Post-COVID-19 dentistry

Risk Factors for poor Covid-19 Outcomes

The novel coronavirus, officially named as Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), started in Wuhan, China in December 2019 and has become a major challenging public health problem not only for China but also countries around the world. The World Health Organization on 30th January 2020 announced that this outbreak had constituted a public health emergency of international concern. The virus has a predominantly respiratory transmission through aerosol and droplets. This means that the dental profession is particularly at risk, due to the physical proximity to patients and close contact with patients’ saliva. During the dental appointment patients’ droplets can be inhaled, get on the skin or mucous membranes, and/or stay on the surfaces and dental tools. The importance of infection control is therefore crucial in limiting the dissemination of the virus. Also, in a study conducted in the epicenter of the pandemic in Wuhan by Meng et al. (1), the occurrence of 9 cases of COVID-19 among 169 dental practitioners (5.3%) is reported, emphasizing the high risk of occupational hazard. To manage the threat of continued SARS-CoV-2 infection and the risk to public health caused by COVID-19, oral health professionals need up-to-date information and guidance at all times.

 

COVID-19 Transmission Risks in Dental Practice

During the pandemic of COVID-19, dental activities are limited to emergency treatments only. Therefore, dentists are organizing their schedule with no more than 1 patient per hour, no companions in the waiting room and employing adequate personal protective equipment to avoid infection. Furthermore, the Italian National Institute of Health suggests limiting the time of health care contact with patients to 15 min to reduce the risk of infection. Thus, treatment should be effective and pragmatic, aimed only for emergency patients. The Scottish Dental Clinical Effectiveness Programme (SDCEP) has produced a guide for managing acute oral conditions during the pandemic. There are potentially 4 types of patients who may be presenting dental emergencies: 

  1. subjects with known SARS-CoV-2 infection,
  2. subjects at potential risk of infection,
  3. subjects with unknown risk of infection, and
  4. subjects who have healed from COVID-19.

Having said that, every patient should be treated with caution, due to the unknown risk of being contagious, as one of the dangerous aspects of COVID-19 is the presence of the virus and contagiousness in the asymptomatic stage as well.

General recommendations for safe and efficient dental practice are the following (2):

  1. Patient Triage to investigate current health status and/or the presence of risk factors for COVID-19. Telephone screening during appointment scheduling, epidemiological questionnaire, measuring body temperature with a contact-free forehead thermometer and excluding presence of suspect symptoms (coughing, sneezing, respiratory difficulty) will improve safety for both patients and dental team members.
  2. The use of mouth rinses prior to dental treatment such as 0.2% to 1% povidone, 0.05% to 0.1% cetylpyridinium chloride, or 1% hydrogen peroxide.
  3. The dental practitioner should perform careful hand washing for at least 60 seconds, employing a 60% to 85% hydroalcoholic solution, prior to wearing gloves. It is crucial to perform thorough hand washing when coming into contact with patients and non disinfected surfaces or equipment, and avoid touching eyes, mouth, and nose without having hands carefully washed.
  4. The use of personal protective equipment (PPE), including gloves, masks, protective outerwear, protective surgical glasses, and shields, is strongly recommended to protect eye, oral, and nasal mucosa. The importance of the barrier protection equipment has been stressed by the European Centre for Disease Prevention and Control to fundamentally protect operators from the SARS-CoV-2 contagion and their guidance can be accessed (3). The recently published Cochrane Review (4 and 5), aimed to evaluate which type of full-body PPE and which method of donning (putting on) or doffing (taking off) PPE have the lowest risk of contamination or infection for health care workers, and which training methods increase compliance with PPE protocols. The review suggests that covering more parts of the body (e.g. using a long gown rather than merely an apron) provides better protection against contamination. However, the authors highlight the difficulty in donning and doffing such PPE which could potentially increase self-contamination. PPE made from more breathable material may help increase user satisfaction, with a little impact on contamination. The head and neck areas of the dental teams are particularly at risk during dental procedures and PPE coverage protecting these areas is highlighted within the review. Better fitting PPE, sealed gown and glove combinations and tabs to grab during donning and doffing may all help reduce contamination. Recommendations for education and training in donning and doffing are particularly important for dental teams who may not be familiar with the processes involved in using more extensive types of PPE.
  5. Limitation of Aerosol-Producing Procedures The limitation of aerosol-producing procedures might be easier said than done, especially when it comes to dental procedures for dental pain relief. It has been known that dental mist suction systems can reduce aerosol, but only if they are powerful with suction volume of 300l/min. (6). Recently, information about extraoral dental suction units for aerosoles  raised attention among dental professionals, but no comparative studies have been done yet on their effectiveness. 
  6. All surfaces should be disinfected with sodium hypochlorite 0.1% or 70% isopropyl alcohol. After the procedure, all the disposable protections should be removed and high-level disinfection performed. Powered air purifying respirators with HEPA filters are recommended for dental offices during dental procedures even on non-symptomatic patients and those without known exposure to COVID-19. (7)  If air purifiers are not available, then, at least a 5-min air change is advised after each patient with the highest level of respiratory protection. Since the virus tends to remain in airborne particles, it is recommended not to remove personal protective equipment prior to exiting the contaminated area. 
 

Clinical Experience

The overall data on the clinical experience in the dental transmission of COVID-19 are still scarce due to the rapid pandemic outbreak. Meng et al. (1) reported treatment of >700 patients at the school and hospital of dentistry at Wuhan University, China, during the outbreak of the virus and the lockdown of the overall area. Emergency dental treatments, such as pulpectomy and dental extractions, were described and a total of 1,600 online consultations were performed. Although there is some information that COVID-19 might have oral manifestations urging patients to seek dental care even before the infection is confirmed (8), until now no information on the number and type of treatment of patients affected by COVID-19 was reported for countries of Western Balkans.  

Restrictive social measures, lockout of many private practices in the region during pandemic, the change in scheduling and reception, implementation of triage of dental patients lead to decrease of non-emergency dental services.

 

Post-COVID-19 dentistry

Adoption of strict preventive measures in the field of dentistry is of utmost importance due to the extreme risk of exposure to SAR-CoV-2 infection. There is no doubt that shortly all dentists will go back to their everyday dental practices, under more extensive precaution measures. Therefore, the need for guidelines for treating patients in different stages of the disease from asymptomatic to positive and recovered is of high importance. One is for sure, the entire profession will change significantly to practice safer, responsible dentistry in terms of disinfection protocols and patient safety, which will reduce the volume of patients per day.

 

Currently, dental chambers and associations worldwide are creating protocols or guidelines to control the COVID-19 in dental practice. The table below summarizes presently available information published in the countries of Western Balkans. For up-to-date information please follow the official national dental chambers web-sites.

 

Country
Protocol published by
Bosnia and Herzegovina (R. Srpska)
Dental chamber RS – link
Bosnia and Herzegovina (Federation of Bosnia and Herzegovina)
Dental chamber Federation of Bosnia and Herzegovina – link
Serbia
Dental chamber Serbia – link
R. North Macedonia
Dental chamber of North Macedonia- link1 link2 link3
Croatia
Dental chamber of Croatia – link
Montenegro
Dental chamber of Montenegro – link
Albania
Ministry of Order of Dentists Albania and
Albanian Dental association

Without any wish to diminish the importance of strict protective measures during dental care procedures, there is one important concern regarding the post-COVID-19 dentistry. It is a financial aspect of all above recommendations. Reduction of patient flow, some additional new equipment, and must-have personal protective equipment, both reusable and single-use, might give additional financial burden to dental offices. Aside from problems regarding the supply of PPE in countries of Western Balkans, there has been a significant rise in prices for ordinary surgical masks and single-use surgical gloves. Some investigation, with good results, has been done on the possibility of decontamination and reuse of PPE, naimly N95 and disposable surgical masks, for the purpose of cutting costs (9). It could be beneficial to keep this possibility in mind, in case that dental professionals need to deal with the expected price rise of dental services. Financially, the silver lining might be the expected increase of demands for non-emergency dental services needed by patients that were postponed during the pandemic. (10)  

Written by: Stefana Chakar Kocevski, DMD, MSc, dental scientist and Selma Zukić, PhD, associate professor in dental forensics

Date: 7th May 2020