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COVID-19 pandemic: multilevel dental technical guidelines based on new scientific evidence

ABSTRACT

The COVID-19 pandemic imposed restrictive measures on dentistry in different regions of the world, ranging from stoppage of care to only permission for urgent and emergency dental services. Thus, new biosafety guidelines for resuming activities, whether in single dental offices, large clinics or dental education activities, are urgently required. In this sense, herein, guidelines that incorporate common points of the main protocols found in the literature for the resumption of dental activities at their different levels, whether in the scope of care or education, are presented. Furthermore, we present the incorporation of measures that allow an increase in the level of biosafety, such as the control of the dental team, the inclusion in the history of conjunctivitis as a possible alert for COVID-19, and the use of the pulse oximeter to assess the risk of silent hypoxemia, which may indicate a complication of COVID-19. In addition, new perspectives for directing research and innovation for biosafety in dentistry are discussed.

Keywords:
Coronavirus infections; COVID-19; SARS-CoV-2; Pandemics; Betacoronavirus; Guideline; Dentistry; Dental care; Containment of biohazards; Telescreening, medical; Personal protective equipment

INTRODUCTION

Undoubtedly, March 11, 2020 will be remembered for generations to come, when the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) as a pandemic.(11 World Health Organization (WHO). WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Geneva: WHO; 2020 [cited 2020 Aug 8]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/director-general/spe...
) In this context, governments around the world imposed strict measures to contain the spread of the outbreak, such as total lockdown.(22 Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J, Bania J, et al. The positive impact of lockdown in Wuhan on containing the COVID-19 outbreak in China. J Travel Med. 2020;27(3):taaa037.) Thus, there were countries or regions that completely closed dental offices, except for urgent and emergency care.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.) Thereupon, due to the need to reopen dental services, guidelines were established by regulatory agencies, class entities or suggested in the scientific literature, considering specific nuances of dental care and its risks in the context generated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).(55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.1010 Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): implications for clinical dental care. J Endod. 2020; 46(5):584-95. Review.) However, these protocols for urgent and emergency care or the resumption of activities in dentistry should only be considered as a quick response and not as a broad and definitive solution.(44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
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) Thus, such protocols must be constantly improved in order to not only provide solutions for a single viral type, but also to make the profession predictably safe.

Herein, we present the principal converging regulations for resuming dental care, discussing the main impacts of these protocols, outlining perspectives for future research related to these biosafety measures imposed by COVID-19.

IMPACTS OF COVID-19 ON DENTISTRY: A COMPREHENSIVE PERSPECTIVE

When proposing measures that impact or interrupt dental services, the healthcare regulatory agencies or class entities, need to consider oral health as an integral part of general health, with major impacts on the well-being and quality of life of the population. In this sense, dental caries and periodontal diseases have a progressive character, being among the most prevalent diseases with high potential for morbidity related to pain, infection and loss of function, which can lead to loss of teeth with its adverse psychosocial impacts.(77 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19#
https://www.ada.org/en/press-room/news-r...
,1212 World Health Organization (WHO). Oral health. Geneva: WHO; 2020 [cited 2020 Aug 15]. Available from: https://www.who.int/health-topics/oral-health/#tab=tab_1
https://www.who.int/health-topics/oral-h...
,1313 Peres MA, Macpherson LM, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet. 2019;394(10194):249-60. Erratum in: Lancet. 2019;394(10203):1010. Review.) In contrast, oral cancer has high morbidity and mortality rates, affecting 500,550 people with 177,384 deaths, in 2018, and its prognosis is severely affected by the delay in diagnosis.(1212 World Health Organization (WHO). Oral health. Geneva: WHO; 2020 [cited 2020 Aug 15]. Available from: https://www.who.int/health-topics/oral-health/#tab=tab_1
https://www.who.int/health-topics/oral-h...
1414 Andrade SA, Pratavieira S, Ribeiro MM, Bagnato VS, de Pilla Varotti F. Oral cancer from the perspective of wide-field optical fluorescence: diagnosis, tumor evolution and post-treatment follow up. Photodiagnosis Photodyn Ther. 2017;19:239-42.) Hence, it must be considered that measures that propose the suspension of dentistry activities contribute to a greater probability that oral diseases will evolve, causing events with a greater risk of emergency or urgency, resulting in higher complexity and treatment costs.(77 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19#
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) Furthermore, the diagnosis of oral cancer depends on physical examination, which, is impossible to be performed by teletriage and teledentistry.(66 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE
https://www.cdc.gov/coronavirus/2019-nco...
,99 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.) Therefore, the early diagnosis of oral cancer must be highly prioritised to prevent the disease from progressing causing serious and irreversible damage to the patient.(1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
https://bda.org/advice/Coronavirus/Docum...
,1414 Andrade SA, Pratavieira S, Ribeiro MM, Bagnato VS, de Pilla Varotti F. Oral cancer from the perspective of wide-field optical fluorescence: diagnosis, tumor evolution and post-treatment follow up. Photodiagnosis Photodyn Ther. 2017;19:239-42.1616 Downer MC, Moles DR, Palmer S, Speight PM. A systematic review of test performance in screening for oral cancer and precancer. Oral Oncol. 2004;40(3):264-73.)

It is noteworthy that dental workers are among the highest risk groups regarding the exposure to SARS-CoV-2, both for acting in close contact with the patient's upper airways, and the possibility of contamination by aerosol and droplets generated during procedures, contaminated specimens or fomites.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,66 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE
https://www.cdc.gov/coronavirus/2019-nco...
,88 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html
https://www.osha.gov/SLTC/covid-19/denti...
,99 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
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,1717 Coulthard P. Dentistry and coronavirus (COVID-19) - moral decision-making. Br Dent J. 2020;228(7):503-5.1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.) In this context, guidelines from the Centers for Disease Control and Prevention (CDC), American Dental Association (ADA), National Health Service (NHS) and Occupational Safety and Health Administration (OSHA), have become the main references guiding practice of dental care during the pandemic.(66 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE
https://www.cdc.gov/coronavirus/2019-nco...
,77 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19#
https://www.ada.org/en/press-room/news-r...
,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
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)

Thus, guidelines for resuming appointments or maintaining urgent and emergency dental services have been categorized into: engineering control measures, patient management, face-to-face care protocols and instructions for continuing dental education.(1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.) However, it should be emphasised that it is up to the local health authorities to define and adjust the scope of the measures to be followed to resume dental services based on the epidemiological and socio-economic complexity of each region.(1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
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)

PERSPECTIVES AND PRELIMINARY GUIDELINES REGARDING SAFEGUARD OF DENTAL STAFF AND ENGINEERING CONTROL

Table 1 summarises the main recommendations before face-to-face care in both the official guidelines and in scientific literature about COVID-19.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,66 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE
https://www.cdc.gov/coronavirus/2019-nco...
99 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
https://bda.org/advice/Coronavirus/Docum...
,1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)

Table 1
Recommendations prior to face-to-face appointment

In the context of the proposed measures in table 1, dental workers carry a major and indispensable responsibility to safeguard themselves, individuals and the community. Dental workers are highly susceptible to occupational diseases and, especially the elderly and/or those with comorbidities, should be placed among high-risk groups to develop serious complications or die due to COVID-19.(44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,2020 Gold MS, Sehayek D, Gabrielli S, Zhang X, McCusker C, Ben-Shoshan M. COVID-19 and comorbidities: a systematic review and meta-analysis. Postgrad Med. 2020;132(8):749-55.2424 Li X, Xu S, Yu M, Wang K, Tao Y, Zhou Y, et al. Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan. J Allergy Clin Immunol. 2020;146(1):110-8.) Thus, public policies are urgently needed to sufficiently address the need of high risk professionals, who may need to take a break from their jobs to avoid possible serious illnesses as a result of COVID -19 pandemic.

Furthermore, COVID-19 pandemic provided the opportunity for individuals to think and innovate to improve biosafety in dentistry, including architectural aspects, patient flow, ventilation and aerosol minimisation, either by controlling its dispersion or using new dental techniques that would not allow the production of the aerosol.

PERSPECTIVES AND GUIDELINES FOR A FACE-TO-FACE DENTAL CARE FLOW

Table 2 shows the steps and the main characteristics related to the new flow required for resuming dental services during COVID-19.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.99 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
https://bda.org/advice/Coronavirus/Docum...
,1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.,2525 Loffredo L, Pacella F, Pacella E, Tiscione G, Oliva A, Violi F. Conjunctivitis and COVID-19: a meta-analysis. J Med Virol. 2020;92(9):1413-14.3232 Scalinci SZ, Trovato Battagliola E. Conjunctivitis can be the only presenting sign and symptom of COVID-19. IDCases. 2020;20:e00774.)

Table 2
Steps and the main characteristics related to the new flow required for resuming dental services during COVID-19

In the context of teletriage, it is necessary to take the history to cover the need for dental intervention against the risk of COVID-19 infection, mainly with regards to the general health status of the patient. Therefore, social distancing must be strictly applied with special preparations for the high-risk patient groups, such as the elderly and those suffering chronic diseases, who might suffer serious life-threatening condition, on top of COVID-19 infection. Since hypoxemia can be silent in some patients, measuring oxygen saturation, which is part of the first protocol, is an important screening tool for conditions that may potentially predispose to severe complications when combined with COVID-19 infection.(2727 Tobin MJ, Laghi F, Jubran A. Why COVID-19 silent hypoxemia is baffling to physicians. Am J Respir Crit Care Med. 2020;202(3):356-60.,2828 Teo J. Early detection of silent hypoxia in Covid-19 pneumonia using smartphone pulse oximetry. J Med Syst. 2020;44(8):134.) Likewise, we have included conjunctivitis as an important symptom because it may represent the only clinical sign of COVID-19. In addition, due to the dentist working close to the eye region, the need to use goggles and face shield is evident.(2525 Loffredo L, Pacella F, Pacella E, Tiscione G, Oliva A, Violi F. Conjunctivitis and COVID-19: a meta-analysis. J Med Virol. 2020;92(9):1413-14.,3131 Hu K, Patel J, Swiston C, Patel BC. Ophthalmic Manifestations Of Coronavirus (COVID-19). 2022 Jan 8. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.,3232 Scalinci SZ, Trovato Battagliola E. Conjunctivitis can be the only presenting sign and symptom of COVID-19. IDCases. 2020;20:e00774.)

In relation to the personal protective equipment (PPE), despite the scarcity of resources, robust scientific evidence regarding the reuse of PPE in a safe way is currently unavailable. Therefore, the current recommendation is to change these after each patient.(3333 Rubio-Romero JC, Pardo-Ferreira MD, Torrecilla-García JA, Calero-Castro S. Disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the COVID-19 pandemic. Saf Sci. 2020;129:104830.) The recently developed health and safety guidelines in the dental field seem to be directed only towards the prevention of a single viral type, ignoring the provision of protective measures against biological hazards other than COVID-19. Importantly, the presence of viable SARS-CoV-2 in aerosol and on copper has been reported for 3 hours, on wood and fabrics for at least 24 hours, on glass for 48 hours, on stainless steel and plastic for 96 hours, and on external surface of a surgical mask for up to 7 days.(3434 Chin AW, Chu JT, Perera MR, Hui KP, Yen HL, Chan MC, et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe. 2020;1(1):e10.,3535 van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564-7.) Thus, in the dental environment we have wood (cabinets), stainless steel, copper (electrical components), non-woven fabric for PPE, fabrics (clothing), plastic and glass, where SARS-CoV-2 has different stability.(1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.,3434 Chin AW, Chu JT, Perera MR, Hui KP, Yen HL, Chan MC, et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe. 2020;1(1):e10.) Therefore, the strict disinfection and sterilisation of these materials require different disinfection or sterilisation techniques to ensure the proper maintenance of these valuable resources and preventing their damage.(1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.) Furthermore, a new design of dental equipment is necessary to minimise the exposure of different materials to contact with biological samples, mainly from aerosol and droplets, unifying the standards of protection, disinfection and sterilisation.

COVID-19 exposed the inadequacy and defects in the regulations upon which dental biosafety was based.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,2626 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.) The indication of the use of respirators in the guidelines is only superficially justified based on the scarcity of PPE. Thus, if the indication of a given respirator is based on the viral size, we must consider that hepatitis B virus (HBV) with 40nm is much smaller than SARS-CoV-2, measuring 60nm to 140nm, and accordingly, will be more needy of face masks to prevent its transmission than SARS-CoV-2. Otherwise, if the need to use a respirator is based on the risk of the aerosol-mediated viral transmission, it should be noted that, based on the recently accepted hypothesis, the prions can be transmitted by aerosols, which are much smaller than a virus.(3636 Stitz L, Aguzzi A. Aerosols: an underestimated vehicle for transmission of prion diseases? Prion. 2011;5(3):138-41. Review.,3737 Haybaeck J, Heikenwalder M, Klevenz B, Schwarz P, Margalith I, Bridel C, et al. Aerosols transmit prions to immunocompetent and immunodeficient mice. PLoS Pathog. 2011;7(1):e1001257. Erratum in: PLoS Pathog. 2016;12(2):e1005463.) Moreover, the literature describes the possibility of transmission of COVID-19 infection by asymptomatic carriers, which, without testing, implies that everyone must be treated as a COVID-19 patient.(55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,1818 Working group publishes rapid review for re-opening dental services. Br Dent J. 2020;228(10):743.,3838 Liang TJ. Hepatitis B: the virus and disease. Hepatology. 2009;49(5 Suppl):S13-21.,3939 Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W; China novel coronavirus investigating and research team. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-33.) Perhaps the optimal solution to a shortage of PPE supplies is to expand production by industries and not reuse. Therefore, non-reusable face masks with the highest level of protection are urgently needed to combat other pathogenic threats besides SARS-CoV-2, especially that there are no solid scientific basis for processes or conducts that guarantee a wide decontamination regarding all pathogen types.(3333 Rubio-Romero JC, Pardo-Ferreira MD, Torrecilla-García JA, Calero-Castro S. Disposable masks: disinfection and sterilization for reuse, and non-certified manufacturing, in the face of shortages during the COVID-19 pandemic. Saf Sci. 2020;129:104830.,3636 Stitz L, Aguzzi A. Aerosols: an underestimated vehicle for transmission of prion diseases? Prion. 2011;5(3):138-41. Review.,3737 Haybaeck J, Heikenwalder M, Klevenz B, Schwarz P, Margalith I, Bridel C, et al. Aerosols transmit prions to immunocompetent and immunodeficient mice. PLoS Pathog. 2011;7(1):e1001257. Erratum in: PLoS Pathog. 2016;12(2):e1005463.,4040 Ryou C. Prions and prion diseases: fundamentals and mechanistic details. J Microbiol Biotechnol. 2007;17(7):1059-70. Review.) Similarly, there is a need to develop reliable rapid tests that allow for massive testing, and can be used by the dentists, knowing that the current reverse transcription polymerase chain reaction (RT-PCR) COVID-19 test is not feasible for immediate results and subsequent management actions.(44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,55 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,4141 Tang YW, Schmitz JE, Persing DH, Stratton CW. Laboratory diagnosis of COVID-19: current issues and challenges. J Clin Microbiol. 2020;58(6):e00512-20.)

MULTILEVEL PERSPECTIVES AND GUIDELINES FOR DENTISTRY EDUCATION

Table 3 indicates the main guidelines for continued education in dentistry.(33 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,1111 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf
https://bda.org/advice/Coronavirus/Docum...
,2626 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.,4242 Porpiglia F, Checcucci E, Autorino R, Amparore D, Cooperberg MR, Ficarra V, et al. Traditional and virtual congress meetings during the COVID-19 pandemic and the post-COVID-19 era: Is it time to change the paradigm? Eur Urol. 2020;78(3):301-3.)

Table 3
The main guidelines for continued education in dentistry

Dental education was also massively affected by the COVID-19. In this scenario, the resumption of lecturer/student interaction in a virtual environment is extremely important. Furthermore, resumption of laboratory activities requires basic measures of biosafety/risk assessment, and social distance. However, restart of essential clinical activities for training depends on the behaviour of the pandemic in each region, and must be carefully weighed and planned for in order to guarantee the safety of all involved, be them employees, dental staff and patients. All measures essential to the proper and safe functioning of dental services must be readjusted and strictly applied to the current clinical practices environment. Thus, in the context of continued education, there should be a reduction in courses and face-to-face sessions due to measures of social distancing, which, should be partially replaced by webinars and online courses. Nevertheless, mechanisms for validating the information presented in these webinars must be defined, since many have dubious quality and are based on anecdotal evidence.(44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.)

Notoriously, the COVID-19 pandemic has an ambiguous character for dentistry. An example of a negative impact of the COVID-19 pandemic in dentistry is upon determination of suspension or reduction of services and, the increase in the level and number of required biosafety artefacts, with consequent scarcity and increased costs of PPE. This will negatively impact the economic feasibility of the profession.(44 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,1717 Coulthard P. Dentistry and coronavirus (COVID-19) - moral decision-making. Br Dent J. 2020;228(7):503-5.,1919 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.,4343 McMahon DE, Peters GA, Ivers LC, Freeman EE. Global resource shortages during COVID-19: bad news for low-income countries. PLoS Negl Trop Dis. 2020;14(7):e0008412.) On the other side, positively, the pandemic exposed the fragility of the currently prevailing biosafety rules, which will gradually require the generation of new knowledge and adjustment. In addition, the need for rapid testing of the population, can open new opportunities for dentistry, due to the ease of collecting salivary samples. Therefore, there are various questions related to the anti-infection measures, which needs to be addressed through robust scientific research. This includes the need for answers regarding the feasibility of PPE reuse, decontaminating or sterilising while maintaining normal functionality with no occupational health risks, and cross-transmission of infection while seeking to save the expensive and scarce PPE. Another question to address is which paths should be followed to reduce aerosol generation, and if there are possible new less invasive techniques or devices that capture and decontaminate the aerosol. Also, what is the ideal configuration of a dental chair and peripheral dental equipment to standardise and optimise the cleaning and decontamination measures? Importantly, what is the ideal architecture and temporal flow of patients that allows for optimal biosafety, and what is the ideal level of a respirator in dental practice? In fact, COVID-19 showed that dentistry was spending most of its resources on knowledge and innovation of products, techniques and procedures, while forgetting to innovate and develop a safe work environment for professional practice.

CONCLUSION

The drastic effects that COVID-19 imposes on the dentistry profession can be the strongest motivation that may lead to the development of definitive and innovative solutions for a true biosafety in dentistry.

ACKNOWLEDGEMENTS

This study was partly financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) – Finance Code 001 –, Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG) and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

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Publication Dates

  • Publication in this collection
    14 Mar 2022
  • Date of issue
    2022

History

  • Received
    14 Nov 2020
  • Accepted
    17 Dec 2020
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