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Inside Dentistry
May 2020
Volume 16, Issue 5

Coronavirus

Dentistry in the fallout of COVID-19

Catherine Paulhamus, MA

When the spread of SARS-CoV-2 (the "coronavirus") to the United States was still just a threat, the questions of dental healthcare practitioners primarily focused on infection control in the dental practice. What are the guidelines for a novel virus? The first confirmed case of COVID-19 ("coronavirus disease") in the United States was reported on January 20, 2020.1 As additional cases began to be identified, and the US Centers for Disease Control and Prevention (CDC) reported person-to-person and community spread, dental healthcare workers came to expect that they could come into contact with this emerging virus either through patients or through the community at large. Entities such as the Organization for Safety, Asepsis and Prevention (OSAP) and the American Dental Association (ADA), along with many other concerned organizations, responded with resource websites, fact sheets, and other guidance, organizing and disseminating the most authoritative and up-to-date information to help dental teams evaluate and strengthen their infection control protocols in preparation.

Then the situation escalated. On March 11, 2020, the World Health Organization (WHO) characterized COVID-19 as a pandemic because of the rapid increase in cases that were being documented in a growing number of countries. State governments in the United States began to issue "stay-at-home" and "social distancing" mandates and close nonessential businesses. On March 16, the ADA recommended that dentists nationwide postpone elective procedures for 3 weeks.2 To help protect dental healthcare practitioners who would still be rendering emergency care, CDC released updated guidelines for dental settings, noting that they have unique characteristics-such as the use of instruments that create sprays that might contain aerosols-that warrant additional infection control considerations.3 On March 29, the US federal government extended its recommendations for nationwide social distancing through April 30.

As of April 7, approximately 95% of Amer-icans were living under some version of stay-at-home orders, which generally require that they leave their residences only to visit essential businesses such as grocery stores and pharmacies.4 On that day, the ADA issued updated recommendations "that dentists keep their offices closed to all but urgent and emergency procedures until April 30 at the earliest,"5 as well as interim guidance6 on minimizing the risk of COVID-19 transmission when treating dental emergencies (See Dentistry in Transition7,8).

According to CDC, ultimately, most of the US population will be exposed to SARS-CoV-2. There is little to no preexisting immunity, and it is spreading exponentially from person to person. At the time of this writing, there is as of yet no vaccine to protect against COVID-19 and no medications approved to treat it.

The Road Ahead

Even after a vaccination becomes available, it is possible that dental practices will need to continue to address COVID-19 as they do influenza outbreaks. "This is a novel virus with unique characteristics, which we still need to study," says Thomas P. Sollecito, DMD, chairman of the Department of Oral Medicine at the University of Pennsylvania's School of Dental Medicine. "With fluid and rapidly emerging new information, it is extremely difficult to offer any definitive evidence-based guidance-or even any simple research-based guidance at this time. CDC, ADA, and other institutions will continue to offer updated guidance to dental professionals regarding what to do within our offices as information becomes available."

"This novel coronavirus is epidemiologically significant because it's never been seen in humans before," says Eve Cuny, director of environmental health and safety, associate professor, and assistant dean at the University of the Pacific Arthur A. Dugoni School of Dentistry. "When a zoonotic disease transfers from animals to humans, then shifts to where it can transmit from human to human, that can be a reason for concern."

"COVID-19 is a reminder that any respiratory illness should be taken seriously and that we constantly need to take precautions," explains Marie Fluent, DDS, an infection control consultant. People can become complacent with infectious diseases such as influenza, she says, "because we've had decades of scientific studies. We have an influenza vaccination and respiratory hygiene measures that can be taken to prevent influenza transmission. However, scientific information regarding COVID-19 is evolving by the day, and I am sure that we will see new respiratory measures that dental personnel must take against this coronavirus."

Key recommendations for respiratory hygiene and cough etiquette are detailed in the 2016 CDC publication, Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.9 "These are measures that CDC recommends all the time, not just for this current pandemic," Fluent says. "We should all be implementing these measures at all times for any respiratory type of infection. In addition, we should be screening for any patients with any respiratory infections but particularly for those with COVID-19." Fluent stresses that an estimated 80% of the COVID-19 cases are very mild in nature, with symptoms mimicking the flu, colds, or allergies. In many cases, patients may not even be aware that they are infected.

"I think it's a good reminder that in your dental practice, you have to always be prepared," Cuny adds. "Make sure that your team knows that if they are ill, they can call in sick, and they shouldn't be penalized or made to feel guilty. Sometimes, especially in a smaller practice, it's difficult if the only dental assistant or hygienist at the practice is out for a week. Therefore, they may be inclined to return to work before they really should, putting their coworkers and patients at risk. Having reasonable sick leave policies is another important aspect of the whole response."

Transmission Precautions

CDC defines different tiers of infection control precautions. These include standard precautions, which are for all procedures, and transmission-based precautions, which are for diseases that can be transmitted through contact, droplet, or airborne routes.10,11 Droplet precautions are necessary for many respiratory infections such as influenza and COVID-19.Airborne precautions are only necessary for diseases that can be transmitted via the airborne route, such as measles, chicken pox, or tuberculosis. Practices that have been relying only on standard precautions during this pandemic should step up to the next level if they are equipped to do so. "If you're going to prevent the transmission of this virus, transmission-based precautions are needed in addition to standard precautions," Cuny explains.

For SARS-CoV-2, transmission-based droplet precautions are recommended. "That includes the typical surgical masks that dental practitioners wear to protect our mucous membranes, which do not protect our respiratory tracts and shouldn't be worn to protect against airborne diseases," Cuny says. "They're worn to protect against contact with standard or aerosolized body fluids from the patient. Current guidance from CDC recommends the use of fit-tested respirators (eg, N95 respirators) if available when treating patients who are infected with COVID-19." The dental team should also use eye protection. "Any mucous membrane is a potential portal of entry for this virus or any other organism," Cuny notes. "Therefore, team members should always be protecting the mucous membranes of their eyes with protective eyewear, not just regular eyeglasses." In some situations, airborne precautions may also be warranted for certain procedures.

One major concern about SARS-CoV-2 is its aerosol and surface stability, which is still being investigated (See The View From the Laboratory). At this time, CDC guidance states, "Transmission of SARS-CoV-2 to persons from surfaces contaminated with the virus has not been documented. Transmission of coronavirus occurs much more commonly through respiratory droplets than through fomites. Current evidence suggests that SARS-CoV-2 may remain viable for hours to days on surfaces made from a variety of materials. Cleaning of visibly dirty surfaces followed by disinfection is a best practice measure for prevention of COVID-19 and other viral respiratory illnesses in households and community settings."12

The US Environmental Protection Agency (EPA) has published a list of Disinfectants for Use Against SARS-CoV-2 that it is continually updating.13"SARS-CoV-2 and other coronaviruses are enveloped viruses. This envelope contains a lipid as a major component. The envelope makes the virus very susceptible to inactivation by many available surface disinfectants, including EPA-registered hospital disinfectants, which are also termed low-level disinfectants," explains John A. Molinari, PhD, professor emeritus, University of Detroit Mercy School of Dentistry. "Most practices routinely use intermediate-level disinfectants, which require a higher-level of EPA testing and documented antimicrobial efficacy. This includes being able to kill Mycobacterium tuberculosis, which is a much more chemically resistant microorganism than coronaviruses. In addition, manufacturers submit test findings regarding the efficacy of disinfectants against a variety of bacteria, nonenveloped viruses (eg, rhinoviruses), and easier-to-kill enveloped viruses. Although not all disinfectant products on the EPA list have been tested specifically against SARS-CoV-2, some have been tested and proven effective against harder-to-kill viruses and other human coronaviruses; thus, these intermediate-level disinfectants would be considered effective against SARS-CoV-2. Dentists shouldn't need to buy any additional, possibly damaging, disinfectant to treat surfaces."

According to Molinari, the key to effective disinfection is using the products appropriately. "Now is a good time to reinforce proper use. If surfaces are soiled, they need to be cleaned first, and when the disinfection step is applied with a wipe or spray, the surface needs to remain wet for the recommended period of time. Some disinfectants have a 3-minute kill time, others have a 2-minute kill time, and an increasing number have a 1-minute kill time. To achieve maximum effectiveness, the surface needs to be wet for the recommended kill time."

Reviewing the product's instructions for use is critical. "Manufacturers spend a lot of money testing these products to ensure they're effective, and they have to get approval for those instructions," Molinari explains. "We need to be careful and diligent in their use."

A Scientific Response

In this rapidly changing dynamic, helping the population separate facts from anecdotes and misinformation becomes part of the healthcare provider's responsibility. "Unfortunately, we have some people making statements that absolutely don't make any sense at all, and that hurts the overall effort," Molinari says. "Dental professionals need to be involved because their patients look to them for good information that is supported by science."

"As we move forward, I expect that we're going to see further guidance based on additional evidence," says Sollecito. "I'm sure-as with any other major event-that we're going to learn something. We're going to learn how we can refine our behavior, along with the infrastructure, for better delivery of patient care. New ideas are going to emerge."

"I would encourage dental personnel to be careful where you're obtaining your information," Fluent advises. "Rely on websites that have experts who use well-accepted scientific analyses, such as reputable medical or dental journals. Look for sources that have a mission to inform and protect the public, like CDC, WHO, and our own ADA."

As a valuable summary of the current challenge, Fluent cites a statement from Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, in which he emphasizes that "the Covid-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging infectious pathogens and the need for constant surveillance, prompt diagnosis, and robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures."14

Dental healthcare professionals, who are integral to their communities, need to stay informed and ahead regarding the science, Fluent concludes. "We need to understand the biology and provide accurate information," she says. "We need to know what to do to continue protecting ourselves and our patients going forward."

The View from the Laboratory

Within US dental laboratories, infection control procedures are being emphasized and supply chains are being carefully monitored. At the same time, some US laboratories have picked up significant amounts of new business from dentists whose work previously was sent to China. In addition, the National Association of Dental Laboratories (NADL) says it will ramp up its campaign to raise awareness of the lack of regulations on dental laboratories in most states.

It is no secret that a significant percentage of dental restorations in the United States are fabricated in Asia-whether sent directly by dentists, by laboratories with full disclosure, or in some cases, by laboratories that do not disclose the practice. Approximately 8.6% of laboratories who participated in a 2019 NADL survey said they outsource at least some of their work overseas. Only 11 states require laboratories to disclose point of origin.

As of March 17, definitive statements on how the virus can be spread had not been published by government sources. "CDC has not said, ‘This virus can live a certain length of time on certain types of surfaces,'" says Mary A. Borg-Bartlett, president of SafeLink Consulting, Inc. "They have alluded to the fact that that is still under evaluation." As such, Borg-Bartlett's consulting firm has issued guidance to dental laboratories suggesting that they require any offshore partner laboratories to disinfect restorations prior to shipping-something that is not standard practice and is required in only two US states-and note it with a sticker on the package.

"We do not know whether the coronavirus could travel on packaging or the restoration itself," Borg-Bartlett says. "We believe it is incumbent upon any US laboratory importing from another country to inquire of that offshore laboratory whether it is disinfecting, and if not, to require it. Make sure what that laboratory is using is virucidal."

Of course, with the virus having spread into the United States already, person-to-person transmission is a concern for dental laboratories as well. To guard against the possibility of an employee inadvertently introducing the virus into the laboratory, Borg-Bartlett recommends reviewing CDC's 2003 infection control guidelines for dentistry and the summary published in 2016."The dental laboratory definitely needs to monitor its own staff," she says. "If they are sick, they should be sent home."

A second possibility for person-to-person contact is less predictable: patient interaction. Although CDC has provided suggested screening questions for dental offices to ask patients, dental laboratories are not permitted under the Health Insurance Portability and Accountability Act of 1996 privacy and security laws (HIPAA) to ask those questions directly. Thus, the laboratory must rely on the dentist when sending a technician to work chairside or hosting a patient for shade verification services.

"Our opinion is that the dental laboratory should be assured by the dentist that any patients who are being sent to the laboratory for a shade verification or for any other reason have been screened," Borg-Bartlett says. "For chairside services, which are becoming increasingly common, the laboratory owner has always been responsible for the technician who is being sent into the dental practice. The dentist is also responsible for protecting them. Either the dentist needs to provide the personal protective equipment to that technician, or the employer needs to provide it to ensure that they are following standard and universal precautions while that technician is in the dental practice."

Of course, these precautions are not completely foolproof, especially with a virus that has been shown to be contagious even when no symptoms are present. "Some laboratories may want to discontinue direct patient services for the time being if they or their own employees are uncomfortable," Borg-Bartlett says.

While some laboratories are focusing on retaining the new business that came to them under unfortunate circumstances, others hope this is an opportunity to highlight the issue of offshoring. During the past several years, The NADL has invested significant resources in the "What's in Your Mouth" campaign, which aims in part to convince the general public that dentists and patients should know where their dental restorations are coming from, who is making them, and what materials are used in the process. The coronavirus outbreak might finally help get the public's attention.

The NADL confirmed it plans to ramp up the campaign in light of the current situation. Eric Thorn, in-house counsel for the NADL, wrote in a recent post on the NADL's What's in Your Mouth blog that the coronavirus is "a poignant example of why all states should adopt dental laboratory registration and disclosure."

Excerpted from: Mazda J. Special Report: Coronavirus. Inside Dental Technology. 2020; 11(4):20-25.

Dentistry in Transition

On April 1, 2020, the ADA Health Policy Institute reported that 76% of dental practices were closed except for emergency appointments, 19% were closed completely, and only 5% were open, but they were experiencing lower patient volume.7 The abrupt slowdown of economic activity associated with COVID-19 created a domino effect-from patients to dental practices and then to laboratories and the industry at large.

Dental practices are small businesses with large expenses, and rent, payroll, loans, equipment leases, and other liabilities continue despite the absence of patients. The CARES Act, a federal financial relief bill signed into law on March 27, includes a $2 trillion stimulus package aimed at mitigating the financial fallout. According to the ADA, this act "contains many provisions the ADA believes are important to dentists, dental practice owners, dental students, and dental office employees. This includes small business administration loans, retirement account withdrawals, and student loan payment and interest deferral."8 Once the act was passed, the ADA began offering webinars on what resources were available and how dental practices could apply. In addition, suppliers, insurers, and other dental organizations were moving quickly to support practices through information, advice, and even financing options (The ADA urges dentists to talk to their accountants about their specific needs and for what assistance they may qualify.).8

This national shutdown has also created renewed interest in new models of patient care, such as teledentistry for example. Companies that provide these solutions are reaching out with educational resources to providers who may not have considered this option under normal circumstances. "With dental practices closed except for emergencies and the crucial need for improved triage of urgent care needs, teledentistry can play a huge role for all types of practices," says Brant Herman, CEO of MouthWatch. "Beyond the most important emergency cases, teledentistry also creates an opportunity for providers to remain available to their patients despite office closures, while still offering billable evaluations, prescriptions, and home care instructions through remote consultations. Patients want to know their provider is there for them and teledentistry is an effective and important tool to do just that-now and when this crisis is over." Connecting with patients, monitoring their oral health, and performing "virtual triages" for urgent care, can help maintain the critical patient-provider relationship at a time when patients are feeling anxious.

References

1. Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382(10):929-936.

2. ADA Calls Upon Dentists to Postpone Elective Procedures. American Dental Association website. https://www.ada.org/en/press-room/news-releases/2020-archives/march/ada-calls-upon-dentists-to-postpone-elective-procedures. Published March 16, 2020. Accessed April 7, 2020.

3. Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response. US Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Published March 26, 2020. Accessed April 7, 2020.

4. Secon H, Woodward A. More than 95% of all Americans have been ordered to stay at home. Business Insider. https://www.businessinsider.com/us-map-stay-at-home-orders-lockdowns-2020-3. Updated April 7, 2020. Accessed April 7, 2020.

5. ADA urges dentists to heed April 30 interim postponement recommendation, maintain focus on urgent and emergency dental care only. American Dental Association website. https://www.ada.org/en/press-room/news-releases/2020-archives/april/summary-of-ada-guidance-during-the-covid-19-crisis. Published April 1, 2020. Accessed April 7, 2020.

6. Versaci M. ADA releases interim guidance on minimizing COVID-19 transmission risk when treating dental emergencies. American Dental Association website. https://www.ada.org/en/publications/ada-news/2020-archive/april/ada-releases-interim-guidance-on-minimizing-covid-19-transmission-risk-when-treating-emergencies. Published April 1, 2020. Accessed April 7, 2020.

7. Carey M. HPI poll examines impact of COVID-19 on dental practices. American Dental Association website. https://www.ada.org/en/publications/ada-news/2020-archive/april/hpi-poll-examines-impact-of-covid-19-on-dental-practices. Published April 1, 2020. Accessed April 7, 2020.

8. Garvin J. CARES Act becomes law. American Dental Association website. https://www.ada.org/en/publications/ada-news/2020-archive/march/house-passes-cares-act-covid-19-relief-bill. Published March 27, 2020. Accessed April 7, 2020.

9. US Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016.

10. Standard Precautions. US Centers for Disease Control and Prevention website. https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html. Updated June 18, 2018. Accessed April 7, 2020.

11. Transmission-Based Precautions. US Centers for Disease Control and Prevention website. https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Updated January 7, 2016. Accessed April 7, 2020.

12. Cleaning and Disinfection for Households. US Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html. Updated March 28, 2020. Accessed April 7, 2020.

13. List N: Disinfectants for Use Against SARS-CoV-2. US Environmental Protection Agency website. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Updated April 2, 2020. Accessed April 7, 2020.

14. Fauci AS, Lane HC, Redfield RR. Covid-19 - navigating the uncharted. N Engl J Med.2020;382 (13):1268-1269.

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