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Reducing the Risk of COVID-19 Transmission in Dental Offices: A Review

Article

Reducing the Risk of COVID-19 Transmission in Dental Offices: A Review

Abstract

The COVID-19 epidemic has become a major public health challenge around the world. According to the World Health Organization (WHO), as of August 2020 there are more than 833,556 dead and over 24,587,513 people infected around the world. This pandemic has adversely affected many professions around the globe, including dentistry. COVID-19, caused by the Corona virus family, is transmitted mainly by direct contact with an infected person or through the spread of aerosol and droplets. Dentistry by nature is considered to be one of the most vulnerable professions with regards to the high risk of transmission between the dentist, dental team, and patients; therefore, a protocol for infection control and the prevention and spreading of the COVID-19 virus in dental settings is urgently needed. This article reviews essential knowledge about this virus and its transmission and recommends preventive methods based on existing scientific research and recommendations to prevent the spread of this virus in dental offices and clinics. This article is protected by copyright. All rights reserved.
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/jopr.13261.
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Title:
Reducing the Risk of COVID-19 Transmission in Dental Offices: A Review
Running title: Dental Offices and COVID-19
Reza Eftekhar Ashtiani, DDS, MS1; Shabnam Tehrani, MD, MSC2; Marta Revilla-León, DDS,
MSD3; Amirali Zandinejad, DDS, MSc4
1Assistant Professor and Chair, Department of Dental Technology, School of Dentistry, Shahid
Beheshti University of Medical sciences, Tehran, Iran
2Associate Professor of Infectious Diseases and tropical Medicine Research Center, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
3Assistant Professor and Assistant Program Director of AEGD Residency Program, Department
of Comprehensive Dentistry, Texas A&M University, College of Dentistry, Dallas, Texas
4Associate Professor and Program Director of AEGD Residency Program, Department of
Comprehensive Dentistry, Texas A&M University, College of Dentistry, Dallas, Texas
Corresponding author:
Amirali Zandinejad DDS , MSc
AEGD Program, Department of Comprehensive Dentistry
College of Dentistry, Texas A&M University
Room 611, 3302 Gaston avenue
Dallas, Texas, USA.
Email: azandinejad@tamu.edu
Conflict of interest: The authors declare no potential conflict of interest
Accepted date: September 8, 2020
This article is protected by copyright. All rights reserved.
Abstract:
The COVID-19 epidemic has become a major public health challenge around the world. According to
the World Health Organization (WHO), as of August 2020 there are more than
833,556 dead and over 24,587,513 people infected around the world. This pandemic has adversely
affected many professions around the globe, including dentistry. COVID-19, caused by the Corona
virus family, is transmitted mainly by direct contact with an infected person or through the spread of
aerosol and droplets. Dentistry by nature is considered to be one of the most vulnerable professions
with regards to the high risk of transmission between the dentist, dental team, and patients; therefore,
a protocol for infection control and the prevention and spreading of the COVID-19 virus in dental
settings is urgently needed. This article reviews essential knowledge about this virus and its
transmission and recommends preventive methods based on existing scientific research and
recommendations to prevent the spread of this virus in dental offices and clinics.
Keywords: COVID-19, Dental Offices, Review, Reducing transmission
As the world is well aware, in the last months of 2019, a severe form of COVID viral
pneumonia was reported in Wuhan, China.1,2 The disease quickly spread and infected a large number
of Chinese citizens and due to the frequency of worldwide travel, it managed to disperse to
neighboring and distant countries.
The further isolation of the virus and determination of its genome3 revealed that it belongs to
the Corona family of viruses and is capable of infecting humans. On February 11, 2019, the World
Health Organization (WHO) named the new virus COVID-19. It is the seventh member of the Corona
family of viruses that is able to infect humans. Two other member of this family named SARS-CoV
and MERS-CoV, also caused fatal respiratory diseases in 2002 and 2012 respectively and regrettably
they still continue to cause respiratory diseases.4-6
In terms of nucleotide sequence, COVID-19 is about 80% similar to its other two noxious family
members. It has the ability to cause deadly respiratory infections but is also able to spread much faster
than other members of its family7 and as a result, the virus has spread extremely quickly to countries
around the world. 8 WHO declared COVID-19 an International Public Health Emergency on January
31, 2020.9
According to a WHO announcement, as of August 2020, there have been over 833,556 deaths and in
excess of 24,587,513 people infected.
Symptoms and Transmission
Common symptoms of the disease include fever, cough, muscle pain, excessive fatigue, sore
throat, and/or reduction/loss of smell or taste10-12 which can be present along with abnormal
radiographic findings in the lungs. However, in a few cases, the disease can be present but
symptomless or resemble a common cold (runny nose) or a stomach upset (nausea and diarrhea).13-15
The virus can be transmitted by direct contact with an infected person or through the spread
of aerosol droplets (e.g. coughing, shouting, or sneezing) 16 as well as through contact with
contaminated surfaces. The virus can also be transmitted to mucosal surfaces of the face such as the
oral environment, nose, and eyes 17,18 by an infected hand. These are all documented transfer modes in
respiratory tract infections. 19
Studies have shown that respiratory viruses are transmitted directly or indirectly through
salivary droplets18,20 as well as through aerosols dispersed in the air from coughing, sneezing, or
medical procedures. 21,22 Although the COVID-19 virus is detectable in a patients’ feces on day 7 23,
the possibility of transmitting of the COVID-19 virus via feces is still under investigation. 24
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Receptors of COVID-19 in Humans
Understanding the path of the virus to the human body can demonstrate the variety of
transmission routes. Both SARS-CoV and COVID-19 use ACE2 cell receptors to infect humans.25,26
This receptor is found in the lung and in small intestinal mucosa cells;27 therefore, the virus is capable
of infecting both the upper respiratory and digestive system. 27,28 There have been some reports of
upset stomachs as a symptom, especially in the younger age groups.29 The ACE2 receptors are
particularly seen in epithelial cells of salivary glands. 28,30 This receptor is also found extensively in
epithelial cells of the tongue.31,32 Locations of this receptor indicate where the body is infected and
how the virus is transmitted, including saliva and respiratory droplets and therefore the oral
environment is a notorious transfer zone for potential transmission of the virus.
Dentistry and Transmission of Disease
Production of aerosols and droplets during dental treatment are the main route for airborne
pathogens.33,34 Dental treatments can spread a large amount of these virus-containing nano, small, and
large particles in the air 22,34,35 causing consequent spread of the illness to dental health workers and
subsequent patients.36,37 Also dental patients can be asymptomatic carriers of COVID-19 at the time of
dental treatments.15,38 The droplets released from the dental treatment can survive for several hours in
the air and ultimately be a potential source of multiple transmissions.21,22,31,35
Current infection control strategies for dentistry recommended by the Center for Disease
Control (CDC) have been focused mainly on Blood Born infections and dentists are well-trained in
this area but the guidelines about Airborne Diseases in dentistry is not as strong.39-42 The likelihood of
cross-contamination of this pathogen between dental offices and dental laboratories is also unclear
and more standardized worldwide guidelines should be provided in this area as a result of further
studies.
Uncertainty and fear in the community around visiting dental offices can have many adverse
economic effects on the dental community and also negative effects on the dental health of the
population. New strategies are absolutely essential to alleviate fear and bring people back into dental
offices as needed.43,44
Based on the possible direct and indirect methods of transmission, the protection of Health
Care Workers (HCW’s) as well as patients is extremely important. 45,46 The Corona virus family has
produced three worldwide dangerous epidemics over the past 18 years which shows that attention to
airborne diseases is extremely essential in dentistry. This pandemic has shown that dentists around the
world need to unite to contain the risk of infection in their practices.
Methods for Protecting Against Airborne Diseases in Dentistry
Due to the worldwide spread of diseases that can be transmitted by droplets and aerosols, it is
necessary to pay meticulous attention to this topic and include them in infection control guidelines for
dental offices. 31 Implementing and following recommendations are important to keep dental offices a
safe place for all patients and personnel and to prevent the spread of such respiratory diseases.
Tele-Screening and Communication Before Appointments
Tele-screening of patients by phone or other internet-based communication system is
recommended before attending in office. This includes asking the patients about any symptoms
resembling a cold, flu, or even stomach/digestive issues as well as about any recent travel.
Based on worldwide recommendations for observing social distancing rules, it is recommended to
observe personal hygiene and coughing etiquette as well as the use of effective face masks. Patients
should also be encouraged to do so in public as well as when attending a dental office. It is
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recommended to instruct patients to come alone for dental appointments and to avoid bringing any
unnecessary items with them. There must be an appropriate interval between patients’ appointments
in order to allow for enough time for disinfection and airing of the dental office which will help
significantly to reduce possible aerosol contact between patients.
All common decorative, promotional, or unnecessary devices/tools such as pamphlet,
magazines, books, etc., should be removed from the waiting area. The reception area must be
disinfected routinely and also have good ventilation. There must be a protocol in place for payment
and the subsequent disinfection of credit cards.
Patient Arrival
All patients must wear a shoe cover that is put on immediately before entering the dental
office and also disinfect their hands immediately upon entering the office. The dentist should be able
to assess the patient’s health based on observations, depending on the type and symptoms of the
common illness40,41, so completing a questionnaire at each treatment session is helpful in this process.
Questions should reveal information such as having a fever in the past 14 days, any reduced sense of
smell or taste, have flu-like symptoms, cough, difficulty breathing, body ache or diarrhea, history of
traveling to high risk areas or contact with people who have recently travelled to high risk areas; 41
however, we should always consider that some patients can be carriers of the virus and symptomless
and therefore can still spread the virus by cross contamination.38 If a patient is a suspected carrier,
other symptoms should also be considered. Since the last three epidemics have been transmitted by
the Corona family of viruses over the past two decades, the assessment of body temperature must
become routine in-patient evaluation.
Dental Radiographs
Intraoral radiographs are commonly taken for diagnosis of dental diseases. If possible, try to
use extra oral radiography including panoramic tomography, CBCT’s, or oblique lateral views. If
intraoral radiographs are absolutely necessary, the use of pre-radiographic disinfectant mouthwashes
such as peroxides are recommended 31 as well as the use of plastic disposable covers to avoid
infection through cross-contamination. Disinfection of the X-ray equipment is also vital and there
must be meticulous attention given to the ventilation of radiograph room.47
Hand-Hygiene
Indirect transmission by touching infected surfaces is one of the proven methods of
transmission of airborne diseases;48 therefore, reinforced hand hygiene must be made compulsory and
all members of the dental team and other staff should follow the guidelines in place. 48,49
The recommendation for hand hygiene is before the patient's examination, before the dental treatment,
after contact with the patient, after touching the materials and equipment that have not been
disinfected, and after examination of oral mucosa, damaged skin, blood or body fluids, exudates, and
human waste. This is known as “Two Before and Three After” and this protocol is needed to enhance
and improve hand hygiene. 49 The potential for Fecal-Oral transfer of COVID-19 should be
considered and hand hygiene is the key element of prevention in this regard too.41 In the protocol,
Two Before/Three After, the dentist and the rest of the medical staff should wash their hands as
indicated above. 41,50 It is recommended that the hands should be washed after removing the gloves as
well due to the permeability of latex gloves.51,52 The system of washing hands before and after
wearing latex gloves was recommended even before the SARS outbreak. It is also recommended that
HCW’s do not wear any jewelry or watches to the dental practice if possible, and to remove them
before seeing any patients.
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Personal Protective Equipment `
Indications and correct utilization of Personal Protective Equipment (PPE) play a key role in
COVID-19 protection for the patient and for personnel. Aerosols and droplets are common methods
of transmitting airborne diseases and are created in ample amounts with ultrasonic and dental hand
pieces; therefore, wearing masks, shields, goggles, disposable caps, gloves, and protective clothing
should be made compulsory for all dental health professionals in the operatory.34 For those who do
not deal with the patient directly (such as office personnel) surgical masks are recommended while
chair side personnel must use N-95 masks. It is also recommended to observe the sequence of
donning and discarding personal protective equipment. The donning sequence has been recommended
to be as follows: washing hands, wearing gown, face mask, scrub hat, face shield, and surgical gloves.
The doffing sequence is as follows: first remove surgical gloves in the formats recommended,
face shield, scrub hat, and face mask, and finally the body gown and then subsequent surgical hand
washing.
Reprocessing of PPE due to lack of supply can be essential. Concerning respirator reuse,
highly energetic, short-wave, ultraviolet germicidal irradiation (UVGI) at 254 nm was determined to
decontaminate N95 respirators from viral respiratory agents, but UVGI requires careful consideration
of the type of respirator and of the biologic target. Most studies suggest surgical masks are not inferior
compared with N95 respirators in terms of protective efficacy among healthcare workers. Therefore,
the use of N95 respirators should be limited to high-risk situations. Also, for N95 masks the fit test is
recommended. 53,54
Antimicrobial Mouthwashes
Use of mouthwash prior to treatment reduces the number of microorganisms in the mouth and
subsequently decreases airborne microorganisms following dental treatments. 40,41,55,56
Chlorhexidine is commonly suggested as a pre-treatment mouthwash56 but it is not effective against
the Corona virus.41 Oxidizing mouthwashes such as hydrogen peroxide 1%, povidone or
cetylpyridinium chloride (CPC) 0.10% to 0.05% are recommended for protection against Corona
viruses.40,55,56,57,58 Povidone-iodine can safely be used in the mouth with up to 2.5% and it rapidly
inactivates coronaviruses when applied for 15 seconds.59
Reduce Oral Aerosols and Droplets
Airborne particles can be one of the main causes of disease transmission. These particles will
be suspended in the air33 and their suspension time will be depend on their size and weight.21 These
droplets can spread up to several meters in the environment and if smaller than 5μ, they will remain
in-air for more than 3 hours.31,35 They infect the surfaces by sedimentation, so decreasing the quantity
of aerosol and droplets during dental procedures is very critical. There are different ways to reduce
aerosol and droplets as shown in Table 1. 31,41,60,61,62,63,64
Dental High Speed Hand Piece
Due to the heat generation on the tooth during preparation, continual water coolant is
required. The coolant collides with the bur and cavity causing many suspended aerosol and droplets.
Some articles describe the use of disinfectant liquids instead of water as coolants 65-67 which may
reduce the microbial load on airborne droplets and disinfect the waterline.68-70 Although these liquids
may interfere with dental bonding techniques,71 the use of 0.1% of CPC is recommended due to its
disinfection capability which has no effect on the adhesive and bonding process. In general, the use of
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anti-retraction hand pieces is recommended for dental treatments for waterline protocols.72-74
Reducing Treatment Sessions
If possible, it is recommended to increase the number of treatments per session in order to minimize
the number of patient appointments.
Surface Disinfection
Surfaces can be contaminated directly or indirectly by the deposition of droplet particles and the
lifetime of the virus on surfaces varies depending on the materials and the presence of moisture.19,21
The CDC Guidelines provide good protocols for cleaning contaminated surfaces.76,77 It is naturally
advisable to utilize disinfectants that work on both airborne and blood born viruses and
microorganisms.77
Fogging or “Aerosol disinfection” is also an option for disinfection of surfaces without touching
between the patients. There are some chemicals which can be used as vapor disinfectant including
hydrogen peroxide and hypochlorous acid. The recommended method for hydrogen peroxide is 20%
(w/v) working solution of hydrogen peroxide (stabilized by 0.01% of silver nitrate) prepared. The
amount of solution required is approximately 1000 mL per 1000 cubic feet. For use of chemical in the
form of vapor, we must consider the contact time, concentration of active disinfectant, dilution of
material in air, and last but not least the possible negative effect on respiratory system of health care
workers. To reduce the time between the patients, we may accelerate the removal of infected aerosol
by using heavy ventilation or accelerate the surface disinfection by means of HOCL fogging for 10
minutes by 20 micron vapor.78,79
Disposable Barrier
The dentist and his/her assistant may need to touch different devices that may not always be
fully disinfected. On the other hand, sterilizing chemicals can cause lung damage and environmental
pollution;80 therefore, these surfaces may be covered with disposable barriers and the barrier discarded
immediately after each dental treatment. Examples of such barriers include full chair coverage,
counter coverage, and dental microscope coverage. Also, implementing 4-handed dentistry or
working closely with your assistant and preplanning can avoid the need to touch surfaces with
infected gloves.
Ventilation
Infected droplets suspend in the air for hours20,61,81,82 so attention to ventilation is essential.
The use of declared guides is very effective in controlling droplets but cannot remove the
contaminated particles completely.61 Research carried out by Zemouri in 201735 shows that there can
be 38 different types of microorganisms dispersed in the air in dental clinics. Although these articles
have not investigated the Corona family of viruses specifically, it has been proven that SARS-CoV
and COVID-19 viruses are present in the saliva of infected individuals28,30,32 and therefore attention to
proper ventilation during and after treatment is very important. There are different ways to ventilate
dental offices and clinics as shown in Table 2.83-85
Dental Laboratories and Cross-Contamination
Cross-contamination between dental clinics and laboratories has been proven 86,87 and the
CDC has provided specific guidance on infection control for both laboratories and dental offices. The
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general advice in this case is to disinfect all outgoing items before sending them to the lab as well as
after receiving items from the lab including packaging and boxes.88,90 The routine items and their
protocols are shown in Table 3.86-9
Medical Waste
Medical waste is divided into two categories: infectious and non-infectious. The existing guidelines
seem to be sufficient and must be closely executed.
Conclusion
COVID-19 has impacted many aspects of our life and dentistry is not excluded. Dental practices
should reinforce and follow new guidelines to protect themselves, their patients and their dental team
against COVID-19. However, as we learn more about this new infection the guidelines may change.
Also, further clinical studies are recommended to investigate the effectiveness of existing guidelines
and be able to improve them for a safe environment for practicing dentistry. It is recommended that
all dental practitioners and dental axillaries keep themselves updated as new scientific data evolves
regarding COVID-19.
Acknowledgement:
The authors gratefully acknowledge Dr. Laleh Alim Marvasti for her contribution and Ms. Rachel
Jones for editing and formatting the manuscript.
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Table 1: Different ways to reduce aerosols and droplets in dental offices
Abandoning and/or substituting techniques that produce droplets, if possible. For
example: decreasing the use of three-way syringe or using manual instruments for
caries removal or root scaling
High volume evacuation with a large diameter suction tip and expert hands
accompanied by four-hand discipline, can prevent a large amount of contamination;
however, this type of suction should be disinfected daily and the suction exhaust must
be discharged out of the treatment environment
Implementation of four-hand dentistry and well-trained dental assistants and also
minimizing the presence of personnel in the room during the procedure
Use of rubber dams also tends to prevent contamination; 31,59 therefore, rubber dam
practice should also become a habit and be used whenever possible
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Table 2: Recommended effective ways for dental office ventilation
1
Use air purifiers with HEPA (High Efficiency Particulate Arrestor) filters. HEPA
filters need to be replaced frequently.
2
Use of strong or industrial fans for ventilation of the clinic is also a convenient
and low-cost method but carry the risk of possibly spreading the infected droplets
to the outside air.
3
Use of UV light after each patient.
4
Use of a negative pressure room, if possible.
5
Use of antiviral disinfectant sprays such as Nano-Silver disinfectant.
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Table 3: The common lab items and their disinfection protocol
1-Dental Impressions
These impressions are routinely sanitized according to the
disinfection protocol, and it seems that current methods,
are capable for eliminating airborne viruses.
2-Prosthesis
Prosthetic appliances after try-in stage such as fixed and
removable prostheses must be disinfected by chemical or
physical method by the dentist according to material.
3-Gypsum Dental Models
Existing guidelines have provided methods for sterilizing
dental models by chemical solutions, but these methods
are not reliable and may damage the model. There are
many articles on the use of autoclaves or microwave
furnace for disinfecting the gypsum, but dental models
usually contain metal parts that limit the use of physical or
microwave techniques. As a result, dentists should
minimize the contact with dental models during the try-in
phase. This can be done by analyzing the model with
clean hands or gloves.
... Indirect transmission by touching infected surfaces is one of the proven methods of transmission of airborne diseases therefore, reinforced hand hygiene must be made compulsory and all members of the dental team and other staff should follow the guidelines in place [11] . ...
... Oxidizing mouthwashes such as hydrogen peroxide 1%, povidone or cetylpyridinium chloride (CPC) 0.10% to 0.05% are recommended for protection against Corona viruses. Povidone-iodine can safely be used in the mouth with up to 2.5% and it rapidly inactivates coronaviruses when applied for 15 seconds [11] . ...
... As reported by Meng et al., it is advisable to minimize the operations involving the generation of aerosol and droplets while employing use of personal protective equipment [14] . In general, the use of antiretraction hand pieces is recommended for dental treatments for waterline protocols [11] . ...
... The specifications of the drill (drill material and geometry) and drilling conditions (revolution speed, axial pressure, and irrigation method) strongly influence intrapulpal temperatures intraoperatively [2]. For restorative and prosthetic tooth preparations, air-turbines and high-torque electric handpieces are frequently used, which require constant water coolant due to heat generation [3]. These high-speed rotating instruments generate spray, resulting from a mixture of the water coolant and "chip air" [4]. ...
... Potential methods of managing exposure to aerosols include applying more effective highvolume evacuators, using individual protective transparent acrylic chambers, increasing mechanical ventilation using air cleaners and filters, and reducing the formation of aerosol spray by decreasing either the rotational speed of the drills or the amount of water coolant [3,6,[12][13][14][15][16][17][18]. However, reducing irrigation may result in more limited visualisation during fine and precise movements; moreover, chip clogging of the drill and increased friction can occur [6,19]. ...
... The current COVID-19 pandemic caused by the coronavirus (SARS-CoV-2) has demonstrated the importance of and concerns regarding existing infection control measures for dental healthcare professionals, as they have an extremely high risk of becoming infected with SARS-CoV-2 [6,12]. Current preventative protocols recommend patient triage, preoperative mouth rinses, hand hygiene, personal protective equipment, rubber dam isolation, cleaning of contaminated surfaces, and limitation of aerosol-producing procedures [3,5,[11][12][13]. Since dental aerosols and droplets can be a primary causes of disease transmission, there are some specific recommendations for reducing aerosol spray [16][17][18]. ...
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Objectives Decreasing aerosol leaks are of great interest, especially in the recent era of COVID-19. The aim was to investigate intrapulpal heat development, coolant spray patterns, and the preparation efficiency of speed-increasing contra-angle handpieces with the spray air on (mist) or off (water jet) settings during restorative cavity preparations. Methods Standard-sized cavities were prepared in 80 extracted intact human molar teeth using diamond cylindrical drills with a 1:5 speed-increasing contra-angle handpiece. A custom-made device maintained the standardized lateral drilling force (3 N) and predetermined depth. Temperatures were measured using intrapulpal thermocouple probes. The four experimental groups were as follows: mist cooling mode at 15 mL/min (AIR15), water jet cooling mode at 15 mL/min (JET15), mist cooling mode at 30 mL/min (AIR30), and water jet cooling mode at 30 mL/min (JET30). The coolant spray pattern was captured using macro-photo imaging. Results The JET15 group had the highest increase in temperature (ΔT = 6.02 °C), while JET30 (ΔT = 2.24 °C; p < 0.001), AIR15 (ΔT = 3.34 °C; p = 0.042), and AIR30 (ΔT = 2.95 °C; p = 0.003) had significantly lower increases in temperature. Fine mist aerosol was formed in the AIR15 and AIR30 preparations but not in the JET15 and JET30 preparations ( p < 0.001). The irrigation mode had no influence on the preparation time ( p = 0.672). Conclusions Water jet irrigation using coolant at 30 mL/min appeared to be the optimal mode. Considering the safe intrapulpal temperatures and the absence of fine mist aerosols, this mode can be recommended for restorative cavity preparations. Clinical significance To increase infection control in dental practices, the water jet irrigation mode of speed-increasing handpieces with coolant flow rates of 30 mL/min should be considered for restorative cavity preparations.
... The respiratory system is the common transmission way of COVID-19 infection. Because of the enormous amount of aerosol, dental clinics and universities are the riskiest places (33). The uncertainty and unpredictability of this virus cause the world to face a vast and stressful problem. ...
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Objective The purpose of the present study was to investigate the association of COVID-19 vaccination with the quality and quantity of sleep, the level of stress, and temporomandibular joint (TMJ) disorders (TMDs) in Iranian dental students.Materials and methodsIn this cross-sectional research, we applied a questionnaire including 30 questions on the Perceived Stress Scale (PSS), sleep quality and quantity, Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), and vaccination status. All vaccinated students of the dental schools located in the city of Tehran were invited to participate in the study. Participants were divided into three groups: those vaccinated for less than a month, those vaccinated for 1–3 months, and those vaccinated for more than 3 months. A paired t-test served for statistical analysis.ResultsOverall, 171 out of 235 students (72.77%) completed the questionnaire, among which 90 individuals were fully vaccinated, and were included in the data analysis. Stress levels decreased (mean difference = −1.23, p-value = 0.002) and sleep quality and quantity improved mostly 1–3 months after the vaccination (mean difference = −0.5, p-value = 0.016). However, TMD symptoms were mostly alleviated in people vaccinated for more than 3 months (mean difference = −2.86, p-value <0.05). In this respect, no significant difference was observed between the two genders.Conclusion According to the results of the study, vaccination was associated with the improvement of psychological consequences of the COVID-19 pandemic. It is recommended that further longitudinal studies be conducted on larger sample sizes and different age groups by using various data collection methods (especially regarding the assessment of TMD).
... However, different reports confirmed the deaths of dentists, dental nurses, and staff due to coronavirus during the pandemic [17,19,20]. Related studies have reported the risks of coronavirus diffusion, along with the recommendations to manage the coronavirus diffusion during dental procedures [21][22][23]. King's College London and Imperial College London researchers reported an aerosol generation procedure to limit the virus spread and improve safety [24]. ...
Article
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The COVID-19 pandemic has affected all the professions of life, particularly the healthcare sector. In dentistry, prevention of viral spread among healthcare professionals and patients was a substantial challenge. The virus can directly or indirectly infect dentists during dental procedures. This study focuses on the purpose of pediatric patients’ emergency visits to dental clinics and the treatments practiced during the lockdown. It compares the purpose of emergency pediatric patient visits in dental clinics and their treatments before, during, and after the lockdown periods. Computerized data for two consecutive years (2019 and 2020), between 19 March and 30 April and after the lockdown period from 1 May to 12 June 2020, were collected from five random dental clinics in Israel. The emergency visits of patients under 18 years before, during, and after the lockdown was organized into demographic characteristics, the purpose of the visits, and the treatments with medication or dental procedures. Categorical variables were compared and correlated with the chi-squared test and Pearson’s test, respectively, by using SPSS version 21. During the lockdown, emergency cases got appointments for a physical checkup. Herein, we found higher cases of emergency visits of pediatric patients with pain (n = 281, 32.6%) than trauma (n = 18, 24.7%), followed by infection (n = 31, 28.4%) and treatment continuation (n = 7, 20.6%) during the lockdown period, compared to before and after the lockdown periods. The patients treated with medication and dental procedures during lockdown were significantly different (p < 0.001) than before and after the lockdown. Extraction (n = 81, 41.5%), filling (n = 84, 50.6%), fluoride (n = 13, 92.9%), and pulp treatment (n = 92, 42.6%) were substantially practiced in pediatric patients during the lockdown. Further, this study confirmed the rapid adaptation of professional dentists to deal with non-vaccinated pediatric patients and reinforced the better preparation and requirements for such challenges in the future.
... Dental visits are a specific care need constrained by COVID-19 prevalence in Japan [17,18]. This study also showed that 66 people had foregone dental visits. ...
Article
Full-text available
The coronavirus disease (COVID-19) continues to be a widespread pandemic. We investigated the relationship between anxiety/stress and health behaviors during the COVID-19 pandemic in homebound Japanese older adults during January and February 2021. We surveyed 1507 community-dwelling, older Japanese adults using a self-administered questionnaire on primary attributes, including family structure, evaluation of psychological anxiety/stress, and health behaviors. Participants were divided into four anxiety/stress groups based on the frequency of experiencing anxiety/stress, and their association with health behaviors was analyzed using bivariate and multivariate analyses. Responses were received from 469 (31.1%) respondents. In the bivariate analysis, age and family structure were significantly associated with anxiety/stress (p < 0.01). The health behaviors significantly associated with anxiety/stress were walking, balanced eating habits, limited snacking, regular lifestyle, and dental visits. Logistic regression analysis was performed using the variables in the bivariate analysis that showed a significant association with anxiety/stress status as independent variables. Finally, age and dietary habits were significantly associated with anxiety/stress status. No significant associations were found between any other variables. Among older adults living in the rural areas of Japan during the COVID-19 pandemic, anxiety/stress status was significantly associated with age and dietary habits but not with other health behaviors.
... Given that dentistry is considered a high-risk profession because of the easy spread of viral agents in the air during dental procedures and the persistence of biological agents in operating rooms (14), new recommendations for biosecurity protocols and the use of personal protective equipment (PPE) have been proposed (15,16). Among these recommendations is the use of particulate respirators, eye protection, gowns, and gloves during dental procedures (17). Although studies have shown that using N95 masks does not result in significant clinical changes in body temperature (14), wearing all necessary PPE at the same time could cause an increase in body temperature. ...
Article
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Background: This study evaluated the association between knowledge and management of ventilation and air-conditioning systems (VAC) to avoid the spread of the SARS-CoV-2 virus in health facilities by dentists and demographic variables. Material and Methods: A cross-sectional digital media survey was administered to dentists as part of global research. The core questionnaire was used including four additional questions on VAC (Q1: knowledge, Q2: work settings, Q3: temperature, and Q4: maintenance). A descriptive analysis was conducted for sociodemographic and VAC variables, and bivariate analysis was carried out using different tests. Results: 5,370 dentists answered the survey (median age of 45 years; 72.22% women). About half of the respondents said that they knew about the guidelines issued for the management of air conditioners (AC) during the pandemic, and 16.77% have made modifications to their VAC systems during this period. The most frequent AC temperature range used in the dentists’ offices during the pandemic was 18°C to 20°C. As age increased, self-reported knowledge about VAC guidelines expanded. Remote and rural regions were perceived to have less knowledge of the guidelines. Conclusions: Although perceptions of knowledge about VAC systems during the COVID-19 pandemic was high, the temperature in dental offices was colder than that recommended. Greater disclosure of VAC management practices and adherence to VAC management guidelines are required.
... Another critical point in the work of dentists is in relation to the ventilation requirements that the operating room must have. The current recommendation is that it must be well ventilated or have an air conditioning system with EPA filters [2,21]. ...
Article
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Dentists are highly exposed and vulnerable during the coronavirus disease (COVID-19) pandemic, as physical proximity to patients is necessary for effective dental examination and treatment. The objective of this study was to describe the concerns, knowledge, and infection control practices of dentists in Mexico during the COVID-19 pandemic. In this cross-sectional study conducted from 22 May 2020 to 8 July 2020, an anonymous survey was distributed to dentists, which covered information regarding dentists’ sociodemographic and professional characteristics, clinical practices during the pandemic, and perceptions regarding the application of infection prevention and control guidance for dental settings during the COVID-19 pandemic. Out of 703 respondents, 73.1% (n = 514) were women and 53.6% (n = 377) were dentists with 1–10 years of experience. Regarding the statements issued by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), the responses for 11 survey items had total agreement rates >90% (high frequency); seven and nine items had moderate and low frequency of total agreement, respectively. Most dentists in this study agreed with the WHO and CDC statements and were concerned regarding the possibility of infection, despite using the protective gear.
Chapter
Oral health maintains in good condition by the saliva that is an aqueous fluid in the oral cavity and constantly covers the teeth and oral mucosa. Saliva is secreted by the three major salivary glands: the parotid, submandibular and sublingual glands, and numerous minor salivary glands. The three major salivary glands generate about 90% of the fluid secretion and minor salivary glands less than 10%. The average daily flow of the whole saliva has been reported to vary in health between 1 and 1.5 L. In unstimulated conditions, the average range of flow rate is 0.3–0.4 mL/min with an osmolality ranging from 50 to 70 mOsmol/kg. However, the volume, flow, and composition of saliva can be altered under the influence of various factors and stimuli. Stimulation like masticatory or gustatory enhances flow rate up to 7 mL/min and changes the percentage contributions from each gland. The parotid is contributing more than 20% of total salivary secretions under unstimulated conditions; however, 50% of secretions are under stimulation.
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Purpose To evaluate the in vitro inactivation of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) with hydrogen peroxide (H2O2) and povidone‐iodine (PVP‐I) oral antiseptic rinses at clinically recommended concentrations and contact times. Materials and Methods SARS‐CoV‐2, USA‐WA1/2020 strain virus stock was prepared prior to testing by growing in Vero 76 cells. The culture media for prepared virus stock was minimum essential medium (MEM) with 2% fetal bovine serum (FBS) and 50 μg/mL gentamicin. Test compounds consisting of PVP‐I oral rinse solutions and H2O2 aqueous solutions were mixed directly with the virus solution so that the final concentration was 50% of the test compound and 50% of the virus solution. Thus PVP‐I was tested at concentrations of 0.5%, 1.25% and 1.5%, and H2O2 was tested at 3% and 1.5% concentrations to represent clinically recommended concentrations. Ethanol and water were evaluated in parallel as standard positive and negative controls. All samples were tested at contact periods of 15 seconds and 30 seconds. Surviving virus from each sample was then quantified by standard end‐point dilution assay and the log reduction value of each compound compared to the negative control was calculated. Results After the 15‐second and 30‐second contact times, PVP‐I oral antiseptic rinse at all 3 concentrations of 0.5%, 1.25% and 1.5% completely inactivated SARS‐CoV‐2. The H2O2 solutions at concentrations of 1.5% and 3.0% showed minimal viricidal activity after 15 seconds and 30 seconds of contact time. Conclusions SARS‐CoV‐2 virus was completely inactivated by PVP‐I oral antiseptic rinse in vitro, at the lowest concentration of 0.5 % and at the lowest contact time of 15 seconds. Hydrogen peroxide at the recommended oral rinse concentrations of 1.5% and 3.0% was minimally effective as a viricidal agent after contact times as long as 30 seconds. Therefore, preprocedural rinsing with diluted PVP‐I in the range of 0.5% to 1.5% may be preferred over hydrogen peroxide during the COVID‐19 pandemic. This article is protected by copyright. All rights reserved
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The COVID-19 pandemic has spread across the globe and is the greatest challenge faced by world nations today. The first outbreak of this disease occurred in a seafood market of Wuhan City, China. The community pattern of spread was alarming and has gripped the entire international society. The dentists and other health care professionals should take stringent measures to prevent the spread of infection while providing care. In this article, we discuss the etiology, clinical manifestations, route of transmission, general and specific infection control protocols to protect the dental health care professionals as well as patients from COVID 19 disease while providing emergency dental care.
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Objectives Approaches to nasal and oral decontamination with povidone-iodine (PVP-I) have been published to reduce nosocomial spread of Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). The safety of PVP-I topically applied to the nasal and oral cavity is addressed by a literature review. The specific efficacy of PVP-I against coronaviruses and its potential efficacy against SARS-CoV-2 is discussed. Methods A review was performed utilizing PubMed and Cochrane Databases. All citations in protocols for nasal and oral PVP-I use regarding COVID-19 were independently reviewed. Results Povidone-iodine has been safely administered for up to 5 months in the nasal cavity and 6 months in the oral cavity. Concentrations less than 2.5% in vitro do not reduce ciliary beat frequency or cause pathological changes in ciliated nasal epithelium, upper respiratory, or mucosal cells. Adverse events with oral use have not been reported in conscious adults or children. Allergy and contact sensitivity is rare. Chronic mucosal use up to 5% has not been shown to result in clinical thyroid disease. PVP-I is rapidly virucidal and inactivates coronaviruses, including SARS-CoV and Middle East Respiratory Syndrome (MERS). Conclusions Povidone-iodine can safely be used in the nose at concentrations up to 1.25% and in the mouth at concentrations up to 2.5% for up to 5 months. Povidone-iodine rapidly inactivates coronaviruses, including SARS and MERS, when applied for as little as 15 seconds. There is optimism that PVP-I can inactivate SARS-CoV-2, but in vitro efficacy has not yet been demonstrated.
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Purpose To investigate the optimal contact time and concentration for viricidal activity of oral preparation of povidone‐iodine (PVP‐I) against SARS‐CoV‐2 (‘corona virus’) to mitigate the risk and transmission of the virus in the dental practice. Materials and Methods The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) USA‐WA1/2020 strain, virus stock was tested against oral antiseptic solutions consisting of aqueous povidone‐iodine (PVP‐I) as the sole active ingredient. The PVP‐I was tested at diluted concentrations of 0.5%, 1% and 1.5%. Test media without any virus was added to 2 tubes of the compounds to serve as toxicity and neutralization controls. Ethanol (70%) was tested in parallel as a positive control, and water only as a negative control. The test solutions and virus were incubated at room temperature (22 ±2°C) for time periods of 15 and 30 seconds. The solution was then neutralized by a 1/10 dilution in minimum essential medium (MEM) 2% fetal bovine serum (FBS), 50 μg/mL gentamicin. Surviving virus from each sample was quantified by standard end‐point dilution assay and the log reduction value (LRV) of each compound compared to the negative (water) control was calculated. Results PVP‐I oral antiseptics at all tested concentrations of 0.5%, 1% and 1.5%, completely inactivated SARS‐CoV‐2 within 15 seconds of contact. The 70% ethanol control group was unable to completely inactivate SARS‐CoV‐2 after 15 seconds of contact, but was able to inactivate the virus at 30 seconds of contact. Conclusions PVP‐I oral antiseptic preparations rapidly inactivated SARS‐CoV‐2 virus in vitro. The viricidal activity was present at the lowest concentration of 0.5 % PVP‐I and at the lowest contact time of 15 seconds. This important finding can justify the use of preprocedural oral rinsing with PVP‐I (for patients and health care providers) may be useful as an adjunct to personal protective equipment, for dental and surgical specialties during the COVID‐19 pandemic. This article is protected by copyright. All rights reserved
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Introduction: The occurrence of anosmia/hyposmia during coronavirus disease 2019 (COVID-19) may indicate a relationship between coincidence of olfactory dysfunction and coronavirus disease 2019 (COVID-19). This study aimed to assess the frequency of self-reported anosmia/hyposmia during COVID-19 epidemic in Iran. Methods and Materials: This population-based cross-sectional study was performed through an online questionnaire from 12th and 17th March, 2020. Cases from all provinces of Iran voluntarily participated in this study. Patients completed a 33-item patient-reported online questionnaire including smell and taste dysfunction and their comorbidities along with their basic characteristics and past medical histories. The inclusion criteria were self-reported anosmia/hyposmia during recent 4 weeks, from the start of COVID-19 epidemic in Iran. Results: In this study, 10,069 participants aged 32.5±8.6 (7-78) years, 71.13% female and 81.68% non-smoker completed online questionnaire. The correlation between the number of olfactory disorders and reported COVID-19 patients in all provinces till 17th March 2020 was highly significant (Spearman correlation coefficient=0.87, P-value<0.001). A sudden onset of olfactory dysfunction was reported in 76.24% of the participations. Persistent anosmia was reported in 60.90% from the start date of COVID-19 epidemic. In addition, 80.38% of participants reported concomitant olfactory and gustatory dysfunctions. Conclusions: It seems that there is an outbreak of olfactory dysfunction happened in Iran during the COVID-19 epidemic. The exact mechanism(s) by which anosmia/hyposmia occurred in patients with COVID-19 mandate(s) further investigations.
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Background SARS‐CoV‐2, the virus that causes COVID‐19 disease, is responsible for the largest pandemic since the 1918 H1N1 influenza outbreak. The symptoms presently recognized by the World Health Organization are cough, fever, tiredness, and difficulty breathing. Patient‐reported smell and taste loss has been associated with COVID‐19 infection, yet no empirical olfactory testing on a cohort of COVID‐19 patients has been performed. Methods The University of Pennsylvania Smell Identification Test (UPSIT), a well‐validated 40‐odorant test, was administered to 60 confirmed COVID‐19 inpatients and 60 age‐ and sex‐matched controls to assess the magnitude and frequency of their olfactory dysfunction. A mixed effects analysis of variance determined whether meaningful differences in test scores existed between the two groups and if the test scores were differentially influenced by sex. Results Fifty‐nine (98%) of the 60 patients exhibited some smell dysfunction [mean (95% CI) UPSIT score: 20.98 (19.47,22.48); controls: 34.10 (33.31,34.88); p<0.0001]. Thirty‐five of the 60 patients (58%) were either anosmic (15/60; 25%) or severely microsmic (20/60; 33%); 16 exhibited moderate microsmia (16/60; 27%), 8 mild microsmia (8/60; 13%), and one normosmia (1/60; 2%). Deficits were evident for all 40 UPSIT odorants. No meaningful relationships between the test scores and sex, disease severity, or comorbidities were found. Conclusions Quantitative smell testing demonstrates that decreased smell function, but not always anosmia, is a major marker for SARS‐CoV‐2 infection and suggests the possibility that smell testing may help, in some cases, to identify COVID‐19 patients in need of early treatment or quarantine. This article is protected by copyright. All rights reserved
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Huge citizens expose to social media during a novel coronavirus disease (COVID-19) outbroke in Wuhan, China. We assess the prevalence of mental health problems and examine their association with social media exposure. A cross-sectional study among Chinese citizens aged≥18 years old was conducted during Jan 31 to Feb 2, 2020. Online survey was used to do rapid assessment. Total of 4872 participants from 31 provinces and autonomous regions were involved in the current study. Besides demographics and social media exposure (SME), depression was assessed by The Chinese version of WHO-Five Well-Being Index (WHO-5) and anxiety was assessed by Chinese version of generalized anxiety disorder scale (GAD-7). multivariable logistic regressions were used to identify associations between social media exposure with mental health problems after controlling for covariates. The prevalence of depression, anxiety and combination of depression and anxiety (CDA) was 48.3% (95%CI: 46.9%-49.7%), 22.6% (95%CI: 21.4%-23.8%) and 19.4% (95%CI: 18.3%-20.6%) during COVID-19 outbroke in Wuhan, China. More than 80% (95%CI:80.9%-83.1%) of participants reported frequently exposed to social media. After controlling for covariates, frequently SME was positively associated with high odds of anxiety (OR = 1.72, 95%CI: 1.31–2.26) and CDA (OR = 1.91, 95%CI: 1.52–2.41) compared with less SME. Our findings show there are high prevalence of mental health problems, which positively associated with frequently SME during the COVID-19 outbreak. These findings implicated the government need pay more attention to mental health problems, especially depression and anxiety among general population and combating with “infodemic” while combating during public health emergency.
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