COVID-19 and the problem with dental aerosols…

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COVID-19 and the

problem with dental
aerosols
Dentistry is classified in the very-
high-risk category of occupations
involved with aerosol production.
What does this have to do with
COVID-19? Quite a lot. Here is the
latest research.
Author — Scott Froum, DDS, Michelle Strange,
MSDH, RDH
Apr 7th, 2020

Figure 1: Coronavirus particles range have distinctive

spikes that give the appearance of “coronas” around
the sun.

Updated April 13, 2020

Background
A novel human coronavirus—now named
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2)—emerged
from Wuhan, China, in late 2019 and is
causing a pandemic.1 Coronaviruses are
enveloped RNA viruses that affect animals
and humans.2 Coronavirus particles range
from 60 to 140 nanometers (0.06 to 0.14
micrometers), with an average of 0.125
micron, and have distinctive spikes of nine
to 12 nanometers that give the appearance
of “coronas” around the sun (figure 1). Cell
death is observed 96 hours after
inoculation on surface layers of human
airway epithelial cells.2

Currently, there are six coronavirus

species that cause human disease. Four of
them—229E, OC43, NL63, and HKU1—
often result in symptoms of the common
cold.3 The other two strains—severe acute
respiratory syndrome coronavirus (SARS-
CoV) and Middle East respiratory
syndrome coronavirus (MERS-CoV)—are
zoonotic (originate from animals and cross
over to humans), more serious, and
sometimes linked to fatal illness.4
SARS-CoV-1 was the causal agent of the
severe acute respiratory syndrome
outbreaks in 2002 and 2003 in Guangdong
Province, China.5 During this outbreak,
approximately 8,098 patients were
affected with 774 deaths, resulting in a
mortality rate of 9%. This rate was much
higher in elderly individuals, with
mortality rates approaching 50% in those
over age 60. Transmission of SARS-CoV-1
was relatively inefficient because it spread
only through direct contact with infected
individuals; once an individual exhibited
symptoms, the virus spread. The outbreak
was largely contained because it was easy
to identify those individuals who were
capable of spreading the disease. A few
cases of super-spreading events occurred
whereby individuals with higher viral loads
and the ability to aerosolize the virus were
able to infect multiple people. As a result
of the relatively inefficient transmission of
SARS-CoV-1, its outbreak was controllable
through the means of quarantining
individuals in households and health-care
centers.6
The stability of SARS-CoV-2 is like SARS-
CoV-1, with an 80% genetic makeup
similarity. Both viruses bind to the human
cell via the spike (S) protein to
angiotensin-converting enzyme 2 receptor
(ACE2) to gain entry, but there are a few
differences (figure 2). First, higher viral
loads have been detected in nasal passages
and the upper respiratory tract of
individuals infected with SARS-CoV-2,
which mean coughs and sneezes may
contain higher viral loads than its
predecessor virus. Second, the potential
for individuals infected with SARS-CoV-2
to shed and transmit the virus while
asymptomatic is much greater, and those
in the latent stages of the disease often
shed the virus at a higher rate.7 Third—and
most significantly—this new virus strain
has been shown to be much more efficient
at traveling more considerable distances
and becoming aerosolized.

Aerosol particle transmission

Particles are classified based on size:

coarse particles are 2.5–10 microns, fine
particles are less than 2.5 microns, and
ultrafine particles are less than 0.1
micron. The nose typically filters air
particles above 10 microns. If a particle is
less than 10 microns, it can enter the
respiratory system. If it is less than 2.5
microns, it can enter the alveoli. A particle
less than 0.1 micron, or an ultrafine
particle like the COVID-19 virus, can enter
the bloodstream and target organs such as
the heart and brain. The current scientific
consensus is that most transmission via
respiratory secretions happens in the form
of large respiratory droplets rather than
small aerosols. Droplets are often heavy
enough that they do not travel very far;
instead, they fall from the air after
traveling up to six feet (figure 3).

The problem occurs when viral particles

are aerosolized by a cough, sneeze, or
dental care. In these instances, particles
can potentially travel across far greater
distances, with estimates up to 20 feet,
from an infected person and then incite
secondary infections elsewhere in the
environment. These aerosolized droplet
nuclei can remain in an area, suspended in
the air, even after the person who emitted
them has left and thus can infect health-
care workers and contaminate surfaces.
Here are some examples of the longevity
of COVID-19 in various places:8

• The virus is viable up to 72 hours

 after application to plastic and
stainless steel surfaces.
• The virus is viable up to 24 hours on
cardboard surfaces.
• The virus is viable up to nine hours
on copper surfaces.
• The virus is viable in suspended
aerosols up to three hours.

Viral dosimetry and dental

considerations
Whenever a new virus emerges, the
question needs to be asked if there is a
dose-dependent response between viral
load contact and severity of the disease. In
other words, does the number of viral
particles a patient initially encounters, or
repeated dosing, determine the severity of
the symptoms? One study reported that
viral loads in nasopharyngeal swabs from a
group of patients with severe COVID-19
were 60 times higher on average than the
viral loads seen among patients with a
mild form of the disease.9

If this is the case, dental aerosolization

may pose an additional threat. Does a
patient who has viral particles confined to
the nasopharyngeal area become
susceptible to aerosol aspiration into the
lungs, leading to increased disease
severity? This question was inspired by
and based on the work of Bruce L
Davidson, MD, MPH—a pulmonary
physician and researcher in Seattle, expert
in respiratory transmission of infection,
former president of the National
Tuberculosis Controllers Association, and
member of the HHS Secretary’s Advisory
Council for the Elimination of
Tuberculosis—who has extensively looked
at aspirational types of pneumonia.15
According to Dr. Davidson, "This very real
possibility can be easily diminished by
reducing biofilm viral load in the mouth
and pharynx region with 1.5% peroxide for
60 seconds, thereby reducing viral load
and basically disinfecting the throat.
Peroxide drops cornavirus replication by
>4 logs. These types of debridement
controls are often overlooked." In addition,
Dr. Davidson states that nose-covering
filters and devices are simple and
effective. Of course, well-designed
controlled studies are needed to further
this research and recommendation.
Dental aerosolization

Dentists who treat patients using

aerosolization are at an extremely
dangerous risk of inoculation of
themselves, their dental assistants, other
office staff members, and reinoculation of
the patients. Most risk occurs from
splatter and droplet transmission to the
midface of the dentist and assistant, as
well as the nasal area of the patient.10 In
addition, periodontal treatment has a
much higher incidence of droplet
transmission than prosthetic treatment.11
Ultrasonic and sonic transmission during
nonsurgical procedures had the highest
incidence of particle transmission,
followed by air polishing, air/water
syringe, and high-speed handpiece
aerosolization.12 One study found that
ultrasonic instrumentation can transmit
100,000 microbes per cubic foot with
aerosolization of up to six feet, and, if
improper air current is present, microbes
can last anywhere from 35 minutes to 17
hours.13
Because of these inherent dangers to
dentists, team members, and patients, the
Occupational Safety and Health Act
(OSHA) just released a new report
called “Guidance on Preparing Workplaces
for COVID-19.”14 This document
categorizes occupational risk as very high,
high, medium, and lower risk. The
occupations that are involved with aerosol
production fall into the category of very
high risk, according to OSHA.

Since dentistry is in the very-high-risk

category, the section “Implement
Workplace Controls, Engineering
Controls” recommends that dental
practices install negative-pressure rooms
or airborne infection isolation rooms for
operatories in which procedures involving
aerosol will be performed. In addition,
recommendations for the dentist and staff
working in areas of direct contact with
aerosols include wearing the following
personal protective equipment (PPE)
masks: “Other types of acceptable
respirators include: a R/P95, N/R/P99, or
N/R/P100 filtering facepiece respirator;
an air-purifying elastomeric (e.g., half-face
or full-face) respirator with appropriate
filters or cartridges; powered air-purifying
respirator (PAPR) with high-efficiency
particulate arrestance (HEPA) filter; or
supplied air respirator (SAR).”14

Conclusion

Many changes in infection control

procedures and the associated dental
armamentaria can be expected to arise in
the post-COVID-19 world of dentistry. The
extent and severity of change will be
dictated by evidence and research into the
best and safest practices. Prior to
mandating change that will involve an
extreme financial and architectural
change of the current dental office,
research should be conducted that
evaluates current available practices,
methodology, and instrumentation that
can mitigate/obviate the risk of
transmission, while being financially and
practically expeditious.

References

1. Coronavirus disease 2019 (COVID-

2019) situation report—32. World
Health Organization. February 21,
2020.
https://www.who.int/docs/default-
source/coronaviruse/situation-
reports/20200221-sitrep-32-covid-
19.pdf

2. Zhu N, Zhang D, Wang W, et al. A

novel coronavirus from patients with
pneumonia in China, 2019. N Engl J
Med. 2020;382(8):727-733.
doi:10.1056/NEJMoa2001017

3. Su S, Wong G, Shi W, et al.

Epidemiology, genetic recombination,
and pathogenesis of coronaviruses.
Trends Microbiol. 2016;24(6):490-502.
doi:10.1016/j.tim.2016.03.003

4. Cui J, Li F, Shi ZL. Origin and

evolution of pathogenic
coronaviruses. Nat Rev Microbiol.
2019;17(3):181-192. doi:10.1038/s41579-
018-0118-9

5. Drosten C, Günther S, Preiser W, et

al. Identification of a novel
coronavirus in patients with severe
acute respiratory syndrome. N Engl J
Med. 2003;348(20):1967-1976.
doi:10.1056/NEJMoa030747

6. Peiris JSM, Yuen KY, Osterhaus

ADME, Stohr K. The severe acute
respiratory syndrome. N Engl J Med.
2003;349(25):2431-2441.
doi:10.1056/NEJMra032498

7. Bai Y, Yao L, Wei T, et al. Presumed

asymptomatic carrier transmission of
COVID-19. JAMA. Published online
February 21, 2020.
doi:10.1001/jama.2020.2565

8. van Doremalen N, Bushmaker T,

Morris DH, et al. Aerosol and surface
stability of SARS-CoV-2 as compared
with SARS-CoV-1. N Engl J Med.
Published online March 17, 2020.
doi:10.1056/NEJMc2004973

9. Verity R, Okell LC, Dorigatti I, et al.

Estimates of the severity of
coronavirus disease 2019: a model-
based analysis. Lancet Infect Dis.
Published online March 30, 2020.
doi:10.1016/S1473-3099(20)30243-7

10. Nejatidanesh F, Khosravi Z, Goroohi

H, Badrian H, Savabi O. Risk of
contamination of different areas of
dentist’s face during dental practices.
Int J Prev Med. 2013;4(5):611-615.

11. Williams GH, Pollok NL, Shay DE,

Barr CE. Laminar air purge of
microorganisms in dental aerosols:
prophylactic procedures with the
ultrasonic scaler. J Dent Res.
1970;49(6):1498-1504.
doi:10.1177/00220345700490065701

12. Harrel SK, Molinari J. Aerosol and

splatter in dentistry: a brief review of
the literature and infection control
implications. J Am Dent Assoc.
2004;135(4):429-437.
doi:10.14219/jada.archive.2004.0207

13. Miller RL. Characteristics of blood-

containing aerosols generated by
common powered dental instruments.
Am Ind Hyg Assoc J. 1995;56(7):670-676.
doi:10.1080/15428119591016683
 14. Guidance on preparing workplaces
for COVID-19. US Department of
Labor. Occupational Safety and Health
Administration.
2020. https://www.osha.gov/Publicati
ons/OSHA3990.pdf

15. Davidson BL. Doctor: How to

reduce your vulnerability to
coronavirus -- when sleeping. CNN.
Updated March 13, 2020.
https://www.cnn.com/2020/03/12/o
pinions/coronavirus-vulnerability-
while-sleeping-bruce-
davidson/index.html

Author's note: Special thanks to Dr. Bruce

L. Davidson for the consult on this article.

Editor’s note: This article originally

appeared in Perio-Implant Advisory, a
newsletter for dentists and hygienists that
focuses on periodontal- and implant-
related issues. Perio-Implant Advisory is
part of the Dental Economics and
DentistryIQ network. To read more
articles, visit perioimplantadvisory.com, or
to subscribe, visit
dentistryiq.com/subscribe.

Scott Froum, DDS, a graduate of the State

University of New York, Stony Brook
School of Dental Medicine, is a
periodontist in private practice at 1110 2nd
Avenue, Suite 305, New York City, New
York. He is the editorial director of Perio-
Implant Advisory and serves on the
editorial advisory board of Dental
Economics. Dr. Froum, a diplomate of the
American Board of Periodontology, is a
clinical associate professor at SUNY Stony
Brook School of Dental Medicine in the
Department of Periodontology. He serves
on the board of editorial consultants for
the Academy of
Osseointegration's Academy News. Contact
him through his website
at drscottfroum.com or (212) 751-8530.

Michelle Strange, MSDH, RDH, has been a

dental clinician since 2000 and is
currently a practicing hygienist, speaker,
writer, content developer, consultant, and
podcast cohost for A Tale of Two
Hygienists. With a master's in dental
hygiene education and a belief in lifelong
learning, she hopes to continue to learn
and grow within the dental profession and
one day see the gap bridged between
medicine and dentistry.

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Implant Advisory
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