Summary
The following is a short summary of the available evidence on the infection prevention and control guidance for dental procedures that potentially involve aerosol transmission of SARS-CoV-2. Three systematic reviews, one rapid review, five guidance documents, one literature review and one single study were found to answer this question and were used in this REAL Summary. For additional information about each of the sources, see the Table below.
The authors of two reviews, and guidance from the Royal College of Dental Surgeons of Ontario agree that contamination from spatter and aerosolization from potentially infectious dental patients remains a significant hazard for dental personnel, as aerosols containing SARS-CoV-2 can travel more than six feet (approx. 2 meters) and remain infectious in the air for 3-4 hours [1,2,6]. One State of Washington study (November 2020) found that based on 26,799 laboratory-confirmed cases as of June 16, 2020, the 15 occupations with the overall highest predicted risk of a COVID-19 infection were all healthcare professions, with four of the top five in the dental health field [9]. The COVID-19 Transmission in Dental Practice: Brief Review of Preventive Measures in Italy (April 2020) found that the distribution of contaminated aerosols and spatter during dental procedures may vary by: 1) the type of procedure and whether high-volume evacuation as used; 2) the position of the operator relative to the patient; 3) the position of the patient in the dental chair; and 4) the levels of microorganisms in the patient’s mouth [3].
The following recommendations are outlined for dental settings by the Centers for Disease Control and Prevention (CDC) in its Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response (December 2020), and in the updated guidance by the Royal College of Dental Surgeons of Ontario, COVID-19: Managing Infection Risks During In-Person Dental Care (January 2021): 1) use an N95 respirator (fit-tested and seal-checked), gloves, eye protection and/or a face shield and a protective gown when performing aerosol generating procedures; 2) avoid aerosol-generating procedures whenever possible; 3) avoid the use of dental handpieces and the air/water syringe; and 4) avoid the use of ultrasonic scalers is also not recommended [5,6]. If aerosol-generating procedures are necessary, it is recommended by the CDC (December 2020) and by Public Health Ontario (November 2020) to use: 1) four-handed dentistry (when a dentist and dental assistant work on a procedure together); 2) high evacuation suction; and 3) a dental dam to minimize droplet spatter and aerosols [1,4,5]. In the Public Health Ontario Guidance (July, 2020), it states that certain dental procedures are associated with significant aerosol generation including ultrasonic and sonic scalers, high-speed dental handpieces, air polishers and air-water syringes [8]. Therefore, a waiting period of 15-30 minutes between patients would allow for aerosols that may pose a risk of COVID-19 infection to settle [8]. The Dental Risks and Precautions during COVID-19 Pandemic: A Systematic Review (August 2020) state that a preprocedural mouth rinse is effective in reducing the proportion of microorganisms in oral aerosols and that high velocity evacuation (HVE) and high efficiency particulate air (HEPA) filters should be considered in filtering and removing contaminated air in treatment areas [1]. This systematic review also recommends that surfaces should be cleaned with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite or ultraviolet treatment after each patient visit [1].
The College of Dental Hygienists of Ontario (September 2020) and Office of the Chief Dental Officer of Canada (November 2020) guidance recommends that dental hygienists in the client treatment room should use N-95 masks, isolation gowns, gloves and eye protection (goggles or face shield), especially when aerosol-generating procedures cannot be avoided [10,11]. Implementation of a system to allow more time between patients (fallow time) between clients should be considered to reduce the risk of aerosol transmission [10,11].
In addition to patient procedures, the CDC recommends in the above report? that high-touch surfaces (e.g., doorknobs, plexiglass barriers, handrails, counters and arms of chairs) in the dental offices should be disinfected at least twice a day and that procedure rooms should be cleaned and disinfected between each patient [4]. A review (August 2020) advises that since SARS-CoV-2 is susceptible to oxidative agents, pre-treatment mouth washes containing 0.1% hydrogen peroxide, or 0.2% povidone might reduce viral salivary load [7]. In contrast, in the Public Health Ontario’s review (November 2020), it states that hydrogen peroxide should no longer be recommended due to its lack of efficacy against SARS-CoV-2 [4]. The CDC recommends that dentists should: 1) post visual alerts (e.g., signs, posters) within the office space to direct patients; 2) provide supplies for respiratory hygiene and instruction for cough etiquette (such as signage to cover your cough and wash hands); and 3) install physical barriers wherever possible to eliminate the spread of aerosol transmission [5]. Patients that request/require dental care should be screened prior to a dental examination such that a procedure can be deferred if COVID-19 is suspected [6]. Lastly, physical distancing is advised by limiting the number of visitors in the facility (e.g., video-call consults, minimizing overlapping appointments, and having patients wait in a personal vehicle or outside prior to their appointment) [5].
Evidence
What‘s Trending on Social Media and Media
Some Winnipeggers are questioning if they should keep their dental appointments out of fear that they contract COVID-19. The Manitoba Dental Association advises against postponing appointments, emphasizing they have additional safety measures in place to ensure everyone’s safety. The association said if you’re not feeling well on the day of your appointment, you should reschedule for another day. Access the full Global News article here (January 2021).
Organizational Scan
In a webpage titled “COVID-19: What to Expect at the Dental Office” (January 2021), the Ontario Dental Association lists for patients the precautions that will be taken by dental staff and offices to prevent the spread of COVID-19. They also answer a series of frequently asked questions regarding the safety of dental visits, how to deal with a dental emergency and how to know if you are infected with COVID-19.
The Ontario Dental Association guidance, updated on January 14, 2021, lists all precautions to be taken by dentists and staff in dental offices to ensure that their patients and staff are protected. Some precautions include spacing out appointments, consulting with patients both prior to their appointments and upon arrival regarding COVID-19 symptoms, the use of appropriate PPE by staff (i.e., masks, face shields and gowns), requesting patients to wash their hands with 70-90% alcohol-based solution and paying with touchless payment. The website also includes a patient protocol for dental emergencies, medical prescriptions and self-assessment of COVID-19 [12].
Review of Evidence
| Resource | Type/Source of Evidence | Last Updated |
|---|---|---|
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Dental Risks and Precautions during COVID-19 Pandemic: A Systematic Review — Turkistani and Turkistani |
Systematic Review |
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Protection and disinfection policies against SARS-CoV-2 (COVID-19) — Fathizadeh et al. |
Systematic Review |
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COVID-19 Transmission in Dental Practice: Brief Review of Prevention Measures in Italy — Izzetti et al. |
Rapid Review |
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Open operatory dental setting infection control practices and risk of transmission during aerosol-generating dental procedures — Public Health Ontario |
Rapid Review |
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Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response — CDC: Centers for Disease Control and Prevention |
National Guidance |
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COVID-19: Managing Infection Risks During In-Person Dental Care — Royal College of Dental Surgeons of Ontario |
Professional Organization |
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COVID-19 Pandemic: Dental Considerations and Review of Literature — Patil et al. |
Literature Review |
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COVID-19 in Dental Care Settings — Public Health Ontario |
Provincial Guidance |
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Estimation of differential occupational risk of COVID-19 by comparing risk factors with case data by occupational group — Michael Zhang |
Single Study |
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Guidance on Returning to Dental Hygiene Practice — College of Dental Hygienists of Ontario |
Provincial Guidance |
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Evidence to support safe return to clinical practice by oral health professionals in Canada during the COVID-19 pandemic: A report prepared for the Office of the Chief Dental Officer of Canada — Office of the Chief Dental Officer of Canada |
National Guidance |
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COVID-19: What to Expect When Your Dentist’s Office Reopens — Ontario Dental Association |
Organizational Scan | Last Updated: January 13, 2021 |
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COVID-19: Managing Infection Risk During In-Person Dental Care — Royal College of Dental Surgeons of Ontario |
Organizational Scan | Last Updated: January 13, 2021 |
| Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source. | ||