Original Article

Effects of preprocedural mouth

Department of
1
rinse on microbial load in aerosols
Periodontics, Govt
Dental College,
produced during the ultrasonic scaling:
Ghungoor, Silchar,
2
Department of A randomized controlled trial
Periodontics,
Regional Dental Swarga Jyoti Das1,2, Darimeka Kharbuli2,3, Syed Tanwir Alam4
College, Guwahati,
4
Department of
Microbiology, Guwahati Abstract:
Medical College and Background: During ultrasonic scaling, the harbored microorganisms in the oral cavity get aerosolized, which
Hospital, Guwahati, have important impacts on air quality and can cause a serious health threat to the clinician, patients, and the
Assam, 3Consultant surroundings. Therefore, this study was conducted to evaluate whether preprocedural mouth rinse has any
Periodontist, effect on bacterial load in aerosols generated during ultrasonic scaling. Materials and Methods: A total of 80
Mebaaihum Dental subjects with chronic periodontitis were selected and randomly grouped into four comprising twenty in each. The
Clinic, Shillong, groups were based on the use of preprocedural mouth rinse: no rinse group (control) (A), and test groups with
Meghalaya, India preprocedural mouth rinse with water (B), 0.2% Chlorhexidine gluconate (C), and herbal mouthwash (D). The
aerosol produced during ultrasonic scaling was collected on blood agar plates positioned at the chest area of
This work belongs patients, operators, and assistants. Aerosol collected in the operatory before the procedure was considered as
to the Department baseline. Colonies on the blood agar plates were counted after incubating at 37°C for 24 h. Pairwise comparisons
of Periodontics, involving positions and mouth rinses on microbial colonies were conducted using independent sample t‑test and
Regional Dental Tukey’s test for post hoc analysis considering 0.05 as the significance level. Results: Microbial colonies were
significantly reduced with chlorhexidine gluconate compared to that of others (P < 0.001), followed by herbal
College, Department mouthwash and water. Again, microbial colonies were highest at the chest area of the operator and lowest at the
of Microbiology, chest area of the assistant. Conclusions: 0.2% Chlorhexidine gluconate is superior in reducing the microbial
Guwahati Medical load in aerosols produced during ultrasonic scaling.
College and Hospital, Key words:
Guwahati ‑ 781 032,
Aerosol, chlorhexidine gluconate, herbal mouthwash, microbial colonies, preprocedural mouth wash, ultrasonic
Assam, India scaling

Access this article online

Website:
www.jisponline.com
INTRODUCTION The maximum amount of aerosol is produced by
ultrasonic scalers compared to that of the other

D
DOI: dental equipment.[4,5] Patients and practitioners
ue to a uniquely moist and warm
10.4103/jisp.jisp_281_21
environment, the oral cavity harbors are regularly exposed to tens of thousands
Quick Response Code: millions of bacteria and viruses from the of bacteria per cubic meter generated during
respiratory tract, saliva, and dental plaque. procedures, [6,7] and inhalation of this may
These microorganisms get aerosolized cause adverse health effects such as common
when they come in contact with the dental cold, tuberculosis, severe acute respiratory
equipment, particularly the high‑speed syndrome (SARS), and even transmission
dental drills and ultrasonic scalers. [1,2] The of blood‑borne pathogens, namely human
ultrasonic scaler uses ultrasound to remove
calculus deposits from the teeth effectively.
Address for It oscillates (move forward and backward) a This is an open access journal, and articles are
correspondence: distributed under the terms of the Creative Commons
typically blunt metal tip at a high‑frequency Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Prof. Swarga Jyoti Das,
Department of producing mechanical vibratory, cavitational, allows others to remix, tweak, and build upon the work
and acoustic microstreaming forces in the non‑commercially, as long as appropriate credit is given and
Periodontics, Government the new creations are licensed under the identical terms.
Dental College, Ghungoor, associated cooling water that remove/disrupt
Silchar ‑ 788 014, Assam, the deposits. However, the water used as a For reprints contact: WKHLRPMedknow_reprints@
India. wolterskluwer.com
coolant is splattered during the vibration of
E‑mail: swargajyoti_das2@ the tip and becomes contaminated when it is
rediffmail.com How to cite this article: Das SJ, Kharbuli D,
mixed with saliva and plaque. The amount of
contamination of dental aerosol depends on Alam ST. Effects of preprocedural mouth rinse
Submitted: 02‑May‑2021 on microbial load in aerosols produced during the
Revised: 26-Jul-2021 the quality of saliva, nasal and throat secretion,
ultrasonic scaling: A randomized controlled trial.
Accepted: 09‑Jan‑2022 blood, dental plaque, and any dental infection
J Indian Soc Periodontol 2022;26:478-84.
Published: 01-Sep-2022 including periodontal.[3]

478 © 2022 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow

 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

immunodeficiency Virus, Hepatitis B and C virus.[8] This disease Microbiology in accordance with the ethical guidelines of
transmission may be bidirectional, i.e., from patient‑to‑patient, the Institutional Research and Ethical Committee. A total
patient‑to‑clinician, or clinician‑to‑patient.[2,9‑11] Notably, the of 80 subjects with periodontitis were selected from the
aerosols are not dispersed evenly in the entire operatory room, outpatient department irrespective of sex, religion, and
and the greatest concentration has been shown within two feet socioeconomic status. Subjects were explained the entire
of the patient, radiating more toward the chest of the patient procedure in detail and written consent was obtained
or the face of the operator.[11‑15] In addition, the aerosolized from each of them. The subjects were selected based on the
microorganisms remain suspended in the air for extended following criteria.
periods with greater potentiality.[11,16] Thus, the risk of health
threat by aerosols exists even after the completion of the Inclusion criteria
treatment procedure. Oral health professionals should be aware 1. Subjects of 20–65 years old with chronic periodontitis with
of these invisible dangers in the operatory and should follow not <20 teeth
the recommended protocols for the prevention of infection 2. Systemically healthy
before, during, and after patient care. 3. Subjects received no antibiotics and Periodontal treatment
during the last 3 months.
Harmful effects of the microbial load in aerosols demand
the minimization of microbial quantity in the oral cavity Exclusion criteria
before the generation of aerosol/splatter to reduce the risk of 1. Allergic to mouthwash
cross‑infection in the dental environment. Current research 2. Pregnant and lactating mothers
suggests that making a patient rinse with antimicrobial 3. Smokers.
mouthwash before the treatment procedures may reduce the
number of microorganisms in aerosols,[11,14,17‑19] though no The subjects were randomly categorized into four groups by
antimicrobial agent has been identified as a superior prerinse a single investigator (SJD) using block randomization. The
so far. Commonly used mouthwashes in dental practice are groups were named A (Control), B, C, and D, containing 20
chlorhexidine gluconate and herbal mouthwash. subjects in each. Group A was allotted no preprocedural mouth
rinse, Group B, C and D were allotted water, chlorhexidine
Chlorhexidine gluconate is a bisbiguanide antiseptic and gluconate (0.2%), and herbal mouthwash as a preprocedural
is widely used chemical plaque control agent. It is effective mouth rinse, respectively. The treatment group was not
against an array of microorganisms and also exhibits publicized to the patient as well as the operator.
substantivity up to 12 h.[20] This makes it the “gold standard
of chemical plaque control,” though a number of side effects, All subjects underwent periodontal examination by a
such as brownish discoloration of teeth, restorative materials single examiner (SJD). Periodontal status was assessed
and the dorsum of the tongue, taste perturbation, oral mucosal using plaque index,[25] probing pocket depth, and clinical
erosion, etc., have been reported.[21] Considering the wide range attachment level.
of disadvantages of chlorhexidine gluconate mouthwash,
alternative antiplaque agents have been developed in recent Nonselective culture medium (Blood agar) was prepared by
years using heterogeneous herbal products. Various naturally boiling 40 g of HIMEDIA Blood agar base in 1000 ml of distilled
available herbs have been used either alone or in combination water, which was then cooled to 45°C–50°C and autoclaved.
as safe and effective antibacterial agents in the form of After that 5% sterile defibrinated sheep blood was added. It
mouthwash.[22] A Herbal mouthwash (HiOra® Mouthwash, was then poured into sterile Petri plates, which were stored in
Himalaya) containing Bibhitaki (Bellirica Myrobatan), the refrigerator at 2°C–8°C for 5–6 days. The agar plates were
Meswak (Salvadora persica), and Betel leaf (Nagavalli) with coded and positioned at four different places prior or during
no sugar or alcohol is available commercially. It possesses a ultrasonic scaling for the collection of aerosols.
significant antimicrobial  (anticaries) and antifungal activity, 1. Position 1: Operatory room, 4 feet away from the dental
and thus, offers a safe and effective option without any adverse chair (baseline count)
effects.[23,24] 2. Position 2: Chest of the patients during treatment
3. Position 3: Chest of the operator during treatment
Considering the potential hazard of cross‑contamination 4. Position 4: Chest of the assistant during treatment.
from aerosols produced during ultrasonic scaling, this
prospective, randomized, double‑centered, double‑blind study To determine if there were any aerosolized bacteria present in
was conducted to assess the effectiveness of chlorhexidine the operatory room, the blood agar plate was kept at position 1
gluconate (0.2%), herbal mouthwash, and water as for 30 min before conducting the ultrasonic scaling. The plates
preprocedural mouth rinse on the bacterial load in aerosols were positioned with the help of double‑sided adhesive tape
by assessing the number of bacterial colonies formed in blood during ultrasonic scaling for Positions 2, 3, and 4. Various
agar culture plates positioned at various areas of the operating phases of the study are shown in Figure 1.
room during ultrasonic scaling.
The operatory room was fumigated using formaldehyde (40%)
MATERIALS AND METHODS for 15 min on the day before treatment. Only one patient
per day was treated to avoid aerosol contamination. The
It was a randomized, prospective, double‑blind clinical same operatory room was used for all samples. Before each
trial, carried out in the Department of Periodontics and appointment, the operatory surfaces were cleaned and
Oral Implantology in collaboration with the Department of disinfected using 70% ethyl alcohol.

Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022 479
 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

Figure 1: A flowchart representing the study design. n – number of samples

After the baseline sampling and before the treatment RESULTS

procedure, the subjects were instructed to undergo a 30 s
preprocedural rinse of 10 ml of chlorhexidine gluconate (0.2%), The mean plaque index, probing pocket depth and clinical
herbal mouthwash, or water depending upon the group to attachment level of the various groups is depicted in Table 1.
which the subjects were assigned. Coded agar plates were The mean ± standard deviation of plaque index, probing pocket
placed accordingly and stabilized for aerosol collection. The depth, and clinical attachment level group in Group A, B, C,
treatment procedure comprising of scaling was carried out for and D were found to be statistically not significant (P ≥ 0.05),
30 min using a piezoelectric ultrasonic scaler (DTE‑D5), with which indicates that all the participants were suffering from
controlled frequency and the pressure of the water coolant was periodontitis of equal intensity.
maintained at constant level. A motorized suction was used
during the treatment procedure. Immediately after scaling, agar Microbial colony count at Position 1 was considered as the
plates were removed and sealed, which were then incubated baseline. The average microbial colony count at this position
at 37°C for 24 h in an increased CO2 chamber (BOD Incubator, was found to be 14.91 ± 11.42, being ranged from 13.25 to
Chennai, India) and microbial colonies that grew on each plate 16.80 [Table 2].
were counted using a colony counter (INSIF, Haryana, India),
where an audible beep confirms the count and digital readout In Position 2, the mean number of microbial colonies was
appears on the display. 232.50 ± 90.33 (range 20.00–357.00), 70.55 ± 31.78 (range 30.00–132.00)
and 129.70 ± 53.35 (range 37.00–205.00) in the groups of
All the data collected was analyzed statistically using IBM preprocedural mouth rinse with water, chlorhexidine gluconate,
Statistical Package for Social Sciences (SPSS) version 20 and herbal mouthwash, respectively. In contrast, the mean
(Armonk, New York, US). Analysis of variance (ANOVA) number of microbial colonies in preprocedural no‑rinse group
tests was done to compare the mean of four groups by the was 302.95 ± 74.48 (range 105.00–458.00), as shown in Table 2.
variance between and within groups ratio with significant Thus, the numbers of colonies were reduced by 23.10%, 76.69%,
inference at P ≤ 0.05. In the case of statistical significance, post and 57.17% with water, chlorhexidine gluconate, and herbal
hoc pairwise comparisons were done by Tukey’s Honestly mouthwash, respectively, compared to that of the no‑rinse group.
Significant Difference test. Pair‑wise independent sample
t‑tests were conducted at a 5% level of significance to test In Position 3, the mean number of microbial colonies was
the pair‑wise difference in the mean values of microbial 378.80 ± 73.94 (range 210.00–530.00), 121.75 ± 32.37 (range
colonies grown in agar plates position wise. The inferences 63.00–190.00), and 206.60 ± 53.12 (range 115.00–310.00) in the
were drawn with the help of the P ≤ 0.05. groups of preprocedural mouth rinse with water, chlorhexidine
gluconate, and herbal mouthwash, respectively, as depicted
To assure equivalency of groups at baseline, we conducted in Table 2. In contrast, the mean number of microbial colonies
a one‑way ANOVA on baseline values to assess potential in preprocedural no‑rinse group was 429.20 ± 62.62 (range
differences in airborne bacteria in the ambient air before 298.00–560.00). Thus, the numbers of colonies were reduced
instrumentation with the ultrasonic scaler. Since no difference by 11.85%, 71.63%, and 51.86% with water, chlorhexidine
in baseline means was found between treatment groups, gluconate, and herbal mouthwash, respectively, compared to
baseline values were omitted from the subsequent analyses. that of the no‑rinse group.

480 Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022
 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

Table 1: Average plaque index, probing pocket depth and clinical attachment level (mean±standard deviation) in
various groups
Groups Description Plaque index Probing Clinical
Pocket depth Attachment level
A (n=20) No rinse (control) 2.17±0.38 3.90±0.70 4.63±0.78
B (n=20) Water rinse 2.23±0.25 4.01±0.73 4.57±0.98
C (n=20) Chlorhexidine gluconate rinse 2.01±0.44 3.89±0.44 4.71±0.72
D (n=20) Herbal mouthwash rinse 2.23±0.26 3.67±0.52 4.29±0.67
P 0.09 (NS) 0.35 (NS) 0.37 (NS)
P value was considered significant, when it is<0.05. NS – Not significant; P – Probability value; n – number of samples; Group A – control (no preprocedural
mouth rinse); Group B – water; Group C – chlorhexidine gluconate (0.2%); Group D – herbal mouthwash as preprocedural mouth rinses

Table 2: Position wise mean microbial colonies

Position of agar plate Rinse group Mean±SD Range
Baseline† Regardless of rinse 14.91±11.42 13.25-16.80
On chest of patients‡ No rinse 302.95±74.48 105.00-458.00
Water 232.50±90.33 20.00-357.00
Chlorhexidine gluconate 70.55±31.78 30.00-132.00
Herbal mouthwash 129.70±53.35 37.00-205.00
On chest of operator‡ No rinse 429.20±62.62 298.00-560.00
Water 378.80±73.94 210.00-530.00
Chlorhexidine gluconate 121.75±32.37 63.00-190.00
Herbal mouthwash 206.60±53.12 115.00-310.00
On chest of assistant‡ No rinse 193.90±87.92 65.00-415.00
Water 132.55±61.98 15.00-282.00
Chlorhexidine gluconate 27.50±21.80 10.00-90.00
Herbal mouthwash 79.00±47.60 20.00-200.00
†
4 feet from dental chair 30 min prior to treatment; ‡During treatment. SD – Standard deviation

In Position 4, the mean number of microbial colonies

was 132.55 ± 61.98 (range 15.00–282.00), 27.50 ± 21.80
(range 10.00–90.00), and 79.00 ± 47.60 (range 20.00–200.00)
in the groups of preprocedural mouth rinse with water,
chlorhexidine gluconate, and herbal mouthwash,
respectively, while the mean number of microbial colonies
in preprocedural no‑rinse group was 193.90 ± 87. 92 (range
65.00–415.00) [Table 2]. Thus, the numbers of colonies
were reduced by 31.64%, 85.81%, and 59.25% with water,
chlorhexidine, and herbal mouthwash, respectively,
compared to that of the no‑rinse group.

On position‑wise comparison, the lowest number of

microbial colony was seen in the operatory room before
scaling (14.91 ± 11.42), while the highest number of the
microbial colony was observed in the agar plates placed on
the operator’s chest (Position 3) (284.09 ± 137.78) followed Figure 2: A schematic representation of microbial colonies in all four positions of
by Position 2 (patient’s chest) (183.93 ± 111.38), and Position blood agar plates with or without preprocedural mouth rinse. Note the minimum no
4 (assistant’s chest) (108.13 ± 85.49) [Table 3]. The number of microbial colonies in Position 1
of colonies was observed to be 12.33‑, 18.78‑ and 7.25‑times
more in Position 2, 3, and 4, respectively, compared to that Regardless of the position of the agar plates, the highest
of position 1 (aerosolized bacteria present in the operatory number of microbial colonies were seen in no‑rinse
room). The differences in the mean values of microbial group (308.68 ± 75.00), followed by water (247.85 ± 75.41),
colonies in all four positions were found to be statistically herbal mouthwash (138.43 ± 51.35), and 0.2% chlorhexidine
very highly significant (P < 0.001). Microbial colonies in all the gluconate (73.26 ± 28.65). The lowest no of microbial colonies
four groups at all four positions of blood agar plates with or was seen in Group 3, where preprocedural mouth rinse
without preprocedural mouth rinse are schematically shown was chlorhexidine gluconate (0.2%). As shown in Table 4,
in Figure 2. intergroup comparison involving all four groups showed a
statistically significant difference.
Pairwise comparison involving both the position and
preprocedural mouth rinse, the mean number of microbial DISCUSSION
colonies between the groups at Positions 2, 3, and 4 were
analyzed using Tukey’s test for post hoc analysis and found to Aerosols produced during the various dental procedures
be highly significant statistically. are the potential to spread the infection to dental personnel

Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022 481
 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

Table 3: Comparison of microbial colonies at different positions

Position of agar plates Mean±SD Range Difference in means
Position 2 Position 3 Position 4
1 14.90±11.42 13.25-16.80 169.01*** 269.18*** 93.31***
2 183.93±111.38 20.00-357.00 100.16*** 75.80***
3 284.09±137.78 30.00-132.00 175.96***
4 108.13±85.49 37.00-205.00
***Very highly significant (P<0.001). Mean microbial colonies at various positions in different groups are not similar, differ significantly from each other at
P (<0.05). SD – Standard deviation; P – Probability value

Table 4: Microbial colonies (mean±standard deviation) involving all the groups at various positions and pairwise
comparison
Positions Rinse group Microbial colony counts Pairwise mean difference (P)
Water Chlorhexidine gluconate Herbal mouthwash
2 No rinse 302.95±74.48 70.45**(0.007) 232.4*** (0.001) 173.25*** (0.001)
Water 232.50±90.33 161.95*** (0.001) 102.8*** (0.001)
Chlorhexidine 70.55±31.78 59.15* (0.030)
Herbal 129.70±53.35
3 No rinse 429.20±62.62 50.4* (0.035) 307.45*** (0.001) 222.6*** (0.001)
Water 378.80±73.94 257.05*** (0.001) 172.2*** (0.001)
Chlorhexidine 121.75±32.37 84.85*** (0.001)
Herbal 206.60±53.12
4 No rinse 193.90±87.92 61.35** (0.009) 166.4*** (0.001) 114.9*** (0.001)
Water 132.55±61.98 105.05*** (0.001) 53.55* (0.029)
Chlorhexidine 27.50±21.80 51.5* (0.036)
Herbal 79.00±47.60
Average No rinse 308.68±75.00
Water 247.85±75.41
Chlorhexidine 73.26±28.65
Herbal 138.43±51.35
*Statistically significant (P<0.05); **Highly significant (P<0.01); ***Very highly significant (P<0.001). Microbial colony counts are not similar in all groups differ
significantly from each other at P (<0.05). SD – Standard deviation; P – Probability value

and other individuals in the dental operatory room. This In this study, chlorhexidine gluconate, herbal mouthwash and
has long been considered as one of the main concerns in water were used as preprocedural mouth rinses. Chlorhexidine
dentistry. It must be emphasized that “layering of protective gluconate (0.2%) has a broad‑spectrum antimicrobial activity
procedures” is required in reducing the potential danger against both Gram‑positive and‑negative organisms, yeasts,
from dental aerosols. In this procedure, multiple steps are dermatophytes and some lipophilic viruses with a substantivity
involved in the reduction of the risk of infection; a single step for 12 h.[11,20] It is an effective antiseptic for free‑floating oral
reduces to a certain extent to which another step is added that bacteria and those loosely adhering to mucous membranes,
further reduces the remaining risk until the risk is minimal. though not affect bacteria in a biofilm, does not penetrate
It indicates that the dental team should not depend on a subgingivally, and is unlikely to affect viruses and bacteria
single precautionary strategy. Personal protection barriers harbored in the nasopharynx. Although herbal mouthwash is
constitute the first layer of defense, which is upgraded accomplished with antimicrobial (anticaries), antifungal and
by antiseptic preprocedural mouth rinse (second layer of anti‑halitosis properties, little evidence is available regarding
defense). This is further elevated by the routine use of a its efficacy on bacterial load in aerosols when used as a
high‑volume evacuator (HVE), which is further augmented preprocedural rinse.[27]
by high‑efficiency particulate air (HEPA) filter. The first two
layers of defense are inexpensive and should be followed Blood agar was used to collect the aerosols. This is a valid
routinely as a part of infection control practices. Furthermore, medium for culturing airborne bacteria.[28] On settle down in
the maximum amount of contaminated aerosol is observed to the blood agar culture medium, bacteria grows and multiply to
be within two feet of the patient,[12] where the dental health form clusters of colonies. In this study, these microbial colonies
professional is usually positioned. This observation reinforces were counted in the agar plates to evaluate the usefulness of
the importance of personal protective barriers such as eye two commonly used mouthwashes in dentistry.
shields and face masks, head cap, glove, and gowns.
Highest number of microbial colonies was observed in
The maximum amount of aerosol production is reported no rinse group (Group A), followed by water (Group B),
during the ultrasonic scaling procedure.[26] By following the herbal mouthwash (Group D), and 0.2% chlorhexidine
American Dental Association protocols dental aerosols may gluconate (Group C) preprocedural mouth rinse. Maximum
be minimized, though complete elimination is difficult.[11] The reduction of microbial colonies was observed with
most basic and feasible methods to reduce bacterial load in 0.2% chlorhexidine gluconate (Group C). The pairwise
the aerosols is preprocedural rinse suggested by a number of comparison between chlorhexidine gluconate (Group C)
investigators.[11,14,15,27] with water (Group B), herbal mouthwash (Group D),

482 Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022
 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

and no‑rinse (Group A) showed a statistically significant used for the collection of the bacteria is subjected to a level of
difference (P < 0.01). This supports the observations of various inaccuracy, because bacteria exposed to the air may remain
studies.[11,14,29‑31] Higher effectiveness of 0.2% chlorhexidine viable, or may lose the ability to form colonies and become
gluconate may be related to its substantivity on oral tissues nonculturable. Thus, counting only aerobic bacteria gives
and its subsequent slow release in an active form. In contrast, only a partial picture of the airborne contamination that
Rani et al., (2014) observed more reduction in microbial colonies occurs during dental procedures and underestimates the true
with herbal mouthwash compared to that of chlorhexidine extent of bacterial populations in aerosols.[27] Future studies
gluconate, though not significant statistically.[15] are necessary to investigate the viable pathogenic organisms
generated during ultrasonic scaling. To evaluate the levels
Three plates were kept at different positions, namely the of airborne bacteria remaining in the operatory room after
chest of the patient (Position 2), operator (Position 3), and the ultrasonic scaling procedure, culture plates would have
assistant (Position 4) during the scaling procedure to collect exposed posttherapeutically as well.
aerosols. The highest number of microbial colonies was
observed in Position 3, followed by Position 2 and 4. This CONCLUSIONS
indicates that Position 3 is closer to the patient’s mouth
compared to that of position 2. This finding supports the In the light of the study carried out, we may conclude that
observation made by Rani et  al., (2014).[15] However, a large preprocedural mouth rinse could eliminate the majority
number of studies observed a greater number of microbial of bacterial aerosols generated by the ultrasonic scalers.
colonies in the agar plates placed over the patient’s chest than Chlorhexidine gluconate (0.2%) is more effective in reducing
that of the operator, explaining the fact larger salivary droplets the microbial load in aerosols produced during ultrasonic
generated during dental procedures settle rapidly from the air scaling compared to that of herbal mouthwash and water when
and would heavily contaminate the agar plates on a patient’s used as a preprocedural mouth rinse. Again, more microbial
chest.[13,14,29‑31] Greatest concentration of the microorganisms colonies are formed on the agar plates placed on the chest area
in aerosols was observed within 2 feet of the patient[12] and of the operator than that of the plates placed on the chest area
the number of microbial colonies decreases with increase of the patients and the assistants. This states the importance
in distances from the operating area.[11] Bentley et  al. (1994) of protection for the dentists and dental hygienists, who are
suggested that distribution of bacterially contaminated aerosols the main targets of the microorganisms generated during oral
and splatter is extremely variable and may be influenced by the procedures.
type of therapeutic procedure, use of HVE, the position of the
subject in the dental chair, position of the tooth in the mouth Financial support and sponsorship
that affects the position of the operator relative to the subject, Nil.
levels of the microorganisms in the subject’s mouth, etc.[8] The
reason of the highest number of colonies at position 3 in this Conflicts of interest
study may be explained based on the fact of the height of the There are no conflicts of interest.
operator that influences the position of the operator. Due to
the low height of the operator (DK), the agar plates placed on
REFERENCES
her chest were probably closer to the patient’s mouth than
that of the distance between his mouth and chest (Position 2).
1. Grenier D. Quantitative analysis of bacterial aerosols in two
different dental clinic environments. Appl Environ Microbiol
This study suggests that 0.2% chlorhexidine gluconate is more 1995;61:3165‑8.
effective as a preprocedural mouthwash than that of the herbal 2. Harrel SK, Barnes JB, Rivera‑Hidalgo F. Aerosol and splatter
mouthwash in reducing microbial load in aerosols produced contamination from the operative site during ultrasonic scaling.
during ultrasonic scaling. Even preprocedural mouth rinse J Am Dent Assoc 1998;129:1241‑9.
with water also plays a significant role in reducing microbial 3. Szymańska J. Dental bioaerosol as an occupational hazard in a
load in aerosols. Notably, the observations of this study dentist’s workplace. Ann Agric Environ Med 2007;14:203‑7.
reinforce the significance of personal protective equipment 4. Miller RL, Micik RE, Abel C, Ryge G. Studies on dental
and validate preprocedural mouth rinsing as an additional aerobiology. II. Microbial splatter discharged from the oral cavity
barrier to cross‑contamination and minimizes the risk of team of dental patients. J Dent Res 1971;50:621‑5.
members and the patients. 5. Hinds WC. Aerosol Technology: Properties, Behavior and
Measurement of Airborne Particles. 2nd ed. New York: Wiley;
The limitation of this study should be considered in interpreting 1999.
the results. Microbial colonies give a good picture of total 6. Pippin DJ, Verderame RA, Weber KK. Efficacy of face masks in
preventing inhalation of airborne contaminants. J Oral Maxillofac
airborne bacterial count from a particular procedure, but it
Surg 1987;45:319‑23.
does not provide any differentiation between whether the
7. Kharbuli D, Das SJ, Deka A, Alam ST, Bora GH. Position wise
bacteria are relatively benign or a pathogenic species. Any
quantification of microbial load in aerosols produced during
bacteria that require special media or growth conditions, ultrasonic scaling. J Med Dent Sci 2020;2:175‑80.
such as mycobacteria or strict anaerobes that are common in 8. Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and
periodontal pockets, were not cultured and counted in this aerosol contamination during dental procedures. J Am Dent Assoc
study. Furthermore, because they do not grow on the type 1994;125:579‑84.
of media used for bacterial studies, no viral particles such 9. Smith WH, Davies D, Mason KD, Onions JP. Intraoral and
as influenza, rhinoviruses, and SARS coronavirus would be pulmonary tuberculosis following dental treatment. Lancet
measured. Moreover, the plate count or “fall out” approach 1982;1:842‑4.

Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022 483
 Das, et al.: Preprocedural mouth rinse and microbial load in aerosols

10. Legnani P, Checchi L, Pelliccioni GA, D’Achille C. Atmospheric chlorhexidine in the human oral cavity after mouthrinses. Arch
contamination during dental procedures. Quintessence Int Oral Biol 1974;19:1209‑22.
1994;25:435‑9. 21. Flötra L, Gjermo P, Rölla G, Waerhaug J. Side effects of
11. Logothetis DD, Martinez‑Welles JM. Reducing bacterial aerosol chlorhexidine mouth washes. Scand J Dent Res 1971;79:119‑25.
contamination with a Chlorhexidine gluconate pre‑rinse. J Am 22. Kulkarni P, Singh DK, Jalaluddin M, Mandal A. Comparative
Dent Assoc 1995;126:1634‑9. evaluation of antiplaque efficacy between essential oils with
12. Holbrook WP, Muir KF, Macphee IT, Ross PW. Bacteriological alcohol‑based and chlorhexidine with nonalcohol‑based
investigation of the aerosol from ultrasonic scalers. Br Dent J mouthrinses. J Int Soc Prev Community Dent 2017;7:S36‑41.
1978;144:245‑7. 23. Salam R, Khokon JU, Baidya S, Mussa MT. Effect of neem and
13. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber betel leaf against oral bacteria. Int J Nat Soc Sci 2014;1:52‑7.
dam as a barrier to the spread of microorganisms during dental 24. Santhosh S, Siji J, Thangakumaran S, Sasikumar PK, Mahesh J.
treatment. J Am Dent Assoc 1989;119:141‑4.
Miswak an indigenous plant in dentistry – A general outlook.
14. Gupta G, Mitra D, Ashok KP, Gupta A, Soni S, Ahmed S, et al. Indian J Med Res Pharm Sci 2018;5:10‑4.
Efficacy of preprocedural mouth rinsing in reducing aerosol
25. Löe H. The gingival index, the plaque index and the retention
contamination produced by ultrasonic scaler: A pilot study.
index systems. J Periodontol 1967;38:l610‑6.
J Periodontol 2014;85:562‑8.
26. Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic:
15. Rani KR, Ambati M, Prasanna JS, Pinnamaneni I, Reddy PV,
A review. Int Dent J 2001;51:39‑44.
Rajashree D. Chemical vs. herbal formulations as preprocedural
mouth rinses to combat aerosol production: A randomized 27. Mamajiwala AS, Sethi KS, Raut CP, Karde PA, Khedkar SU.
controlled study. J Oral Res Rev 2014;6:9‑13. Comparative evaluation of chlorhexidine and cinnamon extract
16. Reddy S, Prasad MG, Kaul S, Satish K, Kakarala S, Bhowmik N. used in dental unit waterlines to reduce bacterial load in aerosols
Efficacy of 0.2% tempered chlorhexidine as a pre‑procedural during ultrasonic scaling. Indian J Dent Res 2018;29:749‑54.
mouth rinse: A clinical study. J Indian Soc Periodontol 28. Johnston JR, Butchart AM, Kgamphe SJ. A comparison of sampling
2012;16:213‑7. methods for airborne bacteria. Environ Res 1978;16:279‑84.
17. Fine DH, Mendieta C, Barnett ML, Furgang D, Meyers R, 29. Rao RM, Shenoy N, Shetty V. Determination of efficacy of
Olshan A, et al. Efficacy of preprocedural rinsing with an antiseptic pre‑procedural mouth rinsing in reducing aerosol contamination
in reducing viable bacteria in dental aerosols. J Periodontol produced by ultrasonic scalers. NUJHS 2015;5:52‑6.
1992;63:821‑4. 30. Yadav S, Kumar S, Srivastava P, Gupta KK, Gupta J, Khan YS.
18. Yamada H, Ishihama K, Yasuda K, Hasumi‑Nakayama Y, Shimoji S, Comparison of efficacy of three different mouthwashes in
Furusawa K. Aerial dispersal of blood‑contaminated aerosols reducing aerosol contamination produced by ultrasonic scaler:
during dental procedures. Quintessence Int 2011;42:399‑405. A pilot study. Indian J Dent Sci 2018;10:6‑10.
19. Sawhney A, Venugopal S, Babu GR, Garg A, Mathew M, Yadav M, 31. Sethi G, Kumar K. A comparative evaluation of efficacy of 0.2%
et al. Aerosols how dangerous they are in clinical practice. J Clin chlorhexidine with a herbal mouthwash as pre‑procedural
Diagn Res 2015;9:C52‑7. mouthrinse in the reduction of aerosol contamination produced
20. Bonesvoll P, Lökken P, Rölla G, Paus PN. Retention of by ultrasonic scaler. Acta Sci Dent Sci 2018;2:2‑6.

484 Journal of Indian Society of Periodontology - Volume 26, Issue 5, September-October 2022