Coronavirus disease 2019, also known as COVID-19, has rapidly become a worldwide emergency. The World Health Organization (WHO) has recently declared the global pandemic. The pathogen responsible for such infection is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although the new COVID-19 virus is different from SARS-CoV, it uses the same host receptor, namely human angiotensin-converting enzyme 2 (ACE2).

Why dentistry is a risk branch?

The COVID-19 virus was recently identified in saliva of infected patients. Saliva can have a pivotal role in the human-to-human transmission. Dentists and other healthcare professionals that perform aerosol-generating procedures may be unknowingly providing direct care for infected but not yet diagnosed COVID-19 patients, or those considered to be suspected cases for surveillance. As in bronchoscopy, inhalation of airborne particles and aerosols produced during dental procedures on patients with COVID-19 can be a high-risk procedure in which dentists are directly and closely exposed to this virus. Therefore, it is crucial for dentists to refine preventive strategies to avoid the COVID-19 infection by focusing on patient placement, hand hygiene and all personal protective equipment (PPE). 

Figure taken from “Transmission routes of 2019-nCoV and controls in dental practice” – Peng et al. 2020

Due to the characteristics of dental settings, the risk of cross infections may be high between dental practitioners and patients. For dental practices and hospitals all over the world (the outbreak is pandemic), strict and effective infection control protocols are urgently needed. Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection.

What can dentists do to protect themselves and patients?

Hand hygiene has been considered the most critical measure for reducing the risk of transmitting microorganism to patients (Larson et al. 2000). SARS-CoV-2 can persist on surfaces for a few hours or up to several days, depending on the type of surface, the temperature or the humidity of the environment (WHO 2020c). This reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within dental clinics. Every surface in the waiting room must be considered at risk; therefore, in addition to providing adequate periodic air exchange, all surfaces, chairs, magazines and doors that come into contact with healthcare professionals and patients must be considered “potentially infected”. It may be useful to make alcoholic disinfectants and masks available to patients in waiting rooms. The entire air conditioning system must be sanitized very frequently.

The use of personal protective equipment (including masks, gloves, gowns and goggles or face shields) is recommended to protect skin and mucosa from (potentially) infected blood or secretions. As respiratory droplets are the main route of SARS-CoV-2 transmission, particulate respirators (e.g., N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union) are recommended for the routine dental practice.

The management practice of the operating area should be quite similar to what happens with other patients affected by infectious and highly contagious diseases. As often as possible, the staff should work at an adequate distance from patients; furthermore, handpieces must be equipped with anti-reflux devices to avoid contaminations, improving the risk of cross-infections. Dentists should take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols. The 4-handed technique is beneficial for controlling infection. The use of saliva ejectors with low or high volume can reduce the production of droplets and aerosols (Kohn et al. 2003; Li et al. 2004; Samaranayake and Peiris 2004).

Decision making processes in patient management

In order to perform a clinically- and ethically-driven decision-making process, dental interventions can be divided in the following categories:

  • Emergency management of life-threatening conditions;
  • Urgent conditions that can be managed with minimally invasive procedures and without aerosol generation;
  • Urgent conditions that need to be managed with invasive and/or aerosol-generating procedures;
  • Non-urgent procedures;
  • Elective procedures.
Furthermore, the following considerations should be assessed before starting any urgent treatment.
  • Operative procedures should be as minimally invasive as possible and aerosol-generating interventions should be avoided whenever possible;
  • Disposable devices and instrumentation should be used whenever possible to limit cross-infection risks;
  • Potential viral load in patients’ saliva could be reduced with 0.23% povidone-iodine mouthwash for 15 s before intervention;
  • Isolation with rubber dam should be used whenever possible to limit the spread of microorganisms;
  • Intraoral radiographs should be limited in favor of extraoral imaging, in order to reduce salivation and gag reflex;
  • If pharmacologic management of pain is necessary, ibuprofen should be avoided in suspected and confirmed COVID-19 cases.

    Dental emergencies

    • Uncontrolled bleeding
    • Cellulitis or a diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromises the patient’s airway
    • Trauma involving facial bones, potentially compromising the patient’s airway

    Dental urgencies

    • Severe dental pain from pulpal inflammation
    • Pericoronitis or third-molar pain
    • Surgical post-operative osteitis, dry socket dressing changes
    • Abscess, or localized bacterial infection resulting in localized pain and swelling
    • Tooth fracture resulting in pain or causing soft tissue trauma
    • Dental trauma with avulsion/luxation
    • Dental treatment required prior to critical medical procedures
    • Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
    • Biopsy of abnormal tissue

    Non-urgent dental treatments that can be postponed

    • Initial or periodic oral examinations and recall visits, including routine radiographs
    • Routine dental cleaning and preventive therapies
    • Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma) or other issues critically necessary to prevent harm to the patient
    • Extraction of asymptomatic teeth
    • Restorative dentistry including treatment of asymptomatic carious lesions
    • Aesthetic dental procedure
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