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2021, Number 2

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Rev Odont Mex 2021; 25 (2)

Clinical practice guidelines for the control of SARS-CoV-2 infection in the dental office (a review in America)

Navarro, Eduardo Alejandro1; Gómez Clavel, José Francisco1; Gaitán Cepeda, Luis Alberto2

Language: English/Spanish [Versión en español]
References: 53
Page: 166-183
PDF size: 382.18 Kb.


ABSTRACT

The objective of this study was to review and describe the health guidelines and policies in response to the pandemic caused by the SARS-CoV-2 outbreak that caused COVID-19 in different countries of the American continent, to determine what measures should be implemented in dental practice during and after the pandemic, to minimize the risk of infection within the dental clinic or office. This includes universal measures such as social distancing, hand washing, use of PPE (personal protective equipment), reduction of aerosols in dental procedures, ventilation, disinfection, use of mouthwashes, etc. The information obtained from the health guidelines and policies of eight countries (United States of America, Mexico, Costa Rica, Colombia, Peru, Brazil, Argentina, and Chile) was compiled from the different national health authorities, as well as dental associations and federations. From each of the countries. Changes made to dental practice guidelines depend on the severity of the COVID-19 pandemic in each country. Dentistry is one of the professions that has received the greatest impact due to the COVID-19 pandemic, so dentists have had to adapt to the new regulations, as well as the changes imposed to return to a dental practice as normally possible.



INTRODUCTION

In December 2019, a COVID-19 emergency began in Wuhan City, China when what were then unexplained cases of pneumonia, caused by a highly infectious pathogen later named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), were reported. On March 11, 2020, the World Health Organization (WHO) declared a COVID-19 pandemic. So far it has affected about 3% of the world's population with an estimated total of 266'504,411 cumulative cases up to December 8, 2021, and a total of 5'268,849 deaths.

The Americas is the continent with the highest number of cases with a total of approximately 95'120,017 cases.1 The United States tops the list with the highest number of cases, followed by Brazil and Mexico.

The pandemic has significantly impacted and disrupted socio-economic activities in virtually all parts of the world. Resolving this economic crisis has been the priority of the governments of each of the countries over the past two years.

Transmission of SARS-CoV-2 can occur directly or indirectly. Through direct contact, droplets, airborne particles, fomites, and probably fecal-oral transmission. SARS-CoV-2 infection primarily causes respiratory illness that can range from mild to severe and even cause death, although some people remain asymptomatic.2 It has been suggested that anyone can be infected; however, people at increased risk are older adults, immunocompromised, people with obesity, hypertension, heart disease, and diabetes.3

Among the most common symptoms of COVID-19 are runny nose, anosmia, nasal congestion, dysgeusia, hypogeusia, diarrhea, nausea-vomiting, shortness of breath, conjunctivitis, fatigue, and abdominal pain.4

Saliva plays an important role in the transmission of COVID-19. At least three routes by which SARS-CoV-2 may be present in the saliva of the infected patient have been suggested: 1) presence of the virus in the upper and lower respiratory tract, with a continuous bidirectional transfer of secretions; 2) in the crevicular fluid; and 3) by infection of the salivary glands and consequent release of viral particles into the saliva.5

Since the SARS-CoV-2 outbreak, dentistry has been listed as one of the most affected professions. However, it has gone a step ahead in the management of COVID-19 thanks to the implementation of rigorous measures for universal use.6 At the beginning of the pandemic, there was a severe impact on this branch of healthcare where almost all countries involved were forced to limit dental care to emergency care only.7

The dental activities most affected during the pandemic with a significant reduction in their practices were clinical practices dedicated to prevention (-80%), periodontics (-76%), and prosthodontics (-70%).8

To provide safe dental care during the pandemic and post-pandemic, in addition to developing biosafety standards necessary to reduce the risk of infection in the dental office, specific guidelines were created for the management and control of COVID-19.9,10

At present, most countries have allowed the reopening of dental offices, restoring most of the services they provide. In this "new normal", protective measures have already been put in place to minimize COVID-19 transmission during clinical dental procedures.11 With the end of the pandemic, COVID-19 will become an endemic disease and socioeconomic activities will begin to resume a normal course, in which the various measures and policies already in place will continue to be involved.

The COVID-19 pandemic has been a wake-up call for the entire world. Humanity's inadequate preparedness to face this terrible disease was evident at the beginning of this pandemic, coupled with dysfunctional and inefficient vaccination programs, mainly in developing regions.12 So far, about 10 billion doses of vaccines have been administered worldwide with some countries approaching 70% of their total population vaccinated, as is the example of Israel or the United Kingdom. As countries move forward with their vaccination programs, governments may make changes in their surveillance methods to prevent a resurgence of SARS-CoV-2, as well as new variants that may further delay the end of the pandemic.13 As has occurred with the appearance of the omicron variant, which has initiated a new global outbreak.14

In this study, we reviewed the dental practice guidelines during the COVID-19 pandemic in each of the selected countries to determine the recommendations that have been implemented and will be implemented once the pandemic ends intending to reduce exposure to SARS-CoV-2 and the risk of infection in the dental clinic. Clinical practice guidelines (CPG) from the countries involved in this study were used for this purpose. The updated status of COVID-19 infection in each of the selected countries has been recorded in Table 1.

United States of America

The United States of America, one of the five largest countries in the world, despite being one of the countries with the highest technological, scientific, medical, economic, and political development, is the country with the highest number of cases registered by COVID-19 and with the highest number of deaths. Dentists in the United States were forced to close dental offices until May 2020, when they began to reopen. This had a marked impact on the dental industry and practice as costs and wait times for patients increased. Thus, the COVID-19 recession may continue to impact the use of dental services and the oral health of individuals.15

Due to the rapid evolution of COVID-19 information and evidence, dental and public health organizations have periodically reviewed and updated information relevant to dental care. To reduce the spread of COVID-19, the CDC (Centers for Disease Control and Prevention) recommended that dental services delay or reschedule outpatient services, and only allow urgent care appointments following recommendations for medical services.

The CDC regulated within its general guidelines for health services the following recommendations in general: use of full PPE (personal protective equipment); 4-handed work; high-speed suction; avoidance of aerosol-generating procedures if possible; constant disinfection and sterilization of equipment and instruments; efficient heating, ventilation, and air conditioning (HVAC) ventilation systems.16

In the United States, within the different health care professions, dentists are the professionals with the lowest infection rate concerning other health care services, which determined that the information and recommendations of the different organizations are sufficient to prevent infection during dental procedures.17 Currently, the best protection for dentists and their patients remains awareness and avoidance of contact with anyone suspected of having COVID-19, as well as continued proper use of personal protective equipment and attention to hygiene measures, especially ventilation or filtration of operatory air.17

Studies have shown that the use of mouthwashes or mouth rinses before dental procedures can reduce the SARS-CoV-2 viral load (Table 1).18

Mexico

The first case detected in Mexico occurred on February 27, 2020, at the Institute of Respiratory Diseases in Mexico City, and the first death was reported on March 18 of the same year.19 Mexico ranks 12th in the number of confirmed cases globally.1 Since the first case was confirmed in Mexico, several efforts have been made to contain the rate of transmission of the disease, which led the government at the time to take strict measures for the population, including widespread confinement and the closure of non-essential businesses.20 During the first months of the pandemic, the Secretary of Health in Mexico created the "recommendations for dental practice" which, as of the date of writing this article, have not undergone significant changes.21 These include the following measures: hygiene and handwashing; preoperative mouthwash; use of PPE; use of containers (RPBI) for the disposal of potentially infectious materials; sterilization of instruments; and avoiding the use of rotary equipment and triple syringes as much as possible. Also included was the use of N95 mouth covers when treating patients with symptoms of respiratory disease in the last 14 days, as well as the use of shoe covers that have not been shown to have any efficacy as part of PPE according to CEBM (Center for Evidence-Based Medicine) and the use of disposable surgical gowns.20

Costa Rica

Costa Rica is a country located in Central America with a small territorial extension and a population of more than 5 million inhabitants. The COVID-19 pandemic has left a total of 564,159 confirmed cases, which means that just over 10% of the population of this country was infected by the SARS-CoV-21 virus. The first suspected case was reported on March 5, 2020, with a 52-year-old woman who arrived on a trip from Tunisia and Italy.22 On August 12, 2020, the Costa Rican Ministry of Health in conjunction with the College of Dental Surgeons promulgated the guidelines for the prevention and containment of COVID-19 for dentists and auxiliaries based on the guidelines proposed by the CDC and the ADA. The guidelines emphasize only attending emergency or urgent appointments, triage of patients for suspected cases, the use of elective PPE depending on the type of dental procedure (aerosol-generating or non-aerosol generating), use of a rubber dam, sterilized instruments between each patient, cleaning with disinfectant solutions paying attention to the spittoon, suction filters, and dental chair, as well as the use of mouthwashes for one minute before the dental procedure such as hydrogen peroxide or povidone.23

Colombia

Since the adoption of confinement measures in Colombia, dental care has decreased drastically, postponing appointments for esthetic treatments such as smile design, orthodontic treatment, whitening or implants, and only prioritizing emergency appointments such as bleeding, acute pain, tooth avulsion, or odontogenic abscesses.24

The approximately 60,000 dentists in that country suffered negative effects in the first months of the pandemic during the quarantine. The Colombian Dental Federation estimated losses of around 700 million pesos at the beginning of the pandemic.24 Around 300,000 people depend on the dental activity in Colombia, including professionals, assistants, technicians, support personnel, and the dental industry, so the Colombian Dental Federation created a coalition to lessen the damage caused by the pandemic to dentistry in this country.

It was estimated in a study of 5,370 dentists that less than 1% of dentists in the country tested positive for COVID-19, probably because the professionals adhered to the biosafety protocols provided by both the Colombian Ministry of Health and the Colombian Dental Federation. Within the same study, the follow-up of procedures such as triage by telephone, verification of health status before consultation, temperature taking, disinfection of surfaces, hand washing, preoperative mouthwashes were highlighted. The importance of the use of PPE was also emphasized, adding the use of face masks, N95, FFP2, or FFP3 respirators, and disposable gloves.25-27

Peru

Peru, like other Latin American countries, was severely affected by the pandemic. As of December 2020, it was the fifth nation with the highest rate of COVID-19 deaths in the world.28 The first confirmed case in Peru occurred on March 6, 2020, so the Ministry of Health (MINSA) of that country, at the beginning of the pandemic, ordered that people diagnosed with COVID-19 be referred to and concentrated in five hospitals in Lima.29 In Peru, only 12% of dentists are state employees (General Directorate of Health Personnel), which means that the remaining 88% are independent. Thus, because of the health emergency, the confinement measures, and the strict rules of only attending emergency dental appointments, the Peruvian dental industry suffered a major crisis during the first months of the pandemic.30

In April 2020, the Peruvian Dental Association in conjunction with the Ministry of Health (MINSA) published the "Biosafety Protocol for the Dental Surgeon During and Post Pandemic COVID-19". This protocol includes guidelines to ensure the health of staff and patients by reducing the risk of cross-infection. Among the most important measures, as in most countries, the following stand out: Telephone triage, telemedicine, waiting room, and office disinfection, use of preoperative mouthwashes, use of disposable plastic shields, adequate office ventilation, sterilization, and use of complete PPE. For procedures where aerosols are generated, they used reinforced PPE with the use of a surgical apron (gown) and N95 or FFP2 mask.31

Brazil

Worldwide, Brazil is the country with the third-highest number of accumulated cases and the second-highest number of deaths only after the United States.1 The situation in this country could be the result of the decision not to take restrictive measures to contain the rapid transmission of SARS-CoV-2, arguing economic reasons.32

Faced with the pandemic and the rapid increase of cases in Brazil, dentists were forced to interrupt dental services, in adittion to the shortage of PPE (personal protective equipment), attending only emergency appointments. When dental care was resumed, the Health System together with several universities decided to avoid the use of aerosol-generating rotating equipment by implementing a minimally invasive technique called atraumatic restorative treatment (ART). ART is based on the removal of caries only with hand instruments and the placement of glass ionomer cement to avoid or reduce the risk of cross-infection in dental offices when using rotating equipment.33 On June 24, 2020, the Ministry of Health published a resolution where ART is included in the list of the Unified Health System (SUS).34

The Conselho Federal de Odontologia (CFO) in conjunction with the Conselho Regional de Odontologia (CRO) released the E-Book "COVID-19 and Dentistry: Measures to increase the safety of patients and professionals" in which they include measures such as monitoring of personnel, distancing in waiting rooms from 1.5 to 2 meters, and emergency care only for the following cases: alveolitis, pericoronaritis, pulpitis, biopsies for suspected malignancy, dental fractures, abscesses, and removal of necrotic tissue.

In addition to proper handwashing, use of complete PPE (personal protective equipment), cleaning and disinfection of surfaces, avoidance of rotary and ultrasound equipment for prophylaxis.35

Argentina

The first case reported in Argentina was diagnosed in Buenos Aires on March 3, 2020. On March 20 of the same year, the suspension of activities and the establishment of isolation to mitigate the spread of the coronavirus36 began.

As the quarantine was prolonged, many activities were established for remote work or total closure in some cases in which dental care was involved.

Due to the high risk of infection during the treatment of oral diseases, during the isolation imposed by health authorities, dental care was limited to emergency care. At the School of Dentistry of the University of Buenos Aires (FOUBA), consultations were provided to low-income people.37

On April 23, 2020, the Government of the Province of Buenos Aires published the "Protocol for the care of oral and dental emergencies and emergencies" and on June 10, 2020, the Ministry of Health of Argentina published "COVID-19 Recommendations in Dentistry". Both protocols share the same criteria and as of the date of this writing have not been updated. It is worth highlighting important points in these protocols such as the classification of urgent and emergency procedures. Among the emergencies are hemorrhages; cellulitis or bacterial infection, and trauma involving facial bones. Within emergencies are severe dental pain, pericoronitis, postoperative surgical osteitis, abscess, dental fractures, extensive caries, definitive cementations, prosthetic or orthodontic appliance adjustments, suture removal, TMJ luxation, and peri-implantitis.

The PPE level was divided into two, according to the risk of producing aerosols and droplets (PGA):

  • • Level I: disposable or disposable gown, three-layer mask, face mask and/or goggles, latex gloves.
  • • Level II: water-repellent gown, N95 mask, face mask and/or goggles, latex gloves.

Each patient must undergo temperature control and triage to minimize risks. The protocols include constant hand washing, cleaning, and disinfection of surfaces with 70% alcohol-based solutions and the use of preoperative mouthwashes.38,39

Chile

Chile had its first confirmed case on March 3, 2020, and since then the regions most affected by the pandemic have been Santiago, Araucanía, Antofagasta, and Magallanes. As in most countries, confinement was ordered by the health authorities.40

In July 2020, the Faculty of Dentistry of the University of Chile published the "Recommendations for dental care in the face of the COVID-19/SARS-CoV-2 pandemic" based on the norms dictated by the Ministry of Health (MINSAL). Within these guidelines, general measures are drafted from patient triage, use of PPE (PPE for aerosol-generating procedures and PPE for non-aerosol-generating procedures) including the use of a disposable cap, disposable surgical gown, use of mask (mouthpiece) or N95 or FFP2, eye protection and use of latex or nitrile gloves, the only difference being the type of mask (mouthpiece) to be used depending on the type of dental procedure to be performed. In addition, the use of a rubber dam, high-power suction, use of a turbine or handpiece with a non-return system, a disposable physical barrier for ejectors, and the use of the four-handed technique at all times is also recommended.41,42

By September 10, 2021, the Chilean College of Dental Surgeons published an updated clinical practice guideline to minimize the risk of SARS-CoV-2 transmission during bioaerosol-generating dental care. The important measures to be highlighted within this update were the consideration of the use of N95 or KN95 over the mask in addition to ventilating the working room or office for at least 15 minutes after each procedure, the use of HEPA filters (high efficiency particulate air) is not recommended and the recommendation to keep dental chairs with a minimum distance of 2 meters (Table 2).43



DISCUSSION

The SARS-CoV-2 pandemic has generated several changes and significantly affected society in different areas and aspects, from the economy, education, health care system, tourism, etc. Therefore, each country has had to implement different measures to contain and reduce the risk of SARS-CoV-2 infection in its population. Dentistry is one of the health branches most affected by the COVID-19 pandemic because it is a practice of proximity between the dentist and the patient, where most of the time there is a constant generation of aerosols (PGA) and fluids that significantly increase the risk of contracting an infection.

Despite the differences and complications of the countries included in this analysis (Table 2), each of them has established standards and guidelines according to their regulations, which agree on the following:

The spread of aerosols should be minimized with good ventilation in this area. We know that the route of transmission of COVID-19 is through saliva droplets and direct contact with contaminated surfaces, so that the stomatology health professional has greater exposure, due to the use of rotating equipment for dental treatment, which generates aerosols with saliva and blood that are dispersed in the environment, in addition to the proximity with which the dentist works with the patient (less than 50 centimeters).44

Social distancing

Concern about coronavirus transmission in the dental clinic has been widely recognized throughout the world. Depending on the nature of dental procedures and the proximity between dentist and patient. The virus can spread from infected patients to dental staff, and vice versa, and subsequently to other patients, if established control measures are not taken.45,46 Proper social distancing is impossible in the dental clinic due to the proximity < 0.5 meters between patient and dentist. However, in common areas such as waiting areas, it should be practiced correctly thus maintaining at all times a minimum of 1.5 meters up to 2 meters between each person.

Patient triage

An important measure to identify new or possible COVID-19 cases in the clinic or dental office is the use of patient triage, as well as categorizing the patient and managing their care. The application of triage looks for signs and/or symptoms that may indicate risk of SARS-CoV-2 infection such as the onset of fever (temperature of 37.8oC or higher); loss of smell (anosmia) and loss of taste (ageusia), considered cardinal symptoms of the disease; cough, shortness of breath (dyspnea), or increased respiratory rate; headache, myalgia, difficulty in swallowing (odynophagia), vomiting, diarrhea, nasal congestion, etc.

In addition to a questionnaire indicating: Possibility of contact with a suspect or positive case during the 14 days before the onset of signs and symptoms; If travel in countries reporting local transmission of COVID-19 during the last 14 days. If the triage result categorizes the patient as a suspect case, dental care should be postponed at all times unless it is highly urgent and only, in this case, using all the PPE measures advised for dental care.41

Use of mouth rinses

Of the guidelines reviewed, Brazil does not make specific recommendations. The use of mouthwashes has been widely used only as a standard measure before dental treatment, especially preoperatively, but they play an essential role in reducing or decreasing the number of microorganisms in the oral cavity. Although there is still no clinical evidence that the use of mouth rinses can prevent the transmission of SARS-CoV-2, the American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC) have recommended the use of mouth rinses before procedures.16 Various studies recommend the use of different types of mouth rinses or mouthwashes to reduce the number of bacteria and/or viral load. There are three antiseptic options that demonstrate an oxidative content that favorably decreases the viral load in saliva without causing damage to the oral mucosa, these are 1% diluted hydrogen peroxide and 0.2% povidone or 0.05-0.1% cetylpyridinium chloride.

According to available studies, the mouthwash of choice is hydrogen peroxide since COVID-19 is vulnerable to oxidation. To obtain 15 mL of rinse at 1% concentration, 5 mL of 10 volumes of hydrogen peroxide is used with 10 mL of distilled water.47

Ventilation

Another critical point in the work of dentists is about the ventilation requirements that the dental operatory space should have. The current recommendation is that it should be well ventilated or have an air conditioning system with HEPA filters or air purifiers with HEPA filters.2,7 However, the guidelines from Mexico, Costa Rica, and Chile do not address or issue any recommendation, although it is established that sufficient ventilation of oral health offices reduces the risk of transmission in enclosed spaces.

Since there is no evidence that SARS-CoV-2 contaminates heating, ventilation, and air conditioning (HVAC) systems in buildings potentially exposed to this disease, CDC does not guide decontamination of these systems. However, there are recommendations regarding proper maintenance of ventilation systems. We know that many dental clinics and/or dental offices do not have a ventilation system, in these cases it is recommended that airflow is always kept active as much as possible by keeping windows and doors open to maintain constant ventilation.48

Systems should provide airflow from clean to less clean. Filtration efficiency should be increased to the highest level, especially through air conditioning equipment. Dental offices should have adequate ventilation to remove stale air from the room and replace it with fresh air. Ventilation systems can effectively help control the transmission of infectious diseases in enclosed spaces.49 When admitting a patient not suspected of being infected with COVID-19, standard ventilation should provide a rate of ≥ 1.5 air changes per hour, both during and after the visit. When a patient is suspected of being infected with COVID-19, mechanical ventilation should provide a constant air change of 6 times per hour, both during and after dental treatment. The use of air purifiers with HEPA 14 or higher filters, where the filtration efficiency is ≥ 99.995%, is highly recommended.50

Poorly maintained ventilation and air conditioning systems can be a potential source of fungi and other microbial organisms. Air conditioning systems could, therefore, act as a vehicle for the transmission of microorganisms in the dental clinic. Some aerosols containing viral particles remain in the dental office after a working day and after the air conditioning system is turned off, so air conditioning systems should be cleaned and disinfected periodically, especially during the COVID-19 pandemic. A good method for disinfecting air conditioners is fogging. It is also imperative to establish a routine of opening windows and exchanging air between patients and after the working day in the dental clinic.51

Disinfection of instruments and equipment

The application of cleaning and disinfection measures for dental offices and/or clinics should follow a strict and mandatory protocol since it is a fundamental measure to reduce the risk of contagion, as well as the level of pathogenic microorganisms in the work areas. Between each patient, a cleaning and disinfection cycle should be performed in the workspaces and all surfaces that have been touched. It should be ensured that major or continuous contact surfaces, such as handles, chairs, telephones, counters, etc., are cleaned regularly with detergent to reduce the number of microorganisms before disinfection.

Many disinfectants are effective against COVID-19. WHO recommends: 70% ethyl alcohol for disinfecting small surfaces, and 0.1% (1,000 ppm) sodium hypochlorite for disinfecting surfaces and 0.5% (5,000 ppm) for disinfection where blood or body fluid spills have occurred within the work area or room; and chlorine solutions should be prepared daily if this is not possible they should be monitored to ensure correct concentration of the solution.7

All instruments used on patients should be washed and sterilized according to the manufacturer's standards or subjected to a high level of disinfection.52

Personnel performing cleaning and disinfection tasks should wear appropriate PPE. Discard respirators, surgical masks, gowns, and gloves after each patient. Reusable eye protection and face shields should be cleaned and disinfected before reuse.

Healthcare waste should be managed according to best practices, policies, and routine procedures and should be collected safely in clearly marked and labeled lined containers for infectious waste.48

Personnel protective equipment

In most of the countries included in this study, reference is made to the type of PPE that should be used when treating any potential COVID-19 patient.

However, maximum protection with PPE should be recommended without distinction between patients, as well as between procedures that generate aerosols and procedures that do not generate aerosols. The WHO recommends the use of respirators or masks (N95, FFP2, FFP3, or equivalent), especially for those procedures that generate aerosols, as well as eye protection and face shield and body protection.7 These measures are recommended in each of the guidelines of the nine selected countries without distinction, to avoid or reduce any type of infection and/or contagion.



CONCLUSIONS

In conclusion, despite the differences in the severity of the COVID-19 pandemic in the selected countries, the measures imposed by the health authorities and dental associations for the dental practice are similar and since the SARS-CoV-2 outbreak began, the guidelines and/or recommendations for dentists have not undergone significant changes because the measures have been effective and dentists have adhered to all the norms to mitigate the risk of infection in the clinic and dental offices. Among the most important measures that should continue to be applied and implemented in the long term post-pandemic, we conclude the use of PPE with emphasis on the correct use of N95 respirators, constant hand washing, disinfection and sterilization of dental equipment and instruments, use of patient triage to detect possible COVID-19 positives and the use of mouthwashes to reduce the viral load in the saliva of patients and above all ventilation of workspaces.


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AFFILIATIONS

1 Laboratorio de Investigación en Educación y Odontología. Facultad de Estudios Superiores Iztacala. Universidad Nacional Autónoma de México. México.

2 Departamento de Patología y Medicina Bucal y Maxilofacial, División de Estudios de Postgrado e Investigación, Facultad de Odontología. Universidad Nacional Autónoma de México. México.



CORRESPONDENCE

José Francisco Gómez Clavel. E-mail: gomclave@unam.mx




Received: Febrero 2022. Accepted: Marzo 2022.

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