How safe are we at dental clinics during COVID-19 pandemic?

COVID-19 is the new kid on the block, yet, we do know a thing or two about it from the World Health Organisation (WHO).

COVID-19 is an infectious disease caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. We know the spread of this virus is commonly caused by direct or indirect contact, as well as respiratory droplets.

Virus transmission via direct contact and respiratory droplets happens when a person is in close contact (within 1m) with an infected person. The droplets, which are 5 to 10μm in diameter, are produced when the infected person coughs, sneezes or speaks.

We know that indirect COVID-19 virus transmission can occur by touching surfaces in the vicinity of the infected person, or by touching objects used on the infected person. For example, shopping trolleys, stethoscopes or contact thermometers.

We also know that the risk of infection is higher closer to the source of infection. We recently know, another possible transmission route is via aerosolised droplets, which are less than 5μm in diameter. Aerosols are produced in specific settings and procedures such as endotracheal intubation, open suctioning and a few others including dental procedures. The transmission of aerosols was reported to be up to 4m.

In April 15, 2020, the Centres for Disease Control and Prevention (CDC) had highlighted that unrecognised asymptomatic and pre-symptomatic infections are likely to contribute to disease transmission in healthcare settings.

In Malaysia, the first community COVID-19 screening tests that were conducted in Hulu Langat identified 4 out 5 positive cases who were asymptomatic. That affirms how asymptomatic individuals are equally contagious as symptomatic individuals.

Asymptomatic individuals in particular then will pose a reasonable threat to the safety of the healthcare professionals and public at large.

The Malaysian Dental Council (MDC) has advised postponing all elective dental procedures during this COVID-19 pandemic except emergency dental treatments. That measure is practically relevant, given there is a potential risk for SARS-CoV-2 virus transmission between patients, dental practitioners as well as dental auxiliaries. This risk revolves around the nature of dental setting and procedures as:

No possible social distancing between patient and dental practitioner. A study published in Sains Malaysiana by Saadun and colleagues (2020) revealed that patient-dentist distance is about 0.24m.

Dental procedures involve high aerosol formation from motorised dental instruments, for example, during scaling and filling procedures. The aerosol is also contaminated with saliva and blood from patients prior to its diffusion into the surrounding air.

Dental treatment is usually confined in a small room and takes relatively long sessions. As a result, aerosols produced during dental procedures persist within that limited space and would contaminate dental treatment equipment.

The standard protective measures in daily clinical work are not effective enough to prevent the spread of SARS-CoV-2 virus, especially when the dental patients have no symptoms of COVID-19, are unaware if they are infected, or choose to conceal their infection.

In dental teaching institutions, the situation varies slightly. Despite similar dental procedures being undertaken, the settings are different. Dental treatments are carried out by dental students concurrently under supervision of dental specialists.

The treatments take place in an open space called polyclinics and patients are separated by cubicles. There is no specific separation between those with comorbidities or young patients.

The circumstances in dental practice and dental teaching institutions do not seem to fit the “Three Cs” model of avoiding (i) Crowded places (ii) Confined places (iii) Close contact with one another.

For these reasons, both dental workers and patients are at risk of COVID-19.

The New York Times has published an article on March 15, 2020 regarding the risk of COVID-19 infection based on occupation.

The risk is based on 2 factors (i) exposure (how frequent a worker is exposed to diseases) and (ii) proximity (physical distance when at work). The article reported that among the high-risk groups are healthcare workers (including general medical practitioners and general dental practitioners) and first responders (including police personnel and paramedics).

To date, no transmission of SARS-CoV-2 virus or a cluster arising from the dental care sector has been reported.

Therefore, prevention of a cluster arising from this sector is an utmost priority. At this point of writing, we believe that more stringent infection control protocols are being discussed and will be implemented at dental settings.

However, we know at the back of our minds, more stringent infection control protocol by means of more COVID-19-proof personal protective equipment (PPE) would incur more cost to the dental treatment.

In addition, temporary limitations on the practice of aerosol generating procedures would limit certain necessary procedures which would increase the burden of dental diseases in the future.

This highlight is not meant to induce fear in the public, but it is rather a moral responsibility in helping patients to make well-informed decisions as well as for dental fraternities to be more prepared.

The dental profession had survived many virus sagas in the past, and the profession always adopts a ‘new norm’ after each.

In the 1980’s, during the mounting epidemics of human immunodeficiency virus (HIV), dentists around the world adopted a ‘new norm’ by wearing gloves, glasses and masks.

Prior to this, dentists used to treat patients with bare hands. Thus, SARS-CoV-2 is just another invisible opponent. As time will pass by, dentists will survive in this novel “new normal” - it might take a little more time, and efforts with precautions.