Implications for oral healthcare providers
Healthcare workers such as physicians, nurses, respiratory therapists,
dentists, oral healthcare specialists, speech pathologists,
ophthalmologists, and otolaryngologists are at an elevated risk of
exposure to COVID-19. Oral healthcare providers (OHCP) are at a high
risk in particular for nosocomial transmission of respiratory infectious
diseases owing to their proximity to the nasopharynx and oral cavity of
patients. The general consensus in dental medicine is that the greatest
threat of airborne infection is from aerosols (particles smaller than
50µm in diameter) due to their ability to stay suspended in the air and
contaminate the mucous membranes of the mouth and respiratory
passages.28,29 Fine aerosols of usually 0.5 to 10 µm
in diameter have an even higher potential for transmitting infections.
The practice of dental treatment involves the use of surgical and dental
equipment, such as aerosol-generating ultrasonic scalers, air-water
syringes and handpieces. These instruments create a visible spray of
water droplets, salivary spatter, debris, blood and microorganisms, and
have the potential to spread nosocomial infections such as tuberculosis
and SARS in the exam rooms.28-30
Currently there are no data available to assess the risk of transmission
of SARS-CoV-2 in the office settings of dental and specialty practices;
however, the Occupational Safety and Health Administration (OSHA) has
categorized oral healthcare providers under the “very high exposure
risk” category for SARS-CoV-2.31 OSHA has also
recommended the use of powered air-purifying respirators (PAPRs) or
supplied air respirators (SARs) for procedures involving aerosol
generation. The Centers for Disease Control and Prevention (CDC) has
laid out interim infection control guidance for dental
settings,14 which includes postponement of all
elective procedures, surgeries, and non-urgent visits. These guidelines
advise the use of highest level of PPE available, such as a gown,
gloves, eye protective gear (goggles or face shields that cover the
front and sides of the face), and N95 or higher-level respirator during
emergency procedures.
The CDC and the American Dental Association (ADA) have recommended that
all dentists and oral specialists keep their offices closed and postpone
all elective procedures except for urgent and emergency care
particularly those in hospital-based practices, although new guidelines
are expected for non-urgent care.32 They have put
forth interim guidelines for triaging patients for emergency procedures.
The ADA has highlighted special considerations for clinical procedures,
such as the use of extraoral radiographs, including panoramic
radiographs and cone beam CT over intraoral radiographs, minimizing the
use of aerosol-generating instruments and prioritizing the use of hand
instruments, using rubber dams and high-volume saliva evacuators, and
placing resorbable sutures to eliminate the need for follow-up
appointments.32 Likewise, the American Association of
Oral and Maxillofacial Surgeons (AAOMS) has recommended that non-aerosol
generating procedures and emergent treatments such as antibiotic therapy
should be handled in a manner that is as minimally invasive as possible,
with the use of adequate PPE.33 Previous studies have
investigated the virucidal efficacy of pre-procedural mouthrinse such as
0.23% povidone iodine and 1% hydrogen peroxide, and found them to be
highly effective against viruses, including
SARS-CoV.34,35 Currently there are no clinical studies
supporting the use of such agents against SARS-CoV-2. However due to its
vulnerability to oxidation, topical mouthrinse containing oxidative
agents such as povidone iodine may be effective in reducing the salivary
viral load of SARS-CoV-2.30
Special considerations are needed for oral and maxillofacial specialists
working in an oncology practice. Initial screening of patients should be
conducted via telemedicine consults, and short-term deferment should be
considered. Patients who report a recent travel history to any of the
designated COVID-19 hotspots, and the presence of any symptoms of
respiratory illness should be instructed to self-quarantine for 14 days
and report to their physician for COVID-19 testing. Cancer patients are
considered as highly vulnerable to COVID-19 due to their
immunocompromised status. The MD Anderson head and neck surgery
consortium has devised guidelines for triaging patients based on
site-specific head and neck cancers.36 All elective
oral surgical procedures should be deferred, however procedures such as
planned dental extractions, surgery for patients with early and
intermediate malignant disease, and fabrication of oral stents for
radiation therapy are to continue. The management of these patients
requires a needs assessment on a case-by-case basis with patient’s
primary oncologist, and the interdisciplinary team; and more in depth
considerations are beyond the scope and purpose of this report.
Due to the disruption of all major supply chains and increasing global
demands, there is a critical shortage of PPE for healthcare personnel.
Such an unprecedented situation demands for innovative ideas to address
these concerns. Many academic institutions, researchers and private
organizations have come up with creative solutions such as open-source
designs for 3D-printed respirators and face
shields.37,38 Customized face shields allow for a more
secure fit of the headband, and longer shields are suitable for
protection from splatter during dental and surgical procedures. COVID-19
is now a widespread and constant presence in our community. As we adapt
to this rapidly evolving situation and make adjustments based on new
information, revised guidelines from the regulatory authorities will be
critical in ensuring the safe reopening of oral healthcare operations.
Development and implementation of a rapid COVID-19 diagnostic test at
the point-of-care will be vital in safeguarding the health of both
patients and OHCP, and minimizing the burden of disease in our
community. The American Medical Association (AMA) as of May 1, 2020
stated “as public health experts determine that it is safe to see
patients and stay-at-home restrictions are relaxed, physician practices
should strategically plan when and how best to reopen.” In parallel,
the Centers for Medicare and Medicaid Services (CMS) published a Phase 1
guide for reopening facilities to provide non-emergent, non-COVID care.
The AMA and CMS guidance include pre-visit screening template and
checklists of criteria for reopening private and hospital-based
practices.39,40