Biohazard Aerosols, Airborne Particles, and Splatter
The following information I have present to the dental profession for many years. I have revised the contents to accommodate changes based on current issues and developments.
Please keep in mind, the information is my recommendation for establishing a higher standard when dealing with biohazard aerosols, airborne particles, and splatter contaminates; however you can build on what I have outlined and by all means, please do.
FYI, government regulations are minimum requirements. It is the responsibility of management and staff to do what is needed to mitigate risk in your specific work environment. Following precisely the word of regulations, you are doing the minimum and not your best work.
Many dental procedures produce biohazard aerosols, airborne particles, and splatter contaminates. Hygienist produces a higher volume of biohazard aerosols, airborne particles and splatter contaminate than a dentist. Biohazard aerosols, airborne particles, and splatter contaminate forms two types of contamination sources, direct and indirect.
Direct source, meaning directly from the patient as the procedure is performed. Indirect meaning items, instruments, and surfaces, etc. after the procedure is completed. The latter is known as OPIM or “other potentially infected material.”
From this point on, I will be using the word “contaminants,” which is referring to biohazard aerosols, airborne particles, and splatter contaminates.
Primary Protection (Protection from Direct Source)
Reducing contaminants from the direct source, the patient’s mouth is crucial. This step requires a complete understanding of how air contaminants act. Every surface that comes in contact with the patient’s contaminants is now considered OPIM. So a lot of thought must go into knowing what works and what doesn’t work in reducing direct source contamination. Do not take this step lightly, mitigating contaminants at the direct source is primary protection. Procedures involving the following equipment produce direct source contaminants,
- Ultrasonic Scaler
- Piezoelectric Scaler
- Dental Lasers (laser smoke plumes)
The following are three methods for reducing direct source contamination. I have listed the methods in order of effectiveness, the best listed first. However, one method will not be sufficient. It will take a combination of the methods to reduce direct source contamination effectively.
Reduction by Suction. The mindset is in a procedure that produces contaminants; suction should never leave the mouth but be continuously repositioned to trap and remove the contaminants. You need to research various suction techniques that have developed over time, which are used to reduce contaminants in procedures. Try to incorporate as many techniques as you can and train staff until the techniques are a substantial skill. Do not underestimate the importance proper suction techniques can play in mitigating direct source contaminants; it can make a difference as night and day. The concept is to capture the aerosol risk while in the mouth, close to the generation point. Doing so with skill, the risk can be 99.99% eliminated!
Reduction by Systems. Actively look into products that are available like the Isolite, Purevac HVE system, ADS Extraoral, Vaniman, Mr. Thirsty One Step Isolation, Blue Boa, and ReLeaf Hands-Free Dental Suction, to name just a few. Please consult with your dental supply representative for product information, samples, and option. I do not use patient treatment products, so I cannot recommend or provide my opinion; it’s not my lane.
Reduction by Pre-Rinsing. Pre-procedure rinsing should be considered an essential step in mitigating direct source contaminants. You should research the different available products, which can become a standard process with patient treatments. There has been a lot of studies recently about the importance of pre-procedure rinsing, and new products are in development. Consult with your dental supply representative for information, options, and recommendations.
Secondary Protection (Protection form Indirect Source)
Since biohazard aerosols, airborne particles, and splatter contaminates everything in its path, some items cannot be cleaned, disinfected, or even sterilized. Therefore I highly recommend the use of disposable PPE when possible. However, I need to stress the importance of fitting PPE to the wearer best as possible and not stay with the “one size fits all” concept.
Remember, disposable is just that, disposable. Which means it must be discarded after each patient use. PPE that becomes contaminated during a procedure is now OPIM. Using disposable PPE with multiple patients adds risk to the wearer and patients, so discard after use.
Surgical Cap – A disposable surgical cap should be worn when performing procedures that produce contaminates. Consult with your dental supply representative for information, styles, sizes, and options.
Eye Protection – Select eyewear based on proper fit and protection from exposure by fluids and aerosols. Trying eyewear on before purchasing is a must, so consult with your dental supply representative regarding fitting and returns policy.
Face Shield – I recommend wearing a face shield during procedures that produce contaminants. There are many sizes, styles, and materials of face shield available today. Size and fit should be kept in mind when selecting a face shield. It is best to try on face shields before purchasing. Ask your dental supply representative for their help in this.
Mask – I recommend a Level 3 surgical mask as a standard mask for dentistry, a laser mask when using a laser, and a surgical N95 mask for procedures that produce aerosol risk*. Also, when removing amalgam or working with high-risk situations. * if the aerosol risk is not eliminated or mitigated.
Always read the manufacture’s instructions on how to use the mask, fitting, and the limitations of the mask. Most masks have a permitted exposure limit (PEL) of one hour wear and are single patient use, therefor must be discarded after each patient.
FYI, as a mask is worn, it becomes saturated with contaminants, which converts the mask to OPIM. This alone is a good reason not to wear a used mask under your chin, place in a pocket, leave on a counter, or continuously touching the mask. Also as the mask is worn the integrity of the mask degrades losing the ability to protect the wearer.
Gloves – Quality gloves offer better protection. Always wash hands with soap and water before putting on gloves and right after taking off the gloves. Do not use hand sanitizers. Gloves are single-use, therefor discard the gloves once removed.
Gown – I recommend disposable gowns, lab coats, and alike. It is essential that the gown provides protection from fluid penetration and reasonably covers exposed areas of the body. So size and fit are crucial. Always read the manufacture’s instructions before using to learn about fitting and limitations. Consult with your dental supply representative for suggestions and options.
Treatment Rooms – Treatment rooms must be kept free of clutter at all times, stripped down as much as possible. When setting up a room for a procedure, only the items needed for the procedure should be out and covered to protect from contamination.
Another way to look at it, items in the room and on the counter is for the current patient procedure, all other items must be stored to prevent being contaminated. Covering up items with plastic does not guarantee it won’t be contaminated, especially when working with aerosol discharge. You must keep results in mind at all times; an attempt does not count as a result.
Surface Barriers – Place barriers on surfaces that are hard to disinfect. Because most barriers do not “seal-off” aerosol discharge, an attempt to disinfect the surface must be made after the barrier is removed. Remember, barriers in a contaminated treatment room are OPIM, handle, and dispose of accordingly.
Surface Disinfectants – Surface disinfectants are one of the top ten products that are misused in a dental office. Properly disinfecting contaminated surfaces (aka OPIM) is a skill. Knowing the manufacture’s instructions of the surface disinfectant being used along with the type of material being disinfected is critical and not an option. If results are not obtained, nothing has been gained!
Note: Until COVID-19 appears on the label of disinfectants the rule of thumb is to increase the maximum contact time to an additional 5 minutes and use a two-step wiping process, meaning wiping the surface to clean it and then use a second fresh wipe to disinfect.
Always treat patient body fluids, which include blood (not just red blood), salvia in a dental procedure, and OPIM as if it contains a highly infectious disease disregarding the health history of the patient.
Dental Office Air Purifiers – There are several air purifiers available today like Purealizer, Surgically Clean Air, Levoit to name a few. I recommend looking into the different products available and contact the companies local representative for information and recommendations. Remember, these systems are secondary protection and don’t replace the need to master primary protection.
Hand Hygiene – Hands make up for 68% of cross-contamination in a dental office. Washing hands to produce a decontaminated result takes knowledge, time, and skill. However, the hands must be prepared, meaning fingernails length must not be longer than the tips of the fingers. Nails must not be covered with artificial surfaces. Fingers and wrists must be free of all jewelry.
Using soap and water, lather the hands and work the lather on all surfaces of the hands and wrist for at least one minute. I know the CDC recommendation is 20 seconds minimum, but since most people do not use a timer when washing their hands, I say go for the one minute. If you fall short in time, it should be well above the CDC 20 seconds minimum. Drying hands is a very important step in the hand hygiene process. Make sure your hands are thoroughly dry.
Committing To Excellence In Employee and Patient Safety
As I mention, I have been talking for many years about biohazards aerosols, airborne particles, and splatter contaminates that are generated in dental procedures. Now is the time dental professionals take a look at what is working and what is not. Make the commitment to raise their own and the office’s standards in the area of employee and patient safety, because that is what Professionals do!
Be Safe, Be Healthy!