COVID-19 and Dentistry in 72 Questions: An Overview of the Literature

Pragmatic Return to Effective Dental Infection Control through Triage and Testing (PREDICT): an observational, feasibility study to improve dental office safety

BACKGROUND

During the COVID-19 pandemic, there was a substantial interruption of care, with patients and workers fearful to return to the dental office. As dental practice creates a highly aerosolized environment, the potential for spread of airborne illness is magnified. As a means to increase safety and mitigate risk, pre-visit testing for SARS-CoV-2 has the potential to minimize disease transmission in dental offices. The Pragmatic Return to Effective Dental Infection Control through Testing (PREDICT) Feasibility Study examined the logistics and impact of two different testing mechanisms (laboratory-based PCR viral testing and point-of-care antigen testing) in dental offices.

METHODS

Dental healthcare workers (DHCWs) and patients in four dental offices within the National Dental Practice-based Research Network participated in this prospective study. In addition to electronic surveys, participants in two offices completed POC testing, while participants in two offices used lab-based PCR methods to detect SARS-CoV-2 infection. Analysis was limited to descriptive measures, with median and interquartile ranges reported for Likert scale responses and mean and standard deviation for continuous variables.

RESULTS

Of the total 72 enrolled, 28 DHCWs and 41 patients completed the protocol. Two patients (4.9%) tested positive prior to their visit, while 2 DHCWs (12.5%) tested positive for SARS-CoV-2 infection at the start of the study. DHCWs and patients shared similar degree of concern (69% and 63%, respectively) for contracting COVID-19 from patients, while patients feared contracting COVID-19 from DHCWs less (49%). Descriptive statistics calculations revealed that saliva, tongue epithelial cells, and nasal swabs were the most desirable specimen collection method; both testing (LAB and POC) protocols took similar amounts of total time to complete; and DHCWs and patients reported feeling more comfortable when both groups were tested.

CONCLUSIONS

While a larger-scale, network study is necessary for generalizability of results, this feasibility study suggests that SARS-CoV-2 testing can be effectively implemented into dental practice workflows and positively impact perception of safety for DHCWs and patients. As new virulent infectious diseases emerge, preparing dental personnel to employ an entire toolbox of risk mitigation strategies, including testing, may have the potential to decrease dental practice closure time, maintaining continuity of dental care services for patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05123742.

Detection of anti-SARS-CoV-2 salivary antibodies in vaccinated adults

Since the introduction of efficient anti-SARS-CoV-2 vaccines, the detection of antibodies becomes useful for immunological monitoring and COVID-19 control. Therefore, this longitudinal study aimed to evaluate the detection of SARS-CoV-2 antibodies in the serum and saliva of COVID-19-vaccinated adults. The study included 13 not vaccinated and 35 vaccinated participants with two doses of CoronaVac (Sinovac/Butantan) vaccine who subsequently received BNT162b2 (Pfizer-BioNTech) vaccine as a booster dose. Vaccinated participants donated saliva and serum in three different time points. Enzyme-linked immunosorbent assay was used for antibody detection. In our results, the serum neutralizing antibodies (NAb) were detected in 34/35 samples after second dose and in 35/35 samples one and five months after the booster dose. In saliva, NAb were detected in 30/35 samples after second dose and in 35/35 of samples one and five months after the booster dose. IgA was detected in 19/34 saliva samples after second dose, in 18/35 one month after the booster and in 30/35 five months after. IgG in saliva was detected in 1/34 samples after second dose, 33/35 samples one month after the booster dose and in 20/35 five months after. A strong correlation was found between IgG and neutralizing activity in saliva, and salivary IgA would be a sign of recent exposure to the virus. In conclusion, saliva can be suitable for monitoring antibodies anti-SARS-CoV-2 after vaccination. Heterologous vaccination contributed to increase anti-SARS-CoV-2 antibodies in the Brazilian health context. Complementary studies with large groups are mandatory to conclude the interest in following mucosal immunity.

The COVID-19 Pandemic and Dental Professionals' Infection Risk Perception: An International Survey

A global survey among dentists was used to identify the various impacts of the COVID-19 pandemic on this professional group. Special attention was given to perception and assessment of infection risk. From May to August 2020, the questionnaire was delivered in 36 countries by respective research groups and was completed by 52,491 dental professionals. The survey was designed as a cross-sectional survey based on a previously standardized questionnaire. This study focuses on the part of the questionnaire that deals with the perception of the infection risk of COVID-19 by dentists and their patients. A logistic regression model was used, which consisted of four Likert items as response options and the additional self-reported routine or emergency treatment as the dependent variable. Analysis by continent found that European and Asian dentists were particularly likely to be infected at work (OR = 1.45 95%CI = 1.02/1.84 and OR = 2.68, 95%CI = 1.45/3.22, respectively), while it was likely that Australian dentists did not feel particularly at risk due to low infection rates. Three quarters of Americans treated only emergencies during this survey period, while Europeans (64.71%) and Asians (66.67%) provided mostly routine care. This could affect the Europeans' confidence that they would not be able to protect themselves from infections in the long-term. The COVID-19 pandemic and its impact on dental professionals' infection risk perception is determined by the geographical origin of dentists. This study shows that, especially in high-incidence countries, infection risk perception was higher when dentists tried to provide routine dental procedures to their patients. Dental professionals can offer themselves and their patients good protection by maintaining high standards of hygiene. However, their concerns should be taken seriously and the dental professionals' group that is of great importance for oral health care and prevention, should not be neglected in the future, even in the event of emerging pandemics.

Pragmatic Return to Effective Dental Infection Control through Triage and Testing (PREDICT): A feasibility study to improve dental office safety

Background

The COVID-19 pandemic highlights the need for practitioners to enhance workflows to increase safety and mitigate risk. As dental practice creates a highly aerosolized environment, pre-visit testing for SARS-CoV-2 has the potential to be an effective mitigation strategy to minimize disease transmission in dental offices. The Pragmatic Return to Effective Dental Infection Control through Testing (PREDICT) Feasibility Study examined the potential, logistics, and impact related to laboratory-based PCR viral testing and point-of-care (POC) antigen testing.

Methods

Dental healthcare workers (DHCWs) and patients in four dental offices within the National Dental Practice-based Research Network participated in this prospective study. In addition to electronic surveys, participants in two offices completed POC testing, while participants in two offices used lab based PCR methods to detect SARS-CoV-2 infection. For this feasibility study, analysis was limited to descriptive measures. Median and interquartile ranges were reported for Likert scale responses and mean and standard deviation for continuous variables.

Results

Forty-one of forty-three consented patients and twenty-eight of twenty-nine DHCWs completed the protocol. Descriptive statistics calculations including median and interquartile ranges revealed (1) saliva, tongue epithelial cells and nasal swabs were the most desirable specimens for testing for groups (2) both LAB and POC protocols took similar amounts of total time to complete the full testing protocol and (3) DHCWs and patients reported feeling more comfortable when both groups were tested.

Conclusions

This feasibility study suggests that pre-visit SARS-CoV-2 testing can be effectively implemented into dental practice workflows and positively impact perception of safety for DHCWs and patients, though a larger scale, network study is necessary for generalizability of results. As new virulent infectious diseases continue to emerge, preparing dental personnel to employ an entire toolbox of risk mitigation strategies, including testing, may have the potential to decrease dental practice closure time, maintaining continuity of dental care services for patients.

Trial registration

This trial was registered on ClinicalTrials.gov: NCT05123742.

The COVID-19 outbreak on dental practice in State of São Paulo, Brazil

Brazil has become the epicenter of coronavirus disease, and the São Paulo State has the worst scenario. This study evaluated the effect of the COVID-19 in dentists of São Paulo State, Brazil. A self-administered web-based survey with 33 multiple-choice questions was sent to dentists. Descriptive statistics were used to assess the 302 valid responses. Data were analyzed by Chi-square, McNemar and Wilcoxon tests (α = 0.05). Most of the participants aged until 34 years (61.6%) and were female (74.5%). They reduced work to less than 20 h per week. Monthly remuneration was reduced (86.8%). Personal protective equipment at the office was changed (p < 0.05). A few dentists (7.6%) had COVID-19, and more than 99% were aware of the disease. Most of the participants (90.2%) were insecure about being contaminated. The dentists of São Paulo State had coronavirus knowledge and have adopted strict biosafety protocols, but the pandemic affected their financial and psychological features.

Dental Care and Education Facing Highly Transmissible SARS-CoV-2 Variants: Prospective Biosafety Setting: Prospective, Single-Arm, Single-Center Study

With the arrival of the highly transmissible Omicron variants (BA.4 and BA.5), dentistry faces another seasonal challenge to preserve the biosafety of dental care and education. With the aim of protecting patients, students, teachers and healthcare professionals, this paper introduces a prospective sustainable biosafety setting for everyday dental care and education. The setting developed by dental clinicians, epidemiologists, and teachers of dentistry consists of a combination of modern technologies focused on the air-borne part of the viral pathway. The introduced biosafety setting has been clinically evaluated after 18 months of application in the real clinical environment. The protocol has three fundamental pillars: (1) UVC air disinfection; (2) air saturation with certified virucidal essences with nebulizing diffusers; (3) complementary solutions including telehealth and 3D printing. A pseudonymous online smart form was used as the evaluation method. The protocol operates on the premise that everybody is a hypothetical asymptomatic carrier. The results of a clinical evaluation of 115 patient feedbacks imply that no virus transmission from patient to patient or from doctor to nurse was observed or reported using this protocol, and vice versa, although nine patients retrospectively admitted that the clinic visit is likely to be infectious. Despite these promising results, a larger clinical sample and exposition to the current mutated strains are needed for reliable conclusions about protocol virucidal efficiency in current dental environments.

Quantitative Health Risk Assessment of the Chronic Inhalation of Chemical Compounds in Healthcare and Elderly Care Facilities

Previous studies have described the chemical pollution in indoor air of healthcare and care facilities. From these studies, the main objective of this work was to conduct a quantitative health risk assessment of the chronic inhalation of chemical compounds by workers in healthcare and elderly care facilities (hospitals, dental and general practitioner offices, pharmacies and nursing homes). The molecules of interest were 36 volatile and 13 semi-volatile organic compounds. Several professional exposure scenarios were developed in these facilities. The likelihood and severity of side effects that could occur were assessed by calculating the hazard quotient for deterministic effects, and the excess lifetime cancer risk for stochastic effects. No hazard quotient was greater than 1. Three compounds had a hazard quotient above 0.1: 2-ethyl-1-hexanol in dental and general practitioner offices, ethylbenzene and acetone in dental offices. Only formaldehyde presented an excess lifetime cancer risk greater than 1 × 10⁻⁵ in dental and general practitioner offices (maximum value of 3.8 × 10⁻⁵ for general practitioners). The health risk for chronic inhalation of most compounds investigated did not appear to be of concern. Some values tend to approach the acceptability thresholds justifying a reflection on the implementation of corrective actions such as the installation of ventilation systems.

Indoor Carbon Dioxide, Fine Particulate Matter and Total Volatile Organic Compounds in Private Healthcare and Elderly Care Facilities

Poor indoor air quality can have adverse effects on human health, especially in susceptible populations. The aim of this study was to measure the concentrations of dioxide carbon (CO₂), fine particulate matter (PM_2.5) and total volatile organic compounds (TVOCs) in situ in private healthcare and elderly care facilities. These pollutants were continuously measured in two rooms of six private healthcare facilities (general practitioner’s offices, dental offices and pharmacies) and four elderly care facilities (nursing homes) in two French urban areas during two seasons: summer and winter. The mean CO₂ concentrations ranged from 764 ± 443 ppm in dental offices to 624 ± 198 ppm in elderly care facilities. The mean PM_2.5 concentrations ranged from 13.4 ± 14.4 µg/m³ in dental offices to 5.7 ± 4.8 µg/m³ in general practitioner offices. The mean TVOC concentrations ranged from 700 ± 641 ppb in dental offices to 143 ± 239 ppb in general practitioner offices. Dental offices presented higher levels of indoor air pollutants, associated with the dental activities. Increasing the ventilation of these facilities by opening a window is probably an appropriate method for reducing pollutant concentrations and maintaining good indoor air quality.

COVID-19 VACCINATION AND DENTISTRY: ARE WE FACING NEW CHALLENGES OR WORKING WITHIN OUR POSSIBILITIES? ANALYTICAL REVIEW

Objective. To systematize available data regarding COVID-19 vaccination aspects among dental specialists and highlight relevant occupationally-related features of vaccination challenges. Materials and Methods. Search of pertinent literature sources associated with above-formulated objective was provided via PubMed Central database (https://www.ncbi.nlm.nih.gov/) and Google Scholar search engine (https://scholar.google.com/). Criteria of publication date included 2020-2021 years period. Publications in English or at least with English abstract/summary were collected within primary sample for further preliminary content-analysis. All articles collected for in-depth content-analysis were evaluated due to the text-mining, text-identification and text-extraction principles with further clusterization and systematization of outcomes at the Microsoft Excel 2019 software (Microsoft Office, 2019). Results. After full reading of articles’ texts 24 of them were interpreted as those containing new and/or unique information, interpretations or facts, out of which 9 were cross-sectional online surveys, 4 were editorials, 6 were literature/clinical reviews, 1 was brief report, 1 was opinion article, 1 was ethical moment, 1 was advice article, and 1 was web-source. New challenges related with COVID-19 vaccination within dental filed are represented by personal hesitancy of dental professionals and students, which in turn associated with provided information support, previous COVID-19 experience, fear of getting infected or transmit disease to the patients or family members, fear of potential development for post-vaccination side-effects, changes of occupational status, and interaction within dental team. Conclusions. Further improvement of dental care field possible only after vaccination of dental professionals. Vaccination of dentists widening window of their possibilities regarding potential role of dental specialist as members of COVID-19 vaccine’s delivery team, improvement of quality of life among dental patients (after its decreasing changes during pandemic), and providing dentists with important role in so-called “behaviorally informed strategies” and public motivational programs aimed at amplification of positive willingness for COVID-19 vaccination among general public.

Orthodontic Adolescent Patients’ Attitudes toward Protective Face Mask Wearing during the COVID-19 Pandemic

Background and Objectives: The COVID-19 pandemic led to restrictive measures, which aimed to limit the spread of the SARS-CoV-2 virus. These restrictions impacted all areas of life, including the activity of dental offices. For patients with orthodontic appliances, closing the dental offices was a major issue, as most orthodontic treatments last for more than a year and require regular checkups. The aim of this research was to assess the impact that the restrictive measures that were imposed during the COVID-19 pandemic, and, especially, wearing a face mask had on a sample of Romanian teenagers undergoing fixed orthodontic treatment. Material and Methods: The study group consisted of 277 orthodontic patients, with ages between 12 and 17.9 years, from North-Western Romania. They completed a 9-item questionnaire. The control group consisted of 231 participants, with ages between 12 and 17.9 years. They completed an 8-item questionnaire. Results: Most patients from the study group were not worried that wearing a protective face mask would hide their braces (never—49.5%; rarely—26.7%), and their desire to undergo an orthodontic treatment was not affected by the compulsoriness of face mask wearing (never—51.6%; rarely—26%). In contrast to that, in the control group, more than 50% of the participants were worried to some degree that wearing a protective face mask would hide their smile (occasionally—29.9%; frequently—18.2%; very frequently—2.2%). The majority of the participants from the study group did not consider interrupting the orthodontic treatment due to the COVID-19 pandemic (62.5%), and the majority of the participants from the control group did not consider not going to the dentist due to the COVID-19 pandemic (70.6%). Most of the participants from the study group were not happy that they had to wear a face mask, which covered their orthodontic appliances, during the orthodontic treatment (68.6%). The attitude was similar to that of the participants from the control group, who were not happy that they had to wear a face mask, that covered their smile (51.1%). In the study group, most patients did not want face mask wearing to continue to be compulsory, given the fact that their orthodontic appliances were no longer visible (52%). In the control group, the attitude was similar, with 48.1% of the participants not wanting face mask compulsoriness to be maintained. Conclusions: In conclusion, although, most patients would not like to continue wearing a face mask as a mandatory regulation, they were not concerned or negatively affected by wearing a protective face mask, even though face masks hid their braces.

Microbiological Contamination of the Office Environment in Dental and Medical Practice

The microbiological contamination of the environment in independent healthcare facilities such as dental and general practitioner offices was poorly studied. The aims of this study were to describe qualitatively and quantitatively the bacterial and fungal contamination in these healthcare facilities and to analyze the antibiotic resistance of bacterial pathogens identified. Microbiological samples were taken from the surfaces of waiting, consulting, and sterilization rooms and from the air of waiting room of ten dental and general practitioner offices. Six surface samples were collected in each sampled room using agar contact plates and swabs. Indoor air samples were collected in waiting rooms using a single-stage impactor. Bacteria and fungi were cultured, then counted and identified. Antibiograms were performed to test the antibiotic susceptibility of bacterial pathogens. On the surfaces, median concentrations of bacteria and fungi were 126 (range: 0–1280) and 26 (range: 0–188) CFU/100 cm², respectively. In indoor air, those concentrations were 403 (range: 118–732) and 327 (range: 32–806) CFU/m³, respectively. The main micro-organisms identified were Gram-positive cocci and filamentous fungi, including six ubiquitous genera: Micrococcus, Staphylococcus, Cladosporium, Penicillium, Aspergillus, and Alternaria. Some antibiotic-resistant bacteria were identified in general practitioner offices (penicillin- and erythromycin-resistant Staphylococcus aureus), but none in dental offices. The dental and general practitioner offices present a poor microbiological contamination with rare pathogenic micro-organisms.

Consequences of the COVID-19 Pandemic and Governmental Containment Policies on the Detection and Therapy of Oral Malignant Lesions-A Retrospective, Multicenter Cohort Study from Germany

Simple Summary

Due to the COVID-19 pandemic, the oncology community was challenged with the need to protect a vulnerable population from a potentially fatal infection without jeopardizing cancer treatments. The impact of the crisis on the medical care of patients with oral cancer is largely unexplored. This multicenter cohort study from Germany aims to assess the consequences of the COVID-19 pandemic by comparing the healthcare of patients during the lockdown and post-lockdown periods in 2020 with the corresponding periods in 2018/19. We found the closure of dental practices during lockdown to possibly delay the diagnosis of oral cancer. Even if during this period no higher incidence of oral cancer was observed, data point to potentially fatal consequences for longer periods of treatment delay.

Abstract

(1) Background: In response to the global COVID-19 pandemic, governmental measures have been undertaken. The impact of the crisis on the healthcare of patients with cancer is largely unexplored. This multicenter cohort study aimed to investigate a potential screening delay and its consequences in patients with oral cancer (OC) during the pandemic. (2) Material and Methods: Data of patients who were first diagnosed with OC during different periods were collected, especially in terms of OC incidence, tumor stage/entity and time to intervention. The periods lockdown (LD) (13 March–16 June 2020), post-lockdown (PLD) (17 June–1 November 2020), and the corresponding equivalents in 2018/19 were differentiated and compared. (3) Results: There was no obvious trend towards a higher incidence of OC or higher tumor stages, whereas a trend towards a shorter time to intervention during the LD2020 could be observed. Subgroup analyses revealed an increased incidence in OC within the PLD2020 in Mainz, which might be explained by the partial closure of dental practices in this federal state during LD. (4) Conclusions: While there was no overall higher incidence of OC, we found closure of practices during LD to possibly delay cancer diagnosis. Therefore, measures must be taken to identify patients at risk and to ensure basic healthcare, especially in the context of dental screening measures.

Methodology for Addressing Infectious Aerosol Persistence in Real-Time Using Sensor Network

Human exposure to infectious aerosols results in the transmission of diseases such as influenza, tuberculosis, and COVID-19. Most dental procedures generate a significant number of aerosolized particles, increasing transmission risk in dental settings. Since the generation of aerosols in dentistry is unavoidable, many clinics have started using intervention strategies such as area-filtration units and extraoral evacuation equipment, especially under the relatively recent constraints of the pandemic. However, the effectiveness of these devices in dental operatories has not been studied. Therefore, the ability of dental personnel to efficiently position and operate such instruments is also limited. To address these challenges, we utilized a real-time sensor network for assessment of aerosol dynamics during dental restoration and cleaning producers with and without intervention. The strategies tested during the procedures were (i) local area High-Efficiency Particle Air (HEPA) filters and (ii) Extra-Oral Suction Device (EOSD). The study was conducted at the University of Washington School of Dentistry using a network of 13 fixed sensors positioned within the operatory and one wearable sensor worn by the dental operator. The sensor network provides time and space-resolved particulate matter (PM) data. Three-dimensional (3D) visualization informed aerosol persistence in the operatory. It was found that area filters did not improve the overall aerosol concentration in dental offices in a significant way. A decrease in PM concentration by an average of 16% was observed when EOSD equipment was used during the procedures. The combination of real-time sensors and 3D visualization can provide dental personnel and facility managers with actionable feedback to effectively assess aerosol transmission in medical settings and develop evidence-based intervention strategies.