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In this observational investigation to track the origins of microbiota in aerosols generated during dental procedures (AGDP), preprocedural unstimulated saliva from 28 patients undergoing dental procedures in a defined and controlled environment and irrigant from the dental unit were obtained, as was postprocedural condensate from the face shield of the dentist and dental assistant, and the chest of the patient. DNA from the samples was analyzed and sequenced, and significant class separation between the salivary and aerosol microbiomes was found, irrespective of the type of AGDP (P < .001). Also, irrespective of the AGDP, microbiota from the irrigant contributed 78% of the microbiota to the condensate while saliva contributed to a median of 0%. SARS-CoV-2 virus was detected in the saliva of 17 participants, but the virus was undetectable in the condensate on the operator, assistant, patient, or environment in any of these cases.
Understanding the sources of microbial bioload in aerosols is of immediate urgency, not only for infection control in dental operatories during the COVID-19 pandemic but also to inform best practices in aerosol reduction, mitigation, and abatement in the long term. The key discovery of this study was that irrigant fluid contributes to the majority of the bioload in dental aerosols and that high-volume intraoral evacuators are highly effective in reducing salivary contamination of the surrounding environment while preprocedural mouthrinses considerably reduce salivary microbial bioloads.
On March 16, 2020, 198,000 dentists in the United States closed their doors to patients, fueled by concerns that aerosols generated during dental procedures are potential vehicles for transmission of respiratory pathogens through saliva. Our knowledge of these aerosol constituents is sparse and gleaned from case reports and poorly controlled studies. Therefore, we tracked the origins of microbiota in aerosols generated during ultrasonic scaling, implant osteotomy, and restorative procedures by combining reverse transcriptase quantitative polymerase chain reaction (to identify and quantify SARS-CoV-2) and 16S sequencing (to characterize the entire microbiome) with fine-scale enumeration and source tracking. Linear discriminant analysis of Bray-Curtis dissimilarity distances revealed significant class separation between the salivary microbiome and aerosol microbiota deposited on the operator, patient, assistant, or the environment (P < 0.01, analysis of similarities). We also discovered that 78% of the microbiota in condensate could be traced to the dental irrigant, while saliva contributed to a median of 0% of aerosol microbiota. We also identified low copy numbers of SARS-CoV-2 virus in the saliva of several asymptomatic patients but none in aerosols generated from these patients. Together, the bacterial and viral data encourage us to conclude that when infection control measures are used, such as preoperative mouth rinses and intraoral high-volume evacuation, dental treatment is not a factor in increasing the risk for transmission of SARS-CoV-2 in asymptomatic patients and that standard infection control practices are sufficiently capable of protecting personnel and patients from exposure to potential pathogens. This information is of immediate urgency, not only for safe resumption of dental treatment during the ongoing COVID-19 pandemic, but also to inform evidence-based selection of personal protection equipment and infection control practices at a time when resources are stretched and personal protection equipment needs to be prioritized.