Aerosol extraction at the source to decrease the spread of infectious diseases in a dental setting

After COVID-19 struck the U.S. in March of 2020, companies and businesses all over the country had to shut their doors. On March 15, 2020 dental offices in California were asked to close to conserve PPE (Personal Protective Equipment).  Like many other businesses forced to close, Dr. Larsen chose to use that time to learn as much as possible about the virus and how her dental practice could be the safest possible facility.

Dental healthcare professionals have long been exposed to various illnesses and understand the importance of infection control precautions that include always wearing masks to protect themselves from large particle splatter. This includes Dr. Larsen, a San Diego dentist who has been practicing for 20-years at Xceptional Dental. Dr. Larsen graduated from Dental School just as the world addressed the risks of AIDS.  Known to be a blood-borne disease, AIDS was managed using ‘Universal Precautions’, effectively assuming that any person could be infectious.  Dental precautions of surgical masks, eye protection, gloves and gowns became the standard of practice.

 

With COVID-19, a whole new challenge was presented. COVID-19 had no cure, spread worldwide very quickly, and no person has an immunity to it. When the pandemic hit there was great debate about whether the virus transmission was by fomites (touching surfaces) or by aerosols (large and small droplets suspended in the air). Around the world there were “instant experts” that created near hysteria about how it should be contained. Dr. Larsen took a rational but comprehensive approach to battling the spread and keeping her dental practice safe.  Beginning in April, the team immediately addressed the transmission risks with all known protocols:

• Installed a continuous plexiglass barrier separating the reception area from the front desk;
• Disinfected the office with regular ‘fogging’ of the entire facility with HypoChlorous Acid (HOCL), the FDA approved technique now used in casinos, ships and large public venues;
• Enhanced disinfection with the wipe down of all surfaces, switches, doorknobs and other touch-points with a FDA registered disinfectant
• Removed of all magazines, brochures and other reading materials that might transfer the virus
• Restricted the use of the “waiting room” and increased separation of people inside the office
• Reduced cross-contamination with doctor and her staff changing into and out of full surgical garb in a separate facility
• Established a ‘Call before entering’ protocol for patients arriving at the dental office
• Replaced HVAC (Heating, Ventilation & Air Conditioning) filters with HEPA-grade units (High Efficiency Particulate Air)
• Developed a reliable supply of disposable PPE: KN-95 masks, face shields and gloves.

Even with all these precautions, Dr. Larsen knew she needed something more to keep her practice safe form the incredibly small virus that was looking more like it was airborne. Dr. Larsen knew that all dental offices had to better manage their Aerosol Generating Procedures - a challenge that has been increasing in dentistry because of its high speed handpieces, air-water spray, and ultrasonic scalers - all great at increasing quality and efficiency but also adding contamination and infection risks for the team and subsequent patients in the office.

Despite the precautions dentists take for ensuring proper hygiene and preventing the spread of disease, dental offices present viruses and infectious diseases with an environment difficult to manage. In the case of the incredibly small COVID-19 virus, it is even more difficult. That’s because routine dental equipment, like ultrasonic scalers and high-speed handpieces, are regularly used in Aerosol Generating Procedures. The result are aerosolized particles that can linger in the air and can infect the team and subsequent patients. This is the crux of the ‘Source Capture’ strategy - you greatly improve the situation by collecting all the potentially contaminated particles immediately as they leave the patient’s mouth.

PPE is commonly called the ‘last line of defense’ and is never a complete solution to an aerosol viral threat. Dr. Larsen and her team evaluated the existing aerosol management devices and found them lacking in both capture of the aerosol particles and their reliance of using a filter with the hope that it would allow the recirculation of the air back into the treatment rooms. Dr. Larsen concluded that she needed to capture the aerosol particles with a powerful suction and then exhaust that to a safe location outside the facility. Working with Nederman her team employed this strategy with a ventilation system that completely removes the threat of contaminated aerosols at the source, the patient’s mouth.

Finding benefits from a long-term aerosol control strategy

In mid-March, immediately after receiving the government order to halt regular services, Dr. Larsen began frequent virtual calls with her dental team.  They discussed the known and suspected challenges to reopening the office.  “The staff was having panic attacks,” said Dr. Larsen. She knew she needed an effective aerosol solution since the virus was most likely spread by aerosols, these team conversations also reinforced her conclusion that she needed to deploy a solution that was superior to any system being marketed by the regular dental vendors.

In May, as dental offices restarted regular patient services, many hygienists had left the dental field altogether because of the fear of coming in contact with COVID-19 at work. The threat of aerosol transmission combined with the exceptionally close proximity to patients who may be infected created a situation that left many fearing the worst. The hygienist working at Xceptional Dental hadn’t quit, but she was afraid to return to the office. They had installed and tested the Nederman system at each chair, but could not convince the nervous hygienist to even examine the safety precautions.

Coincidentally, Xceptional Dental had arranged for a hygienist working with another dentist to fill-in while they restarted regular services.  This temporary hygienist was so impressed with Dr. Larsen’s infection control preparations and the Nederman system that she is now the full time hygienist for Xceptional Dental.

As part of their aerosol management, the office upgraded all filters in their Heating, Ventilation and Air Conditioning (HVAC) system to HEPA-grade.  While HVAC ventilation systems do help purify and capture some infectious particles by filtering the circulating air, they do not eliminate aerosols at the source and potentially distribute contaminated air in the facility. Dr. Larsen and her team understand that without the Nederman source capture equipment, people in the room and throughout the facility can come in contact with aerosols before they’ve been extracted from the environment.

Lastly, but probably most important, the patients of Xceptional Dental have all remarked how the Nederman system and other precautions have created a feeling of safety that they truly appreciate. The office is in a high technology location with many patients that are technically qualified to understand the value of source capture and direct exhausting of the air to improve the ventilation and reduce the chance of infection. Dr. Larsen has reported that there has not been a single incidence of patients feeling uncomfortable with the proximity of the Nederman vacuum arm; just the opposite.

It’s a Win-Win-Win situation for the dentist, her team and the patients.

Chairside Aerosol Extraction at Xceptional Dental using the FX₂ Extraction Arm

 

Nederman FX₂ an aesthetic, smooth and durable aerosol control solution

At the beginning of the COVID-19 outbreak, Dr. Larsen and her husband, a mechanical engineer, sought out information on all manners of aerosol management systems.  Their quick assessment was that the problem was too important and difficult to be solved with a ‘Vac-In-A-Box’ being hastily marketed throughout all the dental magazines and suppliers. These stand-alone units could not solve the basic problem of maintaining enough airflow while satisfying their other requirements. They wanted a solution that would do the infection control job while meeting several competing challenges:

1. The ventilation device must have a high flow rate to capture large and small particles ejected from the aerosol-generating procedures that could be the source of COVID-19 infections and other future threats.
2. The ventilation equipment must be industrial-grade to hold up under the continuous work of a dental office, yet must be attractive and not look completely out of place in the aesthetic treatment rooms. The Nederman FX₂ Extraction Arm uniquely met this need.
3. The noise created by the high airflow rates cannot be distracting or discomforting to the patients and team. Xceptional Dental’s former theme was ‘A Calm & Comfortable Dental Experience’. This new equipment and all the other precautions have transformed that theme to ‘A Calm, Comfortable & Safe Dental Experience.’
4. The installed piping, fans and electrical equipment must fit within the limited workspace of existing treatment rooms and be near-free of any special maintenance.That was only possible with ‘best-in-class’ selection of equipment and custom installation

Dr. Larsen asked the simple question: “What other industry in the world does this sort of source-capture air extraction?”  The now-obvious answer is to look outside of typical dental and medical solutions.  A quick search led to identifying Nederman as the supplier of vacuum systems for industrial processing like welding, chemical processing and other hazardous situations. Very quickly it became apparent the dental ventilation system would be based upon the Nederman FX₂ Extraction Arm.

The FX₂ Extraction Arm is engineered and designed to act as a long-term solution for aerosol removal with an aesthetic, smooth, and durable design that suits medical office atmospheres. The FX₂, which can be mounted to the wall or ceiling, was adapted to floor mounting of Dr. Larsen’s single chair arrangements. The arm is easy to position, extend, and retract because it’s highly flexible and can rotate 360 degrees. The hood can be locked into place, securely positioned adjacent to the patient’s mouth, without obstructing any dental procedures.

When Dr. Larsen first learned about the FX₂ Extraction Arm, she was impressed by many of its features. First and foremost, it didn’t require any filter maintenance, unlike a Vac-In-A-Box system where the filter has to be changed in order to ensure optimal efficiency.

The FX₂ was designed in such a way that it works within the complex treatment room. Mounted to Dr. Larsen’s floor, it didn’t obstruct the footpath of any of her staff during their normal dental procedures. This is a key difference between the FX₂ and other Vac-In-A-Box mobile vacuum systems, which require large, noisy machines to be plugged in, consuming valuable floorspace while making the patient even less comfortable.

What Dr. Larsen liked best about the FX₂ Extraction Arm was that it actually looked like it belonged in a dental setting. Visually, it didn’t remind patients of the potentially dangerous aerosols that the machine was designed to extract. The patients didn’t feel uneasy because the FX₂ uses effective engineering of low-noise airflows in its design and it’s motors and fans are mounted outside the building.

What Dr. Larsen liked best about the FX2 Extraction Arm was that it actually looked like it belonged in a dental setting. Visually, it didn’t remind patients of the potentially dangerous aerosols that the machine was designed to extract. The patients didn’t feel uneasy because the FX2 uses effective engineering of low-noise airflows in its design and it’s motors and fans are mounted outside the building. “The solution can’t look scary,” Dr. Larsen said. “Patients are already filled with fear and anxiety. I thought about how claustrophobic patients would feel with intrusive stand-alone floor equipment, and I wanted an aerosol solution that wouldn’t scare them.” When she saw the FX2 Extraction Arm, she thought, “Oh that does look nice.” After Dr. Larsen contacted Nederman, a representative helped her find the optimal area to mount the arm, as well as helped her find technicians to complete the installation. Nederman understands that installation of the FX2 is technical in nature and requires someone with special training, which is why the company partners with customers and connects them with trained clean air professionals to properly install and set up the arm.

  Nederman FX₂ Aerosol Extraction System

FX₂ aerosol extraction - a clear signal of enhanced safety

After the FX₂ Extraction Arm was installed, Dr. Larsen saw a small adaptation period requiring minimal adjustments from her team, like putting the dentist tray off to the left rather than on the other side of the dentist chair. Otherwise, her staff was able to resume their day-to-day processes of treating and caring for patients. She noted that many mobile units rely on a large, intrusive shield to compensate for their limited flow rates, significantly changing the treatment procedures.

With the FX₂ Extraction Arm in place, Dr. Larsen and her staff began to feel much better and safer about going to work each day. The new office hygienist loves the FX₂, and in fact, is the biggest fan.

“It captures aerosols and increases ventilation. It's like having open window right by your mouth,” said Dr. Larsen said. “If I could do dentistry outside, this is the closest thing. It’s bringing the outdoor in.”

Due to the FX₂’s efficient design and unobtrusive nature, it offered Dr. Larsen a long-term solution that she could continue to use in the future to enhance the infection control safety of her overall practice. She believes it will offer protection not just from COVID-19, but also from other contagious diseases and illnesses like the flu.

Dr. Larsen also noticed that the FX₂ Extraction Arm helped change her patients' perception of dentists. Before, patients didn’t really notice all of the precautions Dr. Larsen and her team took to keep the office safe. The installation of the FX₂, however, was a clear signal to patients that Dr. Larsen put their safety and comfort above all else.

“Patients say that they just feel so safe and feel very comfortable coming back,” said Dr. Larsen, “They really like it.

Xceptional Dental – Calm, Comfortable and Safe Dental Experience

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