Chen J. Pathogenicity and transmissibility of 2019-nCoV – A quick overview and comparison with other emerging viruses.. Microbes Infect. 2020; 22:69-71
Monaghan NP. Emerging infections – Implications for dental care.. Br Dent J. 2016; 221:13-15
Harrel SK, Molinari J. Aerosols and splatter in dentistry – a brief review of the literature and infection control implications.. J Am Dent Assoc. 2004; 135:429-437
Wang WK, Chen SY, Liu IJ Detection of SARS-associated coronavirus in throat wash and saliva in early diagnosis.. Emerg Infect Dis. 2004; 10:1213-1219
To KK-W, Tsang OT-Y, Chik-Yan Yip C Consistent detection of 2019 novel coronavirus in saliva.. Clin Infect Dis. 2020;
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Musher DM. Medical progress: How contagious are common respiratory tract infections?. New Engl J Med. 2003; 348:(13)1256-1266
Ireland AJ, Moreno T, Price R. Airborne particles produced during enamel cleanup after removal of orthodontic appliances.. Am J Orthod Dentofacial Orthop. 2003; 124:683-686
Day CJ, Sandy JR, Ireland AJ. Aerosols and splatter in dentistry – a neglected menace.. Dent Update. 2006; 33:601-606
Day CJ, Price R, Sandy JR Inhalation of aerosols produced during the removal of fixed orthodontic appliances: a comparison of 4 enamel cleanup methods.. Am J Orthod Dentofacial Orthop. 2008; 133:11-17
Johnston NJ, Price R, Day CJ Quantitative and qualitative analysis of particulate production during simulated clinical orthodontic debonds.. Dent Mater J. 2009; 25:1155-1162
Micik RE, Miller RL, Mazzarella MA Studies on dental aerobiology I. Bacterial aerosols generated during dental procedures.. J Dent Res. 1969; 48:49-56
Miller RL, Micik RE, Abel C Studies on dental aerobiology 2. Microbial splatter discharged from oral cavity of dental patients.. J Dent Res. 1971; 50:621-625
Micik RE, Miller RL, Leong AC. Studies on dental aerobiology 3. Efficacy of surgical masks in protecting dental personnel from airborne bacterial particles.. J Dent Res. 1971; 50:626-630
Miller RL, Micik RE. Air-pollution and its control in dental office.. Dent Clin North Am. 1978; 22:453-476
Moller W, Haussinger K, Winkler-Heil R Mucociliary and long-term particle clearance in the airways of healthy nonsmoker subjects.. J Appl Physiol. 2004; 97:2200-2206
Vig P, Atack NE, Sandy JR Particulate production during debonding of fixed appliances: Laboratory investigation and randomized clinical trial to assess the effect of using flash-free ceramic brackets.. Am J Orthod Dentofacial Orthop. 2019; 155:767-778
Smales FC, Samaranyake LP. Maintaining dental education and specialist dental care during an outbreak of a new coronavirus infection. Part 1: A deadly viral epidemic begins.. Br Dent J. 2003; 195:557-561
Armbruster PC, Strother EA, Ballard RW Application Data as an Indicator for Post-Katrina Recovery of LSU Postdoctoral Dental Programs.. J Dent Educ. 2011; 75:768-774
Decontaminaton Health Technical Memorandum 01-05: Decontamination in primary care dental practices..: Department of Health; 2013
Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures.. J Am Dent Assoc. 1994; 125:579-584
Harrel SK, Barnes JB, Rivera-Hidalgo F. Reduction of aerosols produced by ultrasonic scalers.. J Periodontol. 1996; 67:28-32
King TB, Muzzin KB, Berry CW The effectiveness of an aerosol reduction device for ultrasonic scalers.. J Periodontol. 1997; 68:45-49
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Orthodontics at Times of National Emergency: Past and Current Crises Part 2. COVID-19: Implications for Clinical Practice Tara V N Lee Peter V Fowler Julie C Williams Pamela Ellis Nikki E Atack Dental Update 2024 13:3, 707-709.
Authors
Tara V NLee
BDS, DDS, MOrth RCSEd
Senior Registrar in Orthodontics, University of Bristol Dental Hospital and Royal United Hospitals, Bath
This paper explores the disease COVID-19 caused by the SARS-CoV-2 virus. This disease has caused a global pandemic affecting the way society both works and lives. COVID-19 is spread through droplets from the mouth and nose, which has implications for how we practice orthodontics. Our clinical practice will therefore need to be adapted to keep both patients and staff safe. This paper addresses the adaptations that should be considered. We also address what the future of orthodontics may look like in light of the issues with cross infection that COVID-19 has raised.
CPD/Clinical Relevance: How to adapt our clinical practice to keep both staff and patients safe.
Article
Tara V N Lee
In the first part of this two-part article, past crises were looked at in relation to the recovery process and how this impacted the delivery of orthodontics. In this second part, the way forward after the impact of this novel disease of COVID-19 will be discussed and how the lessons learnt from previous crises can influence this.
In late 2019, the World Health Organization (WHO) was notified of an outbreak of pneumonia cases of unknown cause in Wuhan, China. On 7 January 2020, the Chinese government identified a new coronavirus as the cause of this pneumonia outbreak.1 Coronaviruses can cause illnesses in both animals and humans, presenting with a range of symptoms ranging from the common cold to more severe diseases such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).2
On 11 February 2020, this new virus was given the name SARS-CoV-2 due to its genetic resemblance to the coronavirus responsible for the 2003 SARS outbreak, and the disease it causes was named COVID-193 (Figure 1). The SARS-CoV-2 virus has a higher transmissibility than the SARS-CoV and MERS-CoV viruses.4
Figure 1. Sars-CoV-2. Source: Centers for Disease Control. CDC ID 23312. Photo by Alissa Eckert, MS; Dan Higgins, MAMS. https://phil.cdc.gov/Details.aspx?pid=23312
Coronavirus is spread from person to person through droplets from the mouth or nose. These droplets are expelled when a person with COVID-19 coughs, sneezes, or speaks. The droplets can also land on objects and surfaces and remain viable for several days. If a person touches these objects and surfaces and then touches their face, including their eyes, nose or mouth, they can become infected.2 There have also been reports of the virus being transmitted by asymptomatic people.2 The time between exposure to COVID-19, and when symptoms start, can range from 1−14 days, but typically symptoms start around days five to six.2
The world has watched as this disease has spread rapidly around the globe infecting millions of people. On 18 May 2020 there were 4,589,526 confirmed cases and 310,391 confirmed deaths worldwide.5
The main strategy of many countries to contain the spread, and thereby reduce deaths, has been to impose restrictions on movements through lockdowns, leaving only essential services to continue.
Recently, many of the latest epidemics have been viral infections of the respiratory tract with the ability to spread through droplets and aerosols.6 Orthodontists work in close proximity to the airway and carry out any number of different types of aerosol generating procedures, creating a high risk environment for both catching and spreading infections.7 Previous studies have shown that respiratory viruses can be detected in saliva,8 and a recent small study in Hong Kong reported finding COVID-19 in saliva.9
Orthodontists therefore need to be aware of emerging infections, including symptoms, incubation periods and geographical areas affected.6 Infections can be spread via several routes in the dental environment, including direct contact with body fluids, contact with contaminated surfaces and instruments and from aerosols from the infected patient.10 The virulence of the organism, as well as the number of organisms transmitted, has an impact on whether a person subsequently becomes infected following contact.11
Several orthodontic procedures create aerosols, splatter and dust.12 Splatter particles are greater than 50 µm in diameter. When splatter particles are produced they quickly land on nearby surfaces due to their size. Aerosols, on the other hand, are smaller than 50 µm in diameter. This smaller size allows them to remain airborne for hours, even days in turbulent air, before being inhaled, or settling on nearby surfaces.
Based on the clinical procedure performed, aerosols and splatter may contain tooth tissue, dental materials, saliva, blood, bacteria and viruses.13,14 The particulates produced in any one clinical procedure can vary in both physical size and aerodynamic diameter,15 and it is their aerodynamic diameter, measured in microns, which is important in determining where they might eventually end up.
Particles smaller than 10 µm within an aerosol are the most likely to be inhaled and deposited in the respiratory tract, and also have the greatest potential to transmit infections.16,17,18,19 When an aerosol particle is inhaled, it is the anatomy of the respiratory tract and the aerodynamic properties of the aerosol that determines where it settles in the lung.20,21 Particles greater than 2.5 µm in aerodynamics tend to be deposited predominantly in the upper airways (pharynx, trachea and primary bronchi) and are cleared by the mucociliary escalator.20 Particles less than 2.5 µm in size tend to be deposited in the terminal bronchioles, and are cleared by alveolar macrophages, which can take days to months.14 The overall time taken to clear the particles is influenced by the level of deposition in the lung, the solubility of particle and a person's respiratory health. Any piece of equipment powered by a compressor, including high and slow speed handpieces, three in one syringes, and ultrasonic scalers, have all been shown to produce aerosols and splatter (Table 1).7,12,13,14,15,22 It is also important to note that aerosols can also be produced and not be visible to the naked eye.7
High speed handpiece
Slow speed handpiece
Three in one syringes
Sandblaster
Ultrasonic scalers
Acrylic trimming bur
Removal of fixed appliances using a high speed handpiece and irrigation creates the largest number of particulates and a slow speed handpiece and no irrigation the least number of particulates.14
Due to the novelty of the current coronavirus virus and the suddenness in which it has significantly changed how we live and work, a potential recovery in three phases will be addressed:
Short term − this comprised the two weeks prior to the Chief Dental Officer's (CDO) announcement on 25 March 2020.
Medium term − this comprised the period immediately following the CDO's announcement.
Long term – at the time of writing, this period had not been reached but it is anticipated that it will follow another CDO announcement about returning to work in dentistry.
Short term
In England, orthodontic treatment can be accessed either through the National Health Service (NHS) or under private contract. Even prior to direct instruction from the CDO for England to stop all routine treatment, including orthodontics, there were some providers in England that had already decided to stop treating patients, or at least to limit the type of treatments provided, due to uncertainty about COVID-19. For example, the orthodontic department at Bristol Dental Hospital (BDH) decided to stop seeing patients that required any aerosol generating procedures such as bond up or debond. All other patients, including fixed and removable adjustments, were still seen but, if they presented with a bracket off, this was either not rebonded or rebonded using glass ionomer cement. During this time, staff wore standard personal protective equipment (PPE), which included gloves, disposable plastic apron, surgical face mask and eye protection. All toys and magazines were also removed from the waiting rooms, and a limit of only one parent/guardian entering the clinic with their child was imposed. A number of patients also called to cancel their appointments due to the uncertainty with regards to the risks of exposure to the disease.
Often, in the initial absence of official guidance, clinical indecision can arise in the presence of a new emerging disease. This is because there is a balance to be struck between preserving the health and wellbeing of both clinicians and patients. For example, in the case of the SARS epidemic in 2002, The Prince Philip Dental School in Hong Kong stopped treating patients on 18 March 2003, before restarting a few days later, only to stop once again on 27 March 2003 until 24 April 2003.23 This stopping, re-starting and then stopping again can create uncertainty and be unsettling for all parties.
Medium term
On 25 March 2020, the Chief Dental Officer(CDO) of England said ‘All routine, non-urgent dental care, including orthodontics, should be stopped and deferred until advised otherwise’.24 This instruction was given to reduce the spread of the disease, to save lives, protect our valuable NHS and to preserve PPE for frontline staff. All dental practices, either individually or as a group, were responsible for setting up a telephone triage system to manage patients with urgent dental needs. Based on a patient's presenting symptoms, they would either be managed remotely through advice, analgesia, and antimicrobials or they would have to be referred to one of the local urgent dental care centres (Dental Hubs), to receive treatment.
At BDH, all new patients and those under active orthodontic treatment were contacted by clerical staff via telephone, to inform them their appointment had been cancelled, which was a labour intensive and time-consuming process. In the case of orthognathic patients that were less than 6 weeks post op, they were asked to keep their appointment, if safe to do so, in order to monitor their occlusion and healing.
Due to the government directive of ‘Stay Home, Protect the NHS, Save Lives’, which applied to both patients and staff, it was felt that the orthodontic department at BDH needed to reduce the number of staff coming to work. Orthodontic postgraduate trainees were advised to stay home and work on their research projects, and weekly online teaching sessions were arranged. A rota system of senior clinicians was introduced to ensure that there were a maximum of two orthodontists at work each day, with a third on standby, if necessary. Previous crises, such as Hurricane Katrina and the Christchurch Earthquakes, have shown that times of uncertainty can have a negative effect on mental wellbeing. Having two clinicians working meant that clinical decisions could be supported, if need be, as well as providing a means of distanced social contact. All emergency contacts received through reception were passed to the two orthodontists, who then contacted the patients to provide appropriate advice. For any patient whose emergency was causing severe pain or a potential airway risk, arrangements were made for them to attend the department. They were advised to attend alone and to arrive only a few minutes before their appointment. On arrival at the main entrance, they were asked screening questions before being allowed to enter the dental hospital.25 The questions included:
Do you have a new continuous cough?;
Do you have a high temperature (37.8ºC or over)?;
Does anyone in your household have a new continuous cough or a high temperature? If you or anyone in your household has tested positive for coronavirus, are you still in the self/household isolation period?
A Plexiglass screen was also installed at the orthodontic reception desk to protect reception staff.
All orthodontic patients that had been cancelled due to COVID-19 received a telephone consultation by one of the senior clinicians working, in order to discuss patient concerns, give clinical advice and to reinforce oral hygiene and diet advice. Patients appeared to be grateful for the contact and reassurance. During this time, the British Orthodontic Society also produced very useful written and video guidance on how to manage orthodontic emergencies during COVID-19, at home and for use by both patients and clinicians.26 During the telephone consultation, patients were made aware of this resource.
Regular departmental ZOOM meetings were arranged by the orthodontic clinical lead to ensure that all consultants and senior trainees were kept up to date, and to discuss plans for when patient treatment recommenced in the long term. No direct patient information was ever discussed at these meetings to ensure that no data breach occurred. Larger management meetings were also held on ZOOM to keep all Dental Hospital staff up to date. This was very effective and important and was similar to the online approach taken by Prince Philip Dental School, Hong Kong during the SARS outbreak.23 The very first virtual orthodontic clinics using Trust approved software were also held for patients in active treatment or retention.
It was during this time that thoughts were also given to the potential recovery plan with two arms. The first arm would be to identify which orthodontic patients should be seen more urgently once the department was to re-open, by reviewing the patient notes and outcomes of the recent telephone consultations. The second arm would be how to change our daily practices in order to see routine cases, ie the new normal. The aim would be to continue to reduce the risk to both patients and staff until an effective COVID-19 treatment or vaccination had been found. This will be discussed in the following long-term section.
As per the directive of the CDO, orthodontic practices stopped seeing routine patients as well. Their patients who had an orthodontic emergency were managed remotely with phone advice but, if not possible, they were offered an appointment to resolve the problem. These appointments either occurred at the dental hub, but some practices that had adequate PPE saw their own patients. Practices and hospital departments also started or continued to use websites and social media such as @keepstokesmiling on Instagram to keep their patients up to date.
Long term (re-opening for routine treatment)
Until an effective treatment or vaccine is developed for COVID-19, dental care will have to be delivered differently to protect both patients and staff, ie the new normal. The following are factors that should be considered within a potential long-term re-opening plan. The list is not exhaustive and practitioners should also follow advice from the appropriate government/regulatory bodies, as well as dental associations.
Patient information − Firstly, a letter should to be sent to all patients prior to re-opening in order to reassure them that their safety is paramount, and what to expect when they attend on their first appointment after lockdown with respect to: screening, accompanying persons, waiting arrangements and treatments.
Staff information − Prior to seeing the first patients, it is important that all staff are briefed and aware of the new practices and procedures.
Rebooking of patients − Patients should be rebooked in order of urgency, as well as in respect to their cancellation date.
New patient waiting lists − Is there the capacity to see these patients or does the list need to remain closed and for how long?
Appointment letters − Should inform patients that if they, or a member of their household, are suffering from COVID-19 symptoms, they should cancel their appointment. Offering a new appointment within 4 weeks of their cancelled appointment will facilitate sufficient time for self-isolation. A similar rebooking offer was made to patients in Hong Kong during the SARS epidemic with patients rebooked within 2 weeks.23 The incubation periods differ for both diseases, hence the longer time needed for COVID-19. They should also be advised to attend alone for the appointment, if possible but, if not possible, then only one parent/guardian should attend.
Screening − To protect both patients and staff, all patients attending should be screened using the same questions as described earlier, in addition to a temperature check at the entrance.
Testing − Weekly swab testing of staff for COVID-19, as well as daily logged temperature checks on arrival at work.
Shielded patients − These are patients with specific medical conditions that put them at a greater risk of experiencing severe illness if they contracted COVID-19.27 All shielded patients were sent a letter by their GP and should be aware of their status. Shielded patients include: those with solid organ transplants; those suffering from severe respiratory conditions; certain cancers; a rare disease; or taking immunosuppressants. Special arrangements will need to be made for this category of patient to minimize both their appointment times and their exposure to other patients. For example, they should not wait in the same waiting room, nor use the same treatment rooms as other patients.25 Ideally, their appointment should be scheduled in the morning in order to allow sufficient time for the air in the surgery to clear overnight and before their visit. A closed treatment room should be designated for these patients. When the patient arrives, they should ring a designated number held by a designated dental nurse. This nurse will then collect the patient from a side or less used entrance and escort them directly to the surgery. The nurse escorting the patient should also hold a sign to say ‘Shielded Patient’.
Posters with information regarding the measures being taken to keep patients safe;
Markings on chairs and floors to aid social distancing;
One-way flow system for patients entering and leaving the department;
Alcohol gel prior to entering the dental hospital and again on entering the clinic;
Follow-up appointments should be posted out to prevent congestion at reception, and to aid the one-way system;
Regular cleaning of the waiting room and any toilets between patients.
Attending with parent/guardian − If a parent attends with a patient, ideally, they should not enter the clinical area. The parent should remain in the waiting room or outside the building, depending on the layout of premises. If the parent does have to enter the orthodontic clinic, they should be given a mask to wear as per government guidelines.28 Once treatment is complete, the parent and child are reunited in the presence of the dental nurse/team member, if they had been separated, and then escorted to the exit.
Appointment timing and productivity − The time necessary to put on and take off surgical gowns and decontaminate clinical areas necessitates longer appointment times. This will have an impact on clinical productivity, and the overall length of a patient's treatment. Ways to increase productivity should be looked into, such as extended or extra session days, renting rooms or space from local practices who may have spare capacity, mobile vans, and running two dental chairs at a time. For some of the postgraduate trainees in New Orleans they had to attend the offices of private practitioners to ensure that they achieved their clinical requirements.29 In addition, a shift system (week A/week B or starting work at different times) may have to be implemented to reduce the number of clinicians working in order to allow for social distancing, eg in the clinic, offices and waiting room, as well as for aerosol control.
Virtual appointments − Appointments should be done virtually where possible, eg retainer checks. It will be important that this is done using dedicated software that is deemed to provide the correct levels of online security.
Storage of instruments and orthodontic materials − Clean instruments and materials should be kept in cupboards away from clinical surfaces until necessary. Ideally, only the essential instruments and materials for the specific patient should be set up prior to the patient entering the surgery. If additional instruments or materials are required during the appointment, either time will need to be set aside for the assistant to remove and replace their PPE to do so, or a nurse runner may be required. Paper notes should be reviewed before the patient enters and then stored in the cupboard to prevent aerosol contamination.
Computer equipment − Should be covered with plastic and cleaned between patients.
Radiographs and impressions − If possible, only extra-oral radiographs should be taken in order to reduce the chance of a cough/gag reflex. If there is a clinical need for intra-oral radiographs, radiographers should protect themselves with the appropriate PPE and place the film carefully to prevent gagging. Impressions should also be done with care to prevent gagging and will require stringent disinfecting prior to going to lab.30 Alternatively, the use of intra-oral scanning will reduce the risk of gagging and negate the potential transmission of the virus to the laboratory.
Personal protective equipment (PPE) − Regular daily checks to ensure that adequate numbers are present.
Non-Aerosol Generating Procedure (Non-AGP) − Non AGP treatment can be carried out with standard infection control procedures to prevent contact or droplet transmission (splatter) of COVID-19. This includes adequate eye protection, disposable fluid resistant surgical masks, disposable apron and gloves.25 An in vitro study by Johnston et al found that surgical masks can reduce exposure to particulates produced during debond by 96%.15 The limitation of this study is that it does not account for factors such as breathing, moisture through breathing and fit of mask, which could potentially reduce efficiency of the mask. Decontamination of rooms should be done with a disinfectant or detergent according to HTM-01-05 guidelines.30
Aerosol Generating Procedure (AGP) − Most hospital orthodontic departments and many specialist practices provide treatment in open bay clinics rather than closed rooms, which is not ideal to control aerosols (Figure 2). Ways to convert open bays into closed bays should be investigated. If this is not possible, then strategic use of bays to ensure distancing will need to be engaged. Guidance should be sought from government bodies and local infection control specialists prior to recommencing AGP treatments.
It is said that there are three possible layers of protection to consider when carrying out an AGP:7
The first layer is PPE which should include a disposable, fluid repellent surgical gown (waterproof long sleeved protective apron), gloves, eye protection and an FFP3 respirator mask. These should be worn by those undertaking and assisting in the procedure to reduce transmission25 (Figures 3 and 4).
The second layer includes the use of High Volume Evacuators/Suction (HVEs). HVE is used to remove airborne contamination before it leaves the immediate treatment site. HVEs usually have openings 8 mm or greater in size and should be connected to a system which is able to remove up to 100 cubic feet of air per minute. They have been shown to reduce airborne contamination at the operative site by more than 90%.15,31,32,33,34,35
The third layer involves the consideration of the use of a preprocedural mouthwash. Mouthwashes containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone have been suggested for the purpose of reducing the salivary load of oral microbes, including COVID-19.36,37 However, as yet there is little evidence that this works in the case of COVID-19. Interestingly, a study on the effectiveness of a preprocedural mouthwash, either sterile water or Chlorhexidine (CHX), prior to orthodontic debond and enamel clean-up, found the use of a mouthwash actually increased the number and diversity of airborne bacteria within the created aerosol, rather than reducing it.38 Chlorhexidine mouthwash is likely to have little or no effect on COVID-19, even though its use was recommended during the SARS pandemic.39
Surgery airflow in AGP treatments − Ideally AGP should be carried out in a negative pressure room.25 Once treatment is complete, the negative pressure room should be left vacant with the door closed for 20 minutes, dependent on the rate of air exchange, before a terminal clean is done. Negative pressure rooms have a minimum of 12 air changes per hour, or at least 160L/s per patient.40 If the room is neutral pressure, the room should be left for one hour before a terminal clean is done. High Efficiency Particulate Air (HEPA) filters or ultraviolet (UV) chambers in the ventilation system can be a substitute to a negative pressure room.7,41 Like a negative pressure room, HEPA filters and UV chambers both take time to clear the contaminated air. Leaving windows open also helps to remove any contaminated air.25 Terminal cleans should be carried out with 0.1% hypochlorite.42 For rooms that have air conditioning, the majority of airborne contaminants can be negated through good filtration, regular cleaning and maintenance.43,44 It is vital that advice is sought about any air conditioning system prior to seeing patients to ensure that it is providing high quality filtered air.
Rubber dam − The use of rubber dam has been shown to reduce dental aerosols.45 Although orthodontic treatment can be done under rubber dam, eg bonding fixed appliances to patients with disabilities under general anaesthesia, or debonding ceramic brackets to prevent accidental ingestion,46,47 for routine orthodontic treatment this is most likely impractical, and is still not without risk during placement and removal.
Figure 2. Open Bay Clinic.Figure 3. Personal Protective Equipment for AGP procedures.Figure 4. FFP3 facemask to be used during aerosol generating procedures.
The future
The genetic sequence of SARS-CoV-2 was published on 11 January 2020 and, since then, there have been significant levels of global research and development activity to try to develop an effective vaccine against the disease.48 On the 26 April 2020, there were 89 candidate vaccines, seven of which were at the clinical trial stage and the remaining 82 in the preclinical phase. In addition to the vaccine trials, researchers have also been trialling existing drugs/therapeutics, used to treat other conditions, that might be effective against the COVID-19 virus, in a bid to help us exit this pandemic even sooner49,50 (Table 2).
Vaccines
Solidarity Trial by WHO
Remdesivir
Chloroquine or hydroxychloroquine
Lopinavir/ritonavir
Lopinavir/ritonavir with beta-1α
Convalescent Plasma
Stem Cell Therapy
Intravenous Immunoglobulin
Treatments for cytokine release syndrome
Bacille Calmette-Guerin (BCG) vaccine
Bemcentinib − experimental anticancer drug
Angiotensin − II receptor antagonists eg losartan
Other antivirals eg oseltamivir, darunavir
It can be seen that past crises can present opportunities to renew and improve. The natural disasters that took place in New Orleans and Christchurch showed that orthodontists were able to bring about improvements in the use of new technologies to create more efficient and reactive practices. Previous pandemics, such as SARS and HIV, have led to us embracing improvements in infection control practices. As we look ahead at the opportunities present in this unprecedented time of the COVID-19 pandemic, there are perhaps further opportunities to improve both our infection control practices and new technology. Examples of these opportunities might include:
Replacing open bays in polyclinics with plexiglass closed or partially closed bays and reserving closed bays for AGP procedures;
More widespread use of electronic patient records to prevent contamination, allowing for remote access and improved security;
Use of digital intra-oral scanning;
Instituting a mass notification system to keep patients up to date quickly;
Regular virtual clinics where possible, eg retainer checks.
At times during this pandemic it has been felt that communication has been slow from government bodies in giving directives to the dental body. Like previous crises, dentistry, including orthodontics, is often forgotten. Consideration should be given to appointing someone in public health who is responsible for assessing the link between dentistry (including orthodontics) and emerging infections so that our profession can receive early, appropriate advice.6
Although this novel virus has forced us to alter our ways of living and working radically, one thing that is evident is that people have never been closer. We will hopefully look back in amazement at how we remained resilient in a time of uncertainty, how we adapted to a rapidly changing environment and how we used the time to improve our services. Like all other crises, we will get through this.
