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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 85-89

Managing periodontics patients during the SARS-CoV-2 pandemic


Department of Periodontics, University of Sulaimani, Sulaymaniyah, Iraq

Date of Submission10-Jul-2020
Date of Decision18-Aug-2020
Date of Acceptance16-Sep-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dler A Khursheed
Department of Periodontics, University of Sulaimani, P.O. Box 0778-26, Sulaymaniyah 46001, Kurdistan Region.
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_236_20

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  Abstract 

Nonsurgical periodontal therapy is usually completed with scaling, polishing, and root planing. These are usually associated with aerosol and splatter formation which is composed of saliva, blood, bacteria, and viruses. Studies have shown aerosol-generating procedures can contaminate the dental clinic atmosphere and transmit serious infection. Contamination of saliva with SARS-CoV-2 is a great concern in dentistry, particularly for periodontal practice. COVID-19 is a highly contagious disease and can be easily contracted during aerosol-generating procedures. This will, undoubtedly, have future impacts for periodontal practice in ensuring safe and effective treatment. Careful review of current equipment and practice in controlling cross-contamination can facilitate preparation of proper guidelines for future practice.

Keywords: COVID-19, Infection Controls, Periodontal Practice, Periodontitis, SARS-CoV-2


How to cite this article:
Khursheed DA. Managing periodontics patients during the SARS-CoV-2 pandemic. J Int Oral Health 2020;12, Suppl S2:85-9

How to cite this URL:
Khursheed DA. Managing periodontics patients during the SARS-CoV-2 pandemic. J Int Oral Health [serial online] 2020 [cited 2021 Jan 24];12, Suppl S2:85-9. Available from: https://www.jioh.org/text.asp?2020/12/8/85/301866


  Introduction Top


Since the emergence of the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2003, concerns over viral infection spreading through aerosols have been expressed in dentistry.[1] Aerosols are liquid or solid particles in the air, responsible for transmission of microorganisms.[2] Coronavirus disease 2019 (COVID-19) is an acute infection of the respiratory tract that emerged in late 2019 in China and is caused by SARS-CoV-2.[3] It is a highly communicable disease, associated with human-to-human transmission, and spreads rapidly. Symptomatic, presymptomatic, and asymptomatic patients can spread the virus.[4] The WHO has stated that SARS-CoV-2 spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs, sneezes, and speaks, particularly in confined environments (https://www.who.int/health-topics/coronavirus#tab=tab_1). On the other side, physical distancing is particularly important to contain the virus’s spread and has shown promising results.[5] Results of a study have found that aerosol and fomite transmission of SARS-CoV-2 are possible, as the virus can stay airborne and infectious for multiple hours and on surfaces for days.[6] The primary mode of transmission of SARS-CoV-2 is through direct or indirect inoculation of the mucous membranes (eyes, nose, or mouth) with infectious respiratory droplets or fomites.[7]

Nonsurgical periodontal therapy (NSPT) is usually carried out through relatively long aerosol-generating procedures (AGPs); scaling/root planing and polishing to clean microbial deposits from the teeth. And subsequent AGP for the next patients will amplify microbial aerosol concentration in the air and on inanimate surfaces. During periodontal treatment, patients have their mouth open, subjecting them to inhalation of growing aerosols. The closeness between patients and dental healthcare workers (DHCWs) in the clinic space exposes both to the danger of infection. Therefore, periodontal treatment can be considered as dangerous work compared to other dental procedures regarding the aspect of bioaerosol generation.[8] Globally, healthcare workers are at risk of contracting coronavirus through their occupational exposure.[9] Now that COVID-19 is a pandemic disease and since there are as yet neither effective treatments nor vaccines, infection control measures remain the only way to prevent coronavirus from spreading among DHCWs and patients.

The aim of this review was to establish guidelines for periodontal practice in the post-COVID time, based on past and current evidenced-based periodontal infection control studies, to protect DHCWs and patients from the risk of infection.


  Prevalence and Severity of Periodontal Diseases and COVID-19 Top


The fact that periodontal disease is prevalent and affect about 20–50% of the world’s population makes it a public health concern.[10] Within this percentile range, severe periodontitis constitutes about 11.2% globally and is the sixth most prevalent disease.[11] As a result of its cumulative nature, periodontitis is more prevalent in older adults, with two-thirds (68%) of individuals aged 65 years and older being affected with periodontitis,[12] and further increase of periodontitis is expected in an aging population due to increased tooth retention globally. The literature has provided strong evidence for association of periodontitis with different systemic diseases.[13],[14] Periodontitis is considered as a major cause of adults’ tooth loss globally, consequently affecting their nutrition and quality of life, in addition to the huge socioeconomic impacts and healthcare costs.[11] More than 80% of adolescents and more than half of the adult population have overt gingivitis,[15] whereas periodontitis may affect less than 10% of young populations.[16] Nevertheless, while the severity and prevalence of periodontal disease are expected to decrease in populations younger than 50 years, an increase is anticipated in older age groups.[15]

About 80% of reported COVID-19 cases were mild and approximately 80% of deaths were recorded among adults aged 60 years and older. This finding implies that older age groups, particularly those with serious underlying health conditions, are at higher risk of becoming seriously ill and dying from COVID-19.[17] In contrast, children often have milder symptoms than adults and deaths have been extremely rare.[18] In light of the above knowledge, in the clinic, we may expect to get high risk older patients with symptomatic periodontal disease. Therefore, periodontal practice in the post-COVID-19 era should concentrate on two major strategies: prevention of non-communicable periodontal diseases and protection from highly communicable diseases.


  Evidence-Based Periodontal Practice Guidelines Top


Every transmissible disease in history has imposed further restrictions in terms of infection control measures in dentistry. The majority of these diseases were related to the respiratory system. With the advent of AIDS, infection control measures were strictly reinforced in dentistry. Studies have indicated how periodontal AGP could lead to communication of contagious respiratory pathogens in dental operatory settings. Although advances in technologies have led to the introduction of many safety tools to prevent disease transmission, it is still impossible to provide complete protection in the dental setting. Since the emergence of SARS-CoV, the Center for Disease Control and Prevention (CDC) and American Dental Association (ADA) have recommended the avoidance of any AGP in patients with active SARS. Moreover, patients with such a serious illness should not undergo any elective dental treatment.[1],[19] Recently, ADA has recommended carrying out only emergency dental treatment in the effort to limit the spread of the coronavirus.[20]

General dental precautions and guidelines can be obtained from different sources. However, special guidelines for periodontal practice have not yet been published. The following are evidence-based guidelines drawn up on the basis of past and current experimental and clinical studies for the recommencement of periodontal practice.

Diagnosis and prognosis of periodontal diseases

A major disadvantage of complete periodontal charting is the time requirement. Using a simpler and shorter periodontal index like the basic periodontal examination to evaluate periodontal conditions is necessary to minimize face-to-face contact duration. Noninvasive orthopantograms (OPG) and cone-beam computed tomography (CBCT) images are preferable to periapical radiographs. In future, there may be more focus on periodontal biomarkers to determine risks, prognosis, and diagnosis of periodontal diseases.[21],[22]

Virtual periodontal clinic servicing

Periodontal diseases are preventable and noncontagious. Online patient periodontal education, preliminary diagnosis, and oral hygiene instructions (OHIs) have the major advantage of saving time with patients in the clinic, while proper practice of oral hygiene will reduce clinical signs and symptoms of periodontal inflammation before visiting the periodontist. Teledentistry may come into service for teleconsultation, telediagnosis, teletriage, and telemonitoring as features of a virtual clinic.

Single-unit dental clinic versus multi-unit dental clinic

Bacterial aerosols and surface contamination are many folds higher in multi-chair clinics, particularly at university periodontal clinics. Additionally, contamination levels are higher during procedural hours than at the start and end of the work.[8] Generating a lot of bioaerosols simultaneously will predispose all students, DHCWs, and patients to greater infection inhalation. This model of multi-chair design should be revised and redesigned, particularly in regard to isolation and ventilation, to minimize cross-contamination.

Single visit/multiple visits for nonsurgical periodontal therapy

Different NSPT protocols used in treatment of periodontitis involve combined manipulation of hand and power-driven instruments. Multi-visits may require four sessions, with each taking about 1h, and all sessions needing to be completed within 1 or 2 subsequent weeks. A single extra short session protocol has been proposed which takes about 2h and includes recording of biometric periodontal parameters. Both protocols are equally effective but the latter has the advantage of time saving.[23]In addition to the cost and tiredness implications of multi-visits treatment, reducing the time is an important factor in minimizing periodontitis patients’ exposure to airborne particles.

Preprocedural rinse/gargle

Due to their close proximity to the oral cavity, secretions from nose, throat, and respiratory tract can contaminate saliva with various bacteria and viruses. Throat and salivary glands are potential reservoir sites of SARS-CoV-2 replication and transmission.[24]

Preprocedural antibacterial rinses have shown to be effective in minimizing bacterial contamination.[25] Although no antiviral rinse/gargle has yet been identified in the literature, the antiviral preprocedural rinse/gargle may in future become part of the routine periodontal treatment scheme. Patients should be asked to rinse and gargle to disinfect the whole mouth and throat. As saliva continuously replenishes the fluid in the mouth, it is preferable to use virucidal mouthwashes that have better substantivity. The virucidal activity of 0.5% of povidone-iodine (PVP-I) solution has been tested, and its use is now recommended by some institutes (https://www.mohfw.gov.in/pdf/DentalAdvisoryF.pdf). Compared to PVP-I, hydrogen peroxide solution at different concentrations showed minimal virucidal activity.[26] Preprocedural PVP-I nasal spray could also help in minimizing air contamination in dental clinics.

Hand versus power scaling

The big disadvantage of sonic and ultrasonic scaling is the huge aerosol and splatter formation, even if they are used without water supply, as the scaler tip hits the saliva and blood from the subgingival area. Power-driven scalers produce greater amounts of contamination at greater distances than hand scaling. While hand instrumentation is considerably associated with contaminated droplet formation, this can be effectively blocked by applying simple protective barriers.

Placement of a piece of gauze close to the area of instrumentation can help to reduce contamination of aerosols with saliva and blood. It can also be used instead of frequent water spraying to clean the working areas. High-volume evacuation (HVE) can reduce aerosols by >90% in local settings.[1] Attachment of a modified HVE to the handle of the power scaler has also been found to achieve significant aerosol interception.[19] The HVE Mirror Tip (Purevac®), dental suction mirror, and Isolite Systems® are useful, particularly for dental hygienists and dentists working without dental assistants. The modified extra-oral vacuum aspirator will also help in reducing air contamination.

Angle polishing versus air polishing

Fine particles can hold small-diameter microbes generated during polishing teeth by air polishers. These particles may be a potential source of respiratory infection.

Studies found that rubber cups produce fewer but large droplets that can be controlled by most barriers. In contrast, air polishers generate more aerosols that can reach up to 2 m from the working area and are associated with more bacterial colony-forming units. However, up to 94.8% reduction in bacterial contamination can be achieved when an HVE is used with air polishers. Using an attached aerosol reduction device with the air polisher is effective in lowering bioaerosol generation.[27] Angulation of the air polisher to the tooth surfaces, using an HVE close and parallel to air polisher, increasing the water > powder ratio, adjusting the patient’s position, and patient’s head angulation will minimize aerosol formation. Similar to the ultrasonic scaler, attachment of an HVE to the air polisher is extremely helpful for dentists working without assistants. It is also worth being very selective when polishing teeth; clean surfaces do not need to be polished. Practicing principles of positioning during NSPT will ensure the operator’s head is at a safe distance from the working area.

Periodontal surgery

Aerosol-generating devices such as ultrasonic scalers and different techniques including piezosurgery, rotary instruments, and meticulous irrigation are used during periodontal surgery.

Proper OHI and NSPT before performing periodontal surgery minimizes gingival inflammation, and thus increases visibility and reduces the need for frequent irrigation during the periodontal surgery. Frequent use of sterile gauze around the surgical area will also lessen the need for frequent irrigation. Using an HVE close to the surgical area is highly recommended.

Saliva ejector and water lines

Bacterial contamination from backflow from low-volume saliva ejectors has been reported.[28] This could be a potential source of cross-contamination between patients. Simultaneous use of a saliva ejector with HVE should be avoided and patients should be instructed not to close their lips around the saliva ejector tip. Additionally, the dental unit’s air compressor and waterlines should be monitored and maintained frequently according to the instruction manual.

Face and respiratory protection

This is a major concern in the dental operatory setting. Faces of dental DHCWs can become contaminated with bioaerosol particles generated during periodontal AGP. Most particles are concentrated around the patient’s mouth which is also close to the operators’ face.

Surgical masks are intended to protect patients from microorganism transmission from the wearers, while respirators protect the wearers from inhaling microscopic airborne particles. The respirator has the advantage of fitting better to the wearer’s face to prevent microbial leakage. The N95 respirators filter at least 95% of airborne particles with an aerodynamic diameter of 0.3 μm and above, which is very effective against influenza and coronavirus.[29] However, particles of <5 μm can penetrate a surgical mask. Face shields or vizors act as a barrier to prevent direct communication between aerosols and droplets and the whole face, especially eyes, nose, and mouth.[30] A well-sealed face shield avoids the need for frequent replacement of masks and respirators and frequent face washing, thus preventing aerosols inhalation between dental procedures.

Dental clinic management

Airborne pathogens contaminate the clinic’s atmosphere and inanimate surfaces. Longer working hours and more dental procedures are associated with more contamination.

Surface decontamination is an important approach to prevent cross-contamination among staff. A surface disinfection protocol entails using 1% sodium hypochlorite solution. Bioaerosols produced by ultrasonic devices can be reduced by ventilation. Using an indoor portable air cleaning system equipped with a high-efficiency particulate air (HEPA) filter and ultraviolet (UV) light has also been recommended (https://www.mohfw.gov.in/pdf/DentalAdvisoryF.pdf). Another proposal is to use two dental rooms or allow at least 30min for ventilation before receiving the next dental patient (https://health.mo.gov/living/families/oralhealth/pdf/aerosol-issues.pdf).

Installation of automatic soap and hygienic dispensers, paper holders, automatic doors, and opening outdoor windows would offer extra protection, as would using extra personal protective equipment (PPE) such as head caps, waterproof gowns, and overshoes.


  Conclusions Top


Although COVID-19 is a new and highly contagious disease, its transmission in dental settings has not yet been studied. Moreover, we are living in an era of eco-epidemiology, with global emergence and re-emergence of many communicable diseases.[31] Some principles of preventing virus transmission, such as maintaining physical distance, are impossible to accomplish in dental practices. Meanwhile, closeness, spatter and aerosol generation, confined spaces, lack of PPE, and unsuitable ventilation in the majority of dental clinics are additional risks for spreading viruses. Most of today’s guidelines on infection controls are based on general principles. Future laboratory and clinical studies will be necessary to minimize or eliminate microbial transmission during dental treatments.

Application of four handed dentistry with ergonomic clinic design to ease handling of HVE and saliva ejectors should be routinely performed in periodontal practice. Necessary PPE, surface decontamination, efficient ventilation and air purification, and sterilization should be meticulously employed to mitigate microbial transmission, bearing in mind that no single approach of infection control can prevent cross-transmission. Even with the use of HVE, ocular, oral, and other areas around the dental chair can become contaminated. Therefore, all equipment that is necessary for infection control should be utilized during periodontal treatments.

The most important priorities to focus on in the post-COVID era are public health education, incorporation of advanced technologies, and practicing of strict infection controls in the dental clinics and periodontal academic settings. Undoubtedly, all these will have implications for costs, number of patients to be treated, and patients’ attendance at the appointments.

Summary of the periodontal guidelines

  • Periodontal health education should be provided along with other forms of health education.


  • Virtual periodontal clinics should come into service to minimize the clinic interview duration.


  • Use of a simple, short, and less invasive periodontal examination.


  • Single-visit NSPT is preferable to multiple visits for treatment of periodontitis patients.


  • Preprocedural antiviral mouthwash/rinse should be routinely used before periodontal procedures.


  • Use of manual periodontal instrumentation and angle/cup polishing.


  • Frequent use of sterile gauze instead of irrigation.


  • Saliva ejectors and HVE should be used routinely.


  • N95 respirators and face shields and other necessary PPE should be worn throughout clinic work.


  • Good surface decontamination and air ventilation protocols should be established.


  • The dental unit waterlines should be maintained regularly.


  • Sufficient time should be provided for room decontamination between patients.


  • Multi-unit clinics should be redesigned to ensure the same degree of isolation and ventilation as in single-unit clinics.


  • Acknowledgment

    I would like to express my very great appreciation to the Journal of International Oral Health editors for their constant support in preparing this review article.

    Financial support and sponsorship

    Nil.

    Conflict of interest

    There are no conflicts of interest.

    Authors contributions

    Not applicable.

    Ethical policy and Institutional Review board statement

    Not applicable.

    Patient declaration of consent

    Not applicable.

    Data availability statement

    Not applicable.

     
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