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