Laser Plumes – More Than a Puff of Smoke

Laser Plumes – More Than a Puff of Smoke

LASER is an acronym for ‘light amplification by stimulated emission of radiation’.1Laser. https://en.wikipedia.org/wiki/Laser. Lasers of different wavelengths are used in healthcare to cut, coagulate, ablate, or vaporize biological tissue by generating thermal energy. In dentistry, lasers have become a mainstream option for soft tissue procedures, hard tissue procedures, and other procedures. Options in soft tissue lasers include diode, carbon dioxide, and Nd:YAG lasers. Options for both soft and hard tissue procedures include Er:YAG, and Er,Cr:YSGG lasers.2Luke AM, Mathew S, Altawash MM, Madan BM. Lasers: A Review With Their Applications in Oral Medicine. J Lasers Med Sci 2019;10(4):324-9. doi: 10.15171/jlms.2019.52. During use, these lasers produce a ‘plume’ or ‘laser plume’, also known as ‘surgical smoke’.3United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume. ^,4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. ANSI 136.3-2018 describes a laser plume as “a non-beam laser hazard since it includes viral, bacterial, and other cellular and aerosolized particulates, as well as gaseous toxic compounds and other materials”.5American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018. Note that lasers under other categories are used for non-ablative purposes such as photoinitiation (light curing), tissue fluorescence and photobiomodulation and do not produce laser plumes.

What does laser plume contain?

Laser plume contains materials of biological and non-biological origin. The actual content depends on the procedure, patient health, presence of chemicals (e.g., dyes) and the device used.4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. Biological material present can include aerosolized blood, blood by-products, erythrocytes, cell fragments, and bloodborne pathogens. Viable and non-viable bacterial material (e.g., from Staphylococcus aureus, Escherichia coli) and viral material (e.g., from human immunodeficiency virus (HIV), human papillomavirus (HPV), can also be present.4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. ^,5American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018.^,6Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.^,7Capizzi PJ, Clay RP, Battey MJ. Microbiologic activity in laser resurfacing plume and debris. Lasers Surg Med 1998;23(3):172-4. doi: 10.1002/(sici)1096-9101(1998)23:3<172::aid-lsm7>3.0.co;2-m.^,8Alp E, Bijl D, Bleichrodt RP et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1-5. doi: 10.1016/j.jhin.2005.01.014. Proviral HIV DNA, and HPV DNA, were detected in laser plume more than 30 years ago, and another report noted the production of infectious retrovirus using an Er:YAG laser more than 20 years ago.9Baggish MS, Polesz BJ, Joret D et al. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med 1991;11:197-203. https://doi.org/10.1002/lsm.1900110302^,10Garden JM, O’Banion MK, Shelnitz LS et al. Papillomavirus in the vapor of carbon dioxide laser–treated verrucae. J Am Med Assoc 1988;259(8):1199-202.^,11Ziegler BL, Thomas CA, Meier T et al. Generation of infectious retrovirus aerosol through medical laser irradiation. Lasers Surg Med 1998;22(1):37-41. Since then, numerous studies have confirmed the potential presence of viable viral material.6Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.^,12Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review. Occup Environ Med 2020;77(12):809-17.^,13Cox SV, Dobry AS, Zachary CB, Cohen JL. Laser plume from human papillomavirus-infected tissue: a systematic review. Dermatol Surg 2020;46(12):1676-82.

Non-biological material found in laser plumes includes chemicals and particulate matter. Chemicals found during tissue ablation may include benzene, formaldehyde and acrolein (which are all carcinogens), as well as cyanide, based on studies involving carbon dioxide and Nd:YAG lasers.3United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume. ^,4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. ^,8Alp E, Bijl D, Bleichrodt RP et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1-5. doi: 10.1016/j.jhin.2005.01.014.^,14Tan E, Russell KP. Surgical plume and its implications: A review of the risk and barriers to a safe work place, J Periop Nurs 2017;30:4, Article 2. Available at: https://doi.org/10.26550/2209-1092.1019.^,15Barrett WL. Surgical smoke: a review of the literature. Surg Endosc 2003;17:979-87. Other trace gases that may be found include 1,2-dichloroethane, acetonitrile, ammonia, ethylene, and toluene.6Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.^,16Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 2014;28(8):2374-2380.^,17Bratu AM, Petrus M, Patachia M et al. Quantitative analysis of laser surgical smoke: targeted study on six toxic compounds. Rom J Phys 2015;60(1-2):215-27. Particulate matter found includes polyaromatic hydrocarbons, fatty acids, acrylonitrile and phenols.3United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume. ^,4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. (Table 1)

Findings on health hazards

In a recent systematic review of 21 studies, it was confirmed that HPV-DNA can be present in laser plume during tissue ablation and contaminate the respiratory tract.12Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review. Occup Environ Med 2020;77(12):809-17. In a second systematic review, it was concluded that there is risk of exposure to HPV among ‘laser surgeons’.13Cox SV, Dobry AS, Zachary CB, Cohen JL. Laser plume from human papillomavirus-infected tissue: a systematic review. Dermatol Surg 2020;46(12):1676-82. The same review also concluded that the evidence for occupational transmission of HPV in healthcare was unclear (conflicting). In a case report of HPV-related papillomas in the larynx of a laser surgeon, it was concluded that these may have been caused by HPV viral particle inhalation while treating patients’ lesions involving the same types of HPV (Types 6 and 11).18Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991;248:425-7. https://doi.org/10.1007/BF01463570. A similar event was reported for an operating room nurse with a history of exposure to laser plumes,19Calero L, Brusis T. Laryngeal papillomatosis—first recognition in Germany as an occupational disease in an operating room nurse. Laryngorhinootologie 2003;82(11):790-3. while in another incident, two gynecological surgeons developed oropharyngeal cancer associated with HPV-16 and it was concluded that this was likely transmitted through exposure in surgical plumes.20Rioux M, Garland A, Webster D, Reardon E. HPV positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg 2013;42(1):54. In animal studies, tumors developed when an area was inoculated with laser plume containing bovine HPV.10Garden JM, O’Banion MK, Shelnitz LS et al. Papillomavirus in the vapor of carbon dioxide laser–treated verrucae. J Am Med Assoc 1988;259(8):1199-202.

Symptoms resulting from exposure to non-biological matter in laser plumes include eye, nose, throat, and respiratory irritation (e.g., congestion, bronchiolitis and changes similar to emphysema).4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. ^,21Wenig BL, Stenson KM, Wenig BM, Tracey D. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med 1993;13(2):242-5. doi: 10.1002/lsm.1900130213.^,22Freitag L, Chapman GA, Sielczak M et al. Laser smoke effect on the bronchial system. Lasers Surg Med 1987;7(3):283-8. Other symptoms include headaches, nausea, and muscle weakness. Particulate matter <10 microns (μm) can be readily inhaled below the glottis, while particles <5 μm reach the lower respiratory tract.23Fennelly KP. Particle sizes of infectious aerosols: implications for infection control. The Lancet. Respiratory Medicine. July 24, 2020. Doi: https://doi.org/10.1016/S2213-2600(20)30323-4. Nanoparticles found in laser plumes are <0.1 μm in size and following inhalation can reach the individual’s circulatory systems and organs.24The Joint Commission. Quick Safety Issue 56: Alleviating the dangers of surgical smoke. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-56/quick-safety-issue-56/#.ZC66ZXvMKUk. The amount present varies by procedure. In one study involving laparoscopic surgery, among substances emitted, an unacceptable hazard and risk of cancer was determined for 1,2-dichloroethane and benzene present in the air.16Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 2014;28(8):2374-2380. Surgical smoke is as mutagenic as cigarettes.8Alp E, Bijl D, Bleichrodt RP et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1-5. doi: 10.1016/j.jhin.2005.01.014.

Risk Level
The risk of exposure associated with a specific laser plume obviously depends on the patient, the presence of chemicals (e.g., dyes), the procedure and amount of plume, and the concentration of a given contaminant.4Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. ^,6Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.^,17Bratu AM, Petrus M, Patachia M et al. Quantitative analysis of laser surgical smoke: targeted study on six toxic compounds. Rom J Phys 2015;60(1-2):215-27.^,25Lopez R, Lacey SE, Lippert JF et al. Characterization of size-specific particulate matter emission rates for a simulated medical laser procedure—a pilot study. Ann Occup Hyg 2015;59(4):514-24. The amount of plume generated, including particulate matter, is influenced by the power level, laser beam diameter, pulse repetition, exposure time and type of tissue being lasered (e.g., muscle vs mucosa).6Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.^,17Bratu AM, Petrus M, Patachia M et al. Quantitative analysis of laser surgical smoke: targeted study on six toxic compounds. Rom J Phys 2015;60(1-2):215-27.^,25Lopez R, Lacey SE, Lippert JF et al. Characterization of size-specific particulate matter emission rates for a simulated medical laser procedure—a pilot study. Ann Occup Hyg 2015;59(4):514-24. No safe levels for surgical smoke exist, and the risks are cumulative.8Alp E, Bijl D, Bleichrodt RP et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1-5. doi: 10.1016/j.jhin.2005.01.014.^,26Limchantra IV, Fong Y, Melstrom KA. Surgical smoke exposure in operating room personnel: a review. J Am Med Assoc Surg 2019;154(10):960-7.

Standards

ANSI Z136.3, Safe Use of Lasers in Health Care Facilities contains specific guidance on laser plume management.5American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018. There are currently no OSHA Standards specifically for laser plumes.3United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume. Nonetheless, there are applicable OSHA standards.3United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume. ^,27Galassi T. OSHA requirements for smoke plume generated from laser and electrosurgical instruments in dental offices and hospital operating rooms. October 7, 2016. https://www.osha.gov/laws-regs/standardinterpretations/2016-10-07#:~:text=Question%3A%20What%20are%20the%20OSHA%20requirements%20to%20protect,procedures%20in%20either%20operating%20rooms%20or%20dental%20offices. These include the General Industry Standard 29 CFR 1910.134 requirement for engineering controls to control respiratory hazards caused by breathing air contaminated with harmful substances; OSHA Standard 29 CFR 1910.1000 requirements for appropriate personal protective equipment to control exposure to air contaminants and that air contaminants be within permissible exposure levels; and the Bloodborne Pathogens Standard. (Table 2)

Additional Considerations in Dentistry
Most of the research on laser plumes has been in the medical field, much of that studying carbon dioxide lasers, but also others including Er:YAG, Nd:YAG and excimer lasers. While some procedures would be more extensive and more invasive, the potential health hazards and need for plume mitigation apply to all healthcare disciplines, including dentistry. The current ANSI consensus standard does not specifically address plume mitigation for lasers used with a water spray.

Managing Laser Plumes

Laser plume should be controlled using plume scavenging systems (PSS), also known as smoke evacuators or local exhaust ventilators (LEV). These include wall suction devices, high-volume evacuation devices and mobile or portable smoke evacuators.5American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018. These can remove up to 99% of laser plume under optimal conditions.28Seipp HM, Steffens T, Weigold J et al. Efficiencies and noise levels of portable surgical smoke evacuation systems. J Occup Environ Hyg 2018;15(11):773-81. The LEV device should include a filter with 99.999% efficacy at 0.12 μm, be used within 2 inches of the surgical smoke, and have a wide aperture for effective smoke capture.5American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018.^,29Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. Control of Smoke From Laser/Electric Surgical Procedures. Available at: https://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html. Air flow should be unidirectional and laser plume production limited. In addition, external oral aerosol vacuums can help to decrease the laser plume present.

As with other potential workplace hazards, safe work practices and the use of personal protective equipment are important to reduce risk. For laser plumes, this includes the use of N95 respirators (fit-tested), protective eyewear, single-use disposable surgical gloves, and appropriate clinical attire. It has also been recommended that healthcare personnel at risk of occupational exposure to HPV should consider vaccination against HPV.13Cox SV, Dobry AS, Zachary CB, Cohen JL. Laser plume from human papillomavirus-infected tissue: a systematic review. Dermatol Surg 2020;46(12):1676-82.

Training
It is recommended that healthcare workers are trained on the hazards of surgical smoke and methods to minimize exposure prior to working in areas where surgical smoke is generated.30Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. Health and Safety Practices Survey of Healthcare Workers. Best practices and study findings. https://www.cdc.gov/niosh/topics/healthcareh sps/smoke.html. In accordance with ANSI Z136.1, an individual should be designated as the Laser Safety Officer (LSO).31The Laser Institute. The Laser Safety Officer. https://www.lia.org/node/21279. This person is responsible for evaluating laser hazards and establishing appropriate control measures. In order to be qualified for this position, the LSO must have training and experience to ‘properly establish and administer a laser safety program’ and be authorized by the dentist/owner or the facility administrator.31The Laser Institute. The Laser Safety Officer. https://www.lia.org/node/21279. ^,32Academy of Laser Dentistry. Laser Officer. https://www.laserdentistry.org/index.php?option=com_dailyplanetblog&view=entry&year=2022&month=06&day=14&id=27:laser-safety-officer. The LSO has responsibility for educating the dental team on laser plumes and how these should be dealt with, as well as all appropriate documentation in the patient’s clinical records and policy and procedure guidelines.32Academy of Laser Dentistry. Laser Officer. https://www.laserdentistry.org/index.php?option=com_dailyplanetblog&view=entry&year=2022&month=06&day=14&id=27:laser-safety-officer. More information on laser safety hazards and the responsibilities of the LSO can be found on the Academy of Laser Dentistry website. It goes without saying that the LSO is also responsible for other safety issues (such as protective eyewear to protect the eyes from the laser beam) for both dental healthcare personnel and patients. Hazards other than laser plumes are outwith the scope of this article.

Conclusions

Laser plumes contain both biological and non-biological hazardous materials. While data on causation may still be limited, laser plumes pose a cumulative risk to health and no safe levels of laser plumes exist. Standards and guidelines exist with requirements, best practices and recommendations regarding laser plumes and safety. In addition, States began enacting regulations related to the handling of laser plume in 2018, with Rhode Island the first to do so.24The Joint Commission. Quick Safety Issue 56: Alleviating the dangers of surgical smoke. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-56/quick-safety-issue-56/#.ZC66ZXvMKUk. Engineering and work controls are necessary for laser plume mitigation and protection of healthcare personnel with risk of exposure. In both dentistry and medicine, an individual designated as the LSO is needed and responsible for educating the healthcare team on laser plumes and how these should be dealt with, as well as all appropriate documentation.

References

• 1.Laser. https://en.wikipedia.org/wiki/Laser.
• 2.Luke AM, Mathew S, Altawash MM, Madan BM. Lasers: A Review With Their Applications in Oral Medicine. J Lasers Med Sci 2019;10(4):324-9. doi: 10.15171/jlms.2019.52.
• 3.United States Department of Labor. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. https://www.osha.gov/laser-electrosurgery-plume.
• 4.Canadian Centre for Occupational Health and Safety. Laser Plumes – Health Care. https://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html.
• 5.American National Standards Institute. ANSI Z136.3-201. Safe Use Of Lasers In Health Care. 2018. Available at: https://webstore.ansi.org/standards/lia/ansiz1362018.
• 6.Petrus M, Matei C, Patachia M, Dumitras DC. Quantitative in vitro analysis of surgical smoke by laser photocoustic spectroscopy. J Optoelect Adv Mat 2012;14(7-8):664-70.
• 7.Capizzi PJ, Clay RP, Battey MJ. Microbiologic activity in laser resurfacing plume and debris. Lasers Surg Med 1998;23(3):172-4. doi: 10.1002/(sici)1096-9101(1998)23:3<172::aid-lsm7>3.0.co;2-m.
• 8.Alp E, Bijl D, Bleichrodt RP et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1-5. doi: 10.1016/j.jhin.2005.01.014.
• 9.Baggish MS, Polesz BJ, Joret D et al. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med 1991;11:197-203. https://doi.org/10.1002/lsm.1900110302
• 10.Garden JM, O’Banion MK, Shelnitz LS et al. Papillomavirus in the vapor of carbon dioxide laser–treated verrucae. J Am Med Assoc 1988;259(8):1199-202.
• 11.Ziegler BL, Thomas CA, Meier T et al. Generation of infectious retrovirus aerosol through medical laser irradiation. Lasers Surg Med 1998;22(1):37-41.
• 12.Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review. Occup Environ Med 2020;77(12):809-17.
• 13.Cox SV, Dobry AS, Zachary CB, Cohen JL. Laser plume from human papillomavirus-infected tissue: a systematic review. Dermatol Surg 2020;46(12):1676-82.
• 14.Tan E, Russell KP. Surgical plume and its implications: A review of the risk and barriers to a safe work place, J Periop Nurs 2017;30:4, Article 2. Available at: https://doi.org/10.26550/2209-1092.1019.
• 15.Barrett WL. Surgical smoke: a review of the literature. Surg Endosc 2003;17:979-87.
• 16.Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 2014;28(8):2374-2380.
• 17.Bratu AM, Petrus M, Patachia M et al. Quantitative analysis of laser surgical smoke: targeted study on six toxic compounds. Rom J Phys 2015;60(1-2):215-27.
• 18.Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991;248:425-7. https://doi.org/10.1007/BF01463570.
• 19.Calero L, Brusis T. Laryngeal papillomatosis—first recognition in Germany as an occupational disease in an operating room nurse. Laryngorhinootologie 2003;82(11):790-3.
• 20.Rioux M, Garland A, Webster D, Reardon E. HPV positive tonsillar cancer in two laser surgeons: case reports. J Otolaryngol Head Neck Surg 2013;42(1):54.
• 21.Wenig BL, Stenson KM, Wenig BM, Tracey D. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med 1993;13(2):242-5. doi: 10.1002/lsm.1900130213.
• 22.Freitag L, Chapman GA, Sielczak M et al. Laser smoke effect on the bronchial system. Lasers Surg Med 1987;7(3):283-8.
• 23.Fennelly KP. Particle sizes of infectious aerosols: implications for infection control. The Lancet. Respiratory Medicine. July 24, 2020. Doi: https://doi.org/10.1016/S2213-2600(20)30323-4.
• 24.The Joint Commission. Quick Safety Issue 56: Alleviating the dangers of surgical smoke. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-56/quick-safety-issue-56/#.ZC66ZXvMKUk.
• 25.Lopez R, Lacey SE, Lippert JF et al. Characterization of size-specific particulate matter emission rates for a simulated medical laser procedure—a pilot study. Ann Occup Hyg 2015;59(4):514-24.
• 26.Limchantra IV, Fong Y, Melstrom KA. Surgical smoke exposure in operating room personnel: a review. J Am Med Assoc Surg 2019;154(10):960-7.
• 27.Galassi T. OSHA requirements for smoke plume generated from laser and electrosurgical instruments in dental offices and hospital operating rooms. October 7, 2016. https://www.osha.gov/laws-regs/standardinterpretations/2016-10-07#:~:text=Question%3A%20What%20are%20the%20OSHA%20requirements%20to%20protect,procedures%20in%20either%20operating%20rooms%20or%20dental%20offices.
• 28.Seipp HM, Steffens T, Weigold J et al. Efficiencies and noise levels of portable surgical smoke evacuation systems. J Occup Environ Hyg 2018;15(11):773-81.
• 29.Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. Control of Smoke From Laser/Electric Surgical Procedures. Available at: https://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html.
• 30.Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. Health and Safety Practices Survey of Healthcare Workers. Best practices and study findings. https://www.cdc.gov/niosh/topics/healthcareh sps/smoke.html.
• 31.The Laser Institute. The Laser Safety Officer. https://www.lia.org/node/21279.
• 32.Academy of Laser Dentistry. Laser Officer. https://www.laserdentistry.org/index.php?option=com_dailyplanetblog&view=entry&year=2022&month=06&day=14&id=27:laser-safety-officer.