Dental Tribune India

Generating “virus-free aerosols” to minimize the virus spread (eg. SARS-CoV-2) in dental clinics

By Rajeev Chitguppi, Dental Tribune South Asia
April 04, 2020

Dentists and dental patients are showing an ever-increasing concern about the generation of virus-containing aerosols through various dental procedures, and the resultant risk of infection spread. Povidone Iodine has shown to be effective against most of the viruses including coronavirus. Adding Povidone Iodine to the water bottle attached to the chair could be thought of as a possible solution. This is a hypothesis that can be developed further.

Droplet and aerosol transmission of 2019-nCoV are the most critical concerns in dental clinics because it is hard to avoid the generation of high quantities of aerosol and droplets mixed with patient’s saliva and even blood during dental procedures. Devices such as high-speed dental handpieces when used in the patient’s oral cavity can generate a large amount of aerosol and droplets mixed with the patient’s saliva or even blood. Particles of droplets and aerosols are small enough to stay airborne for an extended period before they settle on environmental surfaces or enter the respiratory tract. Thus, the 2019-nCoV has the potential to spread through droplets and aerosols from infected individuals in dental clinics and hospitals.

Article: Peng, X., Xu, X., Li, Y. et al. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 12, 9 (2020). 

DOI: https://doi.org/10.1038/s41368-020-0075-9

Link: https://www.nature.com/articles/s41368-020-0075-9

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Povidone Iodine antiseptic solutions have demonstrated >99.99% activity against both enveloped and non-enveloped viruses including Ebola, MERS, SARS coronavirus, influenza and HFMD viruses (Enterovirus 71 and Coxsackievirus A16)

Article: Eggers, M. Infectious Disease Management and Control with Povidone Iodine. Infect Dis Ther 8, 581–593 (2019). 

DOI: https://doi.org/10.1007/s40121-019-00260-x

Link: https://link.springer.com/article/10.1007/s40121-019-00260-x

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The rapid bactericidal and virucidal efficacy of povidone-iodine, including PVP-I gargle/mouthwash, against pathogens, causing oral and respiratory tract infections observed in other in vitro and in vivo studies and the established safety profile of PVP-I from over 60 years of use, provide a strong rationale for the use of PVP-I oral solution for protective oropharyngeal hygiene management for individuals at high risk of exposure to oral and respiratory pathogens.

Article: Eggers, Maren et al. “In Vitro Bactericidal and Virucidal Efficacy of Povidone-Iodine Gargle/Mouthwash Against Respiratory and Oral Tract Pathogens.” Infectious diseases and therapy vol. 7,2 (2018): 249-259. 

DOI: 10.1007/s40121-018-0200-7

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986684/

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PVP-I has higher virucidal activity than other commonly used antiseptic agents including chlorhexidine and benzalkonium chloride. It has been shown to be active in vitro against the coronaviruses that have caused epidemics in the last two decades, namely SARS-CoV causing the severe acute respiratory syndrome (SARS) epidemic of 2002–3 and MERS-CoV the agent responsible for causing the Middle East respiratory syndrome (MERS) epidemic of 2012–13. 

Povidone-iodine (PVP-I) has better anti-viral activity than other antiseptics and has already been proven to be an effective virucide in vitro against severe acute respiratory syndrome and Middle East respiratory syndrome coronaviruses (SARS-CoV and MERS-CoV). Povidone-iodine has been shown to be a safe therapy when inhaled nasally or gargled. We propose that a protocolised nasal inhalation and oropharyngeal wash of PVP-I should be used in the current COVID-19 pandemic to limit the spread of SARS-CoV-2 from patients to healthcare workers (and vice versa) and thus reduce the incidence of COVID-19.

Article:

Kirk-Bayley, Justin and Challacombe, Stephen and Sunkaraneni, Vishnu and Combes, James, The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Protect Healthcare Workers and Reduce Cross Infection. (March 28, 2020). 

DOI: http://dx.doi.org/10.2139/ssrn.3563092

Link: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3563092

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A recommended irrigant in the ultrasonic scaler is 10% povidone-iodine diluted 1:9 with water.

A higher concentration can be used if the patient accepts it. Iodophors should not be used 

In patients with sensitivity to iodine or are susceptible to hypothyroidism. Also to be avoided in pregnant women and nursing mothers because the fetus or infant could develop transient hypothyroidism.

Article: Slots J, Jorgensen MG. Efficient antimicrobial treatment in periodontal maintenance care. J Am Dent Assoc. 2000;131(9):1293–1304. 

DOI: 10.14219/jada.archive.2000.0383

Link: https://jada.ada.org/article/S0002-8177(14)62878-6/fulltext

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Conclusion: We should consider using Povidone-Iodine as an irrigant in high-speed handpieces too, as it has already been a recommended irrigant in the ultrasonic scaler. The recommendation is to use 10% povidone-iodine diluted 1:9 with water.

So if you have a half litre bottle attached to your chair: Put 50 ml of 10 % Povidone Iodine solution in the bottle and then add water to fill the bottle. So this dilution will be 50: 450 = 1:9

A few concerns will be how the devices will be able to cope up with this addition in the long run and what would be the maintenance protocols.

20 Comments

  • Dr kamran says:

    Yes only the management of waterlines and instruments have to be checked upon.
    Pvp. I is more palatable than hypo

  • Dr Shilpa Sapre Godbole says:

    Good option.. For post treatment care of our divices, maybe we can run a litre or 2 pure water through the airrotor to get the pvp cleared..just a thought.

  • Dr kumar vijay says:

    Yes good protocol for all dental offices.
    But how to maintain devices and more concern about the life of dental equippments?

  • Gagan Dogra says:

    I think that’s a great suggestion. Will provide lot of relief to dentists

  • Sounds meaningful but I wonder will it interfere in tooth prep for composites and the bearings in the cartridge and irritation for eye etc appart from sensitivity reactions.These are some viable methods if proven suitable for our country considering the socioeconomic status.This will give some hope to the youngsters who are already confused wit the prevailing WhatsApp group who post some vague ideas coming in their mind and claiming one’s experiences in the no of years practice and the wisdom etc.This period has become a good time for many individuals craving to express their credibility .They forget the future of dentistry by at least by considering the already existing situation the youngsters pass through. All the best
    Regards

  • Seems very promising. The devices shall be modified accordingly in due course if deemed so..

  • Dr JOHN JOSEPH says:

    How to correct the water lines of airotor and ULTRASONIC scalers

  • Dr Jyotsna says:

    It seems to be a good option. Although needs more clinical studies like effect of iodine on bonding of composites while doing restorations.

  • Dr Anjali Sukthanker says:

    Seems a good option….but need a study on the constant inhalation and exposure of the dental surgeon to Povidone iodine in the long run.

  • Dr. Ritesh Shekhar Shetty says:

    Please share literature of any research stating that 10 percent dilution of povidone iodine is sufficient for killing most of the virus and especially Corona virus?

  • It is pressurized air that is the problem ! New evidence is that the infected patients is shedding virus even when speaking, breathing & coughing! Rate of multiplication of virus is very high! Rapid suction with filter designed for the room & mouth may offer a good solution along with PPE! Povid iodine could be added to this! Dentists are at very high risk !

  • Really a much needed study & thought has been rolled on. We shud try to start conducting further studies on the efficacy of this pvp solution at various dental institutes level.
    Regarding the effect of it on composites I think dental enchant or dentin conditioner shud be sufficient to wipe away the effect of pvp in the prepared cavities??

  • Manjunath says:

    It’s a good idea.But what should be the contact period of iodine solution for virucidal action..Does iodine solution aerosol will kill virus..

  • Dr Chandrakant Sarangkar says:

    Time will tale us the correct solution
    May be china have been discovered it and will force the world to use it
    But don’t use china things boycott them this should be our future moto
    Use of iodine and it’s concentration it’s side effects on instruments ,on our body and on patients tooth should be checked
    JAY HIND

  • The best evidence to date suggests that the virus load in saliva and the nose is reduced markedly for between 20 and 200 minutes by PVP-I mouthwash for one minute and spray up each nostril. Research is underway to see how long exactly. It means that the risk of transmission to the HCW is reduced for long enough to examine the patient and to undertake relatively rapid procedures.

  • Dr Jyothsna V Setty says:

    The action of Povidone iodine on virus in 10% concentration that to when used as irrigation
    agent is highly questionable. Moreover patient may cough , sneeze. It should be remembered that all the secretions contain virus. This suggestion if accepted without evidence of dental environment totally getting free of covid19 will definitely be disastrous

  • Dr. AMIT KUMAR PATHAK says:

    Seems to be a good idea, but my concern is towards its use in pediatric patient or patients with poor motor control where they might swallow the solution, which may lead to several discomforts. Also on a long run, constant inhalation by doctors and the team is of concern.

  • Dr Anil Kumar Grover says:

    Appeals.,yet …Most important aerosols are known to hang in for plus two hours and over and above that too ‘ can’t be said to be sterile’ . Use of high vac suction , hepafilters and adherence to standard infection control protocol is must.
    Further multi central trial with prior approval from Ethnic Committee and Pharmaco- vigilance might be needed.
    Thanks

  • Dr rajesh k Reddy says:

    Our waterlines will go for a toss

  • Dr vijay says:

    Whats the contact time of povodine iodine which will insures killing of virus ???

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