Journal of Dental Research and Review

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 7  |  Issue : 1  |  Page : 5--9

Effectiveness of 0.2% chlorhex plus and 0.1% turmix as preprocedural mouthrinses on aerosol contamination produced by ultrasonic scalers: An interventional study


S Selva Mani1, Sriram Srikanthan1, Balaji Selvaraj2, V Menaka3, Madan Kumar Parangimalai Diwakar1,  
1 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Microbiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Periodontics and Implantalogy, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
S Selva Mani
Department of Public Health Dentistry, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu
India

Abstract

Objective: Dental handpieces, ultrasonic scalers, air polishers, air abrasion units produce the most visible aerosols. The objective of this study was to assess the effectiveness of Chlohex Plus and Turmix as preprocedural mouthrinses on aerosol contamination produced by ultrasonic scaler inside the Mobile Dental Unit. Materials and Methods: A total of 30 patients were included in this study, they were randomly assigned into two groups and were subjected to scaling before and after rinsing with 0.2% CHX,0.1% turmix. Blood agar plates were used to collect the gravitometric settling of aerosols and were sent for culture. Results: The mean CFU/mL of the anaerobic bacteria from the aerosol generated after pre-rinse with TRX was found to be less than 50% of the mean effective pre-rinse CHX threshold. The TRX pre-rinse was found to be more effective than the CHX pre-rinse. Bacteriodes spp. and the Peptostreptococcus spp. were the most common anaerobic pathogen isolated from the aerosol tested which is strongly suggestive of aerosol were directive from patient sample only. Conclusion: Hence the consideration of routine use of CHX and turmix mouthwash as prior to all dental procedures results in the reduction in number of oral bacteria available for possible induction of bacteremia or dissemination to the attending dentist and other personnel.



How to cite this article:
Mani S S, Srikanthan S, Selvaraj B, Menaka V, Parangimalai Diwakar MK. Effectiveness of 0.2% chlorhex plus and 0.1% turmix as preprocedural mouthrinses on aerosol contamination produced by ultrasonic scalers: An interventional study.J Dent Res Rev 2020;7:5-9


How to cite this URL:
Mani S S, Srikanthan S, Selvaraj B, Menaka V, Parangimalai Diwakar MK. Effectiveness of 0.2% chlorhex plus and 0.1% turmix as preprocedural mouthrinses on aerosol contamination produced by ultrasonic scalers: An interventional study. J Dent Res Rev [serial online] 2020 [cited 2020 Jun 5 ];7:5-9
Available from: http://www.jdrr.org/text.asp?2020/7/1/5/281508


Full Text



 Introduction



Aerosols produced in the dental office possess the quality of disease transmission to health professionals and also the patients and in turn have become an area of paramount importance in dental research. Dental procedures involve compressed air and water to produce contaminated aerosols and splatter. These aerosols when evaporated from the droplet nuclei composed of saliva, dried serum, and microorganisms. Splatter is referred to aerosol-containing particles measuring more than 50 μm, whereas droplet nuclei measure <50 μm which remain suspended in the air hours together, thus leading to infection due to inhalation.[1] Dutil et al. reported that dental professionals are exposed up to 1.86 E + 05 bacteria/m3 of air.[2]

Various dental procedures, such as cavity preparation, ultrasonic scaling, extraction, and oral examination, produce bioaerosols with the mean levels of 24–105 CFU/m3, 42–71 CFU/m3, 9–66 CFU/m3, and 24–62 CFU/m3, respectively.[3] As recommended by Harrel and Molinari, the three levels of defense in the reduction of aerosols are the use of a personal protective barrier such as masks, gloves, and safety glasses, routine use of a preprocedural rinse, and use of high evacuation device.[4]

Chlorhexidine (CHX) is still considered the gold standard antimicrobial mouthwash because of its broad spectrum of the bacterial activity and prolonged substantivity.[5] Though Chlorhexidine has some common side effects like staining of teeth and alternation in taste still consider as gold standard. Essential oil mouthwashes have been used for years as a supplement to toothbrushing in the maintenance of oral hygiene. Literature evidence finds these mouthwashes to be extremely effective in controlling plaque and gingivitis in conjunction with killing microorganisms by destroying their cell walls and inhibiting their enzymatic activity. Herbal products have minimal side effects and also consider as an economical. Among the available herbal products, turmeric possesses anti-inflammatory, anti-oxidant, and anti-microbial properties, along with its hepatoprotective, immunostimulant, antiseptic, and antimutagenic properties. Hence, the use of turmeric in conjunction with essential oil as a preprocedural mouthrinse as compared to CHX requires rigorous research.

The mobile dental unit (MDU) serves primarily in dental camps by providing care to those who are in need of dental care. On the contrary, the closed operatory of the MDU with limited working space and ventilation makes it an area with immense risk in acquiring infections during dental procedures. Aerosols generated during dental treatment procedures, to a larger extent, radiate toward the patient's chest and the operator as well the dental assistant's face.[6] The air-conditioning system of the MDU could, therefore, act as a channel for the transmission of bacteria and other microorganisms in the dental clinic.[5],[7] Hence, this study aimed to evaluate the effectiveness of Chlohex Plus and Turmix (TRX) as preprocedural mouth rinses on the reduction of aerosol contamination produced by ultrasonic scaler inside the MDU.

 Materials and Methods



This experimental study was conducted in the dental operatory of MDU of the Department of Public Health Dentistry, Chennai, India, with patients recruited from dental screening camps. This study was performed in accordance with the Declaration of Helsinki, and ethical approval was obtained from our college. Participants were asked to sign the informed consent before the start of the study.

Inclusion and exclusion

Participants aged between 20 and 55 years having >20 permanent teeth with plaque scores between 2 and 3. Nonsmokers who are systemically healthy in nature were included in the study. Participants under medications that affect oral cavity tissues and those who had undergone any surgical/nonsurgical oral procedure within 3 months before the start of the study or those suffering from any chronic systemic condition were excluded from the study.

Procedure

The MDU was fumigated with portable ultraviolet (UV) torch of wavelength 400 nm UV light and were disinfected using isopropyl alcohol. At the initiation of procedure, a set of Petri dishes of blood agar with 5% red blood cell and neomycin blood agar (selective for anaerobes) were placed on the chest of the patient, and the operator which was stabilized with the help of double-sided adhesive tape at a distance approximately 5 feet away from the patient's mouth shown in [Figure 1]. Ten minutes before the start of treatment with ultrasonic scalers, the patients were asked to rinse with 15 ml 0.2% Chlohex Plus (1:1 dilution) for 30 s who were in Group 1 (15 patients), expectorate immediately and rinse again for 30 s. Similarly, Group 2 (15 patients) were given 15 ml of 0.1% TRX mouth rinse (curcumin longa and essential oil combination)-(1:1 dilution) and they were asked to rinse for 30 s, expectorate, and then rinse again for 30 s. Ultrasonic scaling was performed for each patient for a time period of 15 min using a piezoelectric ultrasonic scaler and a motorized suction was used. The treatment was performed on per patient per day basis.{Figure 1}

Microbiological evaluation

The neomycin blood agar plates were spot incubated in the anaerobic jar using the GasPak system for anaerobiosis and transported immediately for further incubation at 37°C for up to 7 days. After incubation, the total colony counts were estimated with the digital colony counter, and individual colonies were phenotypically identified by colony morphology on blood agar, Gram staining, catalase, and bile esculin agar.

Statistical analysis

The data were collected and tabulated in the Microsoft Excel format, and the statistical analysis was performed using the SPSS software version 18 (IBM, Armonk, NY, USA) and was expressed as mean colony-forming units (CFUs)/mL. The total sample size was thirty patients with chronic periodontitis. The comparison of CFUs formed on blood agar plates in two groups after ultrasonic scaling was also assessed.

 Results



The frequency of anaerobic bacterial distribution of CFUs on blood agar plates for each two groups at two different standard locations (doctor and patient chest area) 5” feet away from the patient's mouth is shown in [Graph 1]. The results demonstrated that, rinsing with these mouthwashes could reduce the microbial load in the oral cavity.[INLINE:1]

This study demonstrates that the number of CFU/mL of the anaerobic bacteria from the aerosol generated after prerinse with CHX was found to be 15% on doctors' chest area and 52% on patients' chest area, respectively. Similarly with TRX, prerinse was found to be 8% on doctor's chest area and 25% on patient's chest area, respectively. The TRX prerinse was found to be more effective than the CHX prerinse. TRX was found to be <50% of the mean effective prerinse CHX threshold.

The quality control was performed with open-plate method before and after UV treatment and the baseline for the total anaerobic bacteria colony count was assessed [Figure 2] shows. The CFU was also tested for the water unit, a swab from probe onto the neomycin blood agar. Bacteriods spp. and the Peptostreptococcus spp. were the most common anaerobic pathogens isolated from the aerosol tested, which is strongly suggestive of aerosol were directive from patient sample only. There are certain few other anaerobic pathogens also isolated from the samples which include Fusobacterium spp., Bifidobacterium spp., Prevotella spp., and Actinomycetes spp., respectively, as shown in [Table 1].{Figure 2}{Table 1}

 Discussion



Aerosol produced while performing a dental procedure in conjunction with bacterial contamination can cause a potential threat to the dentist as well as to the patients. This study has proven that aerosol and splatter are produced in significant amounts by the ultrasonic scaler device in the field of dentistry. There is a potential risk for infection to spread owing to the aerosols produced. This necessitates the use of mouth rinses before the procedure to keep the bacterial load minimal.[8],[9],[10]

The results of this study showed that aerosol from the participants who rinsed with 15 ml of 0.1% TRX mouthrinse (Curcumin longa and essential oil combination 1:1 dilution) before undergoing an ultrasonic scaling, carried a strikingly lower bacterial content than aerosol from participants who rinsed with Chlorhex Plus (CHX based) mouthwash.

Yadav et al.[11],[12] reported that the microbial aerosols were produced in large concentrations in dental clinics during ultrasonic scaling (47%) and to a comparatively lesser extent during cavity preparation (11%).[13],[14] Periodontal procedures caused more contamination because of significantly higher risk of bleeding and irritation to the soft tissues of the oral cavity during scaling. The culture plates which were placed on the chest of the participants who were in the TRX group exhibited fewer bacterial colonies than the participants who rinsed with CHX mouthwash, proving that TRX solution reduces bacterial levels in the oral cavity significantly more than CHX.[9],[15] TRX has an additional advantage over CHX due to its lesser cost and higher patient acceptance.

The CFU recovered from the patient's chest when prerinsed with both the mouthwashes was found to be maximum, which is in concurrence with the results from the research by Bentley et al.,[16],[17] where there was a higher contamination of salivary droplets produced during dental procedures settling rapidly from the air on the chest of participants. However, CFU count on the operator's chest area was found to be comparatively lesser, as the operator was exposed to a spray that was deflected and not the spray directly emitted from the patient's mouth. These findings were in accordance with the research by King et al.[10],[18],[19],[20]

The oral bacteria of Bacteroides, Fusobacterium, and Lactobacillus are involved in causing dental caries and periodontal diseases and have opportunistic pathogens if allowed to accumulated on tooth surface in plaque.[21] TRX showed significant reductions in anaerobic bacterial load on the aerosols produced during ultrasonic scaling. Snophia Suresh et al.[22] found that preprocedural rinsing with CHX mouth rinse was much better in reducing bacterial aerosols when compared with an essential oil mouth rinse, which was in contrast to the findings of our study wherein the results suggest that preprocedural rinsing with TRX mouthwash-containing essential oil was much better in reducing bacterial aerosols when compared with CHX.[23],[24]

The clinical significance of this study result warrants the mandatory use of preprocedural rinse to prevent disease transmission through aerosols, particularly when dentists conduct screening and treatment camps in the MDU. It is mandatory to use preprocedural rinses, especially in those patients with infectious diseases. To prevent aerosol transmission cases with infectious diseases, hand scaling serves as a recommended mode of the treatment.[25],[26]

The limitations of this study are that the CFUs counted here are values that represent the anaerobic bacteria capable of growth on blood agar plates. Moreover, viruses and specific bacteria which require specialized media were not cultured in this study.

 Conclusion



Our study concludes that the usage of a preprocedural mouth rinse shows a significant reduction in microbes generated during ultrasonic scaling. This can be of paramount importance in protecting patients as well as dental care professionals during oral care procedures. Hence, the routine use of CHX and TRX mouthwash before all dental procedures could be a real-time solution in reducing the microbial count in the dental care setting, thereby significantly eliminating the possible induction of bacteremia in a dental care clinical setup.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Samaranayake LP. Essentials of Microbiology for Dentistry. 2nd ed. Edinburgh: Churchill Livingstone; 1998.
2Dutil S, Meriaux A, de Latremoille MC, Lazure L, Barbeau J, Duchaine C. Measurement of airborne bacteria and endotoxin generated during dental cleaning. J Occup Environ Hyg 2009;6:121-30.
3Hallier C, Williams DW, Potts AJ, Lewis MA. A pilot study of bioaerosol reduction using an air cleaning system during dental procedures. Br Dent J 2010;209:E14.
4Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc 2004;135:429-37.
5Bhanu M, Deepali B. Infection control and prevention in dentistry. Int. J Dent Adv 2011;3:577-82.
6Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: A review. Int Dent J 2001;51:39-44.
7Al Maghlouth A, Al Yousef Y, Al Bagieh N. Qualitative and quantitative analysis of bacterial aerosols. J Contemp Dent Pract 2004;5:91-100.
8Gupta G, Mitra D, Ashok KP, Gupta A, Soni S, Ahmed S, et al. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: A pilot study. J Periodontol 2014;85:562-8.
9Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent Assoc 1994;125:579-84.
10King TB, Muzzin KB, Berry CW, Anders LM. The effectiveness of an aerosol reduction device for ultrasonic scalers. J Periodontol 1997;68:45-9.
11Yadav S, Kumar S, Srivastava P, Gupta KK, Gupta J, Khan YS. Comparison of efficacy of three different mouthwashes in reducing aerosol contamination produced by ultrasonic scaler: A pilot study. Indian J Dent Sci 2018;10:6-10.
12Holloman JL, Mauriello SM, Pimenta L, Arnold RR. Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling. J Am Dent Assoc 2015;146:27-33.
13Yadav N, Agrawal B, Maheshwari C. Role of high-efficiency. SRM J Res Dent Sci 2015;6:240-2.
14Swaminathan Y, Thomas JT. “Aerosol”-a prospective contaminant of dental environment. IOSR J Dent Med Sci 2013;11:45-50.
15Miller RL, Micik RE, Abel C, Ryge G. Studies on dental aerobiology. II. Microbial splatter discharged from the oral cavity of dental patients. J Dent Res 1971;50:621-5.
16Kedjarune U, Kukiattrakoon B, Yapong B, Chowanadisai S, Leggat P. Bacterial aerosols in the dental clinic: Effect of time, position and type of treatment. Int Dent J 2000;50:103-7.
17Timmerman MF, Menso L, Steinfort J, van Winkelhoff AJ, van der Weijden GA. Atmospheric contamination during ultrasonic scaling. J Clin Periodontol 2004;31:458-62.
18Runnells RR. An overview of infection control in dental practice. J Prosthet Dent 1988;59:625-9.
19Larato DC, Ruskin PF, Martin A, Delanko R. Effect of a dental air turbine drill on the bacterial counts in air. J Prosthet Dent 1966;16:758-65.
20Travaglini EA, Larato DC, Martin A. Dissemination of organism-bearing droplets by high-speed dental drills. J Prosthet Dent 1966;16:132-9.
21Williams 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;49:1498-504.
22Suresh S, Mahendra J, Kumar AR, Singh G, Jayaraman S, Paul R. Comparative analysis of subgingival red complex bacteria in obese and normal weight subjects with and without chronic periodontitis. J Indian Soc Periodontol 2017;21:186-91.
23Reddy S, Prasad MGS, Kaul S, Satish K, Kakarala S, Bhowmik N, et al. Efficacy of 0.2% tempered chlorhexidine as a pre-procedural mouth rinse: A clinical study. JISP 2012;16:213-17.
24Logothetis DD, Martinez-Welles JM. Reducing bacterial aerosol contamination with a chlorhexidine gluconate pre-rinse. J Am Dent Assoc 1995;126:1634-9.
25Veksler AE, Kayrouz GA, Newman MG. Reduction of salivary bacteria by pre-procedural rinses with chlorhexidine 0.12%. J Periodontol 1991;62:649-51.
26Muir KF, Ross PW, MacPhee IT, Holbrook WP, Kowolik MJ. Reduction of microbial contamination from ultrasonic scalers. Br Dent J 1978;145:76-8.