What Dentists, Their Staff, and Patients Need to Know About a Dental Visit in the Age of Coronavirus

For years, protocols mandated by state and federal laws have been instituted in dental practices, protecting everyone from patients to staff and doctors. In 1991 the Occupational Safety and Health Administration (OSHA) instituted the Bloodborne Pathogens standard,¹ a guideline designed to protect workers from the risk of exposure to HIV and the hepatitis B virus. Over the past nearly 30 years since its inception, this standard has been amended numerous times to include more worker protections, including needlestick preventions, upgrades to personal protective equipment (PPE), and sterilization/disinfection of equipment, instruments, and surfaces. Dentists have strictly adhered to these regulations since their initiation, which was not too difficult to do since they'd already been following most of the guidelines before they were published, such as sterilizing equipment and instruments and wearing gloves and masks.

Though it certainly has heightened awareness, the coronavirus (COVID-19) outbreak² should not necessarily change dentists' vigilance in following these protocols in their offices. What this devastating epidemic has done is forced dentists to reassess how they currently provide dental care. The OSHA guidelines will continue to be embraced while dentists will need to make some modifications to meet the challenges of a global pandemic. Below is a synopsis of the current situation and where dental professionals need to diverge from past practices, along with the rationale for implementing these changes to dental delivery. As always, these practices must be based on prevailing scientific information, wherever and whenever it is available.

In light of the current coronavirus outbreak, people have been asked to stay home, especially if they have any symptoms related to the virus. They've been given instructions on how to stay healthy both at home and when out in public.^3,4 A great deal of scientific information on the disease and its related symptoms is available to both professionals and patients. To assist patients, this material is being shared widely by federal, state, and local governments along with agencies such as the Centers for Disease Control and Prevention (CDC). For everyone's safety and well-being, patients are being asked to not go to the dental office if they have fever, cough, or other respiratory or flu-like symptoms.

Dentists have always asked patients if they have had any changes in their recent health history and how they are feeling. Now when patients present to the office, they will also be asked if they have been traveling abroad. Dentists will be even more thorough in their medical assessments of their patients. For example, the dental staff may now request to take patients' temperature. This perhaps should become routine year round, much like taking blood pressures.

Potential interpatient interactions should be decreased through scheduling, and social distancing should be encouraged in the reception area. This means that dentists need to be highly cognizant of the time scheduled for procedures to avoid waiting times. While dental offices rightfully try to create an environment that is comforting, the distancing practice is necessary for the safety and health of everyone. For the time being, reading materials should be removed from the reception area, and common spaces that patients contact, such as the reception desk, door knobs, and furniture, should be wiped down with CDC-approved antiviral materials on a regular and frequent schedule.⁵ These spaces, like dental office operatories, should be treated with appropriate chemicals and cleansers according to federal guidelines for the safety and security of everyone. These practices will decrease potential interpatient spread of droplets and fomites, the major methods of transmission of the virus. While these practices should be habitual, especially during any flu season, the coronavirus may be considered a wake-up call to rigorously adhering to them and even implementing additional safety practices. Realize, too, that according to CDC estimates, 12,000 people have died in the United States from the flu alone this past winter.

Coronavirus is susceptible to soap and water. Many dental practices have instituted the simple process of asking patients to wash their hands when they enter the operatory if not the office itself. Just as the dentist and hygienist wash their hands prior to donning gloves to decrease potential bacterial and viral loads, it would be prudent to request the same of patients. In addition to hand washing, the availability and use of hand sanitizer is important to avoid the spread of seasonal illness.

Other procedures that dental offices have long followed with regard to sterilizing equipment and instruments will kill this virus like other viruses and bacteria. The same PPE should be worn as in the past; however, let's recall some of the lessons of the H1N1 scourge. This may be a time to reassess the level of filtration that protective masks being used provide. Going forward, dental offices need to consider whether the use of a N95-level mask should be the standard of care at all times. The use of face protection with shields, head coverings, and gowns to protect clinicians' clothing is now being practiced in the short term, but this may need to be considered as routine in the long run to limit cross-contamination from aerosols.⁶

When sitting in the operatory, patients may be asked to use an antiseptic rinse prior to dental treatment.^7,8 This will decrease the amount of live viruses and bacteria that can spread potential infectious agents to other patients and members of the dental team. Additionally, whatever procedures are being performed will benefit from surgery or carious excavation occurring in an area with fewer possible pathogens. Discussions are ongoing among colleagues about what to use as a pre-procedural rinse. Much empiricism is being used based on intuition without any sound science. Dentists need to embrace what is in the literature concerning what may best reduce intraoral bacteria and viruses.⁷ While this approach may not be the optimal solution, until better evidence is available, it is a sound starting point.

How should elective procedures with devices that create aerosolization be handled in this age of coronavirus? Elective procedures requiring a high-speed handpiece might best be delayed on patients who are at high risk for having the virus until a later date when they can be medically cleared. Performing these procedures risks a higher potential for droplet spread of the virus if the patient is carrying it.⁹ Should the situation be an emergency, the dentist will have to weigh the cost/benefit to the patient, staff, and him or her self when determining how to proceed. Any healthcare professional must always follow the credo, "First, do no harm."

Patients may question whether to come in for a routine cleaning and/or periodontal maintenance during this time of uncertainty or, for that matter, any time period when viral transmission may put their health at risk. They wonder if they should delay their cleaning until the period of increased danger passes. In the current environment (as of late March, at the time of this writing), delay may be the best course taken. Conversely, based on controlled studies in the periodontal literature, for specific groups such as diabetic patients, periodontal therapy can reduce systemic inflammation.¹⁰ The CDC website on coronavirus information reinforces the advice of dentists and hygienists for a patient to maintain the hygiene routine that has been specifically tailored to his or her needs. The CDC website specifically states that older adults and people with serious chronic medical conditions like heart and lung diseases and diabetes are at higher risk for coronavirus.¹¹

Various articles have appeared in the periodontal and other dental literature discussing the effects of periodontal treatment on reduction of systemic inflammation.^12,13 The dental team must be familiar with much of the relevant scientific literature, as it is imperative that risks and benefits be discussed with the patients, just as any treatment planned and provided would be.

With a foundation based on past and emerging scientific evidence, and providing the proper protections and training for patients, staff, and themselves, dentists can weather this storm together and proceed with their practice. Dental clinicians, including hygienists, are health professionals who are on the front lines of this battle, having extended, up-close contact with patients. To some, dentistry is filled with too great a risk. It has been identified as being front and center to the potential spread of this disease.¹⁴ As awful as the current environment may seem, dentistry's challenge is no different than the risks faced in the past with the flu, H1N1, AIDS, SARS, and so on.

While information on this epidemic is changing seemingly hourly, dental professionals need to stay current in an effort to overcome this dreaded problem and apply pertinent historic and emerging scientific information as it becomes available in order to deliver ideal therapy in a safe environment. Bear in mind that the numbers of reported cases of coronavirus in the United States, as high as they may be, could be a gross underestimate of the actual number of infected people, according to a recent study.¹⁵ The dental profession has worked hard to gain the trust of the general public. We must reward this trust, and continue to earn it, by protecting those on both sides of the chair.

Robert A. Horowitz, DDS
Adjunct Clinical Assistant Professor, Oral Surgery, Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York; Private Practice, Scarsdale, New York

Paul S. Rosen, DMD, MS
Clinical Professor of Periodontics, University of Maryland Dental School, Baltimore, Maryland; Adjunct Professor, James Cook University, Cairns, Australia; Private Practices, Yardley, Pennsylvania, and New York, New York

1. Goldsmith MF. OSHA bloodborne pathogens standard aims to limit occupational transmission. JAMA. 1992;267(21):2853-2854.

2. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470-473.

3. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). How to Protect Yourself. CDC website. Updated March 18, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Accessed March 23, 2020.

4. Fulton P, Messonnier NE. Transcript for the CDC telebriefing update on COVID-19: press briefing transcript: Wednesday, March 10, 2020. https://www.cdc.gov/media/releases/2020/t0309-covid-19-update.html. Accessed March 23, 2020.

5. Carling PC, Huang SS. Improving healthcare environmental cleaning and disinfection: current and evolving issues. Infect Control Hosp Epidemiol. 2013;34(5):507-513.

6. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135(4):429-437.

7. Dennison DK, Meredith GM, Shillitoe EJ, Caffesse RG. The antiviral spectrum of Listerine antiseptic. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(4):442-448.

8. Syed A. Coronavirus: a mini-review. Int J Curr Res Med Sci. 2020;6(1):8-10. https://salud.edomex.gob.mx/hraez/documentos/ensenanza_inv/covid/general/Coronavirus_A_Mini-Review.pdf. Accessed March 23, 2020.

9. Travaglini EA, Larato DC, Martin A. Dissemination of organism-bearing droplets by high-speed dental drills. J Prosthet Dent. 1966;16(1):132-139.

10. Chen L, Luo G, Xuan D, et al. Effects of non-surgical periodontal treatment on clinical response, serum inflammatory parameters, and metabolic control in patients with type 2 diabetes: a randomized study. J Periodontol. 2012;83(4):435-443.

11. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Are You at Higher Risk for Severe Illness? CDC website. Updated March 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhigh-risk%2Fhigh-risk-complications.html. Accessed March 23, 2020.

12. Correa FO, Gonçalves D, Figueredo CM, et al. Effect of periodontal treatment on metabolic control, systemic inflammation and cytokines in patients with type 2 diabetes. J Clin Periodontol. 2010;37(1):53-58.

13. Piconi S, Trabattoni D, Luraghi C, et al. Treatment of periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid intima-media thickness. FASEB J. 2009;23(4):1196-1204.

14. Gamilo L. The workers who face the greatest coronavirus risk. The New York Times. March 15, 2020.

15. Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020. doi: 10.1126/science.abb3221.