COVID-19: Perspectives for the management of dental care and education

Abstract The rapid and abrupt transmission pattern of the SARS-CoV-2 unleashed the current COVID-19 pandemic, as recognized by the World Health Organization in March 2020. Considering the high risk of transmission of the virus in dental environments and the specificities in clinical practice, COVID-19 posed immediate challenges for dental care and education. Due to the need to establish infection prevention and control guidance in dental health settings to enable a safe clinical practice, this review aims to list the challenges and perspectives in managing dental care in services and schools. This review employed materials collected from PubMed and the main guidelines and studies on the novel coronavirus to provide an overview of the clinical procedures and decisions made by health care personnel in dental offices and dental schools. We expect the COVID-19 scenario to promote significant changes in clinical practice and dental education; dentists should seek specific and particular regulations for dental practice established by their state or country. Biosafety checklists are strongly recommended for appointments at dental services and face-to-face activities in dental schools.

Introduction SARS-CoV-2 is a contagious RNA virus that causes the coronavirus disease 2019  in the human population. This novel coronavirus is thought to spread primarily through respiratory droplets and fomites, but airborne transmission from person-toperson over long distances is unlikely. 3 The virus can survive in aerosols for hours and on surfaces up to days. 4,5 Pre-symptomatic or asymptomatic patients can also spread the virus, facilitating the transmission process. 4,[6][7][8] In December 2019, COVID-19 was first diagnosed in a human and recognized as a serious respiratory disease in Wuhan city, Hubei province, in China.
Since then, a huge scientific task force has been assembled to collect information about the disease. 9 Several studies have been developed to identify its biological mechanism, infectious agent, contagion and transmission modes, diagnostic tests, and to search drugs and vaccines to tackle the virus.
Due to the rapid and abrupt worldwide transmission pattern of the COVID-19, in March 2020 the World Health Organization declared the outbreak a pandemic. 10 Despite global efforts to stem the spread of the disease, the incidence rate of COVID-19 is continuously increasing: the latest issue reported over  dentistry in providing remote consultations for developing treatment plans, promoting preventive care, and supervising home procedures such as pediatric dentistry, oral medicine, orthodontics, prosthodontics, periodontics, and restorative dentistry.
A recent systematic review found telediagnosis and teleconsultation to be the most common applications, grounded on store-and-forward technology and realtime encounters. 23 A future perspective is improving and developing technology to provide access to teledentistry and extend the service in several countries.
A study published on April 19, 2020 reveals the progress and challenges in developing drugs to tackle COVID-19, with some updates. 9 Although no specific drug is currently suitable for treating COVID-19, this study lists some medication and alternative treatments, such as favilair, remdesivir, chloroquine, and hydroxychloroquine. 9 In an attempt of developing a method to confer acquired immunity against the disease, several SARS-CoV-2 vaccine prototypes have been developed and tested by countries around the world. Canada, China, United Kingdom, Russia, Brazil, and United States have been working to develop a vaccine in a short time. It is estimated that it will take at least one year, after pre-clinical and clinical studies, to make vaccine available to the population. 9 Producing and testing these products will demand high costs for the governments.
According to Alharbi, Alharbi, and Alqaidi 24 (2020), suspending dental practices during the course of the novel coronavirus pandemic may contribute to reducing infection, but will increase the suffering of individuals requiring emergency dental care. 24 Such measure may also contribute in overcrowding hospital emergency departments, evincing great importance in providing dental care, even during a global pandemic. Some countries are gradually reopening their economic activities, including dental practices. In this scenario, it is necessary to establish infection prevention and control guidance in dental health settings to enable a safe clinical practice (both in dental offices and schools), during and after the pandemic.
Dental education is being dramatically impacted due to the higher risk of contamination of patients, teaching staff, students, and DHCP, as these individuals circulate in an environment that favors virus spreading. As an example, the number of cases among health care professionals (especially physicians), nurses, and dentists is high. 4,9,16 This review aims to list the challenges and perspectives in managing dental care and education during and after the course of the COVID-19 pandemic. This is not a systematic review. This manuscript was written based on material collected from the PubMed database, using the search terms: "coronavirus", "SARS-CoV-2", "COVID-19", "dentistry", "dental", "oral cavity", "biofilm", "saliva", "dental public health", "infection control", "prevention", "education", and "practice management;" the search was limited to texts written in English.

Infection prevention and control for dental practice
Dental professionals should be prepared to identify patients with COVID-19 and to take extra-protective measures required during clinical practice to prevent the transmission. 4 We will present infection prevention and control measures indicated for these professionals before, during, and after dental procedures implicating a possible droplet and aerosol transmission of COVID-19, most important concerns in dental offices. The ADA proposed three algorithms serving as interim guidance to assist dentists and dental offices in making informed decisions concerning patient triage, evaluation, and treatment during the COVID-19 pandemic: (1) triaging patients for emergency and urgent dental care, (2) screening to identify COVID-19 infection in emergency and urgent dental patients, to determine whether patients can be treated at the dental office (3) and assessing patients' risk during the pandemic. 27 The guidance also recommends dental offices and schools to take actions for preventing and controlling the infection.
Before the dental procedure Initially, dental health care personnel (DHCP) must prepare the dental team. 26  Public areas and clinical environments must be properly and rigorously cleaned and disinfected.
Thoroughly cleaning environmental surfaces with water and detergent and applying high-level disinfectants (such as 3% sodium hypochlorite) are effective and sufficient procedures. 25 Medical devices/equipment and utensils, including knobs, chairs and tables, should be cleaned frequently following safe routine procedures.
Upon patient arrival, the waiting room should allow a social distance of at least 2 meters between people. 27 Consultations must be scheduled by appointment to avoid overcrowding. The service must provide supplies to maintain hygiene/breathing level by offering a medical mask to patients while they wait and asking them to perform hand hygiene (cleaning hands with 70% alcohol for 20 to 30 s, or with soap and water from 40 to 60 s). 25 Professionals should perform another screening to confirm patients' health condition by checking their temperature, preferably using a non-contact forehead thermometer or infrared cameras. If the patient exhibits a temperature higher than 37.5 o C or signs of respiratory diseases, dental care must be postponed for 14 days and patients must follow the recommendations previously listed. 29,30 No clinical study supported using mouthrinse before dental procedures, nor any specific mouthrinse virucidal efficacy against SARS-CoV-2. 31 Although chlorhexidine is considered the gold standard for oral may be vulnerable to oxidation, the ADA suggests using mouthrinse with 1.5% hydrogen peroxide or 0.2% povidone prior to conducting procedures, 26 as well as 0.05% to 0.1% cetylpyridinium chloride, which seems to provide additional protection against upper respiratory infections. 32 During the dental procedure During dental procedures, standard precautions include preparing all instruments, performing hand/respiratory hygiene, using adequate PPE and disposable covers for total protection. 8 According to Peng,et al. 4 (2020, adapted (Chen and Zhao, 2020). For biosafety control, all filters must be replaced and disposed of in regular intervals. 33 To minimize the risk of cross-infection, dentists should use single-use devices, such as disposable air/water COVID-19: Perspectives for the management of dental care and education J Appl Oral Sci. 2020;28:e20200358 5/9 syringe tips, disposable handpieces, and plastic wraps for all exposed surfaces 27 . Services should limit complementary exams, as intraoral images, and perform extraoral radiographs to avoid increased salivary flow rate and pharyngeal reflex, often caused during intraoral imaging. 4,24 Whenever possible, procedures should employ a rubber dam, to reduce aerosols and microorganisms spread, 26,27,34 and a four-handed operation, regardless of the rubber dam. Extra high-volume suction devices should be used in conjunction with regular suction for aerosols, fomites and saliva. 4,27,34 When rubber dam use is unfeasible, manual devices for removing dental cavities and performing periodontal treatment are recommended to minimize aerosol production as much as possible. 4,27 During procedures, patients should wear a protective coat, disposable working cap, and protective goggles.

Patients with suspected or confirmed COVID-19
must be attended only for emergency treatment and instructed to wear a disposable surgical mask.
Appointments should be scheduled far enough apart to avoid possible contact with other individuals.
Treatment should be preferably performed in a negative pressure/air borne precaution room. 29 After the dental procedure According to the ADA, after dental appointment completion, professionals should reinforce instructions on social distance and infection control etiquette (hand and respiratory hygiene). 26 Special attention must be paid to cleaning and disinfecting dental office, reusable PPE (goggles and facial shields), and non-disposable and non-sterilizable equipment (dental x-ray equipment, dental chair and light). Other instruments that go into direct contact with fluids and the oral cavity must be sterilized in an autoclave. Oral hygiene care should be reinforced during this period.

Professionals with symptoms or suspected COVID-19
Professionals exhibiting symptoms or those suspected of COVID-19 (after being exposed to a confirmed COVID-19 patient) must discontinue all healthcare interactions for a 14-day period, 19 tested for COVID-19, and quarantined for 14 days. 25 If test result comes out positive, patients attended in the previous week and DCHP working with the professional must be notified, instructed to self-quarantine at home for 7 days, and report any fever or influenza-like illness experience to local health services.

Dental education
Worldwide, most dental schools suspended teaching activity due to pandemic spread to reduce virus transmission and the spread of COVID-19 in dental departments. As a consequence, this strategy has exerted numerous effects on dental education, such as: interrupting face-to-face instruction, including pre-clinical and clinical activities; interrupting patients' assistance; discontinuing development of human and some animal studies, especially in postgraduate programs; cancelling scientific congresses and conferences; abruptly changing academic calendars, including extra semesters; and postponing graduation ceremonies and new students entry. 35,36 We should also consider the negative impact on the mental health of professionals, professors, and students. 36,37,38 Considering that, a major concern among dental schools is restarting activities. As dental schools cannot extensively adopt web-based teaching for practicing, some urgent considerations are necessary. 38,39,40 Resuming dental schools activities in classroom and clinics depends on the course of this pandemic in each country and specific field. Currently, some dental schools have resumed or prepared to reopen after government decisions, 40 what urges for some recommendations on how to organize dental education considering the "new normal" in Dentistry.

Education
The pandemic forced many dental schools to temporarily adapt to a fully-virtual curriculum. To accommodate the lasting effects of COVID-19, some strategies adopted for distance education should be maintained in a hybrid-teaching format in the upcoming months. 35,38 Considering that, institutions should use remote strategies, such as free digital platforms Preclinical practice Schools should also encourage preclinical activities in the simulation laboratory using mannequins, given the possible reduced availability of clinical practice with patients, especially for first-year students of graduation courses. 35,37 Another alternative is the use of digital strategies, by software capable of creating and reproducing virtual three-dimensional models that can be accessed by computers and mobile devices.
Such approaches may enable students to learn techniques and concepts applied into different dental specialties. 43,44,45 However, remote strategies should not replace clinical practice with patients in acquiring abilities inherent to the dental training.

Clinical practice
As dental school environment aggravates agglomeration, some prevention strategies should be implemented to reduce contamination among those individuals before dental treatment (at-home patients and those entering the dental school). Patients should undergo screening, to investigate their health conditions and suspected cases of COVID-19, 42 by telephone, 24 hours before consultation, or at firstcontact for the appointment, as soon as the patient arrives at the dental school. Patients with difficulty in explaining their oral problem by telephone must receive consultation by video. Those suspected of COVID-19 must be referred to another local health service. 42 When patients arrive at the dental school, practitioners must register their body temperature and apply a current health status questionnaire to Students should provide all necessary materials before the dental procedure to limit contact with other students and personnel and to perform the procedure as fast as possible. Special care must be taken with shared dental consumables. Since procedures become more complex as the graduation course advances, dental students generally take longer to perform procedures, especially at clinical-stage, in the beginning of the course. The risk of cross-infection is higher at this stage because students spend more time in contact with the patient, depending on the nature of the procedure to be performed.
Four-hand work is extremely necessary during dental procedures to prevent contagion and speed up the appointment. Hand hygiene should be rigorously performed at each appointment and PPE should be available for all dental practitioners. Before dental treatment, prescribing mouthrinses is recommendedrinses should contain 1% hydrogen peroxide, or 0.2% to 1% povidone, or 0.05% to 0.1% cetylpyridinium chloride agents, and are particularly indicated when a rubber dam is not used. 16,32 Students should opt for procedures that produce no or little aerosol and for using manual instruments when possible. Patients must wear a protective coat, disposable working cap, and protective goggles during procedures.
After completion, all potentially contaminated surfaces should be cleaned. Sterilizable instruments should be disinfected using enzymatic detergents, which is effective in removing organic matter and rapidly decomposing adhered blood and body fluids.
Other dental settings should be cleaned with 70% alcohol. Surfaces should be disinfected with 0.1% sodium hypochlorite and 70% alcohol. 16 After each practical assistance, disposable PPE should be discarded and the rest of the equipment disinfected. As the virus remains alive in droplets suspended in the air, PPE should not be removed before exiting the area, 16 and during removal touching any external part of the equipment must be avoided, including disposable masks and caps. For a safer practice, the dental team should be constantly monitored by rapid diagnostic tests for  Regarding infection control measures, Emami 36 (2020) argues that dental teams are familiar in treating patients with infectious diseases (hepatitis, HIV) and routinely working with strict environmental control and PPE. As an example, a recent multinational study approaching dentists' knowledge, attitudes, and practices regarding COVID-19 revealed that 92.7% of the participants presented high/good knowledge and 79.5% high/good care practices, evincing these  (2) minimizing learning loss, and (3) reducing students and staff anxiety and concern. The medical school assessed ongoing risk and developed contingency plans to balance staff and student safety and created a monitoring team. It also adopted precautions, such as repeated hand washing and sanitizing, taking temperatures twice a day, and wearing masks. The theranostic approach 54 could also be advanced to manage some diseases using nanomaterials -that is, as a drugs carriers for specific action in tissues or cells using nanobiotechnology and translational research. Due to its predictability, preventive, personal, and participatory potential, 54,55 theranostics promises to increase clinical performance (including in Dentistry), reducing costs and helping identifying the ideal and individualized treatment for each patient, at the right moment, in an analysis beyond the current pandemic scenario. Dentists should seek specific regulations for dental care established by their state or country regarding the COVID-19 pandemic. Biosafety checklists should also be consulted for managing protective personal equipment, dental settings and devices, and surrounding spaces -as those used before, during, and after dental appointments. As significant changes are expected in clinical practice and dental schools, individuals should seek further and rapid information to handle and improve this issue.

Conflicts of interest
The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.