Tackling aerosols and splatter during dental treatments

Aerosols and splatter generated during dental treatments were identified as possible sources of COVID-19 infection. Dentists have had to therefore make significant amount of investments to adhere to COVID-19 safety norms, with no sign of recovering the same in the near future. Even so, Dr Aaditi Mahajan, Founder & MD, Loop Dental, Mumbai believes that prioritising the safety of family and staff over generating revenue, by attending to only emergency cases, stalling cosmetic dental treatments to a few months down the line, is a moral obligation in these COVID-19 times

COVID-19 just turned up out of the blue. This pandemic is a classic example of ‘a black swan’- an event which is unanticipated, falling outside the realm of the usual expectation, having widespread consequences. Since most dental practices were closed for two months in the lockdown period, this has been by far the longest career break of most health professionals. With incessant information and changing guidelines, an atmosphere of panic, confusion and uncertainty was present among the dental fraternity.

While dentists addressed certain patient issues via tele dentistry and home remedies were recommended, dental care is generally less feasible to online support than regular health care. Post the Unlock 1 phase, most dental practices have resumed their services, although it is like treading a treacherous road.

Embracing the post COVID-19 era

Change is ineluctable! As we face turbulent times of global pandemic, dental practices which are facing arduous times had to go through drastic modifications to cater to the current scenario. No dental training school could have foreseen a situation like this one. We needed to have a plan to ensure safe landing, a smooth workflow and to ‘build back better.’

Working with multiple layers of protective clothing, time consuming donning and doffing of PPEs, difficulty in breathing with masks, fogging of glasses and infrequent toilet break appears impossible to accomplish but with practice even this herculean task seems normal now.

We dentists have been maintaining adequate social distancing, wearing masks at all times and ensuring proper personal hygiene. In the Indian scenario, this might pose a challenge if we take into consideration the socio-economic status as most people live in shared accommodation with common washrooms, commuting habits and culture driven by close knit families. Despite our best intentions, it is difficult to follow these precautionary measures in good faith.

While we take all necessary measures like telephonic health screening, temperature check using infrared thermometer and oxygen saturation levels with a pulse oximeter, there is no infallible way to ascertain that the patients are not infected, as asymptomatic patients certainly pose a threat of cross infecting other patients, doctors and our staff.

The menace of aerosols and splatter

Off lately, aerosols and splatter generated during dental treatments have taken the spotlight. Almost all dental equipment such as airotors, ultrasonic and sonic devices like scalers, air water syringes used in common treatments generate aerosols. These aerosols (< 50 um in diameter) and splatter (>50 um in diameter) which contain bacteria, viruses, fungi remain suspended in the air for up to three hours. With time, they settle down on surfaces or are inhaled leading to cross infections in the dental clinic.

In an immune compromised individual, the spread of infection by aerosols and splatter is largely dependent on the presence of pathogen in the aerosol source, the type of pathogen, frequency of exposure, and the infectious dose.

Using a rubber dam, a high-vacuum suction system with a suction volume of at least 250-300 l/min and pre procedural mouth rinse (1% Hydrogen Peroxide/ 0.2% Povidone Iodine), wearing PPEs efficiently helps to curb the spread of this virus. Placing this rubber dam can be a daunting experience in the initial days of your practice; many of us have used it in college times and have sworn not to use it in the ‘real world.’ But once you get a knack of it, your work efficiency increases by multi folds.

In India, most clinics are concise where multiple chairs are not separated with partitions or barriers to prevent transmission of infection, where cross ventilation can be tricky, hence becoming more vulnerable to the spread of COVID-19.

Any surgical procedure or traumatic injuries may have a significant amount of blood in the oral cavity. This may induce a gag reflex if swallowed, which may lead to a splatter, hence it has to be evacuated immediately with high-volume suction.

The path ahead

While the pandemic is still on the growth curve, we as dentists are facing the darkest hour. Along with being at risk for contracting and transmitting the disease, we have had to make significant amount of investments to adhere to the safety norms, with no sign of recovering the same in the near future.

We want to see our patients smile despite the COVID-19 pandemic. However, patients are apprehensive to move out of their safety zone, so we make it a point to ensure highest levels of sanitisation and disinfection protocol which includes fumigation of the clinic and using sterile pouches for autoclaving. Our staff are well trained, and we try to ensure that they do not fall short of the benchmark set by us.

Apart from the evidence-based logic, we dentists also have a moral obligation not only towards our patients, but also to the staff and our families back home. I might call myself a dentist or an entrepreneur, but in these unprecedented times my focus is ONLY on emergency cases, stalling the cosmetic dental treatments to a few months down the line. As for dental procedures keeping distant appointments, one patient at a time policy, choosing treatments that provide favourable outcomes, ideally with fewer visits and with the minimum of aerosol-generating exposures, thus prioritising the safety of my family and staff over generating revenue.

Despite taking all the required precautions if a patient contracts the COVID-19 virus at the dental clinic, it can be an emotionally and monetary draining experience. To add to this, it might set back your practice to a few years, along with building a bad reputation. In this case one tends to wonder if resuming practice can be more damaging than few months of unemployment.

In the worst-case scenario, the virus will stay with us. We must acknowledge the blind faith our patients have instilled in us when they visit us to seek dental treatment. This places an onus on us to practice ethically and be transparent with our treatment planning and knowledge sharing. If we want to fight this pandemic, we must trash the taboo of COVID-19 and let go of the misconceptions and fear factor associated with this.

Change is constant; the one who adapts to this is here to stay!