Dental aerosol evacuation

Best methods for dental aerosol evacuation

Dental aerosol evacuation or reduction is a major issue with the COVID-19 virus and dentists are buying up all kinds of filtration devices without any testing or knowledge of effectiveness.

Why is dental aerosol dangerous?

Dental aerosols are small droplets which remain suspended in air and consist of blood, saliva, tooth debris, dental plaque, calculus and restorative materials. An infected person will cover anyone working on them with dental aerosols that have the potential to infect those individuals. Although this is not likely to be the main method in which dental professionals can contract diseases from patients, it very possible. Prior to COVID, dental aerosol was not seen as a major risk to our profession and that may continue but right now, no one knows.

Differences between true large droplet transmission and airborne transmission

True aerosol transmission or airborne transmission require the disease agent to be transmissible in the 10 μm and under particles. 10 μm and under is the definition of aerosol. 20 μm and over are large droplets and have different properties, they only need surgical masks for PPE. This typically means that those droplets fall to the floor quickly but airflow issues make that complicated. The 10-20 μm particles are the gray area.  Tellier 2019 BMC Infectious Diseases 50 μm particles are considered splatter in dentistry and are definitely not of a concern in regards to aerosols. Harrel JADA 2004

How long do aerosols stick around?

Complicated question because it depends. However, a true aerosol may be present in the air of the operatory for up to 30 minutes after a procedure. Hinds 1999

When do we produce aerosols in dentistry?

Dental handpieces, ultrasonic scalers and piezo units, air polishers and air abrasion units produce the most visible aerosols.

Are HEPA filters the answer right?

Yes, they are. Some will say that since the HEPA filter is rated for .3μm and viruses are around .1μm that means they will not work on viruses. Well that’s not true. The hardest particle size to capture is .3μm but both larger AND smaller are actually easier to catch. The rational is counter-intuitive but is easily understood once you read the attached article.

The problem with N95 masks

N95 filter more particles in the lab but when it comes to real life studies they repeatedly perform no better than surgical masks. Smith 2016 and Long 2020 One can find lab studies that show surgical masks by themselves could prevent corona virus and influenza. Leung 2020 It is my opinion that the PPE is not the weak link and making it better isn’t helping. Stopping people from touching their face and increasing hand washing will help. The biggest thing we can do IMHO is to reduce the creation of aerosol or eliminate it quickly.

What are dental professionals using today to reduce our risk from aerosol?

Dentists currently use pre-procedural rinses, standard and cone modified high evacuation suction, rubber dams, and things such the Isolite to reduce aerosol. The rubber dam reduces nearly all the infectious aerosol. Additionally, simply using a high-volume evacuator reduces the contamination by more than 90%. JADA 2004Harrel However, none of these are 100% effective and we are unlikely to ever hit that number. We can lower the amount and lower our risks but there will never be a perfect solution. We are currently doing a very good job but there is always room for improvement, the question is at what cost. Fox 2010

What methods are there to reduced dental aerosol?

Will mainly discuss the new aerosol units that are popping up everywhere. There is a nice dt thread on the issue. It is my opinion a central exhaust or chair-side external exhaust unit would be best to eliminate the contaminated aerosol outside instead of trying to filter and kill the viruses and bacteria. Theoretically these units could actually make us more sick. These units increase the airflow which prevents droplets from falling to the floor. Furthermore, they can not filter out all of the virus and could possibly end up spreading the virus even further. Overall, I feel they significantly reduce the viral load in the air but that is not known.

Office HEPA units

Surgically clean air is the unit we have in our office. It does not get the aerosol directly and is more like a high level stand-alone HEPA filtration system you buy at the store.

Chair side dental aerosol evacuation units.

The IQAir unit does have some research.

The VacStation looks similar to many “generic” units available. Another similar generic unit. The Vaniman looks very similar to the two units before this but you will be able to get more data and talk to someone from this company. It should be more trustworthy. Another unit that was not meant for dental but should work well.

The DentAirVac has been in dentistry for a long time. It’s primary use was for air abrasion units and holistic dentists removing amalgam. Ajax is the unit that we have bought, only because that is what our rep can get us at this time.

I worry about the practically of these units and how much sound they make.

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Soft tissue lesions

A list of a few of the less common dental soft tissue lesions

Dental soft tissue lesions that I think are interesting.

Epulis granulomatosa

Epulis granulomatosa is found in poorly healing post extraction sites. The lesion just needs excision. I

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All on 3

What is an all on 3?

All on 3 is the short name for an implant supported prosthesis that is only on 3 implants instead of the traditional minimum of 4. It is definitely more controversial but seems to work well in the lower jaw.

All on 3 (AO3) research

An AO3 works according to Oliva 2012, but this was a small study where all but 1 case was loaded conventionally. Bedrossian JOMI 2019 states AO3 is fine but should use wider diameter implants.

The dental implants seem to hold up with same percentage but the prosthesis may have more issues according to Lima JOMI 2018. Mezzari JOMI 2019  has a 5 year study on the all on 3 showing 97% success at 5 years when done in the mandible.

The example below is from a multi-national study and is showing success. Kenji 2020 JOMI

This one is a novel all on 3 design.

All on 2 and all on 1 or fixed-on-1 and fixed-on-2

This can work in the right circumstance. It is very outside the normal treatment regimen though and should be a last effort on a very old patient opposing a denture. Cannizzaro JOI 2019

What are the steps for the AO3?

The steps are the same as any implant supported denture.

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White bump in a baby’s mouth

Did you find a small white bump in your baby’s mouth or on your baby’s gums?

A white bump in your baby’s mouth or on their gums is almost always going to be a benign keratinous cyst. That means it is nothing to worry about and it will go away on it’s on.

What are the small white bumps in your baby’s mouth?

They are likely milia, which are benign, keratinous cysts that commonly look like tiny white heads on the face of newborn babies. When these milia are present in the mouth they are known as Bohn nodules or Epstein pearls.

What are Bohn nodules?

That is the name given to the cysts if they form on the gums of your baby.

What are Epstein pearls?

That is then name given to the cysts if they form on the palate or roof of the mouth of your baby.

 

What should you do about these cysts in your baby’s mouth?

Nothing they will go away on their own. Keratin is what hair and nails are made of and this is somewhat similar. There is no need to see a dentist for this, some may not even know what it is because they are unimportant. A pediatric dentist will likely be able to identify it for you very easily though. As we mentioned though, you should be able to diagnosis this yourself with the help of an image internet search for the terms Bohn nodule or Epstein pearl.

How do these Bohn nodules and Epstein pearl cysts go away?

The cysts grow and rupture on their own over the course of 2 weeks to 5 months. They are most often gone by the time a baby is 3 months of age. However, older babies can get them and they can last longer, it’s just rarer.

 

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The implant retained denture

What are implant retained dentures or locator denture?

Implant retained dentures are a type of overdenture that you can take in and out to clean and attaches to dental implants. It differs from the bar overdenture in that the implants attach directly to the denture instead of to an intermediary bar.

Implant and Tissue Supported Overdenture or Implant retained overdenture

Implant and Tissue Supported Overdenture is a patient removable prosthesis that gets support from both dental implants and patient tissue. I prefer the term implant retained denture. It has either a bar or studs on the implants.  Requires fewer implants than any other option.  Ensure if bar with clips only one as multiple inadvertently creates a supported prosthesis.

For mandible 2 with bar is best and clip with intimate contact OR 2 individual and want lateral throat form

Best location for 2 implant mand OD is in lateral incisor area with short attachments

Some reinforce acrylic with metal mesh to reduce acrylic fractures. 4 is minimum in maxilla with no palatal coverage but full tuberosity coverage. JOMI 2007 Cavallaro Tarnow   2 implants then denture works just like traditional denture.

Minimum requirement vertically is about 10mm with an ideal breakdown of 2mm for tissue, 2mm for denture acrylic base, 3mm for denture teeth, and 3.35mm for a locator.  For horizontal space constraints a Micro-ERA is 4.43mm so 8mm total is minimum, that leaves 2mm acrylic both sides. For a locator overdenture you need about 9mm vertical and horizontal, but would like to see 10-12mm Lee 2006 JPD Sadowsky 2007 JPD

Reference

How do we measure vertical space for a locator denture?

To measure the space available we have 3 main options

1. Make radiographic template (code 6190) and have them wear during CBCT
2. Measure existing/new denture or area with boley gauge, this method is the least diagnostic.
3. Matrix capture of denture teeth, if not doing CBCT then this is best method.

CBCT option 

This is a double scan technique.  One in which they are first scanned wearing the prosthesis and then the prosthesis is scanned by itself.

1. If patient is edentulous then make a duplicate of the finished temporary prosthesis with to wear as a radiographic template.
2. If patient has some teeth remaining do same thing, just remove the teeth that are still present from the duplicated finished temporary prosthesis
3. To make the radiographic template use 1:3 ratio barium sulfate powder (Hypaque Sodium by Amersham Health) OR
4. #6 round but to 1/2 depth around the lingual flange and fill with gp and polish off with rubber OR
5. Add radioopaque glass beads
6. Can mark attached tissue like seen in A Technique to Identify Attached Gingiva During Virtual Implant Planning
7. Patient wears during CBCT and besides reading bone levels can measure space available.

Matrix option

1. Once have approved wax baseplates can just remove from mounted models and measure.
2. There is several much more complex Aug 10ways to do this but I don’t see how they are a whole lot more informative.

Implant retained denture dental code = Locator denture dental code

This would be a locator or ERA retained denture.  These would be dentures that are retained by implants (actually some type of abutments), but are supported by tissue as well as the implants.

D5862 per each Precision attachment (set of male and female components reported as one precision attachment) (so locator or ERA)

D5110 or D5120 denture might be easier to use but D5863 or D5865 Complete Overdenture is the correct code.

Attachment options for implant retained dentures are found in the link.

Treatment planning of the implant overdenture

Implant retained overdenture is very similar to denture and a fixed detachable provisional

 Implant overdenture procedure in a step by step format

Steps for the initial impression for the implant overdenture

1. Measure depth from implant platform to most coronal aspect of surrounding gingival tissue for depth locators
2. Take alginate impression

Steps for the final impressions for the implant overdenture

1. Seat locator abutments to specified torque
2. Place implant impression copings
3. Clear thermoplastic tray by Massad or custom tray
4. Paint tray with PVS adhesive
5. Rigid PVS on palate, tissue areas, and directly over implant copings to act as stops.
6. Trim most away most material except for solid stops on palate, tissue both sides, and on copings.  Leave just enough for positive seat of copings, do not come up sides.
7. Med PVS on periphery and light inside border mold.
8. Ask for processed denture base with metal subframe mesh support (probably? some say rather no and let acrylic break before implant does) with holes to pick up locators exactly.
9. Also want wax rim with central SR Phonares set in wax
10. Follow denture thread instructions from here

Steps if picking up overdenture intra-orally

1. Place locator block out spacer ring and then titanium cap with black processing male (1 at a time? 2 at a time? just not all)
2. Ensure locators with metal housing not hitting
3. GC fit check
4. Adjust as needed and then place undercuts with #8 bur
5. Place vent hole to palatal or lingual
6. Refine occlusion now
7. Adhesive painted on denture area
8. Petroleum jelly in areas don’t want maybe
9. Block out undercuts on implant (if any) with silicone like fit check or Fit Test C&B VOCO
10. Place resin in hole and seat denture  self cure or LC if can
11. Have the patient feel their masseter with their hands as they close and then clench and repeat until they can tell when the muscle is starting to clench.  Tell them you want them to close but not clench at all when doing your reline.
12. Remove and fill small voids with LC resin
13. Remove processing male insert and place appropriate strength

Implant retained denture loading and other instructions

Early loading of the implant overdenture is anytime we load between 48 hours and 3 months. Loading lower unsplinted implants at 1 week has same results as at 6 weeks with 14mm implants and a flapless surgery. While still healing recommend a soft diet and removal at night with thorough oral hygiene instructions. Should fabricate a night guard for removable overdentures in order to protect abutments from any para-functional activity.

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Bifurcated IAN

The bifurcated inferior alveolar nerve (IAN)

Bifurcation of the inferior alveolar nerve is a common anatomical variance but can be difficult to detect.

How common is a bifurcated IAN?

It most likely occurs between 13-37%, which you can find in Yoon Gen Dent 2018. This is a wide range and there is almost certainly going to be regional genetic variation making the number trickier to pin down. The main point of these numbers is to know it exists in fairly high numbers. However, most dentists are not familiar with bifuraction of the IAN because we don’t see them. That is fine because often we don’t have a care or need to look for it. Studies show that less than 1% of the bifurcations will show up on a pano. So similar to the mandibular incisive canal, the better equipment we have the and the better we are at looking for it, the more we find.

When does a bifurcation of the inferior alveolar nerve matter?

A bifurcation could be the reason a patient is difficult to numb even though the IAN block is successful. Essentially you would need to have 2 successful IAN blocks to fully numb. To learn a few other tricks on those hard to numb patients check out the end of our blog on anesthetics.

Knowing the anatomy of the IAN is also be important in dental implant placement because damage to either branch would cause issues.

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ADA codes 2020

ADA dental code changes for 2020

Information about new ADA code changes for 2020. 2019 codes are in another post.

What are the changes this year?

A lot of the changes have to do with re-cementing space maintainers or orthodontic appliances and could have been left the same. Many deal with titanium crowns, which I suppose we need.

Diagnostic ADA code changes

We have a code for salivary flow measurement now. It is D0419.

Preventive and Orthodontic dental code changes for 2020

These dental codes all deal with re-cementing and removing space maintainers. We now have them for specific arches which is probably not something that we need.

Restorative Implant and Pros changes

Many of these deal with titanium being an option for the metal work. Under the implant section there is a whole series for implant supported crowns which are useful for one piece implants like many of the zirconia implant systems.

Removable dental code changes

There are now unilateral  removable denture codes for the newer materials like Duraflex.

Oral surgery ADA code update

This one is a useful code but I doubt insurance companies are going to pay on it. The placement of intra-socket dressing to aid in hemostasis and clot stabilization is now code D7922.

 

 

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