Researching What Works
The realities of dentistry in the age of COVID-19
Sabiha S. Bunek, DDS
In late February 2020, COVID-19 changed our industry dramatically. As a research-based publication, Dental Advisor immediately began reviewing the issues at hand, including where education was necessary and what data was missing from the bigger picture. Protecting our patients and our teams from infection became the focus, and our approach was to carefully assess what was known and return to a basic review of infection control in the dental practice. We dedicated webinars and special editions to covering the use of masks and surface disinfectants, and in order to glean clinical relevance, we developed pilot tests to measure the reduction of bacterial contamination from aerosols and spatter using various devices.
As a whole, dentistry has been excellent about keeping up with requirements for personal protective equipment (PPE). Initially, there were many questions centered around the use of N95 respirators, such as when they were necessary and whether or not they needed to be fit tested. The routine use of N95 respirators is recommended for any aerosol-generating procedure in dentistry. They must be initially fit tested for each individual, each individual must receive medical clearance by a physician to use them throughout the day, and everything must be documented in a respiratory protection program for the practice. So, what happens when N95 respirators are unavailable for dental personnel? A Level 3 mask and face shield is the next most appropriate option according to recommendations provided by the US Centers for Disease Control and Prevention (CDC). In addition, KN95 masks are also available and approved for emergency use during the pandemic, but many have been allowed into the United States without proper testing, and as such, several have been pulled from the market for improper filtration and protection.
Surface disinfection is another area where practices have been carefully following recommendations. Selecting a surface disinfectant from the US Environmental Protection Agency's List N is the first step in disinfection. However, one way in which dental practices can potentially fail in properly disinfecting a surface is by not reading the instructions for use and adhering to the recommended contact time. All disinfectants need to be in contact with a contaminated surface for the recommended time in order for the disinfectant to work properly. In addition, prior to disinfection, all surfaces must first be cleaned to remove any debris. With surface disinfectant wipes being in short supply, Dental Advisor has received several inquiries regarding making your own wipes. This is not advisable for many reasons, but in particular, gauze is often treated with chemicals, and these chemicals can interact with disinfectants.
In lieu of surface disinfection, medical grade barriers may be used and then discarded after one use. Knowing that some offices may use any barrier material that they can find, thinking that it will work or be more cost-effective than the alternative, Dental Advisor tested the efficacy of healthcare grade barriers versus common plastic bags. The results of the testing indicated that trash bags and dry cleaning bags exhibited bacterial contamination within 1 minute of exposure, whereas protective healthcare barriers inhibited the transfer of methicillin-resistant Staphylococcus aureus at every time point tested.
From a clinical perspective, many offices were forced to close down due to state mandates, and many are still under treatment restrictions, avoiding the use of high-speed handpieces and ultrasonic scalers because they are aerosol-generating devices. To date, there have been no reports of COVID-19 transmission in a dental practice. Many of those doctors practicing with restrictions have been inquiring about products that could be useful in focusing on minimally invasive dentistry and that could be used to temporize cases until dentistry is authorized to return to practice in the ways that have been proven most effective.
The only clear recommendation that the CDC has made specific to dentistry is for practices to consider the use of air purification. As such, the market has been overwhelmed by new products that claim to mitigate aerosols and clean the air through various purification processes. There are many considerations, including the total square footage, design, air exchange, and size of the purifiers needed to accomplish the job of air purification in dental offices. We will be researching this in the near future.
In this time, it is very clear that the need for research that is relevant and available to the practicing clinician is greater than ever. As new solutions come to market, ask for independent research to ensure that you are making sound decisions for your practice, your team, and your patients.
About the Author
Sabiha S. Bunek, DDS, is the CEO of Dental Advisor. She maintains a private practice in Ann Arbor, Michigan.