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Izzetti R, Nisi M, Gabriele M COVID-19 Transmission in dental practice: brief review of preventive measures in Italy.. J Dent Res. 2020; https://doi.org/10.1177/0022034520920580
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COVID-19 is an unprecedented virus that is destroying the lives of many people worldwide. Dentistry as a profession falls into a high-risk group due to our close proximity to patients and the aerosols generated in routine dental procedures. The UK dental community has frantically searched for answers to questions about the new virus and guidance on provision of dental care. This article will review the most up-to-date recommendations for infection control procedures and use of personal protective equipment (PPE) in England. PubMed, Embase and Google Scholar databases were searched up until 9 June. This is a review of the current information, guidelines and recommendations about the COVID-19 virus and use of PPE for dentists and orthodontists.
As of 9 June, the dental profession has received mixed guidance on how best to manage our patients whilst national lockdown is eased and we enter a recovery phase, but uncertainty remains for the long-term provision of Orthodontics.
CPD/Clinical Relevance: This article gives an overview of guidance and recommendations for dentists and orthodontists in the UK during the COVID-19 pandemic, especially with regards to infection control and use of PPE.
Article
The World Health Organization (WHO) declared, on 30 January 2020, that the COVID-19 outbreak had become a public health emergency of international concern.1,2 The risk of cross-infection in dental settings can be high between patients and dental health care professionals (DHCP). Countries with COVID-19 needed to impose strict infection prevention and control measures in hospitals and dental practices.3
As COVID-19 was spreading rapidly in the United Kingdom (UK), Public Health England and the National Health Service (NHS) were revising guidelines for personal protective equipment (PPE) for the health care professionals. This guidance was based on the recommendations of the WHO and available scientific evidence.4
As an orthodontist in the UK in the initial stage of the pandemic, it was difficult to obtain consistent information relevant to our profession. DHCPs routinely adopt ‘universal precautions’ for cross-infection control for all patients, however, it became apparent early on that this was not enough to protect us from COVID-19. There is understandably a lot of anxiety and concern, amongst the dental profession in the UK, as to how we deal with the current situation, and what the future will hold. This review aims to answer some of the questions that dental health care professionals have, as the death toll in UK from COVID-19 passes 51,000.
The objectives of this article are to:
Provide an overview of the COVID-19 virus and modes of transmission;
Provide an overview of Personal Protective Equipment (PPE) currently available in the United Kingdom;
To summarize the current guidance and recommendations for dentists and orthodontists following a review of the current literature.
Methods
The main keywords used for the search were ‘COVID-19’, ‘Personal Protective Equipment’, ‘Dentistry’, ‘Guidance’, ‘Orthodontics’.
The review is limited to official guidance in Dentistry and Orthodontics in relation to COVID-19.
Following a search of PubMed, Google Scholar and Embase databases, 10 articles with general dental guidance were found, however, no articles with specific guidance to orthodontics. In addition, official websites were searched for updated guidance to Dentists and Orthodontists during the COVID-19 pandemic including the World Health Organization (WHO), Public Health England, NHS England, British Dental Association, General Dental Council, the Centers for Disease Control and Prevention (CDC), the Royal College of Surgeons of Edinburgh (RCSEd), British Orthodontic Association (BOS), Faculty of General Dental Practice (FGDP) and British Association of Oral and Maxillofacial Surgeons (BAOMS).
Results
What is COVID-19?
COVID-19 is a highly contagious disease of the respiratory tract caused by a new coronavirus SARS-CoV-2. It was first reported in China in December 2019 and, ever since then, it has continued to spread all over the world.5 The WHO Director General declared COVID-19 a global pandemic on 11 March 2020.6
Clinical features
Clinical presentations of COVID-19 range from no symptoms to severe pneumonia. The majority of patients (80%) suffer from mild respiratory infections. Severe illness and death are more common among the elderly and in people with underlying chronic conditions.7 Symptoms include fever, a continuous dry cough, shortness of breath and fatigue. Atypical symptoms include muscle pain, confusion, headache, sore throat, diarrhoea, loss of smell and vomiting. Bilateral pneumonia was shown when computed tomography (CT) of the chest was done for COVID-19 patients, resulting in ‘ground-glass’ appearance and patchy shadows bilaterally.3,8
Based on data from the European Centre for Disease Prevention and Control (ECDC) in March 2020, 32% of diagnosed cases in the EU/EEA and UK required hospitalization, with 2.4% having severe respiratory problems requiring support and/or ventilation. The death rate at this time was 1.5% among diagnosed cases.9
Mode of transmission of COVID-19
According to the WHO, the predominant mode of transmission of COVID-19 is believed to be via respiratory droplets resulting from sneezing or coughing, and via contact with affected surfaces.10,11 As droplets travel short distances through the air; it is recommended we adopt a minimum distance of 2 metres between individuals to prevent droplet transmissions.12
The virus has been shown to survive in aerosols for hours and on surfaces for days. There are also signs that patients may be able to spread the virus while asymptomatic and that during the incubation period they might be carriers.3,13
Why is COVID-19 more serious than the Influenza Virus?
Both COVID-19 and influenza viruses have similar clinical presentation and mode of transmission. However, the reproductive (R) number for COVID-19 is between 2 and 2.5, which means that each coronavirus patient might potentially infect 2 to 2.5 other people, compared to influenza where the average patient spreads the virus to around 1.3 other people. Data suggests that 15% of patients with COVID-19 suffer from severe infection, with 5% experiencing critical infections requiring ventilation. This is higher than that observed for influenza infection.14
The mortality rate for COVID-19 in Italy was over 12% and this was attributed to an elderly population.15 Amongst Chinese patients, it was 3.6%, and outside of China it was reported to be 1.5%.14 These mortality rates are based on the number of deaths divided by the number of confirmed cases of COVID-19, which is not representative of the actual death rate as there are many unconfirmed asymptomatic patients and people who only suffer from very mild symptoms.16
As of 9 June 2020, there have been 29,673 deaths related to COVID-19 in England.17 Public Health England estimates that, on average, 17,000 people have died from the flu in England annually between 2014/15 and 2018/19. However, the yearly deaths vary widely from as high as 28,330 in 2014/15 to a low of 1,692 in 2018/2019.18
The stark overriding difference between COVID-19 and influenza to date is that there is no reliable vaccine and treatment for COVID-19. There is no pre-existing immunity in the population for the new virus and, accordingly, everyone in the population is assumed to be susceptible.10,14
Transmission of COVID-19 in a dental setting
As dentistry involves the use of rotary dental instruments, it can result in excessive generation of aerosols and droplets. Surgical masks may protect the wearer from droplet spatter, but they do not provide complete protection against inhalation of airborne infectious agents.5
DHCPs are at an increased risk of exposure to the COVID-19 virus during certain procedures, in particular aerosol generating procedures (AGP) and the existing standard protective procedures in dentistry are not enough to stop COVID-19 from spreading.3
What is Personal Protective Equipment (PPE)?
Personal Protective Equipment (PPE) is normally worn to protect the health care workers and patients from cross-infection. The choice of PPE worn depends on the risk of exposure to blood and body fluids, and the risk of infection to patients. PPE includes use of gloves; disposable plastic aprons or full body gowns; protective face wear including full-face shields, visors and masks and protective glasses, hairnets, and appropriate footwear.19
Masks routinely used in orthodontics as part of PPE are fluid-resistant (Type IIR) surgical face masks (FRSMs) that cover the face and mouth and come with or without a face shield. They help block large-particle droplets, splashes or sprays that may contain viruses and bacteria, preventing them from reaching the wearer's mouth and nose. They also protect patients from the wearer's respiratory emissions. They don't, however, filter very small particles in the air that may be transmitted by coughs or sneezes. Surgical masks do not provide complete protection from contaminants because of the loose fit between the surface of the face mask and the skin. Surgical masks, therefore, do not provide the wearer with a reliable level of protection from inhaling smaller airborne particles and are not considered respiratory protection.19,20,21
Filtering face piece respirators (FFPs) are disposable respiratory protective equipment designed to achieve a very close facial fit and very efficient filtration of airborne particles. FFPs are classified by the European Standard (EN 149:2001) into FFP1, FFP2, and FFP3, which have filtration capacities of at least 80%, 94%, and 99%, respectively. The FFP2 respirators are almost equal to N95 respirators, which are recommended to be used in the case of airborne infections in the United States (US) and other countries. FFP3 respirators, on the other hand, provide the best level of protection, and they are the ideal respirators in the UK for protection against infectious diseases in health care settings.22,23
Infection prevention and control in a dental setting during COVID-19
The most important measure to reduce the risk of spreading infectious diseases to patients is hand hygiene.11 The virus can survive on surfaces for hours or even days, depending on the type of surface, the temperature and humidity, so comprehensive and meticulous disinfection of every surface in the dental clinic is crucial.3
When seeing known or suspected COVID-19 patients, it is essential to employ both standard infection control precautions (SICPs) and transmission-based precautions (TBPs). SICPs are the essential infection control precautions necessary to decrease the risk of spread of contagious micro-organisms from blood and body fluids. These precautions should be used by all staff at all times for all patients. TBPs are additional infection control measures that must be employed when managing patients who are suspected or confirmed to have contagious diseases.
TBPs are divided into:
Contact precautions, which prevent spread of infection through direct contact or indirectly from the nearby environment.
Droplet precautions which prevent spread of infection from the respiratory tract of one person to another, through short distances by droplets (>5 µm). Usually a distance of approximately 2 metres around the infected individual is considered the ‘zone of risk’ of infection.
Airborne precautions which prevent spread of infection from the respiratory tract of one person to another by aerosols (= 5 µm). For non-aerosol generating procedures, it is essential to employ both droplet and contact precautions to prevent and control the spread of COVID-19. For all aerosol generating procedures (AGPs) airborne precautions are essential (Table 1).11
Setting
Context
Disposable Gloves
Disposable Plastic Apron
Disposable Fluid-repellent Coverall/Gown
Surgical Mask
Fluid-resistant (Type IIR) Surgical Mask
Filtering Face Piece Respirator-FFP3
Any setting
Performing an aerosol generating procedure on a possible or confirmed case
*Single use refers to disposal of PPE or decontamination of reusable items, eg eye protection, after each patient and/or following completion of a procedure, task, or session; dispose or decontaminate reusable items after each patient contact as per Standard Infection Control Precautions (SICPs).
Guidance for UK dentists during the COVID-19 pandemic
The COVID-19 pandemic has been a rapidly changing situation. Many dentists in the UK found that the guidance in the initial stage of the pandemic was unclear and variable. Until very recently, government and professional advice for the DHCP was insufficient.24 The NHS's initial instruction was that DHCP should continue to provide routine dental care for asymptomatic patients with no close contact history with COVID-19 patients, and only to stop seeing patients who had symptoms. There was, however, general fear and anxiety amongst the dental community on whether our routine infection control procedures and PPE were adequate. Moreover, much of the dental profession are worried about the personal financial consequences.25
On 25 March the Chief Dental Officer (CDO) in England issued a guidance letter for DHCP in Primary Dental Care during COVID-19. The guidance letter advised that all routine dental care should be stopped and all practices to establish remote urgent care services (UDC), providing telephone triage for their emergency patients and, whenever possible, treating with advice, analgesia and, when indicated, antimicrobials (AAA). For patients deemed to have a life-threatening emergency, trauma, severe facial/dental pain, bleeding, or any dental conditions that may result in a severe systemic illness or exacerbate an underlying medical condition, the advice was to refer them to a local Urgent Dental Centre (UDC).26
The guidance by the CDO was updated on 15 April27 but, more importantly, a document for standard operating procedures (SOPs) for dental care was published by NHS England. This document explained in specific detail principles for the operation of UDC systems in the UK, infection control measures and the PPE needed during the period of transmission of COVID-19 (Table 2). For infection control, the document gave specific recommendations for DHCP on hand hygiene practices, as well as respiratory hygiene using the phrase ‘Catch it, bin it, kill it’, and advised that DHCPs should receive training for donning and doffing PPE. Urgent Dental Centres were instructed to triage patients and provide a remote service with advice, and face-to-face treatment was for those patients with acute dental problems that required immediate management.28
*Fluid-resistant gowns (or long-sleeved, waterproof apron) must be worn during aerosol generating procedures (AGPs). If non-fluid-resistant gowns are used, a disposable plastic apron should be worn underneath.
Finally, on 28 May, the CDO announced that, from 8 June, primary care dental services can recommence face-to-face dental treatment, whether routine or urgent.29 Accordingly, on the 4 June, the guidance for SOP in England was updated. UDC sites and primary care dental services should continue to have 2 stages for patient management, the remote stage first, followed by face-to-face if deemed essential. Dental treatment for suspected/confirmed COVID-19 patients and their households would continue to be provided at local UDCs. The document emphasized the importance of prioritizing patients with pressing dental care needs and that AGPs should continue to be avoided whenever possible.30
The CDO guidelines categorized procedures into AGPs and non-AGPs. It included specific and clear clinical guidelines for periodontal treatment, paediatric dentistry, restorative dentistry and endodontics. Unfortunately, there were no clear orthodontic guidelines, instead all orthodontic procedures were categorized as non-AGPs.30
A challenge facing the resumption of dental treatment is the need for ‘down time’ following treatment. Following an AGP, the CDO guidelines recommends the room is left vacant for one hour (neutral pressure room) before cleaning. The room should be ventilated by opening windows or using extractor fans which vent to the exterior. Surgical masks, FFP2/FFP3/N95 respirators and eye protection can be used for a session of work. A full-face visor is single use and should be changed between patients to protect the respirator from contamination by droplets or splatter.30
Aerosols are also produced naturally through breathing, speaking, sneezing and coughing, as such, the Faculty of General Dental Practice (FGDP) recommended that the term Aerosol Generated Exposure (AGE) should also be considered alongside AGP. For each procedure the clinician should take into account the duration of a procedure, patient factors, mitigation factors such as using high-volume suction, and natural exposures caused by coughing, sneezing and breathing.31
Guidance for UK Orthodontists during the COVID-19 pandemic
Due to the cessation of all elective treatment in primary and secondary care and the current shortage of PPE in the UK, routine orthodontic treatment stopped on the 25 March.
During this period, the Royal College of Surgeons of Edinburgh32 and the British Orthodontic Society (BOS)33 recommended that orthodontic emergencies should be triaged by telephone and advice provided to relieve pain. The BOS produced a series of excellent videos (https://www.bos.org.uk/COVID19-BOS-Advice/Patients-Advice/Patients-Home-Videos-Repairs) that one could refer patients to, on how best to manage appliance component breakages.34 There was an emphasis to maintain optimal oral hygiene, adopt a low sugar diet and avoid hard and sticky foods that can break the appliance. Only those patients that suffered severe pain or intra-oral trauma from component failure, not relieved by the application of wax, or where there is a risk of inhalation of part of the appliance, were seen in person.33
There has been considerable debate as to what orthodontic procedures are deemed aerosol generating. On the 4 June the CDO published the much-anticipated standard operating procedure, ‘Transition to recovery’ in which it categorized all orthodontic treatment as non-AGP but accepted prolonged use of a 3 in 1 air/water syringe is an AGP.30
The BOS followed up with a statement that there remained a lack of clarity regarding the position of Public Health England on slow speed handpieces and 3:1 syringes with regards to aerosol production and that this may have adverse effects on both staff and patients.35
On 9 June, the BOS went on to state that, although a slow handpiece creates an aerosol, until the present time, there is no evidence linking the AGP with COVID-19 transmission. The BOS therefore concluded that, if orthodontists decide to use a slow speed handpiece, the orthodontic procedure can be carried out with PPE appropriate for non-AGP as long as a fluid-resistant surgical mask is worn in conjunction with high volume evacuation (HVE) as close as possible to the treatment area.36
One can conclude from the guidance that the only orthodontic procedures that would indicate the need to don an FFP3 mask would be the use of a high speed handpiece for removal of aesthetic brackets or following a risk assessment where the clinician perceives that the removal or placement of an appliance will result in a prolonged exposure time and use of a 3:1 syringe.
When do DHCP see patients who had COVID-19 and completed home isolation?
It is important, where possible, that patients known to have, or who may have been exposed to COVID-19, isolate for a minimum time frame before they are seen for assessment and management as an urgent orthodontic emergency.
The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States and they recommend the following time frames based on two strategies:
A non-test-based-strategy requires a minimum of 3 days (72 hours) to have passed since recovery (resolution of fever without the use of medications and improvement in respiratory symptoms) and at least 7 days since symptoms first started.
A test-based-strategy requires patients to have a resolution of symptoms and negative results for COVID-19 from at least two consecutive nasopharyngeal swabs collected ≥24 hours apart (total of two negative specimens).
People with laboratory-confirmed COVID-19 but who had no symptoms need to isolate for at least 7 days since the date of the first positive COVID-19 diagnostic test.5
Potential exposure and crisis planning guidance by the Centers for Disease Control and Prevention (CDC)
Orthodontic emergency patients can be potential COVID-19 carriers. CDC recommends that DHCPs contact patients 48 hours after the provision of emergency dental care to ask them if they have any subsequent signs or symptoms of COVID-19. If a patient reports any signs or symptoms of infection, they should be referred to their medical provider for evaluation and the DHCP should follow the CDC guidance for health care professionals with potential exposure risk.5
In stark contrast, NHS England recommends that, in health care settings, staff who are exposed to a patient who develops COVID-19 symptoms should only self-isolate at home if they develop symptoms, even if they were not using appropriate PPE. If they develop COVID-19 symptoms whilst at work, they must stop work instantly and go home, which should be followed by decontamination of the unit as for a patient with COVID-19 symptoms. If a member of staff tests positive for COVID-19, other members of staff need to follow no additional precautions unless they develop COVID-19 symptoms.30
The CDC recommend those DHCP who are at higher risk from COVID-19, such as pregnant females and those of older age, should avoid carrying out emergency dental care.5
Is pre-operative mouthrinse recommended?
It has been suggested that a pre-operative rinse with 0.2% povidone-iodine or 0.1% hydrogen peroxide mouthrinses may decrease the microbial load in saliva with non-specific virucidal effect on SARS-CoV-2.37,38,39 However, the FGDP guidance recommends that there is no evidence of this virucidal effect.31
Recommending analgesia for orthodontic pain relief: Ibuprofen or Paracetamol?
On 14 April, the Commission on Human Medicines expert group concluded that, until the present time, there isn't enough evidence to conclude that there is a relationship between taking Ibuprofen and predisposition to infection by COVID-19 or even the aggravation of its symptoms.40 NHS England, however, recommends that any COVID-19 patients, or those suspected to have it, as well as their families, should take Paracetamol in preference to Ibuprofen.28
Conclusions and final observation
The surgical masks Orthodontists routinely wore prior to the COVID-19 pandemic do not offer sufficient protection during AGPs; Recommendations from Public Health England are that, during high risk AGPs, such as the use of a high speed handpiece, the health care professional should wear gloves, a long-sleeved, disposable, fluid-repellent gown, an FFP3 respirator, a full-face shield or visor and hairnet.
The CDO stated that orthodontic treatment is a non-AGP and, due to the ever changing climate, this has brought some uncertainty amongst clinicians.
The British Orthodontic Society has confirmed that, although a slow handpiece creates an aerosol, at this time there is no evidence linking the AGP with COVID-19 transmission. Routine orthodontic treatment can be undertaken with PPE appropriate for non-AGPs, as long as a fluid resistant surgical mask is worn in conjunction with high volume evacuation (HVE).
This is an uncertain time for dental health care professionals and, until there is a vaccine or treatment for COVID-19, the manner in which we deliver orthodontic treatment is facing some radical changes.
