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On March 11, 2020, the World Health Organization declared the international spread of SARSCoV- 2, herein referred to as COVID-19, a pandemic. As COVID-19 spreads through aerosols, the American Dental Association, herein referred to as ADA, recommended dental practices postpone elective treatment and remain open for emergencies only until April 30, 2020.1 In March, at the beginning of the pandemic, an ADA poll reported 76% of dental offices were treating emergency patients, 19% were closed completely, and 5% were open but treating fewer patients. Several months into the pandemic, the August poll data revealed that 49% of dental offices are operating as usual, 50% are open but seeing less patients, and 1% are completely closed.2 Dental offices were faced with new challenges during closures and reopening of their facilities. The most common challenges dental offices are facing, according to a recent ADA poll, are planning for the future, difficulty obtaining PPE, financial instability, staying up-todate on recommendations, and convincing their patients it is safe to receive dental treatment.2 These COVID-19 related challenges have required dental professionals to adapt and create innovative techniques to promote optimal oral maintenance care of patients both in and out of the dental office.
Link Between Oral and Overall Health
Since the publication of the Surgeon General’s 2000 report, the public has been well informed of the connection between oral and overall health.1 As the mouth is necessary in life sustaining activities such as eating and drinking, proper oral health directly correlates to quality of life. The most common oral disease risk factors include alcohol and tobacco usage, substance abuse, poor nutrition, stress, psychological issues, domestic violence, and poverty. Due to the COVID-19 pandemic, all oral disease risk factors have increased. Behaviors such as these can exacerbate development of chronic disease and decrease oral health status. Dental professionals can intervene through tobacco cessation and nutritional counseling to reduce patient risk factors.1
COVID-19 and oral disease development share similar high-risk population pools. Vulnerable populations include those with low socioeconomic status, older individuals, those living in rural areas, uninsured individuals, and minorities. The Centers for Disease Control and Prevention (CDC) states that “non-Hispanic blacks, Hispanics, and American Indians and Alaska Natives generally have the poorest oral health of any racial and ethnic groups in the United States”.1 Recent studies demonstrate that these minority groups have a higher incidence rate of COVID-19 contraction and death. Among COVID-19 related hospitalizations, cardiovascular disease and diabetes were the most common comorbidities. From a convenience sample of 10,647 COVID-19 related deaths, 60.9% had cardiovascular disease and 39.5% had diabetes.3 Periodontal disease correlates with both cardiovascular disease and diabetes, proving a possible link between COVID-19 complications and oral health.1
Many hospitalized COVID-19 patients require mechanical ventilation to survive which increases susceptibility to Ventilator Associated Pneumonia or VAP. VAP is the second most common infection acquired in the hospital and the most likely to cause death in patients with illnesses.4 Of patients who are mechanically ventilated for over 48 hours, roughly 10-20% will develop VAP.4 As VAP bacteria originates from the oral cavity, a strong correlation between oral hygiene and VAP prevalence exists. Data shows that each additional maintenance dental visit within three years decreases the likelihood of a patient developing VAP by 5%.4 Studies support the need for promoting and maintaining oral health to reduce the prevalence of VAP. Research proves that VAP prevention should consist of three stages: promotion of effective oral hygiene, increasing oral care for those at risk of VAP, and implementation of oral management protocols for patients on ventilators.4
COVID-19 is transmitted through micro-droplets and aerosols created from saliva, coughing, or sneezing. The distance and length of time particles remain airborne depend on size, humidity, and airflow. Droplets larger than 5 μm can travel up to 3 feet. Particles smaller than 5 μm create an aerosol which can travel greater than 3 feet.5 Transmission occurs from touching contaminated fomites, aerosol contact, and maintaining less than 6 feet proximity with an infected individual for greater than 15 minutes.5 As dental treatment increases COVID-19 exposure risks, dental professionals must strive towards safe dental treatment to ensure their patients’ comfort and health. To reduce COVID-19 exposure, dental professionals must meticulously screen all patients prior to dental treatment. Telephone screenings have proven most effective in preventing spread of COVID-19 within the dental office. Screening questions should include travel history, COVID-19 test history, and any symptoms experienced by the patient in the past 14 days. In the result of positive screening survey answers, patients should wait 14 days to reschedule non-emergent dental treatment. Upon entering the dental practice, patients must have their temperatures evaluated and should only receive treatment with temperatures below 100.4 degrees Fahrenheit.6 Literature recommends encouraging patients to wear masks at all times except during treatment. Recommendations also include lengthened and dispersed appointments to reduce the number of patients in the waiting room at once.6
COVID-19 can spread via indirect or direct contact with infected droplets through oral, nasal, or ocular mucous membranes. To prevent such spread through mucous membranes, proper personal protective equipment, or PPE, is essential during the COVID-19 pandemic. The recommended operational sequence for donning PPE is wearing disposable shoe covers, a respirator mask, headgear, eye protection, gloves, and a waterproof cover gown.6 Particulate filtering face-piece respirators, or FFPs, are categorized into filtering percentage classes: FFP1 filters 80%, FFP2 filters 94%, and FFP3 filters 99%.5 FFP2 and FFP3 masks are recommended when aerosol production is expected. If proper respirators are unavailable, a surgical mask and a face shield offer adequate protection. Surgical masks should not be solely utilized during aerosol production as they often fit poorly and allow for aerosol transmission. Masks should be removed and replaced after each aerosol producing procedure.5 At the end of patient treatment, dental professionals must dispose of all disposable PPE and wash their hands thoroughly with a hydroalcoholic solution. As COVID-19 can survive on inanimate objects, non-disposable PPE items such as face shields or goggles require sanitization with a 62-71% hydroalcoholic solution.6 Failure to adhere to PPE recommendations puts both dental professionals and their patients at risk for COVID-19 exposure.
Due to the high risk of COVID-19 transmission, dental professionals are urged to modify dental treatment to reduce risk of exposure. Dental professionals are advised to reduce aerosol production by limiting ultrasonic scaling and use of air-water syringes. When using equipment with high aerosol generation, high speed evacuation devices are recommended to reduce exposure. In addition, literature advises limiting intraoral radiograph exposure when possible. Studies prove that intraoral radiographs can trigger the gag reflex and spread COVID-19 pathogens via aerosols. Closure of treatment room doors during dental treatment can control aerosol dispersion to other operatories. In scenarios with limited continuous air flow, air filtration systems have proven effective against COVID-19 transmission.6
Due to dental office closures and deeming dental treatment unsafe, many patients have postponed routine dental visits. June ADA poll data revealed that dental practices usually treating 32 patients per day now treat less than 20 patients per day.2 The COVID-19 pandemic has forced dental professionals to find innovative ways to provide optimal patient care. To decrease unnecessary dental visits amidst the pandemic, dental professionals have shifted towards virtual dentistry when possible. “Teledentistry is the remote facilitating of dental care, guidance, education or treatment via the use of information technology rather than through direct face-to-face contact with any patient.”7 Teledentistry offers a vast range of functions to incorporate into routine dental visits. The most common form of teledentistry is teleconsultation in which patients can consult with dental professionals about their problems or concerns. Teleconsultation has reduced the number of referrals to specialists by over 45%.5 A July ADA poll revealed that 12.2% of dental practices were currently using teledentistry.2 In addition, patients can utilize virtual dental visits to access preventative services such as oral hygiene education or monitoring the progress of maintenance treatment.7 When choosing to postpone routine maintenance visits, patients can schedule virtual appointments with their dental hygienist to thoroughly discuss homecare routines and effective ways to reduce COVID-19 exposure within their home. It is essential that patients have a channel to communicate with their dental office during the pandemic.
Maintaining Oral Hygiene at Home
The COVID-19 pandemic has stressed the importance of proper oral hygiene against virus transmission. If an individual within a household is infected with COVID-19, it is crucial that the remaining household members are meticulous with their oral homecare. Household members must not share oral hygiene products such as toothpaste tubes, mouthwash bottles, and toothbrushes as they can harbor pathogens.8 In addition, each household individual should have their own toothbrush holder to avoid spread of germs amongst household members. If stored in a shared location, the oral hygiene item storing area requires daily cleaning. If a household member is ill, individuals are advised to replace all toothbrushes or sterilize current brushes before every use. Amidst the pandemic, it is crucial that all oral appliances must remain pathogen free before entering the oral cavity. Tablets and liquid used to sterilize baby items can sterilize toothbrush heads, occlusal guards, whitening trays, and retainers.8 Patients must prioritize their oral health during the COVID-19 pandemic. For best oral hygiene homecare, patients must follow the optimal oral hygiene routine: flossing, brushing, and rinsing with mouthwash. Dental offices are encouraged to focus on virus prevention by providing their patients with individual personal hygiene kits. These kits should include fluoride toothpaste, floss, a toothbrush, and fluoride mouthwash to ensure each household member has their own oral hygiene items.8 Common antimicrobial dentifrice ingredients such as xylitol, fluoride, and sodium benzoate have proven to reduce pathogenic anaerobic bacteria in the mouth. Research has proven that brands such as Colgate, Crest, Sensodyne, and Aquafresh are effective against pathogenic oral bacteria.9 With clean and effective oral hygiene materials, patients can decrease the likelihood of COVID-19 transmission. Mouthwash has proven a successful tool in COVID-19 patient risk management. Studies show that COVID-19 is weak to mouthwashes containing oxidizing agents such as 1% hydrogen peroxide.6 Science innovators have considered the efficacy of carbamide peroxide in preventing COVID-19 transmission. Dentistry utilizes 10% carbamide peroxide as an adjunctive periodontal therapy and for caries prevention. The oxidizing power of carbamide peroxide improves risk management by reducing inflammation and inactivating viral and bacterial pathogens.10 Although the etiology of COVID-19 is viral, research proves that oral bacterial load contributes to complications such as pneumonia, sepsis, and death. As poor oral hygiene is a risk factor for COVID-19 complications, 10% carbamide peroxide could prove useful in limiting COVID-19 prevalence and the associated complications.10
The COVID-19 pandemic has significantly impacted dentistry and created a wide array of challenges for dental professionals. New challenges include difficulty staying up-to-date with regulations and ensuring patients that dental treatment is safe to schedule.2 The COVID-19 pandemic posed an opportunity for dental professionals to focus on prevention rather than surgical interventions.1 As risk management experts, dental professionals have created innovative techniques to promote patient oral health both in and out of the dental office setting. Teledentistry utilization allows patients to consult with their dental professionals from the comfort of their own home. This open channel of communication allows for oral hygiene education opportunities and improves patient-provider relationships. Amidst the COVID-19 pandemic, dental professionals must optimize patient oral hygiene through education topics such as oral homecare kits and their efficacy in preventing COVID-19 transmission.8 As new studies are conducted, COVID-19 related regulations and recommendations are constantly changing. Although several studies exist, there is limited data regarding oral hygiene and the direct link to COVID-19. Further research and analysis are needed to find the specific relationships between oral hygiene and COVID-19.
About the Author
Breanna Connell, RDH, works at a private practice in Easton, Pennsylvania.
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