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COVID-19 and the dental office

Information and tips for COVID-19

COVID-19 and the dental office

From DentalOffice.org we have prepared this interesting and practical article about everything a dentist should know about the COVID-19 and the tips to follow in the dental clinic.


  • What is COVID-19?
Coronavirus infection has been considered by the WHO as a global pandemic. Since its origin, it has been a threat to world health, not so much because of its symptoms, but because of its rapid spread and contagion and the respiratory complications, it produces in patients with other chronic conditions.
The first outbreak of COVID19 pneumonia originated in the city of Wuhan in late December 2019. Since then, pneumonia infection has spread rapidly from Wuhan to most other provinces and over 150,000 cases, in over 140 countries, are increasing exponentially every day, with Italy and Spain now reporting the most cases every day, growing rapidly in the United States.
  • Etiology
CoVID-19 virus, commonly known as coronavirus, according to the latest studies, has a similar origin to SARS-CoV and SARS-CoV2 coronavirus middle eastern respiratory syndrome, i.e. of zoological origin. Apparently, it is closely related to a Chinese bat as a possible transmitter.

  • Mechanisms of transmission
The main transmission mechanisms described are Pflügge drops, aerosols and direct contact with contaminated surfaces.

  • Incubation period
The incubation period is estimated at an average of 5-6 days, although there is evidence of periods close to 14 days.
  • At-risk population
Epidemiological studies show that the population at greatest risk in terms of symptoms and complications is in the range of 65-80 years, although the population that acts as a vector of infection to a greater extent is the one between 25-30 years.
As for the professional sectors with the highest rate of exposure, there is a recent article in The New York Times newspaper, which talks about which are the professions that have the highest risk when it comes to catching and spreading the virus. This article puts dentistry at the top of the list as the profession with the highest risk due to several factors:
- patient care.
- the activity in the oral cavity and the presence of saliva
- working with ultrasound, and rotating materials that produce aerosols.

  • Symptomatology
Typical clinical symptoms of patients suffering from this new viral pneumonia are: fever, cough and myalgia or fatigue with abnormal chest and less common symptoms were sputum production, headache, hemoptysis, and diarrhea.
The most detailed breakdown of disease symptoms comes from a recent World Health Organization analysis of more than 55,000 confirmed cases in China. These are the most common symptoms and the percentage of people who had them:
  • Fever: 88%
  • Dry cough: 68%.
  • Fatigue: 38%.
  • Coughing up sputum, or phlegm, from the lungs: 33%
  • Shortness of breath: 19%.
  • Bone or joint pain: 15%.
  • Sore throat: 14%.
  • Headache: 14%.
  • Chills: 11%.
  • Nausea or vomiting: 5%
  • Blocked nose: 5%.
  • Diarrhea: 4%
  • Coughing up blood: 1%
  • Swollen eyes: 1%

COVID-19 is a lower respiratory tract infection, which means that most symptoms are felt in the chest and lungs. This is different from colds that cause an upper respiratory tract infection, where you have a runny nose and nasal congestion. These symptoms seem to be mostly absent for people with COVID-19, although they can occur. Recent studies add ageusia and anosmia to these symptoms in young patients.
  • Possible transmission routes of COVID-19
Common routes of transmission of the new coronavirus include direct transmission (coughing, sneezing, and droplet inhalation) and contact transmission (contact with oral, nasal, and ocular mucous membranes). Although common clinical manifestations of new coronavirus infection do not include eye symptoms, analysis of conjunctival samples from confirmed and suspected cases of COVID-19 suggest that transmission is not limited to the respiratory tract, and that eye exposure may provide an effective way for the virus to enter the body.
Several studies have shown that respiratory viruses can be transmitted from person to person through direct or indirect contact, or through coarse or small droplets, and COVID-19 can also be transmitted directly or indirectly through saliva. There is a report of a case of COVID-19 infection in Germany which indicates that such virus transmission can also occur through contact with asymptomatic patients.
Several studies have suggested that COVID-19 may be airborne through aerosols formed during medical procedures.
Dental treatments often involve surgical procedures using air or water syringes, high-speed turbines, micrometers, and ultrasonic scrapers. These devices produce aerosols containing potentially infectious agents, such as those found in the patient's blood, saliva and oral cavity.
Patient blood and saliva are spread as aerosols and droplets during dental treatments and are considered potential sources of cross-contamination, having the potential to cause microbial infections not only in patients but also in dental clinic staff. Contaminating sprays and splashes can also spread to the surfaces of tools and equipment and to the general dental office environment.
It is recommended that dentists and dental hygienists use personal protection
equipment such as masks, gloves, goggles, and gowns to protect themselves from exposure to infectious aerosols and splashes containing patient saliva and blood.
The distance of aerosol spread, splashes and contamination levels that occur during dental treatment are always issues of great concern.
  • How can we help and assist in Dentistry?
Dentists must be familiar with COVID19 or, at least, with the mechanisms of prevention of direct infection, as well as possible cross-infection or the role as an important vector in the routes of transmission of the virus, as we are with other types of infections.
We must also know what kind of extra measures we must take at times of rapid spread of the virus, as in the global pandemic, described by the WHO, that we are currently experiencing.
Obviously, we are at a time when we are growing in wisdom and experience, as the pandemic evolves, which is not ideal, but, today, we are clear about some measures that we can take in terms of prevention, taking into account, above all, the ease with which the virus can spread between the aerosols in the clinic and the pfflüge drops as the main way of spreading the virus.
These recommendations are based on the "Guidelines for the Diagnosis and Treatment of Coronavirus Pneumonia", the "Guidelines for the Prevention and Control of Coronavirus Pneumonia in Medical Institutes" and the "Guidelines on the Use of Medical Protective Equipment and Control of Coronavirus Pneumonia" developed by the National Health Commission of the Chinese Government and the experience of the Eastern China Dental Hospital related to the prevention of COVID19.
- Patient assessment: the dentist must be able to identify a suspected case of COVID19 infection. In general, patients who are currently suffering from fever should not attend the consultation. It is therefore important to ask a few questions, even in the short telephone anamnesis, in order to gather fundamental information that may lead to suspicions.
- The aforementioned guidelines advise against treating patients suspected of being carriers of COVID19, postponing any treatment that is not considered urgent, at least during the time stipulated as quarantine, during which the patient will or will not develop the disease. And referring the patient to the hospital for monitoring of their symptoms and disease.

All these guidelines on the protocol of action place special emphasis on knowing how to detect by telephone the information necessary to include the patient in one protocol or another. To do this they advise asking a series of questions, such as

- Do you have or have you had a fever in the last 14 days?
- Have you had respiratory problems (including cough) during the last 14 days?
- Have you traveled to countries at risk in the last 14 days (although at this point we will have to take into account that, according to the epidemiological data currently being considered, Spain is considered one of the countries at risk, with growth in infections similar to the most conflictive points such as Italy).
- Have you been in contact with people who have had a fever, cough, and/or breathing difficulties in the last 14 days?

If the answer to any of the questions is yes, and you do not have a fever or your body temperature is below 703.4 °F, we will postpone treatment if it is not considered urgent.
If the answer is yes to any of the questions, and the patient has a temperature above 703.4 °F, inform the patient of the possible infection.
If the answer is No to any of the questions, but the patient presents a fever above 703.4 °F, delay treatment unless it is considered urgent.
If the answer is No and there is no fever, postpone treatment if it is not urgent or treat with appropriate measures. 
At this point, it is important to remember that, according to the World Health Organization (WHO), urgency can be defined as the fortuitous appearance in any place or activity of a problem of diverse cause and variable seriousness that generates the conscience of an imminent need of attention on the part of the subject who suffers it or his family.
Dental urgency is the sudden appearance of a pathological condition of the oral and maxillofacial area, which causes a spontaneous demand for attention, whose treatment must be immediate, undelayable, timely and efficient, such as pain, abscesses, and trauma, which are the main pathologies that can cause with limitation of the patient's normal activity or that can pose a risk to the patient's general state of health.
  • Hygiene and handwashing: transmission by contact and oro-fecal transmission have been described as frequent routes of virus transmission. For this reason, and although as health personnel, we must do it frequently and abundantly, during our daily practice, these guidelines encourage us to do it among patients, being an exhaustive and surgical wash to reduce as much as possible this way of contagion.
  • Personal protection measures in the dental clinic: of the three levels described in terms of barrier measures, the guidelines advise us to use level 3 in order to prevent contagion. This level 3 consists of protective glasses fitted to the face with rubber, waterproof, face shield, use of a disposable surgical cap, ffp2/ffp3 mask, disposable waterproof gowns, and nitrile gloves. In any case, it would be for real emergency treatment as advised, treating any patient as a possible transmitter of the virus.
  • Pre-procedure mouthwashes: the National Health Commission of the Republic of China's guide to the diagnosis and treatment of coronavirus pneumonia concludes that the rinses most commonly used in dental clinics, such as chlorhexidine rinses, do not appear to be effective in killing the virus. However, the virus is vulnerable to oxidation, so rinses with oxidative elements such as 1% hydrogen peroxide or 0.2% povidone-iodine are recommended.
Use of rubber dam: it has been shown to reduce the concentration of aerosols by 70%.
Turbines and handpieces with the anti-shrinkage system: handpieces and turbines without anti-shrinkage valves cause microbes, such as bacteria and viruses, to remain in the air hoses that pollute these ducts where the air comes out, and this can be a very noticeable cross-contamination route. The importance of using instruments and equipment that promote disinfection and prevention of contamination of structures that can cause cross-contamination is fundamental in our cabinets.
Disinfection of the cabinet: we must disinfect the clinic and the cabinets according to the "protocol for the management of cleaning and disinfection of surfaces in the medical environment" (WS/T 512-2016) of the National Health Commission of the Republic of China. It is advisable to frequently disinfect any metal structure that is frequently touched, knobs and handles, elevator if there is one, railings... This protocol must be carried out after each patient as we may not know if they are positive or not.
Instruments and material: it is advisable to keep the material and instruments stored in a place where we have the stock, to move to the cabinet only what we are going to use in each intervention.

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