The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 14, 2020
REVIEW ARTICLE

COVID-19 in Dental Practice: Transmission Risk, Infection Control Challenge, and Clinical Implications



Salwa A. Aldahlawi1, *, Ibtesam K. Afifi1, 2
1 Department of Basic and Clinical Oral Sciences, Faculty of Dentistry, Umm Al-Qura University. Makkah, Saudi Arabia
2 Department of Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt

Abstract

Objective:

The COVID-19 pandemic has become a worldwide, significant public health challenge. Dental care providers are at high risk due to the nature of their profession, which necessitates close proximity to the patient's oropharyngeal region and the use of droplet and aerosol-generating procedures.

Methods:

A review of the evolving literature on the COVID-19 pandemic was conducted. Published articles addressing SARS-CoV2 transmission modes and risks, and infection control procedures required in the dental office to protect dental patients and health care providers were assessed. Also, clinical guidelines on the management of dental patients during the pandemic were reviewed.

Results:

The established modes of transmission of SARS-CoV2 appear to be through respiratory droplets and through close contact with either symptomatic or asymptomatic patients. In addition to standard precautions of infection control widely followed in dental practices, extra precautionary measures are needed to control the spread of this highly infectious disease. Dental treatment during the pandemic is limited to emergent and urgent cases after a meticulous patient risk assessment and dental needs are triaged to minimize the risk of COVID-19 transmission and avoid cross-contamination.

Conclusion:

Dentists should be aware of the recently updated knowledge about COVID-19 modes of transmission and the recommended infection control measures in dental settings. Effective management protocols to regulate droplet and aerosol contamination in the dental clinic should be implemented to deliver dental care in a safe environment.

Keywords: Coronavirus disease 2019, Dentistry, Dental clinical guidelines, Infection control, Personal protective equipment, Aerosol.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 348
Last Page: 354
Publisher Id: TODENTJ-14-348
DOI: 10.2174/1874210602014010348

Article History:

Received Date: 28/04/2020
Revision Received Date: 22/05/2020
Acceptance Date: 05/06/2020
Electronic publication date: 21/07/2020
Collection year: 2020

© 2020 Aldahlawi and Afifi.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Basic and Clinical Oral Sciences, Faculty of Dentistry, Umm Al-Qura University. Makkah, Saudi Arabia; Tel: +966125542487; Fax: +9667442-7443; E-mail: sadahlaawi@uqu.edu.sa





1. INTRODUCTION

The COVID-19 pandemic first originated in Wuhan, China, in December 2019. It has been identified as a public health emergency of international concern by the World Health Organization (WHO) and by the 29th April 2020, it reached 2954222 confirmed cases worldwide. [1Li LQ, Huang T, Wang YQ, et al. COVID-19 patients“ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol 2020; 92(6): 577-83.
[http://dx.doi.org/10.1002/jmv.25757] [PMID: 32162702]
-3World Health Organization (WHO). Coronavirus disease (COVID-2019) situation reports 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports]. It was first identified in samples of bronchoalveolar lavage fluid in patients with pneumonia on the 3rd January 2020, and found to be typical of a lineage B beta coronavirus, following which, it was termed novel Coronavirus (2019-nCoV) [1Li LQ, Huang T, Wang YQ, et al. COVID-19 patients“ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol 2020; 92(6): 577-83.
[http://dx.doi.org/10.1002/jmv.25757] [PMID: 32162702]
]. On the 11th February 2020, the International Committee on Taxonomy of Viruses (ICTV) announced “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)” as the name of the new virus as it was genetically related but different to the coronavirus responsible for the SARS outbreak of 2003. Moreover, the WHO named the disease caused by this virus as “COVID-19“ [4World Health Organization (WHO). Naming the coronavirus disease (COVID-19) and the virus that causes it 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it].

2. MODES OF TRANSMISSION OF SARS-COV-2 VIRUS

Several studies were performed to determine the modes of transmission of SARS-CoV-2, which confirmed that it is mainly transmitted through respiratory droplets and direct contact. The primary mode of transmission is thought to occur from droplet spread in which large droplets (≥5-10 μm) carry virus particles. Droplet transmission occurs when a person is in close contact (within one and a half meters) with a patient having respiratory symptoms (e.g., coughing or sneezing) and therefore, they risk exposing their oral and nasal mucosae and eyes to the potentially infective respiratory droplets [5Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist: Preliminary evidence-based review. Laryngoscope 2020.
[http://dx.doi.org/10.1002/lary.28672]
-7World Health Organization (WHO). Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Scientific brief 2020. Available from: https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations]. Another study highlighted the transmission of SARS-CoV-2 through the ocular surface and speculated that the virus enters the tears through droplets, which may pass through the nasolacrimal ducts and then into the respiratory tract [6Lu CW, Liu XF, Jia ZF. 2019-nCoV transmission through the ocular surface must not be ignored. Lancet 2020; 395(10224): e39.
[http://dx.doi.org/10.1016/S0140-6736(20)30313-5] [PMID: 32035510]
].

The infection control guidelines established to avoid such infection, recommend supplementing standard precautions with droplet (transmission-based) precautions. The core element of standard precautions is hand hygiene using soap and water for at least 20 seconds, especially when hands are visibly dirty and after touching any surface, coughing, sneezing or blowing the nose [8Ramesh N, Siddaiah A, Joseph B. Tackling corona virus disease 2019 (COVID 19) in workplaces. Indian J Occup Environ Med 2020; 24(1): 16-8.
[http://dx.doi.org/10.4103/ijoem.IJOEM_49_20] [PMID: 32341630]
]. In circumstances where no soap and water are available, hand hygiene with alcohol-based hand rub (ABHR) containing ethanol (80% v/v) or isopropanol (75% v/v) is used. Alcohol denatures proteins and inactivates enveloped viruses, including coronaviruses and thus ABHR is recommended by the WHO that declared its marked virucidal effect against SARS-CoV and MERS-CoV [9Siddharta A, Pfaender S, Vielle NJ, et al. Virucidal activity of World Health Organization-recommended formulations against enveloped viruses, including zika, ebola, and emerging coronaviruses. J Infect Dis 2017; 215(6): 902-6.
[http://dx.doi.org/10.1093/infdis/jix046] [PMID: 28453839]
, 10World Health Organization (WHO). Guidelines on hand hygiene in health care. First global patient safety challenge clean care is safer care 2009. Available from: https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1]. As diseases transmitted by respiratory droplets require certain proximity of people, droplet precautions recommended by health agencies during this COVID-19 pandemic include cough etiquette and social distancing. Cough etiquette was clarified by Harte 2010 as covering the mouth and nose during coughing and sneezing, using tissues to cover respiratory secretions and quickly disposing them of in a closed area, offering a surgical mask to people with respiratory symptoms to decrease contamination of the surrounding environment and performing hand hygiene after contact with respiratory secretions [11Harte JA. Standard and transmission-based precautions: an update for dentistry. J Am Dent Assoc 2010; 141(5): 572-81.
[http://dx.doi.org/10.14219/jada.archive.2010.0232] [PMID: 20436107]
]. At the level of the community, social distancing is designed to reduce interactions between individuals where unidentified infected persons may exist [12Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27(2)taaa020
[http://dx.doi.org/10.1093/jtm/taaa020] [PMID: 32052841]
].

Among health care workers, personal protective equipment (PPE) includes face masks, respirators, gloves, and goggles or face shields, that are advised to protect from droplet infections. Face masks are used to avoid respiratory droplets and spray of body fluids on the face and also used by patients as source control to prevent the spread of pathogens to others [13Derrick JL, Gomersall CD. Protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks. J Hosp Infect 2005; 59(4): 365-8.
[http://dx.doi.org/10.1016/j.jhin.2004.10.013] [PMID: 15749326]
]. Respirators are used to protect from respiratory aerosols and if properly fitted, they may provide better protection against respiratory infections than a standard face mask. Gloves are also used to prevent hand contamination by body fluids, including respiratory secretions. Additionally, goggles and face shields are used to protect against the transfer of respiratory pathogens into the eyes from contaminated hands and other sources [14Chughtai AA, Khan W. Use of personal protective equipment to protect against respiratory infections in Pakistan: A systematic review. J Infect Public Health 2020; 13(3): 385-90.
[http://dx.doi.org/10.1016/j.jiph.2020.02.032] [PMID: 32146139]
, 15MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in healthcare and community settings. BMJ 2015; 350: h694.
[http://dx.doi.org/10.1136/bmj.h694] [PMID: 25858901]
].

The other documented COVID-19 mode of transmission is through contact, where the immediate environment around the infected person (e.g., chair, glass window in the room, etc.) or objects used by the infected person (e.g., door handle, light switches, elevator buttons and faucet taps, etc.) could act as a potential medium to transmit infection by indirect contact [16Cai J, Sun W, Huang J, Gamber M, Wu J, He G. Indirect virus transmission in cluster of COVID-19 cases, Wenzhou, China, 2020. Emerg Infect Dis 2020; 26(6): 1343-5.
[http://dx.doi.org/10.3201/eid2606.200412] [PMID: 32163030]
-18Ong SWX, Tan YK, Chia PY, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) From a symptomatic patient. JAMA 2020.
[http://dx.doi.org/10.1001/jama.2020.3227] [PMID: 32129805]
]. Environmental contamination is attributed to aerosol transmission in a relatively closed environment exposed to high concentrations of aerosols for a long time as well as under certain circumstances that generate aerosols. These circumstances include endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation. During these maneuvers, the aerosols with virus particles being less than 5μm in diameter can remain in the air for long periods of time, transmitted to others over distances greater than one meter and thus become airborne, increasing the risk of spread [5Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist: Preliminary evidence-based review. Laryngoscope 2020.
[http://dx.doi.org/10.1002/lary.28672]
, 7World Health Organization (WHO). Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Scientific brief 2020. Available from: https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations].

To verify environmental contamination around patients with COVID-19, different surfaces were experimentally exposed to the SARS-CoV-2 virus isolated in tissue culture form. Reported results showed that no infectious virus was recovered from printing and tissue papers after a three-hour (hs) incubation and from wood or cloth on day two. In contrast, SARS-CoV-2 was more stable on smooth surfaces and could not be detected from treated glass and banknote surfaces on day four or from stainless steel and plastic on day seven. More surprisingly, a detectable level of the infectious virus could still be present on the outer layer of a surgical mask on day seven [19Chin AWH, Chu JTS, Perera MRA, et al. Stability of SARS-CoV-2 in different environmental conditions 2020.]. Another study examined SARS-CoV-2 in aerosol form concluded that the virus could remain viable and infectious in aerosols for three hours and on surfaces for days (depending on the inoculum shed). This study proved that the virus is more stable on plastic and stainless steel (72 and 48 hs, respectively) than on copper (4hs) and cardboard (24hs) although the virus titer was greatly reduced [20van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020; 382(16): 1564-7.
[http://dx.doi.org/10.1056/NEJMc2004973] [PMID: 32182409]
].

The infection control guidelines established to avoid COVID-19 infection through contact with environmental surfaces recommend supplementing standard precautions with contact (transmission-based) precautions. Health Care Workers (HCWs) should wear a clean, non-sterile, long-sleeved gown and gloves whenever in contact with the patient or potentially contaminated areas surrounding the patient, with appropriate doffing and disposal of all PPE and hand hygiene after patient care. A new set of PPE should be donned when care is administered to another patient [21Siegel JD, Rhinehart E, Jackson M, Chiarello L. Committee. HCICPA. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007; 35(10)(Suppl. 2): S65-S164.
[http://dx.doi.org/10.1016/j.ajic.2007.10.007] [PMID: 18068815]
]. Equipment should be single-use and disposable, if possible. In case of shared equipment, proper cleaning, disinfection and sterilization should be confirmed with care during transportation to a central sterilization service department. For the disinfection of environmental surfaces, the WHO recommends the use of disinfectants that are active against enveloped viruses, which includes the SARS-CoV-2 virus. These disinfectants include 70% ethyl alcohol for disinfecting reusable dedicated equipment as well as any small areas in use and sodium hypochlorite at 0.5% (equivalent to 5000 ppm) for disinfecting surfaces in healthcare settings [22World Health Organization (WHO). Water, sanitation, hygiene and waste management for COVID-19 Interim guidance 2020. Available from: https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19]. All health care wastes produced during the care of COVID-19 patients should be collected safely in designated containers and bags and then safely disposed of, with all who handle the waste, wearing appropriate PPE (boots, apron, long-sleeved gown, thick gloves, mask, and goggles or a face shield) and performing appropriate hand hygiene straight after [10World Health Organization (WHO). Guidelines on hand hygiene in health care. First global patient safety challenge clean care is safer care 2009. Available from: https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1].

Hoffmann, et al. [23Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell 2020; 181(2): 271-80.e8], highlighted that Angiotensin-Converting Enzyme 2 receptors (ACE2) are highly concentrated in salivary glands and could also be used for host cell entry and infection. This was later supported by the detection of SARS-CoV-2 RNA in the saliva of 25 COVID-19 patients where salivary samples were collected by drooling technique or with a pipette to ensure exclusion of sputum and oropharyngeal secretions from the specimens [24Azzi L, Carcano G, Gianfagna F, et al. Saliva is a reliable tool to detect SARS-CoV-2. J Infect 2020; 81(1): e45-50.
[http://dx.doi.org/10.1016/j.jinf.2020.04.005] [PMID: 32298676]
]. However, it remains to be shown whether SARS-CoV-2 levels in saliva are high enough to be infectious [25Xu R, Cui B, Duan X, Zhang P, Zhou X, Yuan Q. Saliva: potential diagnostic value and transmission of 2019-nCoV. Int J Oral Sci 2020; 12(1): 11.
[http://dx.doi.org/10.1038/s41368-020-0080-z] [PMID: 32300101]
]. SARS-CoV-2 RNA has also been detected in 7 of 10 stool samples from infected subjects raising the likelihood of fecal-oral transmission [26Team C-I. Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States. Nat Med 2020.].

3. TRANSMISSION RISK IN DENTAL OFFICES

In dental practices, COVID-19 transmission is expected via droplets and aerosols generated during clinical procedures especially when using drills or ultrasonic devices that cause aerosol release [27Dave M, Seoudi N, Coulthard P. Urgent dental care for patients during the COVID-19 pandemic. Lancet 2020; 395(10232): 1257.
[http://dx.doi.org/10.1016/S0140-6736(20)30806-0] [PMID: 32251619]
]. Based on previous reports on COVID-19 patients undergoing endotracheal intubation, aerosol transmission in an environment exposed to high concentrations of aerosols for a long time led to the spread of SARS-CoV-2 [1Li LQ, Huang T, Wang YQ, et al. COVID-19 patients“ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol 2020; 92(6): 577-83.
[http://dx.doi.org/10.1002/jmv.25757] [PMID: 32162702]
, 5Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist: Preliminary evidence-based review. Laryngoscope 2020.
[http://dx.doi.org/10.1002/lary.28672]
, 28World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Scientific brief 2020. Available from: https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations]. Furthermore, splatters created during oral surgery procedures, like aerosols, are also contaminated by respiratory pathogens [29Coulthard P. The oral surgery response to coronavirus disease (COVID“19). Keep calm and carry on? Oral Surg 2020; 13(2): 95-7.
[http://dx.doi.org/10.1111/ors.12489]
]. Another important potential mode of transmission in dental practice could be contact with contaminated environmental surfaces.

During various dental procedures, aerosols and splatter can be produced by either patient, dental unit waterlines (DUWLs) or instruments used. For patients, microorganisms present in their mouth and respiratory tract may be transported in the generated aerosol; the amount of contamination is dependent on the amount of saliva, nasal and throat secretion, blood, dental plaque, periodontal infection, and the presence of any dental infection. The contamination of DUWL with very adherent organisms may be precipitated by the design of narrow lines, water stagnation, heating of dental chair unit and anti-retraction valve failure. Microorganisms may shed to the oral cavity during the use of DUWLs in dental procedures and can lead to the spread of infection [30O“Donnell MJ, Boyle MA, Russell RJ, Coleman DC. Management of dental unit waterline biofilms in the 21st century. Future Microbiol 2011; 6(10): 1209-26.
[http://dx.doi.org/10.2217/fmb.11.104] [PMID: 22004039]
, 31Spagnolo AM, Sartini M, Cave DD, Casini B, Tuvo B, Cristina ML. Evaluation of microbiological and free-living protozoa contamination in dental unit waterlines. Int J Environ Res Public Health 2019; 16(15)E2648
[http://dx.doi.org/10.3390/ijerph16152648] [PMID: 31344972]
]. Instruments that can produce dental aerosols include ultrasonic and sonic scalers, air-water syringe and air turbine handpiece used for tooth preparation [32Jain M, Mathur A, Mathur A, Mukhi PU, Ahire M, Pingal C. Qualitative and quantitative analysis of bacterial aerosols in dental clinical settings: Risk exposure towards dentist, auxiliary staff, and patients. J Family Med Prim Care 2020; 9(2): 1003-8.
[http://dx.doi.org/10.4103/jfmpc.jfmpc_863_19] [PMID: 32318458]
, 33Veena HR, Mahantesha S, Joseph PA, Patil SR, Patil SH. Dissemination of aerosol and splatter during ultrasonic scaling: a pilot study. J Infect Public Health 2015; 8(3): 260-5.
[http://dx.doi.org/10.1016/j.jiph.2014.11.004] [PMID: 25564419]
].

Aerosols are defined as a combination of both liquid and solid particles (of less than 50 μm in diameter) and when the liquid evaporates, solid particles form droplet nuclei of 0.5 to 10 μm composed of saliva, dried serum and microorganisms. These droplet nuclei can reach pulmonary alveoli carrying bacteria and viruses and transmitting various infectious diseases such as SARS-COV-2 and Mycobacterium tuberculosis, or it can remain afloat in the air for several hours. Splatters consist of a mixture of air, water and / or solid substances, which are of 50 μm to several millimeters in diameter and are visible to the naked eye. Due to the mass, splatters are able to have the kinetic energy to move in a ballistic manner and settle atop objects due to gravitational forces with limited penetration into the respiratory system [34James R, Mani A. Dental aerosols: a silent hazard in dentistry. Int J Sci Res (Ahmedabad) 2016; 5(11): 1761-3., 35Raj G, Suma B. S., Mangal G. Dental aerosol & splatter- a silent hazard & implication on Infection control in dentistry. Eur J Pharm Med Res 2019; 6(2): 603-7.].

The infection control guidelines to minimize the risk of dental aerosols emphasize on the use of PPE i.e. gloves, face masks and protective eyewear, pre-procedural rinsing, use of focused spray ultrasonic inserts; and disinfection of dental unit waterlines by chemical or non-chemical means [36Center for Disease Control and Prevention (CDC). Interim infection prevention and control guidance for dental settings during the COVID-19 response 2020. Available from https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html]. Given that the incubation period of COVID-19 ranges from 1-14 days, (most commonly around five days) [7World Health Organization (WHO). Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. Scientific brief 2020. Available from: https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations], recent evidence suggests that a non-symptomatic person can spread COVID-19 with high efficiency [37Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020; 382(10): 970-1.
[http://dx.doi.org/10.1056/NEJMc2001468] [PMID: 32003551]
], also patients can spread high amounts of the virus and infect others even after recovery from the acute illness, therefore, the use of N95 masks is advised to ensure the safety of healthcare workers during COVID-19 outbreak [38Chang D, Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med 2020; 8(3)e13
[http://dx.doi.org/10.1016/S2213-2600(20)30066-7] [PMID: 32061333]
]. Protective eyewear with side shields or face shields for dentists, not only protects from aerosols and spatter that transmit infection, but also from debris projected from the mouth, and from injuries caused by sharp instruments [39Sebastiani FR, Dym H, Kirpalani T. Infection control in the dental office. Dent Clin North Am 2017; 61(2): 435-57.
[http://dx.doi.org/10.1016/j.cden.2016.12.008] [PMID: 28317575]
]. Guidelines also advised the use of High Volume Evacuators (HVE) with low volume saliva ejector as this will ensure removal of the water deposited in the floor of the mouth with no air removal. HVE also has a large bore evacuator tip with a diameter of 8 mm or more and thus, it can remove air at the rate of 100 cubic feet per minute, reducing aerosol and splatter by 93“96% [33Veena HR, Mahantesha S, Joseph PA, Patil SR, Patil SH. Dissemination of aerosol and splatter during ultrasonic scaling: a pilot study. J Infect Public Health 2015; 8(3): 260-5.
[http://dx.doi.org/10.1016/j.jiph.2014.11.004] [PMID: 25564419]
, 40Aurangjeb AM, Zaman T, Badruddoza M. Practice of dental Surgeons about dental splatter and aerosol. City Dental College Journal 2013; 10(2): 10-6.
[http://dx.doi.org/10.3329/cdcj.v10i2.16314]
].

Due to the high risk of COVID-19 spread via dental practice, the dental healthcare community needs to take urgent action to protect patients and dental health care providers alike from infection. As of March 18th, the American Dental Association (ADA), and the U.S. Centers for Disease Control and Prevention (CDC) have urged all dentists to cancel, or at least postpone, all elective and non-urgent dental visits and thus routine dental practice has been suspended in several countries [41Dentist“s Advantage. Risk management alert coronavirus (COVID-19) and the dental practice 2020. Available from: https://www.dentists-advantage.com/Prevention-Education/Risk-Alerts/Risk-Alerts-Index/Content/Coronavirus-(COVID-19)-and-the-dental-practice]. However, although patients diagnosed with COVID-19 are not recommended to receive dental treatments, dental emergencies are difficult to avoid, and consequent close contact is unavoidable. Thus, a timely and major reassessment of dental care practices is essential [27Dave M, Seoudi N, Coulthard P. Urgent dental care for patients during the COVID-19 pandemic. Lancet 2020; 395(10232): 1257.
[http://dx.doi.org/10.1016/S0140-6736(20)30806-0] [PMID: 32251619]
, 42Khader Y, Al Nsour M, Al-Batayneh OB, et al. Dentists“ awareness, perception, and attitude regarding COVID-19 and infection control: cross-sectional study among jordanian dentists. JMIR Public Health Surveill 2020; 6(2)e18798
[http://dx.doi.org/10.2196/18798] [PMID: 32250959]
].

4. DENTAL CONSIDERATION IN THE MANAGEMENT OF COVID-19 PATIENTS

The American Dental Association (ADA) has published interim guidance for the management of emergency and urgent dental care to assist dentists in making informed decisions concerning patient evaluation and treatment during the COVID-19 pandemic [43Interim guidance for management of emergency and urgent dental care 2020. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_Int_Guidance_Mgmt_Emerg-Urg_Dental_COVID19?utm_source=adaorg&utm_medium=VanityURL&utm_content=interimguidance-flowcharts&utm_campaign=covid-19]. In addition, many other international and local regulatory bodies have published guidelines and protocols for urgent dental treatment during the COVID-19 pandemic [44Royal College of Dental Surgeons of Ontraio. Guidance on emergency and urgent care during COVID-19 2020. Available from: https://www.rcdso.org/en-ca/rcdso-members/2019-novel-coronavirus/covid-19---guidance-on-emergency-and-urgent-care--46Royal College of Surgeons of England. COVID-19 2020. Available from: https://www.rcseng.ac.uk/dental-faculties/fds/coronavirus/].

Dentists are advised to review their local governance recommendations regarding dental management during the pandemic. However, all guidance highlights the importance of screening patients prior to their dental appointments. The purpose stated for the screening is to identify patients with possible COVID-19 infection and to minimize the chance of exposure to Dental Care Providers (DCP), staff and to other patients. During the screening call, patients should be asked whether they have a fever (above 38°C) or if they are experiencing any respiratory symptoms like sore throat, cough, or difficulty of breathing. Additionally, ADA recommended obtaining a travel history (to any of the affected countries during the last 14 days) as well as the history of contacts with a diagnosed or suspected case of COVID-19. Subsequently, the dental condition of the patient and the urgency of their dental treatment needs are assessed. The list of emergency and urgent dental care conditions that require immediate treatment is presented in Table 1 and adopted from ADA interim guidance [43Interim guidance for management of emergency and urgent dental care 2020. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_Int_Guidance_Mgmt_Emerg-Urg_Dental_COVID19?utm_source=adaorg&utm_medium=VanityURL&utm_content=interimguidance-flowcharts&utm_campaign=covid-19].

Table 1
List of emergent and urgent dental care adopted from ADA intern guidance (2020).


Guidelines from CDC stated that patients reporting dental pain should be evaluated for the level of pain and whether it is controlled by pain medications or not. According to these guidelines, patients with facial trauma, uncontrolled bleeding or cellulitis affecting the airways should be referred to the emergency department. A localized dental abscess, dental pain due to pulpal inflammation or dental trauma, causing avulsion or luxation of the teeth should be seen and managed based on the best recommended treatment guidelines. Other non-urgent dental care should be postponed until further notification from the CDC [47Center for Disease Control and Prevention. CDC recommendation: Postpone non-urgent dental procedures, surgeries, and visits 2020. Available from https://www.cdc.gov/oralhealth/infectioncontrol /statement-COVID.html].

4.1. Dental Treatment of Patients with a Confirmed COVID-19 Infection

ADA guidance does not allow their examination in dental settings and recommends that emergency dental treatment to be limited to control pain and infection in consultation with the medical team. Accordingly, if a dental procedure must be performed, it should be done under rigorous standards, limited contact, and airborne precaution in a negative pressure room [48American Dental Association (ADA). Interim guidance for minimizing risk of COVID-19 transmission 2020. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts]. When infection control measures were strictly followed, none of the dental staff in the School and Hospital of Stomatology in Wuhan University was found to be infected by COVID-19 [49Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res 2020; 99(5): 481-7.
[http://dx.doi.org/10.1177/0022034520914246] [PMID: 32162995]
].

4.2. Pharmaceutical Management of Pain and Infection

Prescription of pain medication or antibiotics might be needed to treat mild pain or localized infection. There has been a number of reports that Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) may exacerbate symptoms in COVID-19 patients. Ibuprofen use has been found to be associated with increases in Angiotensin-Converting Enzyme-2 (ACE2) receptor expression, which may facilitate infection with COVID-19 [50Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? Ecancermedicalscience 2020; 14: 1023.
[http://dx.doi.org/10.3332/ecancer.2020.1023] [PMID: 32256706]
]. However, the literature does not provide any conclusive evidence against the use of NSAIDs in COVID-19 patients [50Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? Ecancermedicalscience 2020; 14: 1023.
[http://dx.doi.org/10.3332/ecancer.2020.1023] [PMID: 32256706]
, 51Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ 2020; 368: m1185.
[http://dx.doi.org/10.1136/bmj.m1185] [PMID: 32220865]
]. The World Health Organization has published a scientific brief regarding the use of NSAIDs in COVID-19 that concluded a lack of evidence of severe adverse events as a result of NSAIDs use in COVID -19 patients [52World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19 2020. Available from: WHO/2019-nCoV/Sci_Brief/NSAIDs/2020.1]. Therefore, prescribing NSAIDs in combination with acetaminophen to manage dental pain, is appropriate until further evidence emerges.

Asymptomatic patients without known exposure to COVID- 19 cannot be assumed to be free of the SARS-COV-2 virus [37Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020; 382(10): 970-1.
[http://dx.doi.org/10.1056/NEJMc2001468] [PMID: 32003551]
]. Therefore, recommendations are given that all aerosol-generating dental procedures should be done in isolated and adequately ventilated rooms or in a negative pressure room (when available). The use of the highest PPE available, including eye protection and face shield, is essential as is the use of fitted N95 respirators or FDA approved N95 equivalent masks for both the dentist and the dental assistant [53American Dental Association (ADA). Interim mask and face shield guidelines 2020. Available from: https://success.ada.org/~/media/CPS/Files /COVID/ADA_Interim_Mask_and_Face_Shield_Guidelines]. For none-aerosol generating procedures, the use of a surgical mask and a face shield is required (if N95 masks are unavailable/ in limited supply); however, there is a moderate risk of infection and professional judgment regarding patient treatment that must be exercised [48American Dental Association (ADA). Interim guidance for minimizing risk of COVID-19 transmission 2020. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts]. The SARS-CoV-2 virus is viable in aerosol for three hours [20van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020; 382(16): 1564-7.
[http://dx.doi.org/10.1056/NEJMc2004973] [PMID: 32182409]
], which emphasizes the importance of following the correct sequence of wearing and removal of PPE as recommended by the CDC [54Center for Disease Control and Prevention (CDC). PPE sequence 2020. Available from: https://www.cdc.gov/hai/pdfs /ppe/ppe-sequence.pdf]. Special recommendations to minimize the risk of disease transmission during dental procedures in those patients are presented in Table 2 [55Zimmermann M, Nkenke E. Approaches to the management of patients in oral and maxillofacial surgery during COVID-19 pandemic. J Craniomaxillofac Surg 2020; 48(5): 521-6.
[http://dx.doi.org/10.1016/j.jcms.2020.03.011] [PMID: 32303420]
-57Kirk-Bayley J, Challacombe S, Sunkaraneni V, Combes J. The use of povidone iodine nasal spray and mouthwash during the current COVID-19 pandemic may protect healthcare workers and reduce cross infection 2020. Available from: https://ssrn.com/abstract=3563092
[http://dx.doi.org/10.2139/ssrn.3563092]
].

For patients with resolved COVID-19 infection, it remains to be established when dental treatment can be safely performed. The duration of immunity to SARS-CoV-2 is also not known yet, however, it is unlikely that patients get re-infected after recovery, but the evidence on the immune response and the possibility of re-infection is lacking in the literature [58Bao L, Deng W, Gao H, et al. Reinfection could not occur in SARS-CoV-2 infected rhesus macaques. bioRxiv 2020. 2020.03.13.990226]. As with any newly emerging infectious disease, the patient must be presumed as infective until counter-evidence is presented, so resolved patients should be managed with the same precautions as asymptomatic patients.

5. PRESENT SITUATION AND FUTURE CONSIDERATIONS

Dental healthcare has been significantly affected by the COVID-19 pandemic. Limitation of dental care to emergency treatment and postponing elective procedures not only challenged the current treatment protocols but also resulted in a significant financial loss to many dental practices [59Farooq I, Ali S. COVID-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers. Postgrad Med J 2020.postgradmedj-2020-137781
[http://dx.doi.org/10.1136/postgradmedj-2020-137781] [PMID: 32245754]
, 60Yang Y, Zhou Y, Liu X, Tan J. Health services provision of 48 public tertiary dental hospitals during the COVID-19 epidemic in China. Clin Oral Investig 2020; 24(5): 1861-4.
[http://dx.doi.org/10.1007/s00784-020-03267-8] [PMID: 32246280]
]. However, this limitation has created telecommunications and online consultations that emphasize patient-education and follow up for early recognition and management of dental problems and hence avoiding life-threatening dental emergencies [61Long L, Corsar K. The COVID-19 effect: Number of patients presenting to The Mid Yorkshire Hospitals OMFS team with dental infections before and during The COVID-19 outbreak. Br J Oral Maxillofac Surg 2020; (20): 30184-4.
[PMID: 32386672]
].

The risk of COVID-19 infection to the dental care provider and potentially infecting patients during emergency dental treatment is significant. Data form the top five affected countries estimated that 15-20% of HCWs were infected with COVID-19 [62Ali S, Noreen S, Farooq I, Bugshan A, Vohra F. Risk assessment of healthcare workers at the frontline against COVID-19. Pak J Med Sci Q 2020; 36(May): s1-5.]. Factors like lack of understanding of the virus and its mode of transmission, the limited availability and inadequate use of PPE, limited diagnostic tests and psychological stress are contributing to the increased rate of COVID-19 infection among HCW [62Ali S, Noreen S, Farooq I, Bugshan A, Vohra F. Risk assessment of healthcare workers at the frontline against COVID-19. Pak J Med Sci Q 2020; 36(May): s1-5.].

Table 2
Special recommendations to minimize the risk of disease transmission during dental procedures.


CONCLUSION

To ensure the safety of dental staff during the outbreak, the US Occupational Safety and Health Administration (OSHA) has recommended regular testing DCPs for COVID-19, daily self-assessment for symptoms of COVID-19 and temperature check for all dental personals including dental assistants, hygienists, receptionists and dental technicians. Dental staff education is essential for protecting staff and patients from further spread of COVID-19, with an emphasis on the progression of the disease, its mode of transmission, clinical presentation and prevention methods, proper training in hand hygiene, the use of PPE and infection control methods according to the updated protocols form CDC and WHO [63U.S. Department of Labor. Occupational Safety and Health Administration. Guidance on preparing workplaces for COVID-19 2020. Available from: https://www.osha.gov/Publications /OSHA3990.pdf].

A better understanding of the present situation will allow for the prediction of future dental needs as dental services may grow in the post-COVID-19 period. Health agencies should be coordinated to implement comprehensive prevention and control measures in future dental care [64Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci 2020.
[http://dx.doi.org/10.1016/j.jds.2020.02.002] [PMID: 32296495]
]. New safety procedures, air purification systems, or additional infection control measures will be developed as our understanding of COVID-19 infection evolves. As the information on this pandemic is continuously changing, it is vital that dental professionals stay updated on the emerging research to be able to continue providing dental treatment in a safe environment.

LIST OF ABBREVIATIONS

WHO  = World Health Organization.
ABHR  = Hand hygiene with Aalcohol-Based Hand Rub
PPE  = Personal Protective Equipment
HCWs  = Health Care Workers
DUWLs  = Dental Unit Waterlines
HVE  = High Volume Evacuators
DCP  = Dental Care Providers
ADA  = American Dental Association
CDC  = Centers for Disease Control and Prevention
ACE2  = Angiotensin Converting Enzyme-2
NSAIDs  = Nonsteroidal Anti-inflammatory Drugs

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Hind Hassan Abdel-Latif for assistance in editing the manuscript.

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