capture aerosols and splatter in dentistry to create clean air quality in dental offices are:
- Servicing and updating the existing building’s heating, ventilation, and air conditioning (HVAC) system.
- Negative Pressure Room, Installing commercial-grade exhaust fans.
- Air scrubber.
- ERV system (energy recovery ventilator).
- Freestanding, commercial-grade air purification systems.
- HVE and the use of the HVE System for hygiene procedures.
- Use of a rubber dam.
- Use of an Isolite.
- Hydrogen peroxide or iodine rinse before any treatment or exam thereby decreasing loads of pathogens coming from patients’ mouths.
- Use of high Filtration, N95 masks.
#1. Servicing and Updating the Existing Building’s Heating, Ventilation, and Air Conditioning (HVAC) System
Dental teams may believe that they are protected from airborne contaminants and pathogens through a building’s heating, ventilation, and air conditioning (HVAC) system. In reality, air conditioning systems recirculate air, bacteria, viruses, and many other airborne particles. It is essential to service your HVAC system to ensure that it works properly and to its fullest capacity. It is also just as important to use high-quality filters and to replace them regularly. Do note, just using an HVAC system is not enough to provide clean air quality in dental offices and prevent the recirculation of potential pathogens.
#2. Creating Negative Pressure Rooms by Installing Commercial Grade Exhaust Fans to Help Create Clean Air Quality in Dental Offices
Negative pressure is maintained and generated by a ventilation system that takes more air out of a room than is what is allowed to enter. For example, if 400 cubic meters of air enters the room, but 900 cubic meters of air leaves the room, more air is leaving the room than coming in. Therefore, by definition, this would be considered a negative pressure room.
Watch How We Created Rooms with Negative Pressure at Our Dental Offices to Help Promote Clean Air Quality in Dental Offices
Q: Does having a negative pressure room help decrease aerosols caused by aerosol producing procedures?
Yes it does.
Q: How do you create a room with negative pressure to help improve air quality in dental offices?
In this case, you can create a negative pressure room by installing a commercial-grade exhaust fan from your local electrical/plumbing company. By adding one, the amount of air that is removed will be greater than the amount of air that enters the room.
Q: Do you need a separate room with a door in order to create negative pressure?
Not necessarily. Technically, you can create a room with negative pressure by adding an air system that would remove more air than the amount of air entering the room.
#3 Air Scrubbers
An air scrubber can be installed as part of your office’s central heating and cooling system. It uses germicidal UV light waves coupled with a catalytic process to attack germs and other particles while still in the air or on surfaces like doorknobs and countertops. Nothing is 100% effective, but air scrubber technology can aid significantly in creating clean air for your office at a reasonable price. The price in Lincoln, NE, for adding an air scrubber is about $800 per office.
Some models can eliminate up to 90% of airborne microorganisms, as well as 99% of surface microorganisms, including black mold, staph, and MRSA. They work by using UV light and sanitizing the air from general office circulation. After desensitizing, the air comes out of the general circulation air system charged, and could almost be compared to having similar properties of hydrogen peroxide. This air, in a way, helps control microorganisms on different surfaces at the office. By helping rid your office of a wide variety of germs and allergens, air scrubbers can help reduce exposure to aerosols, too.
The timing of how fast the air can be cleaned can be calculated by how many cubic feet of air is moved through an air conditioning system. The best way to find out is to measure your office and to know your air conditioner system’s specifications.
Q: Which brand of air scrubber do our dentists prefer ?
ActivePure® is the only Certified Space Technology that was created in cooperation with NASA to protect the health of astronauts onboard the International Space Station.
#4. ERV System (Energy Recovery Ventilator)
What is an ERV system? An ERV (Energy Recovery Ventilator) allows fresh air into a building while retaining pre-conditioned cooling or heating. If the outside temperature is 0ºF, and the indoor air temperature is 70ºF, your HVAC unit must heat the mixture of outside air and the building’s return air to maintain an indoor building temperature of 70ºF. This is similar to your lungs as they can bring cold air in and make it warm. ERVs bring in new air and make it less humid, less hot, or less cold. An ERV brings in more outside air and makes it more accustomed to our liking by changing the temperature or humidity. An ERV doesn’t clean or detox the air, so if you live in a city with pollution, an ERV will bring more air in, but you will also need an air scrubber to help clean it.
To conclude, not every dental office needs to have this system installed. Rather, this option is a way to bring more air into the dental office if desired to do so.
#5. Stand alone Air Purification Machine or APM
A standard air purification machine (APM) can play a significant role in reducing the transmittable bio-aerosols. The placement of APMs should be close to patients while performing aerosol producing procedures.
There are multiple options available to the dental industry to aid in cleaning the indoor air. Furthermore, when choosing a solution, be mindful of these criteria:
- Filtration System – The filtration and the quality of the filters used. How long do they last?
- Air Flow Capacity – Consider the cubic feet per minute (CFM). Make sure that the system can help efficiently clean the air in the room fast enough.
- Sound Level – Air moving through an APM will generate sound. An APM that creates too much sound will have a negative effect on those working near it.
Q: Which APM did we choose for Nebraska Family Dentistry locations?
After researching APM options, we purchased IQAir ProHealth Plus for our home and dental offices. We chose this APM to help remove harmful pathogens from the air.
#6. HVE and the Use of HVE Systems for Hygiene Procedures
High velocity evacuation, or HVE, used during all procedures, has made researchers aware of the potential effectiveness. HVE is effective in the control of aerosols when appropriately used. Some tests show a 95% reduction in aerosols with the use of HVE alone. Likewise, it is as effective when adjusted at optimal velocity and when positioned close to the operating site.
Can you capture 100 % of aerosols and splatter using HVE? Can the use of HVE prevent aerosols when multiple providers work at the office at the same time?
We looked at a few studies to find the answers:
Study #1: Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. STEPHEN K. HARREL and JOHN MOLINARI J Am Dent Assoc 2004;135;429-437)
Conclusion of this study: HVEs do not work well if used separately from a HVE suction tip.
Study #2: Efficacy of High-volume Evacuator in Aerosol Reduction: Truth or Myth? A Clinical and Microbiological Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206761/
Conclusion of this study: The conclusion of the study is that to work properly, the placement of HVE devices should be approximately 6-15 mm away from the active ultrasonic tip or air polisher.
According to those studies, HVE works only when used properly. Consequently, it is easier to do so for dentists while working with a dental assistant. What about hygienists and collecting aerosols while they use ultrasonic instruments?
At Nebraska Family Dentistry we use Ivory ReLeaf. The system is an innovative, hands-free HVE suction device that conveniently connects to existing dental vacuum systems. ReLeaf assists with evacuation, retraction and maintaining a dry field during various dental and hygiene procedures, ultimately helping improve air quality in dental offices.
The answer about HVE’s efficiency: By using HVE properly and using in conjunction with the Ivory ReLeaf system, the amounts of aerosols/ splatter can be dramatically reduced and making the air to be clean and free of pathogens.
#7. Use of a Rubber Dam
A rubber dam isolates the teeth that need to be treated from the saliva, soft tissues, and tongue of the oral cavity. Isolation with a rubber dam will reduce the number of microorganisms in the aerosols generated during treatment. This is in addition to the value of rubber dams in providing a dry area and increased access for visibility when performing restorative work.
#8. Use of an Isolite
The use of an Isolite, from Zyris systems, is a versatile clinical option for practices that want state-of-the-art dental isolation advantage and an ability to catch aerosols without using a rubber dam. We have incorporated an Isolite system in every operatory of every one of our Nebraska Family Dentistry locations.
Isolite(R) Systems, Inc., from Zyris, is the industry leader in dental isolation technology. The newest member of the Isolite product line – the Isovac(TM) Dental Isolation Adapter, connects Isolite system to HVE.
#9 Hydrogen Peroxide or Iodine Rinse Prior to Any Treatment or Exam Decreasing the Loads of Pathogens in Patients’ Mouths
The best mouthwash to kill coronavirus?
The answer is not clear yet. But, an antimicrobial mouth rinse is thought to reduce the number of oral microbes. Listerine, commonly used as a mouth rinse, may not be effective in killing coronavirus. Additionally, since coronavirus is vulnerable to oxidation, any mouth rinse containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone is recommended to reduce the salivary load of oral microbes, including potential coronavirus.
#10. Use of N95 Masks
Q: How Big Are Coronavirus Particles and Can N95 masks protect?
Scientists have used electron microscopes to measure how big the coronavirus is. Coronavirus particles (fancy scientific name “virions”) are spheres with diameters of approximately 0.125 microns (125 nm). The smallest particles are 0.06 microns, and the largest is 0.14 microns.
Q: Do N95 masks provide a 95% protection level against airborne viruses, and are they more efficient than traditional surgical masks?
Answer: The results indicate that the penetration of particles, like virions, through the NIOSH-certified N95 masks (National Institute for Occupational Safety and Health), is significantly less than with surgical masks.
An N95 FFR is a type of mask which removes particles from the air breathed through it. These masks or respirators filter out at least 95% of very small (0.3 micron) particles. N95 FFRs are capable of filtering out all types of particles, including bacteria and viruses.
Q: What is the main difference between N95 and surgical masks?
Answer: The fit of the mask is a major difference. Masks, especially N95 masks, should fit tightly while surgical masks do not provide a tight enough fit thereby allowing aerosols to sneak underneath.
N95 masks reduce the wearer’s exposure to airborne particles, from small particle aerosols to large droplets. N95 respirators are tight-fitting respirators that filter out at least 95% of particles in the air, including large and small particles.
When properly fitted and worn, minimal leakage occurs around edges of the respirator when the user inhales. This means almost all of the air is directed through the filter media.
Certainly, some surgical masks may let a significant portion of airborne viruses penetrate their filters, providing a meager amount of protection against aerosolized infectious agents when speaking in the size range of 10 to 80 nm. Therefore, it should also be noted that surgical masks are primarily designed to protect the environment from those wearing the masks. Respirators are supposed to protect the wearer from the environment.
All in all, the N95 masks do provide a level of protection that a standard mask does not offer.
You can learn more about masks and their differences:
Centers for Disease Control and Prevention. N95 Respirators and Surgical Masks. https://blogs.cdc.gov/niosh-science-blog/2009/10/14/n95/ Accessed 4/1/20.
Conclusion about Controlling Aerosols and Splatter in Dentistry:
Aerosols and splatter generated during dental procedures have the potential to spread the infection to dental personnel and others in the dental office. As with all infection control procedures, it is possible to minimize the risk with the methods described in this article.
Applying high infection control standards are critical while applying techniques for creating clean air quality in dental offices. Combining high infection control standards coupled with the methods for creating clean air, the design of all Nebraska Family Dentistry offices helps keep team members, dentists and patients remain healthy and well.
This article was written by Dr. Kathryn Alderman, a biological dentist, mercury-free dentist in the Lincoln, NE area serving patients at various locations throughout the community.
Dr. Alderman has extensive training in biochemistry and is passionate about helping patients live healthier, happier lives. This Lincoln, NE dentist knows that having a healthy mouth can greatly impact a person’s overall well-being. Learn more about biological dentistry here.
You can schedule with this Lincoln, NE dentist, or her partners, online 24/7 at a Nebraska Family Dentistry Location near you. This “dentist near me” serves the local communities close to Lincoln. Some of the communities include Waverly, Davey, Raymond, Garland, Ceresco, Greenwood, and Malcolm, Roca, Bennet, Firth, Crete, Hickman, and many more!
If you have questions or would like to start a wellness program in your dental office, please email us at firstname.lastname@example.org
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