VCOM Carolinas Research Day 2023

Biomedical Studies

ONGOING CHANGES IN THE USE OF QUATERNARY AMMONIUM COMPOUND DISINFECTANTS IN DENTAL CLINICS SINCE COVID-19 Jessica E. Marino, Harthe D. Blankenship, Kaitlyn F. Braffitt, Theresa J. McCann, Terry C. Hrubec Edward Via College of Osteopathic Medicine – Carolinas Campus – Spartanburg, SC

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Location of Practice


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• There was no difference between the location of practice with respect to number of practices, changes in disinfectant, and percent increases in spraying and wiping.

It was hypothesized that there would be an increase in the number of QAC disinfectant products being used to combat the increased number of cases of COVID-19 in healthcare facilities. dialkyldimethylammonium compounds (DADMACs). These active ingredients have been identified in over 200 common disinfectant products. Due to their ability to inactivate enveloped viruses, the United States Environmental Protection Agency (EPA) added QACs to their list of disinfectants to combat the COVID-19 pandemic. While long considered safe, recent studies in rodent models show that QACs cause neural tube defects at three closure sites and increase embryonic death. Additionally, exposure causes infertility in both males and females with abnormal sperm morphology and decreased sperm concentrations and decreased ovulation of eggs and implantation of embryos. Other studies found that QACs increase proinflammatory cytokines, decrease mitochondrial function, and disrupt cholesterol homeostasis. Similar changes were seen in people. Inflammation was increased, mitochondrial function was decreased, and cholesterol synthesis was disrupted in a dose-dependent manner. The concentration of QACs present in the blood were at a level shown to cause adverse effects in animal and cell culture models. Due to the potential toxicity of these chemicals, we wanted to determine if exposure to QACs has increased due to the pandemic. Quaternary ammonium compounds (QACs) are among some of the active ingredients in common disinfecting products. QACs consist of chemicals like benzalkyl dimethylammonium compounds (BACs), alkyltrimethylammonium compounds (ATMACs), and • States were ranked by 28-health metrics from the Kaiser Family Foundation. Those that fell within ± 3 states from the median were then ranked. The 8 states that were consistently closest to the median were selected. Those 8 states include AZ, DE, FL, IL, MI, PA, SC, and VA. • A survey asking both closed and open-ended questions was created within Question Pro to determine what changes, if any, occurred with disinfection protocols since the COVID-19 pandemic. • Dental clinics listed on the state’s Department of Health were contacted via phone to fill the survey out, either through the phone or by email. • The survey questions focus on the type of disinfectant used, changes in frequency or concentration, and changes in cleaning method (mop, wipe, etc.). • Statistical analysis was conducted using a Chi Square with p < 0.05. • This survey is ongoing and interim results were collected.

Changes in Disinfectant Practices Due to COVID-19

Number of Practices

Increase Spray (%)

Increase Wipe (%)

Change in Disinfectant





46.6% 66.6%

Completed Surveys





50% 70%

Changes in Disinfection Protocols





47.8% 52.2%

Disinfection Occurring More Often


• Although cleaning products containing QACs were widely used before the pandemic, there was an increase in usage after the start of COVID-19. • Out of the practices that completed the survey, the percent of QAC products increased from 92% to 98% after COVID 19. • The number of calls made and the number of responses (blue bars) for a response rate of 7.3%. This is above the national average for phone surveys. • Of the 93 surveys started, 84 were fully completed (teal bars). 58 of these used the same cleaning procedures throughout the entire practice. 16 practices used an outside cleaning service which terminated the survey.

Changes in Disinfectant Type 24.4% Changes in Disinfectant Concentration 22.5%

Survey Calls and Responses

0 10 20 30 40 50 60 70 80 90 100

1000 1200 1400




0 200 400 600 800





Thank you to all the practices who responded to our survey and to all the healthcare personnel who have worked during the COVID-19 pandemic. This project was in part funded by VCOM and is IRB exempt. • Hora, P. I., Pati, S. G., McNamara, P. J., & Arnold, W. A. (2020). Increased Use of Quaternary Ammonium Compounds during the SARS CoV-2 Pandemic and Beyond: Consideration of Environmental Implications. Environmental Science & Technology Letters , acs.estlett.0c00437. • Hrubec, T. C., Melin, V. E., Shea, C. S., Ferguson, E. E., Garofola, C., Repine, C. M., Chapman, T. W., Patel, H. R., Razvi, R. M., Sugrue, J. E., Potineni, H., Magnin-Bissel, G., & Hunt, P. A. (2017). Ambient and Dosed Exposure to Quaternary Ammonium Disinfectants Causes Neural Tube Defects in Rodents. Birth defects research , 109 (14), 1166 – 1178. • Hrubec, T. C., Seguin, R. P., Xu, L., Cortopassi, G. A., Datta, S., Hanlon, A. L., Lozano, A. J., McDonald, V. A., Healy, C. A., Anderson, T. C., Musse, N. A., & Williams, R. T. (2021). Altered toxicological endpoints in humans from common quaternary ammonium compound disinfectant exposure. Toxicology reports , 8 , 646 – 656. • Melin, V. E., Potineni, H., Hunt, P., Griswold, J., Siems, B., Werre, S. R., & Hrubec, T. C. (2014). Exposure to common quaternary ammonium disinfectants decreases fertility in mice. Reproductive toxicology (Elmsford, N.Y.) , 50 , 163 – 170. • Melin, V. E., Melin, T. E., Dessify, B. J., Nguyen, C. T., Shea, C. S., & Hrubec, T. C. (2016). Quaternary ammonium disinfectants cause subfertility in mice by targeting both male and female reproductive processes. Reproductive toxicology (Elmsford, N.Y.) , 59 , 159 – 166. • These results imply higher QAC exposure to dental practice personnel. • The main routes of exposures are inhalation of aerosols during spraying, and orally from touching disinfected surfaces with hand to mouth transfer. • QAC disinfectants have been a cornerstone in preventing the spread of SARS-CoV-2; however, based on their toxicity the disinfectants should be used judiciously and with appropriate PPE. • COVID-19 resulted in increased disinfection protocols to combat COVID-19. • Interim results found an increase in both the use of products containing QACs and the frequency of cleaning.

Calls Made


Completed Surveys

Outside Cleaning Service Used

Same Procedures throughout Practice

Class of Disinfectants Used Before and After COVID-19


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%







QAC + Alcohol


Before COVID-19 Current

• The frequency of

Percent Increase in Method of Cleaning Since COVID-19

cleaning throughout dental practices was increased due to COVID The cleaning methods that showed the largest increase were spraying and wiping.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

19. •










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