Minimizing the aerosol-generating procedures in orthodontics in the era of a pandemic: Current evidence on the reduction of hazardous effects for the treatment team and patients

Abstract

The purpose of this critical review is to list the sources of aerosol production during orthodontic standard procedure, analyze the constituent components of aerosol and their dependency on modes of grinding, the presence of water and type of bur, and suggest a method to minimize the quantity and detrimental characteristics of the particles comprising the solid matter of aerosol. Minimization of water-spray syringe utilization for rinsing is suggested on bonding related procedures, while temporal conditions as represented by seasonal epidemics should be considered for the decision of intervention scheme provided as a preprocedural mouth rinse, in an attempt to reduce the load of aerosolized pathogens. In normal conditions, chlorhexidine 0.2%, preferably under elevated temperature state should be prioritized for reducing bacterial counts. In the presence of oxidation vulnerable viruses within the community, substitute strategies might be represented by the use of povidone iodine 0.2%-1%, or hydrogen peroxide 1%. After debonding, extensive material grinding, as well as aligner related attachment clean-up, should involve the use of carbide tungsten burs under water cooling conditions for cutting efficiency enhancement, duration restriction of the procedure, as well as reduction of aerosolized nanoparticles. In this respect, selection strategies of malocclusions eligible for aligner treatment should be reconsidered and future perspectives may entail careful and more restricted utilization of attachment grips. For more limited clean-up procedures, such as grinding of minimal amounts of adhesive remnants, or individualized bracket debonding in the course of treatment, hand-instruments for remnant removal might well represent an effective strategy. Efforts to minimize the use of rotary instrumentation in orthodontic settings might also lead the way for future solutions. Measures of self-protection for the treatment team should never be neglected. Dressing gowns and facemasks with filter protection layers, appropriate ventilation and fresh air flow within the operating room comprise significant links to the overall picture of practice management. Risk management considerations should be constant, but also updated as new material applications come into play, while being grounded on the best available evidence.

Fig 1

Etching agents with variable viscosity. Note the considerably lower viscosity of the green-colored agent, resembling a liquid etchant state. The green, blue (right side) and red agents should be preferred over the first 2, because they would require less water pressure to be rinsed away.

Fig 2

Network map geometry for competing interventions with regard to bacterial load reduction in produced aerosol within dental settings. Size of the node is analogous to the contribution of the sample size for each intervention overall and width of edge to the number of direct comparisons. HVE, high volume evacuator; ClO₂, chloride dioxide; HRB, herbal; CPC, cetylpiridinium chloride; OZ, ozone.

Fig 3

Tooth enamel and composite remnants after bracket debonding: A, cohesive resin fracture with reduced amounts of remnants; B, Adhesive fracture at the bracket base mesh–adhesive interface leaving excessive composite remnants (bracket base mesh impression is evident on the adhesive surface).