While the overall transmission of pathogenic microorganisms in oral healthcare settings remains rare, the recent COVID‑19 pandemic confirms healthcare-associated infections (HAIs) continue to present a potential hazard to oral health care professionals (OHCPs) and patients alike. The novel SARS‑CoV‑2, the virus that causes COVID‑19, presents several features that, when considered in total, pose a significant new infection control challenge to the OHCP:
It is a highly contagious respiratory virus. 4
It is primarily spread via mucosal (e.g., mouth, nose, eyes, lungs) exposure to respiratory droplets produced when the infected person speaks, coughs, or sneezes.
Airborne transmission of small aerosolized particles or droplet nuclei is likely, but person-to-person transmission over long distances (>6 feet) is unlikely.
Compared to other respiratory viruses (e.g., common cold, influenza), asymptomatic spread (40% - 45%) appears to be significant.
As a novel virus, there is no established natural human herd immunity.
The risk of occupational exposure to SARS‑CoV‑2 in the dental practice environment is considered to be very high.2,6 Dental settings have unique characteristics that warrant specific infection control considerations to guide the safe delivery of dental care during the COVID‑19 pandemic. Common dental procedures such as tooth preparation and osseous removal with rotary handpieces; tooth cleaning with ultrasonic scalers; and cleansing of the oral environment with air-water syringes all generate contaminated visible sprays and aerosols. The commonly used surgical masks in dentistry protect mucous membranes of the mouth and nose from droplet spatter, but they are insufficient to provide high-level protection against inhalation of airborne infectious agents such as SARS‑CoV‑2.7,8
To prevent or minimize COVID‑19 infection among OHCPs and patients, the CDC recently released interim guidance for OHCPs to deliver non-emergent patient care during the COVID‑19 pandemic. The proscriptive nature of these guidelines incur significant additional requirements on the outpatient dental care delivery model. As such, the guidelines attempt to reasonably maximize aerosol mitigation against the reality that most, if not all, outpatient dental facilities are neither designed nor equipped to routinely manage aerosol-based infections.9,10
As more is learned about SARS‑CoV‑2, the interim guidelines will undoubtedly change and OHCPs should regularly consult their state dental boards and state or local health departments regarding practice requirements specific to their jurisdictions, including recognizing the degree of community transmission and impact (Table 1).
Table 1. Community Transmission Categorizations.2
|No to minimal community transmission:|
Evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting.
|Dental care can be provided to patients without suspected or confirmed COVID‑19 using strict adherence to Standard Precautions.|
Given that patients may be able to spread the virus while asymptomatic or pre-symptomatic, it is recommended that OHCP practice according to CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID‑19 Response.
Because transmission patterns can change, OHCP should stay updated about local transmission trends.
|Minimal to moderate community transmission:|
Sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases.
|Dental care can be provided to patients without suspected or confirmed COVID‑19 using the CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID‑19 Response.|
|Substantial community transmission:|
Large scale community transmission, including communal settings (e.g., schools, workplaces).
General measures include:
Practice universal active source control and patient screening for fever and symptoms of COVID‑19 for all who enter the dental facility.
If patients do not exhibit symptoms consistent with COVID‑19, provide dental treatment only after you have assessed the patient and considered both the risk to the patient of deferring care and the risk to OHCP of healthcare-associated disease transmission.
Ensure the availability of the necessary PPE and supplies to support your patient volume. If PPE and supplies are limited, prioritize dental care to manage the highest need, most vulnerable patients first.
Consider all patients infectious and incorporate the additional consideration described in the interim guidance detailed below.