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Meta-Analysis
. 2020 Oct 12;10(10):CD013686.
doi: 10.1002/14651858.CD013686.pub2.

Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases

Sumanth Kumbargere Nagraj  1 , Prashanti Eachempati  2 , Martha Paisi  3 , Mona Nasser  4 , Gowri Sivaramakrishnan  5 , Jos H Verbeek  6
Affiliations
Meta-Analysis

Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases

Sumanth Kumbargere Nagraj et al. Cochrane Database Syst Rev. .

Abstract

Background: Many dental procedures produce aerosols (droplets, droplet nuclei and splatter) that harbour various pathogenic micro-organisms and may pose a risk for the spread of infections between dentist and patient. The COVID-19 pandemic has led to greater concern about this risk.

Objectives: To assess the effectiveness of methods used during dental treatment procedures to minimize aerosol production and reduce or neutralize contamination in aerosols.

Search methods: Cochrane Oral Health's Information Specialist searched the following databases on 17 September 2020: Cochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2020, Issue 8), MEDLINE Ovid (from 1946); Embase Ovid (from 1980); the WHO COVID-19 Global literature on coronavirus disease; the US National Institutes of Health Trials Registry (ClinicalTrials.gov); and the Cochrane COVID-19 Study Register. We placed no restrictions on the language or date of publication.

Selection criteria: We included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) on aerosol-generating procedures (AGPs) performed by dental healthcare providers that evaluated methods to reduce contaminated aerosols in dental clinics (excluding preprocedural mouthrinses). The primary outcomes were incidence of infection in dental staff or patients, and reduction in volume and level of contaminated aerosols in the operative environment. The secondary outcomes were cost, accessibility and feasibility.

Data collection and analysis: Two review authors screened search results, extracted data from the included studies, assessed the risk of bias in the studies, and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random-effects meta-analysis to combine data. We assessed heterogeneity.

Main results: We included 16 studies with 425 participants aged 5 to 69 years. Eight studies had high risk of bias; eight had unclear risk of bias. No studies measured infection. All studies measured bacterial contamination using the surrogate outcome of colony-forming units (CFU). Two studies measured contamination per volume of air sampled at different distances from the patient's mouth, and 14 studies sampled particles on agar plates at specific distances from the patient's mouth. The results presented below should be interpreted with caution as the evidence is very low certainty due to heterogeneity, risk of bias, small sample sizes and wide confidence intervals. Moreover, we do not know the 'minimal clinically important difference' in CFU. High-volume evacuator Use of a high-volume evacuator (HVE) may reduce bacterial contamination in aerosols less than one foot (~ 30 cm) from a patient's mouth (MD -47.41, 95% CI -92.76 to -2.06; 3 RCTs, 122 participants (two studies had split-mouth design); very high heterogeneity I² = 95%), but not at longer distances (MD -1.00, -2.56 to 0.56; 1 RCT, 80 participants). One split-mouth RCT (six participants) found that HVE may not be more effective than conventional dental suction (saliva ejector or low-volume evacuator) at 40 cm (MD CFU -2.30, 95% CI -5.32 to 0.72) or 150 cm (MD -2.20, 95% CI -14.01 to 9.61). Dental isolation combination system One RCT (50 participants) found that there may be no difference in CFU between a combination system (Isolite) and a saliva ejector (low-volume evacuator) during AGPs (MD -0.31, 95% CI -0.82 to 0.20) or after AGPs (MD -0.35, -0.99 to 0.29). However, an 'n of 1' design study showed that the combination system may reduce CFU compared with rubber dam plus HVE (MD -125.20, 95% CI -174.02 to -76.38) or HVE (MD -109.30, 95% CI -153.01 to -65.59). Rubber dam One split-mouth RCT (10 participants) receiving dental treatment, found that there may be a reduction in CFU with rubber dam at one-metre (MD -16.20, 95% CI -19.36 to -13.04) and two-metre distance (MD -11.70, 95% CI -15.82 to -7.58). One RCT of 47 dental students found use of rubber dam may make no difference in CFU at the forehead (MD 0.98, 95% CI -0.73 to 2.70) and occipital region of the operator (MD 0.77, 95% CI -0.46 to 2.00). One split-mouth RCT (21 participants) found that rubber dam plus HVE may reduce CFU more than cotton roll plus HVE on the patient's chest (MD -251.00, 95% CI -267.95 to -234.05) and dental unit light (MD -12.70, 95% CI -12.85 to -12.55). Air cleaning systems One split-mouth CCT (two participants) used a local stand-alone air cleaning system (ACS), which may reduce aerosol contamination during cavity preparation (MD -66.70 CFU, 95% CI -120.15 to -13.25 per cubic metre) or ultrasonic scaling (MD -32.40, 95% CI - 51.55 to -13.25). Another CCT (50 participants) found that laminar flow in the dental clinic combined with a HEPA filter may reduce contamination approximately 76 cm from the floor (MD -483.56 CFU, 95% CI -550.02 to -417.10 per cubic feet per minute per patient) and 20 cm to 30 cm from the patient's mouth (MD -319.14 CFU, 95% CI - 385.60 to -252.68). Disinfectants ‒ antimicrobial coolants Two RCTs evaluated use of antimicrobial coolants during ultrasonic scaling. Compared with distilled water, coolant containing chlorhexidine (CHX), cinnamon extract coolant or povidone iodine may reduce CFU: CHX (MD -124.00, 95% CI -135.78 to -112.22; 20 participants), povidone iodine (MD -656.45, 95% CI -672.74 to -640.16; 40 participants), cinnamon (MD -644.55, 95% CI -668.70 to -620.40; 40 participants). CHX coolant may reduce CFU more than povidone iodine (MD -59.30, 95% CI -64.16 to -54.44; 20 participants), but not more than cinnamon extract (MD -11.90, 95% CI -35.88 to 12.08; 40 participants).

Authors' conclusions: We found no studies that evaluated disease transmission via aerosols in a dental setting; and no evidence about viral contamination in aerosols. All of the included studies measured bacterial contamination using colony-forming units. There appeared to be some benefit from the interventions evaluated but the available evidence is very low certainty so we are unable to draw reliable conclusions. We did not find any studies on methods such as ventilation, ionization, ozonisation, UV light and fogging. Studies are needed that measure contamination in aerosols, size distribution of aerosols and infection transmission risk for respiratory diseases such as COVID-19 in dental patients and staff.

Trial registration: ClinicalTrials.gov NCT04430387.

PubMed Disclaimer

Conflict of interest statement

SKN: none PE: none MP: none MN: none GS: none JHV: none

Figures

1
1
Key infection control methods (inspired by Harrel 2004). Copyright: Prashanti Eachempati. HEPA: high efficiency particulate air; UV: ultraviolet.
2
2
Study flow diagram.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: High‐volume evacuation (HVE) versus no HVE, Outcome 1: Reduction in the level of contamination in aerosols
2.1
2.1. Analysis
Comparison 2: HVE versus conventional dental suction, Outcome 1: Reduction in the level of contamination in aerosols
3.1
3.1. Analysis
Comparison 3: Combination system versus saliva ejector, Outcome 1: Reduction in the level of contamination in aerosols
4.1
4.1. Analysis
Comparison 4: Combination system versus rubber dam + HVE, Outcome 1: Reduction in the level of contamination in aerosols
5.1
5.1. Analysis
Comparison 5: Combination system versus HVE, Outcome 1: Reduction in the level of contamination in aerosols
6.1
6.1. Analysis
Comparison 6: Rubber dam versus no rubber dam, Outcome 1: Reduction in the level of contamination in aerosols
7.1
7.1. Analysis
Comparison 7: Rubber dam + HVE versus cotton roll + HVE, Outcome 1: Reduction in the level of contamination in aerosols
8.1
8.1. Analysis
Comparison 8: Air‐cleaning system (ACS) versus no ACS, Outcome 1: Reduction in the level of contamination in aerosols
9.1
9.1. Analysis
Comparison 9: Laminar air flow with HEPA filter versus without flow or filter, Outcome 1: Reduction in the level of contamination in aerosols (CFU per cubic feet/minute/patient)
10.1
10.1. Analysis
Comparison 10: Antimicrobial coolant versus control coolant, Outcome 1: Reduction in the level of contamination in aerosols
11.1
11.1. Analysis
Comparison 11: Antimicrobial coolant A versus antimicrobial coolant B, Outcome 1: Reduction in the level of contamination in aerosols
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD013686

References

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