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| |
Received: 27 June 2020    Revised: 13 August 2020    Accepted: 10 September 2020

DOI: 10.1111/joor.13098

ORIGINAL ARTICLE

Evaluating aerosol and splatter following dental procedures:

Addressing new challenges for oral health care and
rehabilitation

James R. Allison1,2  | Charlotte C. Currie1,2  | David C. Edwards1,2  |

Charlotte Bowes1,2  | Jamie Coulter1,2  | Kimberley Pickering2  |
Ekaterina Kozhevnikova1  | Justin Durham1,2  | Christopher J. Nile1  |
Nicholas Jakubovics1  | Nadia Rostami1  | Richard Holliday1,2

1
School of Dental Sciences, Newcastle
University, Newcastle Upon Tyne, UK Abstract
2
Newcastle Upon Tyne Hospitals NHS Background: Dental procedures often produce aerosol and splatter which have the
Foundation Trust, Newcastle Upon Tyne, UK
potential to transmit pathogens such as SARS-CoV-2. The existing literature is limited.
Correspondence Objective(s): To develop a robust, reliable and valid methodology to evaluate dis-
Richard Holliday, School of Dental Sciences,
tribution and persistence of dental aerosol and splatter, including the evaluation of
Newcastle University, Framlington Place,
Newcastle upon Tyne NE2 4BW, UK. clinical procedures.
Email: [email protected]
Methods: Fluorescein was introduced into the irrigation reservoirs of a high-speed
Funding information air-turbine, ultrasonic scaler and 3-in-1 spray, and procedures were performed on
Dunhill Medical Trust, Grant/Award
a mannequin in triplicate. Filter papers were placed in the immediate environment.
Number: RPGF1810/101; Faculty of Medical
Sciences, Newcastle University The impact of dental suction and assistant presence were also evaluated. Samples
were analysed using photographic image analysis and spectrofluorometric analysis.
Descriptive statistics were calculated and Pearson's correlation for comparison of
analytic methods.
Results: All procedures were aerosol and splatter generating. Contamination was
highest closest to the source, remaining high to 1-1.5 m. Contamination was detect-
able at the maximum distance measured (4 m) for high-speed air-turbine with maxi-
mum relative fluorescence units (RFU) being: 46,091 at 0.5 m, 3,541 at 1.0 m and
1,695 at 4 m. There was uneven spatial distribution with highest levels of contamina-
tion opposite the operator. Very low levels of contamination (≤0.1% of original) were
detected at 30 and 60 minutes post-procedure. Suction reduced contamination by
67-75% at 0.5-1.5 m. Mannequin and operator were heavily contaminated. The two
analytic methods showed good correlation (r = 0.930, n = 244, P < .001).
Conclusion: Dental procedures have potential to deposit aerosol and splatter at some
distance from the source, being effectively cleared by 30 minutes in our setting.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Journal of Oral Rehabilitation published by John Wiley & Sons Ltd

J Oral Rehabil. 2021;48:61–72.  |

wileyonlinelibrary.com/journal/joor    61
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62       ALLISON et al

KEYWORDS

aerosols, COVID-19, dental high-speed equipment, dental infection control, dental scaling,
suction

1 |  BAC KG RO U N D studies are limited in that they only detect culturable bacteria as
a marker of aerosol and splatter distribution. A smaller number of
The coronavirus disease 2019 (COVID-19) pandemic has had sig- studies have used various fluorescent40-44 and non-fluorescent trac-
nificant impact upon the provision of medical and dental care ers 45,46 to measure aerosol and splatter distribution, although some
globally. In the United Kingdom, routine dental treatment was sus- of these have significant methodological flaws and major limitations.
pended in late March 2020,1-4 with care instead being provided Many studies are small and report only one repetition of a single pro-
through a network of urgent dental care centres. 5 During this cedure, and some have only examined contamination of the opera-
period, it was advised that aerosol-generating procedures (AGPs) tor and assistant; a number of studies which have measured spatial
were avoided unless absolutely necessary, leading to altered treat- distribution of aerosol and splatter have only done so to a limited
ment planning and a negative impact on patient care. 6 As more distance from the source. Few studies have considered the temporal
routine dental services start to resume worldwide, the guidance in persistence of aerosol and splatter with sufficient granularity to in-
the UK and elsewhere is still to avoid or defer AGPs where possi- form clinical practice.
7-13
ble. This will have an effect both on patients attending for ur- Open plan clinical environments such as those common in den-
gent and emergency care, as well as those requiring routine dental tal (teaching) hospitals with multiple patients and operators in close
treatment for oral rehabilitation. Standard operating procedures proximity are problematic. The current lack of robust evidence
(SOPs) have been published by a number of organisations to in- about dental aerosol and splatter distribution and persistence will be
form practice; however, many of these acknowledge a limited ev- a barrier to the reintroduction of routine dental services and dental
idence base.14-18 Additionally, all face-to-face undergraduate and education, which is likely to have a negative impact on the availabil-
postgraduate clinical dental teaching in the UK is suspended at the ity of care for patients, and on the future dental workforce if not
time of writing.19 addressed expediently.19 Patients’ oral health care will also suffer if
Various definitions exist for the terms ‘aerosol’ and ‘splatter’. routine care cannot be re-established, especially for those with high
For the purposes of this study, we define particles which make dental needs and active dental disease.
up aerosols as having a diameter of less than 10 µm, 20 and splat- The aim of the present study was to establish a robust, reliable
ter as comprising of particles larger than this; in reality, aerosols and valid methodology to evaluate the distribution and persistence
and splatter are made up of a spectrum of droplet sizes and this of aerosol and splatter following dental procedures. This can then
distinction is somewhat arbitrary. Many dental procedures pro- be used in future work linking specifically to transmission of SARS-
duce both aerosol and splatter contaminated with saliva and/or CoV-2, as well as other pathogens, in a dental environment. We
blood. 21,22 Saliva has been shown to contain severe acute respi- present initial data on three dental procedures (high-speed air-tur-
ratory syndrome coronavirus 2 (SARS-CoV-2) in infected individu- bine, ultrasonic scaler, and 3-in-1 spray use) and examine the effect
als, 23,24 many of whom may be asymptomatic, 25 with the salivary of dental suction and the presence of an assistant on aerosol and
gland potentially being an early reservoir of infection. 26,27 Equally, splatter distribution.
however, preliminary data suggest that in asymptomatic carriers,
the viral load may be low in saliva and these individuals may have
faster viral clearance. 28,29 Early data suggest that SARS-CoV-2 can 2 | M E TH O DS
remain viable and infectious in aerosol for hours, and on surfaces
for days. 30 Hence, dental aerosols and splatter are likely to be a Experiments were conducted in the Clinical Simulation Unit (CSU)
high-risk mode of transmission for SARS-CoV-2, and it is highly at the School of Dental Sciences, Newcastle University (Newcastle
likely that international clinical protocols across the spectrum of upon Tyne, United Kingdom). This is a 308 m2 dental clinical teaching
dental practice will need to be significantly modified to allow a laboratory situated within a large dental teaching hospital. The CSU
safe return to routine care. is supplied by a standard hospital ventilation system with ventila-
A review of the impact of AGPs generally across health care (in- tion openings arranged as shown in Figure  1; this provides 6.5 air
cluding dentistry) concluded that the existing evidence is limited.31 changes per hour and all windows and doors remained closed during
The current literature regarding the risks posed by aerosols and experiments. The temperature remained constant at 21.5°C.
splatter in dental settings is particularly limited. A number of authors Dental procedures were conducted on a dental simulator unit
have used microbiological methods to study bacterial contamination (Model 4820, A-dec; OR, USA) with a mannequin containing model
from aerosol and splatter following dental procedures, either by air teeth (Frasaco GmbH; Tettnang, Germany). Polyvinyl siloxane putty
sampling, 21,32,33 swabbing of contaminated surfaces,34,35 or most (Lab-putty, Coltene/Whaledent; Altstätten, Switzerland) was added
commonly, by collection directly onto culture media.36-39 These to the mouth of the mannequin to recreate the normal dimensions of
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ALLISON et al       63

F I G U R E 1   A, Schematic diagram (A) (B)

of experimental set up. Position of air
vents shown; square vents = air intake;
long vents = air output. Experimental
set up shown with collection positions
labelled (note: degrees are relative to
facing the mannequin). B, Photograph of
experimental set up showing platforms
spaced at 0.5 m intervals to support
filter papers. C, Demonstration of (C)
polyvinyl siloxane addition to mouth of
mannequin [Colour figure can be viewed
at wileyonlinelibrary.com]

the oral cavity as described by Dahlke et al 42 (Figure 1). Fluorescein visor). Two operators conducted the procedures: RH conducted the
solution (2.65 mmol L−1) was made by dissolving fluorescein sodium high-speed air-turbine and ultrasonic scaler procedures (operator
salt (Sigma-Aldrich; MO, USA) in deionised water, and this was then height = 170 cm); JRA conducted the 3-in-1 spray procedure (opera-
introduced to the irrigation reservoirs of the dental unit and ultra- tor height = 175 cm). There was a single assistant (KP) with a height
sonic scaler. The procedures investigated were as follows: anterior of 164 cm.
crown preparation—preparation of the upper right central incisor Before each procedure, the mannequin, rig and filter paper
tooth for a full coverage crown using a high-speed air-turbine (Synea platforms were cleaned with 70% ethanol and left to fully air dry.
TA-98, W&H (UK) Ltd.; St Albans, UK); full mouth scaling using a A period of 120 minutes was left between each procedure to allow
magnetostrictive ultrasonic scaler (Cavitron Select SPS with 30K for clearance of aerosol and splatter. Following each procedure, the
FSI-1000-94 insert, Dentsply Sirona; PA, USA); 3-in-1 spray (air/ filter papers were left in position for 10  minutes to allow for set-
water syringe) use—washing of mesial-occlusal cavity in upper right tling and drying of aerosol and splatter, before being collected with
first premolar tooth with air and water from 3-in-1 spray. Procedure clean tweezers and placed into a single-use, sealable polyethylene
durations were 10  minutes for anterior crown preparation and ul- bag. For the anterior crown preparation without suction, additional
trasonic scaling, and 30  seconds for the 3-in-1 spray use with air filter papers were placed at 30 minutes and again at 60 minutes to
and water (to represent removing acid etchant). Irrigant flow rate examine persistence of aerosol and splatter. At both of these time
was measured at 29.3 mL/min for the air-turbine, 38.6 mL/min for points, the risk of fluorescein transfer was minimised by placing the
the ultrasonic scaler and 140.6 mL/min for the 3-in-1 spray. We also new filter papers on new platforms, and filter papers were then left
investigated dental suction (measured at 6.3 L of water per minute) for 10 minutes before collection. All experimental conditions were
and the presence of an assistant. repeated three times.
Having developed the methods reported by other investiga-
tors,37,42,44 the present study used a reproducible, height adjustable
rig. This rig was constructed to support cotton-cellulose filter papers 2.1 | Image analysis
spaced at known distances from the mannequin (Figure 1). 30 mm di-
ameter grade 1 qualitative filter papers (Whatman; Cytiva, MA, USA) Filter papers were placed on a glass slide on a black background, cov-
were used to collect aerosol and splatter. These were supported on ered by a second glass slide, and illuminated by two halogen dental
platforms spaced at 0.5 m intervals along eight, 4 m, rigid rods, laid curing lights (QHL75 model 503; Dentsply, NC, USA) with 45 mW/cm2
out at 45° intervals and supported by a central hub, thus creating an output at 400-500 nm; these were positioned at 0 and 180 degrees,
8 m diameter circle around the mannequin; the centre of this circle 5 cm from the centre of the sample horizontally and 9 cm vertically, with
was located 25 cm superior to the mouth of the mannequin, and in both beams of light focussed on the centre of the sample. Images were
the same horizontal plane as the mouth of the mannequin (73  cm captured with a digital single-lens reflex (DSLR) camera (EOS 1000D,
above the floor). Four filter papers were also placed on the body Canon; Tokyo, Japan) at 90  mm focal length (SP AF 90mm F/2.8 Di
of the mannequin: two at 40  cm from the hub and two at 80  cm. Macro, Tamron; Saitama, Japan) with an orange lens filter, positioned
In addition, filter papers were placed on the arms (upper mid-fore- 43 cm directly above the sample (sample to sensor). Exposure param-
arm), body (upper chest) and legs (upper mid-thigh) of the operator eters were f/10, 1/80 seconds and ISO 400. Image analysis was per-
and assistant as well as on their full-face visor (width: 28.0, height: formed using ImageJ47 (version 1.53b, US National Institutes of Health;
27.5  cm) and the vertex of the head. For one condition (anterior MD, USA) in a darkened room by one of four examiners blind to experi-
crown prep with suction and assistant), we also placed three filter mental conditions and sample position (JRA, CCC, DE, RH). Images were
papers on the mask of the operator/assistant (beneath a full-face converted into 8-bit images and the pixel scale set across the maximum
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64       ALLISON et al

TA B L E 1   Dental aerosol and splatter as measured by contaminated surface area using image analysis or by spectrofluorometric analysis.
For each experimental condition, the data from an average of three repetitions for all samples at each distance are included together.
A total is also given for all samples for each condition, which also includes data from samples placed on the mannequin

Min Distance from centre (m)

Mean (SD)
Max
Sum
[n] 0 0.5 1 1.5 2
2
Surface area (mm )
Anterior crown prep (no 668.54 0.00 0.00 0.00 0.00
suction)a  690.07 (19.60) 77.81 (110.30) 1.47 (4.33) 0.03 (0.09) 0.00 (0.00)
706.86 386.87 21.00 0.42 0.08
2070.20 1867.32 35.40 0.75 0.11
[3] [24] [24] [24] [24]
Anterior crown prep with 656.46 0.00 0.00 0.00 0.00
suctionb  671.48 (20.10) 19.58 (36.58) 0.48 (1.57) 0.01 (0.02) 0.00 (0.00)
694.38 145.02 7.65 0.06 0.01
2,014.44 470.01 11.60 0.13 0.01
[3] [24] [24] [24] [24]
Anterior crown prep with 204.55 0.00 0.00 0.00 0.00
suction and assistantc  460.21 (227.75) 10.19 (21.87) 0.04 (0.11) 0.15 (0.73) 0.00 (0.00)
641.29 100.54 0.47 3.58 0.02
1380.64 244.51 1.07 3.60 0.06
[3] [24] [24] [24] [24]
Ultrasonic scaling with suctiond  2.71 0.00 0.00 0.00 0.00
129.11 (191.14) 3.15 (7.99) 0.00 (0.01) 0.00 (0.01) 0.00 (0.01)
349.00 30.04 0.02 0.03 0.02
387.32 75.59 0.06 0.06 0.05
[3] [24] [24] [24] [24]
3-in-1 spray with suctione  0.00 0.00 0.00 0.00 0.00
0.78 (0.13) 20.47 (47.32) 0.02 (0.05) 0.00 (0.00) 0.00 (0.00)
2.30 220.14 0.20 0.00 0.00
2.34 491.29 0.37 0.00 0.00
[3] [24] [24] [24] [24]
Fluorescence (RFU)
Anterior crown prep (no 82,812 89 103 48 70
suction)a  91 406 (12 153) 11 438 (14 907) 889 (932) 319 (390) 381 (600)
100 000 46 091 3541 1545 2097
182 812 274 529 21 355 7661 9141
[2] [24] [24] [24] [24]
30-40 min post-procedure 0 0 0 0 0
collection 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 0 0 0 0
0 0 0 0 0
[3] [24] [24] [24] [24]
60-70 min post-procedure 0 0 0 0 0
collection 0 (0) 0 (0) 14 (49) 12 (60) 0 (0)
0 0 177 294 0
0 0 344 294 0
[3] [24] [24] [24] [24]
a
Anterior crown preparation on upper right central incisor without suction or assistant. 10 minute duration.
b
Anterior crown preparation on upper right central incisor with suction. 10 minute duration.
c
Anterior crown preparation on upper right central incisor with suction and assistant. 10 minute duration.
d
Full mouth ultrasonic scaling with suction. 10 minute duration.
e
3-in-1 spray with suction of a MO cavity in upper right first premolar tooth. 30 second duration to replicate washing acid etchant.
e
All measurements from the rig with the addition of readings from the mannequin, representing an 8 m diameter experimental area.
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ALLISON et al       65

2.5 3 3.5 4 Totale 

0.00 0.00 0.00 0.00 0.00

0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 25.32 (101.04)
0.00 0.00 0.00 0.00 706.86
0.00 0.00 0.00 0.00 5241.05
[24] [24] [24] [24] [207]
0.00 0.00 0.00 0.00 0.00
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 15.14 (83.54)
0.00 0.00 0.00 0.00 694.38
0.00 0.00 0.00 0.00 3,133.33
[24] [24] [24] [24] [207]
0.00 0.00 0.00 0.00 0.00
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 14.26 (76.13)
0.01 0.01 0.01 0.01 641.29
0.01 0.03 0.02 0.03 2952.17
[24] [24] [24] [24] [207]
0.00 0.00 0.00 0.00 0.00
0.00 (0.01) 0.00 (0.01) 0.00 (0.01) 0.00 (0.01) 7.76 (42.67)
0.03 0.02 0.03 0.02 349.00
0.07 0.06 0.08 0.05 1,605.91
[24] [24] [24] [24] [207]
0.00 0.00 0.00 0.00 0.00
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 10.30 (53.19)
0.00 0.00 0.00 0.00 490.77
0.00 0.00 0.00 0.00 2,131.64
[24] [24] [24] [24] [207]

71 56 47 55 0
239 (330) 388 (555) 243 (342) 242 (437) 4056 (14 997)
1506 2739 1106 1695 100 000
5738 9309 5842 5826 835 741
[24] [24] [24] [24] [206]
0 0 0 0 0
0 (0) 0 (0) 8 (39) 0 (0) 1 (13)
0 0 191 0 191
0 0 191 0 191
[24] [24] [24] [24] [207]
0 0 0 0 0
8 (38) 0 (0) 0 (0) 0 (0) 4 (29)
184 0 0 0 294
184 0 0 0 822
[24] [24] [24] [24] [205]
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66       ALLISON et al

F I G U R E 2   Heatmap showing surface area outcome measure for three clinical procedures. A, anterior crown preparation (without
suction). B, anterior crown preparation with suction. C, anterior crown preparation with suction and assistant. For each coordinate, the
maximum value recorded from three repetitions of each clinical procedure was used as this was deemed most clinically relevant. Logarithmic
transformation was performed on the data (Log10). Note the scale is reduced to remove areas showing zero readings [Colour figure can be
viewed at wileyonlinelibrary.com]

diameter of the sample at 30mm. A manual threshold was used to cre- we completed spectrofluorometric analysis to allow validation of
ate a mask selecting all high-intensity areas. The ‘analyse particles’ func- the image analysis technique, and to also capture aerosol produced
tion was used to identify particles from 0 to infinity mm2 in area and 0 to which may not be easily detected in image analysis. Building on the
1 in circularity. The number of particles, total surface area and average methods reported by Steiner et al,48 fluorescein was recovered from
particle size were calculated. Total surface area was selected as the pri- filter papers by addition of 350 µL deionised water. Immersed sam-
mary outcome measure, representing contamination levels of the sam- ples were shaken for 5 minutes at 300 rpm using an orbital shaker at
ples and most likely representing the larger splatter produced from the room temperature. The fluorescein was then eluted by centrifuga-
procedures. Examiners underwent calibration prior to formal analysis tion at 15,890 g for 3 min using a microcentrifuge. 100 µL of the su-
by independently analysing 10 images and then discussing to reach con- pernatant was transferred to a black 96-well microtitre plate with a
sensus. Following this, examiners then independently analysed 30 im- micro-clear bottom (Greiner Bio-One; NC, USA) in triplicate in order
ages to assess inter-examiner agreement. Examiners re-examined the to measure fluorescence. Fluorescence measurements were per-
same 30 images one week later to assess intra-examiner agreement. formed using a Synergy HT Microplate Reader (BioTek; VT, USA) at an
excitation wavelength of 485 ± 20 nm and an emission wavelength
of 528 ± 20 nm with the top optical probe. For background correc-
2.2 | Spectrofluorometric analysis tion, negative controls (n = 26) were included in the measurements
for all runs. These included fresh filter papers out of the box and fil-
For one experimental condition (anterior crown preparation without ter papers that had been placed on platforms in CSU for 10 minutes
suction, samples from the initial, 30-, and 60-minute time points), exposed to air. The negative control filter papers were processed for

F I G U R E 3   Heatmap showing surface area outcome measure for two clinical procedures. A, ultrasonic scaling. B, 3-in-1 spray. For each
coordinate, the maximum value recorded from three repetitions of each clinical procedure was used as this was deemed most clinically
relevant. Logarithmic transformation was performed on the data (Log10). Note the scale is reduced to remove areas showing zero readings in
panel B only [Colour figure can be viewed at wileyonlinelibrary.com]
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ALLISON et al       67

imaging and fluorescent measurements in the same manner as the curve (y  =  fluorescence, RFU; x  =  fluorescein  concentration,  µM).
remainder of samples. The negative control mean + 3SD (164 RFU; For illustrative purposes, we detail these for the 270 degree axis
relative fluorescence units) was used as the limit of detection; hence, (mean values across three repetitions from the initial time point):
a zero reading was assigned to values below 164 RFU. For readings 0 m = 132.6 µmol L−1; 0.5 m = 26.3 µ mol L−1; 1 m = 5.25 µ mol L−1;
above the detection limit of the instrument (>100 000 RFU), a value 1.5 m = 3.02 µ mol L−1; 2 m = 3.44 µ mol L−1; 2.5 m = 3.30 µ mol L−1;
of 100 000 RFU was assigned. 3 m = 2.79 µ mol L−1; 3.5 m = 2.86 µ mol L−1; 4 m = 3.09 µ mol L−1.
The mannequin, operator and assistant were all heavily contam-
inated (Table S1). The operator's left (non-dominant) arm, left body
2.3 | Statistical methods and lower visor were the most contaminated sites. Generally, levels
of contamination were much lower for the assistant, being highest
Data were collected using Excel (2016, Microsoft; WA, USA) and on the left arm and left chest (the assistant used their left hand to
analysed using SPSS (version24, IBM Corp.; NY, USA) using basic hold the suction tip). All areas of the mannequin were heavily con-
descriptive statistics and Pearson's correlation (to compare analyti- taminated. The operator and assistant's masks (only assessed in one
cal techniques). Heatmaps demonstrating aerosol and splatter distri- condition) showed low but measurable contamination, usually at the
bution were generated using Python 3.49 A two-way mixed effects lateral edges.
model was used to assess inter- and intra-examiner agreement by
calculating interclass correlation coefficient (ICC) using STATA re-
lease 13 (StataCorp; TX, USA). 3.3 | Effect of dental suction (with and without
assistant)

3 | R E S U LT S The use of dental suction, held by the operator, reduced the con-
tamination of filter papers at each distance (Table 1), although image
3.1 | Examiner calibration for image analysis analysis still detected contamination up to 2  m. Between 0.5 and
1.5  m, there was a 67%-75% reduction (central site contamination
Inter-examiner ICC for 30 images showed excellent agreement for was unaffected). The spatial distribution was altered as demon-
total surface area (ICC 0.98; 95% CI 0.97-0.99), good agreement for strated in Figure 2. When an assistant was present and held the den-
total number of particles (ICC 0.88; 95% CI 0.80-0.93) and moder- tal suction, this further reduced contamination readings within the
ate agreement for average particle size (ICC 0.63; 95% CI 0.47-0.78). first 1 m; however, we noted a marked increase at the 1.5 m reading
Intra-examiner agreement at one week for the same 30 images was behind the assistant (0°).
excellent for total surface area (ICC 0.97-0.99), good to excellent for
total number of particles (ICC 0.82-0.97) and good for average parti-
cle size (ICC 0.75-0.97).50

3.2 | Aerosol and splatter distribution

Aerosol and/or splatter deposition (assessed by surface area out-

come) was highest at the centre of the rig and decreased with in-
creasing distance from the centre (Table 1). Most contamination was
within 1.5  m, but there were smaller readings up to 4  m for some
conditions. The spatial distribution is shown in Figures 2 and 3.
For one experimental condition (anterior crown prep with no
suction, representing a presumed worst-case scenario), at three time
points, we also completed spectrofluorometric analysis (Table  1).
The particle count was weakly correlated with spectrofluoromet-
ric measurements (r  =  0.344, n  =  244, P  <  .001), average particle
size was moderately correlated (r  =  0.555, n  =  244, P  <  .001) and F I G U R E 4   Heatmap presenting spectrofluorometric analysis of
total surface area was very strongly correlated (r = 0.930, n = 244, the samples from the anterior crown preparation (without suction)
P < .001), supporting our use of surface area as the main outcome clinical procedure at 0 - 10 minutes (surface area data shown in
Figure 2A). For each coordinate, the maximum value recorded
measure from image analysis (Figure S1). Data from one time point
from three repetitions of each clinical procedure was used.
are presented in Figure 4. Using serial dilution of fluorescein, we de- Logarithmic transformation was performed on the data (Log10).
rived a  standard curve  covering the range 50  nM  to 102  µM. The Note the scale includes the full dimensions of the experimental rig.
equation y  = 700.42 x  −  1449.5 was derived from  the standard RFU: relative fluorescence units [Colour figure can be viewed at
wileyonlinelibrary.com]
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13652842, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13098 by INASP/HINARI - INDONESIA, Wiley Online Library on [09/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
68       ALLISON et al

preparation without suction produced the largest particles

(mean ± SD: 0.49 ± 2.98 mm2) which were similar to when suction
was added by the operator (0.56 ± 3.34 mm2). There was a size re-
duction when an assistant provided suction (0.11 ± 0.69 mm2). The
ultrasonic scaling produced the smallest particles (0.05 ± 0.24 mm2)
followed by the 3-in-1 spray (0.08 ± 0.25 mm2). Figure 5 presents
images of all samples for one repetition of a single experimental con-
dition to demonstrate the distribution of particles and size.
When looking at all the experimental conditions combined, the
average particle size was largest closest to the source, decreasing with
distance (mean ± SD): 0 m = 5.52 ± 8.88 mm2; 0.5 m = 0.11 ± 0.28
mm2; 1 m = 0.01 ± 0.00 mm2; 1.5 - 4 m = 0.00 ± 0.00 mm2. Figure
S2 presents the average particle size by distance for each separate
experimental condition.
F I G U R E 5   Composite image comprised of all filter paper
samples images used for image analysis within the first 1 m from
the one repetition of the anterior crown preparation (no suction)
condition. Colour balance and contrast adjusted to aid visualisation. 4 | D I S CU S S I O N
Samples are arranged with the central sample in the centre, and
samples from 0.5 m and 1 m arranged concentrically moving Dental aerosol and splatter are an important potential mode of trans-
outwards. The axis is the same as demonstrated in Figures 1-4
mission for many pathogens, including SARS-CoV-2. Understanding
[Colour figure can be viewed at wileyonlinelibrary.com]
the risk these phenomena pose is vitally important in the reintro-
duction of dental services in the current COVID-19 pandemic. Our
3.4 | Procedure type study is novel in that we are the first to measure aerosol and splatter
distribution at distances up to 4 m from the source, and the first to
Three clinical procedures (anterior crown preparation, ultrasonic apply image and spectrofluorometric analysis to the study of dental
scaling and 3-in-1 spray use) were assessed while the operator aerosol and splatter. This has allowed us to gather urgently needed
held dental suction. The highest readings were obtained from the data relevant to the provision of dental services during the COVID-
anterior crown preparation, but each procedure gave a unique dis- 19 pandemic, and more widely. Specifically, we have demonstrated
tribution (Table 1, Table S1, Figures 2 and 3). The ultrasonic scaler the relative distribution of aerosol and splatter following different
produced high levels of contamination at the centre, reducing mark- dental procedures, the effect of suction and assistant presence, and
edly at 0.5 m, but with low levels of contamination detectable up to the persistence of aerosol and splatter over time.
the 4 m limit of measurement. The 3-in-1 spray procedure produced Previous investigators have used various tracer dyes and vi-
high levels of contamination at 0.5 m but little beyond 1 m. sual examination techniques to evaluate ‘dental aerosol’ and have
demonstrated positive readings at up to 1.2 m.42,44 Our study fur-
ther optimises these methods and we have demonstrated positive
3.5 | Effect of time readings at up to 2 m (and low levels at up to 4 m in the case of ultra-
sonic scaling). This is consistent with the findings of other investiga-
Image analysis demonstrated no detectable fluorescein contamina- tors using bacterial culture methods to detect contamination at up
tion of the filter papers at 30-40 and 60-70 minutes post-procedure to 2 m.37,38,51 Importantly, our spectrofluorometric analysis demon-
(for the anterior crown preparation without suction condition). strates that some fluorescein contamination may occur beyond this
Additionally, spectrofluorometric analysis of these samples demon- on filter papers that appear clean by image analysis, representing
strated very low levels of contamination. The overall contamination aerosol which cannot be detected with image analysis alone. In
across the 8  m diameter experimental area at 30-40  minutes was addition, a DSLR camera with a complementary metal-oxide-semi-
0.02% of the original level, and at 60-70 minutes, it was 0.10% of the conductor sensor is likely to be limited to the detection of larger par-
original level (Table 1). ticles (i.e. splatter) using the methods we report in the present study.
We therefore propose that studies which use dye tracers assessed
by visual examination or image analysis techniques alone are assess-
3.6 | Particle size ing primarily splatter rather than aerosol; this is because in order
for deposits to be visible to the eye or camera, it has to be relatively
Average particle size measurements (from photographic analy- large in size. Previous research using these methods should there-
sis, likely to represent splatter particles) were combined for the fore be interpreted in this context. It is, however, worth noting that
0, 0.5, 1 and 1.5  m readings for each condition to give an indica- larger particles are likely to contain a greater viral load, and given
tion of the nature of the particles in this area. The anterior crown the risk of SARS-CoV-2 transmission through contact with mucosal
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ALLISON et al       69

surfaces,52 from a cross-infection perspective splatter is likely to be suitable device available to measure air flow rate of the system used
highly significant. Reassuringly, in our study splatter was greatly re- in the present study and hence we chose to use the term ‘dental
duced using suction. suction’ as we were unable to confirm whether it met this defini-
Findings from both analytical techniques demonstrate contam- tion. We did, however, measure water flow rate (6.3 L/min) which
ination at a distance from the source although contamination was we found to be similar to that reported by other investigators.39 Our
lower at greater distances; this shows the potential for pathogens findings highlight the importance of suction as a mitigation factor
to travel a similar distance, although our methods replicate a worst- in splatter and aerosol distribution following dental procedures, and
case scenario. Within closed surgery environments, this reinforces future research should examine the impact of this effect in relation
the need for minimal clutter and strict cross-infection control mea- to different levels of suction based on air flow rate.
sures. Within open clinic environments, further research is required Safe times following procedures, after which contamination be-
to investigate parameters such as the impact of partitions on aerosol comes negligible, have rarely been investigated robustly. In studies
and splatter. using tracer dyes, we are only aware of a single paper reporting con-
We demonstrated significant contamination of the operator, as- tamination at 30  minutes.44 This conflicts with our findings of no
sistant and mannequin for all procedures, which is consistent with contamination by image analysis at 30 and 60 minutes, and only very
the findings of other investigators.34,38,41,44 This is unsurprising and low levels by spectrofluorometric analysis (≤ 0.10% of original levels).
underscores the need for adequate personal protective equipment It is unclear from the methods of Veena et al 44 whether new filter pa-
(PPE), for the operator and assistant. Of particular note is the im- pers were placed immediately following the procedure and collected
portance of the full-face visor which was heavily contaminated in at 30 minutes, or placed at 30 minutes and collected thereafter; in
our study. This also highlights the importance of enhanced PPE53 the prior case, any contamination found on the samples could have
during the peak of a pandemic for AGPs, because of the likelihood arisen at any time from the end of the procedure up to 30 minutes,
of treating an asymptomatic carriers. Coverage of the operator and and it cannot therefore be determined when contamination actually
assistant's exposed arms with a waterproof covering would protect occurred. In addition, the authors do not report whether the tape
against contamination, although scrupulous hygiene with an effec- they used to support filter papers was replaced following the initial
tive antiseptic (povidone-iodine or 70% alcohol54,55) would be a exposure, and if not, it is possible that existing contamination was
minimum requirement if this was not used. PPE for patients’ clothes transferred to filter papers placed subsequently. Finally, the inves-
does not feature in dental guidelines relating to COVID-19, and our tigation reported by Veena et al 44 was a single experiment and did
findings would suggest significant contamination of the patient is not use multiple repetitions. It is important to note that our findings
likely during AGPs, presenting a risk of onward cross-contamination relate to the environmental setting studied, with 6.5 air changes per
by contact with surroundings; it is therefore important to provide hour. Air exchange rates in dental surgeries are likely to vary which
waterproof protection for patients’ clothes. may affect translation.
Our findings demonstrate that use of a high-speed air-turbine, Our study has several limitations, and our results need to be in-
ultrasonic scaler and 3-in-1 spray are all AGPs. 3-in-1 use is not terpreted in the context of these. Our methods serve as a model
currently included in the list of defined healthcare-related AGPs for aerosol and splatter contamination, and further work is required
31
recently updated by Health Protection Scotland, which only de- to confirm their biological validity. As our knowledge of the infec-
tails ‘high-speed devices such as ultrasonic scalers and high-speed tive dose of SARS-CoV-2 required to cause COVID-19 develops, the
drills’. The highest levels of contamination were from the high-speed clinical relevance of our findings needs to be put into context; our
air-turbine, although the ultrasonic scaler demonstrated contami- understanding of this is still too basic to be able to draw definitive
nation at greater distances, in keeping with the findings of Bennett conclusions as to the risks posed by dental aerosol and splatter. The
et al. 21 Dental suction was effective at reducing fluorescein con- particle size analysis is likely to overestimate the size of the particles
tamination, with reduction of 67%-75% between 0.5 and 1.5 m. for two reasons: first, when fluorescein droplets are absorbed into
This is consistent with the effect of suction demonstrated by other the filter paper, they will spread out creating an area with a diame-
37,56
investigators. ter greater than that of the original droplet; second, when samples
When dental suction was provided by an assistant, this was more are heavily contaminated the droplets coalesce on the filter paper to
effective in reducing contamination, although increased readings produce larger areas of contamination and the software measures
were seen at 1.5 m, potentially indicating that an additional barrier the total surface area of the fused droplets. Our experimental set
in the form of an assistant may have a more complex aerodynamic up incorporated the tracer dye within the irrigation system of the
effect. High-volume dental suction is recommended in most dental dental units and represents a worst-case scenario for distribution of
guidelines and SOPs relating to COVID-19, as an essential mitiga- biological material.
tion procedure when conducting AGPs. However, we are not aware In reality, a small amount of blood and saliva will mix with large
of any that provide a definition or basic minimal requirements for volume of water irrigant creating aerosol and splatter with diluted
effective high-volume dental suction. National guidelines57 classify pathogen concentration compared to blood or saliva, and a likely
suction systems based on air flow rate (high-volume systems: 250 L/ reduced infective potential.19 It has been estimated that over a
min at the widest bore size of the operating hose). We did not have a 15 minute exposure during dental treatment with high-speed
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13652842, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/joor.13098 by INASP/HINARI - INDONESIA, Wiley Online Library on [09/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
70       ALLISON et al

instruments, an operator may be exposed to 0.014-0.12  µL of J. Coulter, K. Pickering, E. Kozhevnikova, C. J. Nile, N. Jakubovics,
21
saliva. Early data suggest a median SARS-CoV-2 viral load of N. Rostami and R. Holliday contributed to the acquisition, analysis
3.3  × 10 6 copies per mL in the saliva of infected patients23,24; and interpretation of data. All authors were involved in drafting and
taken together, this suggests that an operator without PPE at critically revising the manuscript and have given final approval for
around 0.5 m from the source may be exposed to an estimated 46- publication. All authors agree to be accountable for all aspects of
396 viral copies during a 15-minute procedure. These data were the work.
collected from hospital inpatients, and recent data suggest that
asymptomatic carriers may have lower salivary viral loads28,29; PEER REVIEW
similarly the average concentration of fluorescein detected by The peer review history for this article is available at https://publo​
spectrofluorometric analysis past 2  m in the present study was ns.com/publo​n/10.1111/joor.13098.
almost two orders of magnitude lower than at 0.5  m, and so at
distances beyond 0.5 m, this risk is likely to be lower. Importantly, DATA AVA I L A B I L I T Y S TAT E M E N T
we still do not yet know what the infective dose of SARS-CoV-2 Data available from the authors on reasonable request.
required to cause COVID-19 is.
ORCID
James R. Allison  https://orcid.org/0000-0002-0562-4133
5 |  CO N C LU S I O N S Charlotte C. Currie  https://orcid.org/0000-0001-6297-8600
David C. Edwards  https://orcid.org/0000-0002-0462-7463
Within the limitations of this study, dental aerosol and splatter have Charlotte Bowes  https://orcid.org/0000-0002-9013-5819
the potential to be a cross-infection risk even at a distance from the Jamie Coulter  https://orcid.org/0000-0002-6328-7702
source. The high-speed air-turbine generated the most aerosol and Kimberley Pickering  https://orcid.org/0000-0003-1186-3402
splatter, even with assistant-held suction. Our findings suggest that Ekaterina Kozhevnikova  https://orcid.
it may be safe to reduce fallow times between dental AGPs in set- org/0000-0002-9835-694X
tings with 6.5 air changes per hour to 30 minutes. Future research Justin Durham  https://orcid.org/0000-0002-5968-1969
should evaluate further procedures, mitigation strategies, time peri- Christopher J. Nile  https://orcid.org/0000-0001-8218-2167
ods and aim to assess the biological relevance of this model. Nicholas Jakubovics  https://orcid.org/0000-0001-6667-0515
Nadia Rostami  https://orcid.org/0000-0002-3438-5389
AC K N OW L E D G E M E N T S Richard Holliday  https://orcid.org/0000-0002-9072-8083
Charlotte Currie is funded by a National Institute for Health
Research (NIHR) Doctoral Research Fellowship. David Edwards REFERENCES
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