key: cord-289055-6qndq7m0 authors: suh, michael title: dental and medical collaboration during covid‐19 date: 2020-06-25 journal: j dent educ doi: 10.1002/jdd.12251 sha: doc_id: 289055 cord_uid: 6qndq7m0 nan resources to be available for critically ill patients rather than nonurgent dental patients who may present physically or by telephone consult. i reached out to my medical colleagues to see how i could assist during this covid crisis. my ultimate goal is to foster collaboration between medicine and dentistry, which has been a priority of interprofessional education. in hopes of properly managing dental patients who first contact them via emergency services, the medical residents requested a presentation on triaging dental emergencies and how to make appropriate dental referrals when necessary. referencing the "american dental association covid-19 practice resources," i developed a pow-erpoint presentation that detailed the causes of various dental emergencies and where to refer these patients: general dentist, oral surgeon, or the emergency room if in fact a life-threatening situation had developed. discussion points ranged from the etiology of decay, including proper oral hygiene; impact of diet on oral health; and infection with or without life-threatening cellulitis. i presented this powerpoint to 30 medical residents through zoom teleconferencing (see figures 1-4) . overall, the entire team involved felt that this presentation was a success. the medical residents expressed genuine interest by inquiring not only about dental emergencies, but also about topics such as prevention, optimal dietary habits, and dental access to care. through this application, the medical team has decided to institute more dental-focused questions and oral hygiene education into their well-checks, as well as requiring dental referrals. this is especially critical for children, who should establish a dental home by 1 year of age, according to the american academy of pediatric dentistry. by collaborating more with medicine through opportunities such as the one discussed, dentistry can reinforce its importance in overall patient health. several avenues where dentists can reach out to our medical colleagues and collaborate include university and hospital-based residencies, emergency rooms, private practices, or local and national medical associations. by advocating for this partnership with medicine and marching these small steps, we will eventually cement our bond and take giant strides towards providing healthier, comprehensive patient care. how to cite this article: suh m. dental and medical collaboration during covid-19 key: cord-338817-hxova3a0 authors: tarakji, bassel; nassani, mohammad zakaria title: reactivation of covid‐19 – 14 days from the onset of symptoms may not be enough to allow dental treatment date: 2020-06-10 journal: oral dis doi: 10.1111/odi.13487 sha: doc_id: 338817 cord_uid: hxova3a0 the pandemic of coronavirus disease 2019 (covid‐19) has become a global health disaster (phelan et al., 2020). on the level of dental practice, the risk of cross infection between infected patients and dental professionals is quite alarming. the current recommendations suggest that dental treatment of patients with suspected/confirmed coronavirus disease should be postponed for at least 14 days from the onset of symptoms (peng et al., 2020). this article is protected by copyright. all rights reserved the pandemic of coronavirus disease 2019 has become a global health disaster (phelan et al., 2020) . on the level of dental practice, the risk of cross infection between infected patients and dental professionals is quite alarming. the current recommendations suggest that dental treatment of patients with suspected/confirmed coronavirus disease should be postponed for at least 14 days from the onset of symptoms (peng et al., 2020) . this is the estimated time for the resolve of the virus. however, reactivation of coronavirus following recovery and discharge from the hospital has been reported in some cases (ye et al., 2020) . dental professionals should pay attention for patients who attend the dental clinic and declare infected with covid-19 and (osumi, 2020) . the author indicated that 14 days may not be enough period to produce antibodies in some patients especially the elderly (osumi, 2020) . masaya yamato, director of the infectious diseases center at the osaka-based rinku general medical center, stated that sars-cov-2, similar to other viruses, remains latent in certain cells in the body and once reactivated the virus may again attack the respiratory tract and intestines (osumi, 2020) . in south korea, a recent report indicated reactivation of covid-19 among 90 patients after recovery (farber, 2020) . the rt-pcr (reverse transcriptase polymerase chain reaction) testing for these patients was negative at time of discharge from hospital. however, they tested positive again after some days of clinical recovery (farber, 2020) . although the real causes of reactivation covid-19 are unknown, it is believed that viral load of covid-19 and variable genotypes may play role in reactivation (ye et al., 2020) . the formation of antibodies might be different among infected patients and may take longer time among others especially the old patients (osumi, 2020) . dental professionals should this article is protected by copyright. all rights reserved be aware about the potential for reactivation of covid-19 and this may have an implication on the right time to offer a dental treatment for patients who have recently recovered from the infection with covid-19 virus. as a preventive measure, dental treatment of recently recovered coronavirus patients should be postponed for at least 28 days not 14 days from the onset of symptoms (two continuous rounds of quarantine). this is to allow sufficient time to ensure the patient is free of the virus and there is no risk of infection with covid-19. none to declare who to investigate coronavirus 'reactivation questions raised over covid-19 reinfection after japanese women developed illness again. the japan times news transmission routes of 2019-ncov and controls in dental practice the novel coronavirus originating in wuhan key: cord-032698-ev8gylpf authors: fakhruddin, k. s.; ngo, h. c.; samaranayake, l. title: pandemic paediatrics date: 2020-09-25 journal: br dent j doi: 10.1038/s41415-020-2171-9 sha: doc_id: 32698 cord_uid: ev8gylpf nan sir, paediatric patients presenting with irreversible pulpitis and related afflictions need urgent care delivered through the use of aerosol-generating rotary instrumentation and air/water syringes. these procedures increase the probability of airborne microbial transmission, such as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). two recently published articles in your journal highlighted the utility of silver diamine fluoride (sdf) and potassium iodide (sdf/ki) application, and paediatric patients audit attending emergency care for irreversible pulpitis symptoms during the current coronavirus disease 19 (covid-19) pandemic. 1, 2 children are believed to exhibit only mild sars-cov-2 symptoms or they could be asymptomatic carriers and hence, the care pathway has been sensibly devised to treat every child as a potential covid-19 positive patient. 2 thus, to limit bioaerosol risks, the contemporary treatment algorithm includes the use of pre-procedure oral rinse with 1% hydrogen peroxide or povidone-iodine 3 and the use of dental dam, as well as high-volume suction. nevertheless, the use of mouthwash is contraindicated in children younger than sixyears-old owing to their immature, fine-motor control and oral muscle reflexes, required to properly spit out mouthwashes. 4 additionally, both in young and older children, the saliva laden expectorate laced with the virus itself may pose a threat of sars-cov-2 transmission, if it is not properly collected, contained, and disposed of. it is known that the cavitated dental lesion is a thriving biome of bacterial, fungal, and viral flora. thus, pre-treatment of the cavitated lesions with an antimicrobial, prior to high speed instrumentation, is likely to diminish the aerosolisation of viral particles and their inhalation by dental personnel. there is now ample data to indicate the viricidal potential of both silver and iodide containing formulations. 3, 5, 6 hence, we wish to propose that, for children younger than six years of age, the swabbing of the procedure site with gauze soaked in povidone-iodine should be followed by application of sdf and ki. the latter, while potentiating the antimicrobial effect, can also be an extremely effective dentine desensitiser. 1 in addition, desensitising the exposed operative focus of highly sensitive dentine could mitigate stress, and increase compliance and facilitate paediatric patient management. potential dental team role in supporting the delivery of a flu vaccination programme. 1 in the united states, minnesota and illinois allow dentists to administer vaccines, but only to protect against the flu and only in adult patients. in 2020, oregon becomes the first state in the united states to allow dentists to offer any vaccination to a patient. 2 in scotland, nhs dental contractors (dentists and dental bodies corporate) can opt in to participate in the 2020/21 flu vaccination programme. participation will be agreed locally by nhs boards and area dental committees, depending on the overall requirements to deliver the programme. a one-off participation fee of £250 will be offered to each contractor and in addition, a flat fee of £8.27 will be paid per immunisation. 3 nhs education for scotland is developing learning resources to support delivery of the flu vaccination programme. this is in line with the guidance from the general dental council that dental professionals must be trained and competent for all skills and treatment that they undertake. 3 indemnity cover for dentists will be provided by the scottish government. other members of the dental team will not be allowed to deliver vaccinations. c. a. yeung, bothwell, uk silver diamine fluoride -an overview of the literature and current clinical techniques covid-19 pandemic: the first wave -an audit and guidance for paediatric dentistry povidone iodine gargle and mouthwash pediatric dentistry: infancy through adolescence enhancement of respiratory mucosal antiviral defenses by the oxidation of iodide silver nanoparticles as potential antiviral agents dental team immunisation could vaccines come from your dentist? not yet 2020)12: influenza vaccination programme -2020/21 https://doi.org/10.1038/s41415-020-2183-5 sir, delivering the seasonal flu vaccination programme this year will be more challenging than in previous years due to the impact of covid-19. i fully support the proposal by serban et al. regarding the comment letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space.  british dental journal | volume 229 no. 6 | september 25 2020 325upfront key: cord-348947-o6qpaa6a authors: robson, j. stuart title: duty to extract date: 2020-10-23 journal: br dent j doi: 10.1038/s41415-020-2282-3 sha: doc_id: 348947 cord_uid: o6qpaa6a nan sir, as a past president of the bda i am dismayed and bemused to read frequent reports in national newspapers decrying the number of children awaiting many months for tooth extractions in hospitals. indeed, the daily telegraph claims that this is the most frequent referral cause for children to hospital, numbering equating to 177 cases per day nationally at an estimated cost of £41 million. a further report of this problem appears in the recent bdj (potential surge in post-covid child tooth extractions; bdj 2020; 229: 278). is this because dentists, both in practices and community dental services, are either unwilling or unable to perform this treatment? furthermore, it seems that frequent courses of antibiotics are prescribed to keep infection from carious teeth at bay pending hospital extraction. as we are all too aware, this repeat prescribing is undesirable, building up unnecessary resistances. i presume dental schools still educate undergraduates in the expert technique of extractions, therefore one must conclude that the problem is due to an unwillingness of clinicians in primary care to undertake these treatments. we must remember that for every child suffering from painful teeth, there are parents having to cope with stressful situations. many years ago, i was a member of the then termed 'poswillo' working party, reporting to the department of health on the safety of administering general anaesthetics (ga) in practices, but additionally our role included reviewing other means of anaesthesia. whilst not advocating a return to providing gas in outpatient clinics, in a primary care setting it is perfectly possible and permissible to extract offending teeth using either sedation or local anaesthesia or a combination of both. as healthcare professionals, dentists have a duty to relieve pain and to prevent the risk of complications arising from long-term infections rather than referring patients to a seemingly endless waiting list, especially during these difficult covid-19 times, which is exacerbating this dire state of affairs. j. stuart robson, york, uk https://doi.org/10.1038/s41415-020-2282-3 used a purpose built protection box during aerosol generating procedures (https://www. facebook.com/dentistsatwork). these solutions may not be perfect but they can provide necessary protection in the best and quickest way possible in the face of exponential spread of the pandemic and economic limitations. m. javed, qassim, saudi arabia, y. bhatti, london, uk sir, in the current pandemic, the lack of equitable oral healthcare facilities, shortfall of dental healthcare providers, shortages of equipment/materials, and inadequate management of existing services is well known in developing countries. 1 it may not be possible for such countries to upgrade the dental surgeries in their tertiary care facilities to the suggested level of ventilation, filtration, and negative pressure, due to financial limitations. the alternative solution for resource constrained environments is to explore frugal innovation approaches to make the most of existing assets and skills. 2, 3 for instance, for creating a temporary negative pressure in dental surgeries strong exhaust fans have been connected to the simple duct system to deliver the air from the surgery at the minimum three metres above the roof. 4 to prevent the transmission of infection through aerosol in the dental setting the 'protection box' is an innovative and economical solution for performing aerosol generating procedures. 5 the protection box has excellent visibility and can be reused after disinfection. recently, in pakistan a dental surgeon has designed and sir, i would like to thank all my colleagues who have worked so diligently to up-skill and kindly help guide others through the current covid-19 pandemic. until six months ago, like many colleagues, i had little knowledge of this new respiratory virus and its impact on the dental profession. thanks to this new novel virus, we now have a growing number of colleagues within dentistry who understand much more about respiratory viruses than i ever seem to remember learning at dental school or during my postgraduate studies. if we add to this the long list of acronyms with sops, agps, non-agps, ffps, written and re-written sops, the latest technology to help oral health care systems in developing and developed countries fast and frugal innovations in response to the covid19 pandemic frugal and reverse innovation in surgery frugal solutions for the operating room during the covid-19 pandemic patients' case scenario as well as approaches and strategies adopted to manage covid-19 pandemic at aligarh muslim university letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space. key: cord-335979-gaqa24b9 authors: martins, manoela domingues; carrard, vinicius coelho; dos santos, camila mello; hugo, fernando neves title: covid‐19– are telehealth and tele‐education the answers to keep the ball rolling in dentistry? date: 2020-07-02 journal: oral dis doi: 10.1111/odi.13527 sha: doc_id: 335979 cord_uid: gaqa24b9 larry david, the co-creator and producer of seinfeld, when asked by a reporter from the new york times about what he fears the most while quarantining during the covid 19 epidemic, responded "anarchy and a potential dental emergency and not necessarily in that order"(dowd, 2020).the pandemic introduced a new layer of challenges on how to provide care, alleviate pain. restrictions have been implemented by the majority of governments, as sars-cov-2 has been detected in saliva samples and infection typically spread through respiratory droplets (centers for disease control, 2020). governments, as sars-cov-2 has been detected in saliva samples and infection typically spread through respiratory droplets (centers for disease control, 2020). the management of dental patients during the covid-19 pandemic poses additional challenges also because of widespread, global shortages in ppe and of lock downs, where such recommendations fall short. there isn't such a thing as a 'one size fits all recommendation'. several recommendations have been laid out for the provision of oral health care, including telescreening and triaging, patient evaluation and cohorting, pharmacologic management (ather, patel, nb, diogenes, & hargreaves, 2020) . substitution this article is protected by copyright. all rights reserved of the use of handpieces by hand instrumentation when possible and use of minimally invasive dentistry has also been advocated. in fact, telescreening is an important first measure to determine whether patients may or may not be suspected of infection. however, it constitutes only one of many of the uses of teledentistry, which may be a valuable tool in the management of dental patients during the pandemic. teledentistry refers to the use of information and communication technologies to improve dental care offered to distant or isolated people, with the support of specialists (daniel & kumar, 2014; carrard et al., 2018) . more recently, teledentistry use has increased progressively, particularly in large countries such as brazil. in the case of the telehealth program of the federal university of rio grande do sul, the goal is to strengthen the coordinating role of primary care and improving health care with the use innovative telehealth applications with actions that include teleconsultation, telediagnosis and teleeducation (harzheim et al., 2016) . specifically, we have estomatonet, a telediagnosis service created to support primary care dentists and physicians in the diagnosis and decision making for oral lesions. a survey on the reports of this service reveals that in 25% of the requests, the recommendation was medication prescription or follow up (carrard et al., 2018) . this suggests not only that telescreening and teletriage might be extremely useful, but also that telehealth strategies might be effective in the pharmacological management of several oral conditions, contributing to reduce sars-cov-2 spread. lastly, we will approach tele-education in dentistry, since dental education has come to a halt worldwide. it is clear that the covid-19 pandemic has had an impact on dental education (quinn et al., 2020) , disrupting the traditional education of future dentists for months to come. tele-education quickly became an option (mukhopadhyay et al., 2020) that has been welcomed by health sciences students and faculties. incorporating online elements into education has been reported to bring many benefits, and has been recognized as a successful educational strategy, including dental education (linjawi, walmsley, & hill, 2012) . it may represent an important tool during the pandemic, in terms of increased accessibility, at anytime and anywhere (quinn et al., 2020) . to the benefit of dental educators, the existing evidence supports that dental education with the support of telematics is effective in knowledge acquisition (lima et al., 2019) . however, it should be pointed that distance learning is not transferring the accepted article traditional lecture to a web-based platform. distance learning must not be a poor version of traditional, in-class dental education. in spite of its success, our experience with teleeducation also had its challenges, particularly low attendance (roxo-gonçalves et al., 2017) , which were partially overcame by further adapting and changing the courses to incorporate the needs of students . the novel pandemic undoubtedly created stress throughout the health care system and, for dentistry to keep the ball rolling, dental care delivery needs to be redesigned. evidence supports the use of teleconsultation consulting and tele-education as effective alternatives in this hard period to avoid sars-cov-2 dissemination and more collateral damage. coronavirus disease (covid-19): implications for clinical dental care performance of primary healthcare dentists in a distance learning course in pediatric dentistry telediagnosis of oral lesions in primary care: the estomatonet program teledentistry: a key component in access to care larry david, master of his quarantine telehealth in rio grande do sul, brazil: bridging the gaps. telemedicine and e-health effectiveness of the distance learning strategy applied to orthodontics education: a systematic literature review online discussion boards in dental education: potential and challenges leveraging technology for remote learning in the era of covid-19 and social distancing: tips and resources for pathology educators and trainees covid-19: the immediate response of european academic dental institutions and future implications for dental education teledentistry: a tool to promote continuing education actions on oral medicine for primary healthcare professionals writing-review & editing. vinicius coelho carrard: conceptualization, writing-original draft, writing-review & editing. camila mello dos santos: writing-review & editing. fernando neves hugo: conceptualization, writing-original draft, writing-review & editing key: cord-346225-dmwrm6jl authors: lucaciu, ondine; tarczali, dorottya; petrescu, nausica title: oral healthcare during the covid-19 pandemic date: 2020-05-01 journal: j dent sci doi: 10.1016/j.jds.2020.04.012 sha: doc_id: 346225 cord_uid: dmwrm6jl nan the coronavirus disease 2019 (covid-19) epidemic began in wuhan, china, in december 2019. 1 on january 1st, 2020, who announced that this outbreak represents an international public health emergency, affecting 2,725,920 people by april 24, 2020, causing, 191,061 deaths. 2 on february 11, the international committee on taxonomy of viruses has made public the name of the virus causing covid-19: severe acute respiratory syndrome coronavirus 2 (sars-cov-2). 3 the two modes of transmission are via aerosols, through drops of fluid spread by coughing, sneezing, and fecal-oral (digestive). 1 the incubation period is 1e14 days, most commonly 3e7 days. patients are contagious in the latency period. on average, a patient can infect another 2e2.5 people. 4 the the fraction of severe, critical cases and mortality rate is higher, compared to influenza. the number of deaths per day relative to the total number of cases gives us a percentage of 3e4%. 4 in light of the thread of covid-19 pandemic, the conception of strict and efficient protocols for oral healthcare settings is of paramount importance. this specialty is prone to cross infection among patients and healthcare workers. this article provides recommendation on patient evaluation, treatment approach for dental emergencies and infection control protocols. screening for covid-19 status and triaging for dental treatments during the pandemic, it is recommended to perform exclusively emergency dental procedures to protect the medical personnel, the patients and to reduce as much as possible the consumption of personal protective equipment. patients' general health assessment before dental treatment is very important (fig. 1) , as dental health workers can identify undiagnosed covid-19 patients. emergency dental patients that test positive for sars-cov-2 should be referred for emergency care where appropriate transmission-based precautions are available. the indication for sars convalescing patients was to postpone dental treatments for 1 month. 7 same recommendation could be adopted for covid-19 patients. what is considered an emergency in dentistry, according to ada? dental emergencies are those that put the patient's life at risk and require immediate treatment to stop bleeding, reduce pain and stop infection. the emergency dental cases are represented by: severe pain of pulp origin pericoronaritis, pain in the third molar region postoperative osteitis, dry alveolitis dental fractures causing pain or soft-tissue injuries caused by trauma luxations, dental avulsions dental treatments required before general medical procedures final cementation of crowns, decks if provisional restoration is lost, deteriorated or causes gum irritation biopsies other emergencies shall be considered as follows: extended cavities or damaged restorations causing pain (temporary restorations are performed) suppression of suture threads dental treatments of oncology patients dental adjustments when function is impaired change of temporary fillings in endodontic access cavities, if they have caused pain adjustment of the orthodontic apparatus if it has caused pain or ulceration on the oral mucosa. 8 assessment of the gravity of the dental emergency is very important. the evaluation of the dental and general health status of the patient is based on the workflow in fig. 1 . dental practitioners should aim to ease patients suffering and alleviate the burden that dental emergencies would place on hospital emergency departments. social distancing protocol for patients should be adopted in the dental office. appointments should be scheduled apart to minimize contact between patients. if this standard is not applicable, patients can wait in their personal vehicle, until it is their turn. since the main route of transmission of the virus is the aerial one, it is necessary to use personal protective equipment, gloves, face masks (n-95 or ffp2), goggles or facial shield to protect the skin and mucous membranes of the medical personnel as well as waterproof robes, jumpsuits. if the mask is damaged, or the doctor has difficulties breathing, the mask should be changed. dental health worker should have a seasonal flu vaccine this year, illhealth status of medical personnel has to be assessed daily. rigorous hand hygiene and surfaces in the dental office is the most important measure of reducing the transmission of microorganisms to patients. depending on surface type, temperature, humidity, sars-cov-2 may persist on surfaces from a few hours to a few days. all reading materials, magazines and toys should be removed from the dental office. to minimize the formation of drops and aerosols, it is recommended to perform minimally invasive procedures, to use the surgical vacuum cleaner, 4-hand work, and rubber dam isolation of the operator field. before dental procedures it is recommended that the patient rinses with antimicrobial oral solutions. 9 resorbable sutures after surgical procedures are recommended. aerosol generating procedures should be scheduled at the end of the program. oral healthcare during the covid-19 pandemic if procedures were performed without n95 masks, both the healthcare provider and the patient are at moderate risk for sars-cov-2 infection/transmission. fourteen days of quarantine are recommended after this exposure. as intraoral x-ray can induce saliva secretion and coughing, 10 extraoral radiographies (panoramic, cone beam computer tomography) are alternatives. after providing dental care, facial protective equipment should be cleaned and disinfected. the x-ray equipment, the light and the dental chair should be disinfected according to the instructions of the manufacturer. the floors should also be disinfected. handpieces must be sterilized after each patient. frequently used surfaces such as: door handles, bathrooms, desks must be disinfected often. in the areas severely affected by covid-19, the patients arriving in the waiting room should receive protective masks. 1 the covid-19 pandemic represents a global challenge, given the increased contagiousness of sars-cov-2, dental healthcare providers have to adopt new protocols for a better infection prevention in the dental office and new working protocols aimed to prevent spreading the virus. the authors have no conflicts of interest relevant to this article. coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine reported cases and deaths by country, territory, or conveyance naming the coronavirus disease (covid-19) and the virus that causes it world health organization. coronavirus disease 2019 (covid-19) situation report 46 management of acute dental problems during covid-19 pandemic american dental association. ada interim guidance for management of emergency and urgent dental care the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination available at guidelines for infection control in dental healthcare settingsd2003 modern dental imaging: a review of the current technology and clinical applications in dental practice the authors received no funding for this work. key: cord-031508-1l9dxc16 authors: bradbury, sarah title: mind over matter date: 2020-09-07 journal: bdj in pract doi: 10.1038/s41404-020-0506-5 sha: doc_id: 31508 cord_uid: 1l9dxc16 nan a study conducted by researchers from the university of sheffield and ulster university found that on tuesday 24 march, the day after the prime minister told the british public to stay at home, 38% of study participants reported significant depression and 36% anxiety. this compared with 16% and 17% respectively the day before the announcement. 2 what's more, in april the lancet announced that 42 researchers from around the world, including a professor from the university of bristol, would form the international covid-19 suicide prevention research collaboration, due to the international concerns about the increase in mental health issues. 3 for some people the isolation of feeling confined to their home had a severe impact on their mental health -too much worry, stress or even boredom can have an effect, and if not recognised and dealt with, could see you suffering way beyond the time a vaccine is found for covid-19. and for many of us it wasn't just the lockdown that caused stress, it was the worry of going back to our previous lives; stressful or crowded commutes and for all principals the financial pressure of running a business or potentially having to close the practice because of a covid case, for example, all added to the pressure. and away from the world of work are the responsibilities of families, our health and that of our loved ones, the expectations of a social life with friends and an exercise regime to fit in. basically, our lives being so full they feel overwhelming, and the more the 'pre-virus' world becomes unreal, the more we have to start from scratch to create a 'new normal' . 1 katherine may, author of the book 'how i learned to flourish when life became frozen' wrote in the observer in april this year: 4 "this moment of mass confinement sees many of us grappling with a sudden sense of irrelevance, of being restrained from succeeding. we are urged to think of the bigger picture, and we do, but that does nothing to soothe the sense that our life's work -the sum total of our ambition -is now considered petty… in less interesting times, we will meet acquaintances on the street and tell each other how busy we are, what a rush we're in, how fast life is. in fallow periods, time opens up, and we read it as an insult. the outside world does not require us. we are surplus stock, just another human body… but there is unpicking to be done here, because the pace at which we live is so often destructive. being busy makes us skim over life like a stone on still water. in quieter times, we can feel the presence of all the things we miss in our hurry. " 4 for some, the lockdown provided positive effects on their mental health. once we got into the routine and flow, it gave many of us a chance to step back from our daily grind and find some peace and tranquillity. not feeling guilty about savouring a quiet moment of contemplation, listening to the birds sing, stopping and feeling the warmth of the sun, going for a walk in an unexplored area locally the dental profession for any dental professional, the knowledge of not being able to care for your patients, often whom you have long-term relationships with, was deeply unsettling. 6 added to this having to try to give online consultations with the implications and long-term harm of diy dentistry and not even knowing if the business will ride the storm. taken together all this can be very stressful indeed. 1 in a recent dental defence union (ddu) survey 68% of dental professionals think their stress and anxiety has worsened since the pandemic began, with around half feeling that they couldn't do their jobs properly. 7 moving on to a 'new normal' is even harder when there is limited ppe for dental professionals, social distancing is needed in practices and additional government guidelines to follow. 6 the bda, for example, has a detailed faq page that is updated regularly, as well as a live updates page. these can be useful resources as a one stop shop to keep you up to date on changes with what treatments are permitted, news on regional toolkits and a summary of the governments' changing guidelines on the way you should now work. 8 for england, and there is some variation for wales, northern ireland and scotland, the chief dental officer has published standard operating procedures to cover a phased return for dental practices. from 15 june this year, dental practices were tasked to ensure that staff always wear a surgical mask when not in ppe, that staff should self-isolate for 14 days if they've been in contact with someone covid-19 positive and that practices should follow nhs test and trace requirements. from 20 july, all practices were given the green light for face-to-face contact as required, but still with certain restrictions, so it's important to ensure things don't become even more stressful for you when trying to follow guidelines to protect your patients and teams. mind, the uk national mental health charity, has worked for over 60 years to improve the lives of those who experience mental health problems. they provide specific advice online on how to deal with the personal repercussions of the covid-19 pandemic, from ways to connect with others and stimulate your mind, to how to relax and ways to view the news in a more pragmatic way. 9 bda president roz mcmullan has meanwhile been working to support the mental wellbeing of frontline staff during the crisis, and in a blog in june discussed the level of stress dentists are under and suggested three strategies for coping: not ignoring the signs of stress, empowerment through supporting colleagues and considering what information you consume. 8, 10 she was also the lead in a bda event in february this year, that gathered key stakeholders in uk dentistry to see how they could collaborate on improving the services and support for the mental health and wellbeing of dentists, as it has always been an important consideration, even before the pandemic hit. 10 currently, bda members can access counselling services and a 24-hour confidential helpline, but any dental professionals can access the dental health support trust. there are also a number of closed online groups where dental professionals can join to support each other. many local dental council's (ldcs) also offer practitioner advice and support schemes (pass) in a number of areas and hope to expand around the country. there is also the dental health support programme (dhsp) providing mental health and addictive disorder support. in england, dentists recently gained access to the nhs practitioner health programme (php) and in northern ireland similar support is available through inspire. many indemnity organisations also provide counselling services and courses, so there is support at every turn if you look for it. bear in mind that the gdc does expect dental professionals to look after their own health in the interests of providing safe care for patients. standard 9.2 reminds dental professionals that you may not be best placed to identify or assess your own health concerns. 11 what now? we have already learnt new ways to communicate in our personal and professional lives, whether it is video consultations or talking to a neighbour -with a two-metre gap of course! and if the personal, professional or financial sacrifices that we have made to protect the society we live in don't lead to some lasting improvements from an environmental or societal point of view, then it is a sad reflection on our inability to adapt and find positives despite unwanted change. it has given leaders and individuals a chance to see real opportunities for positive change, which could help us all have a more fulfilled life, understanding a bit better how to look after our mental health and that of others. world health organisation. mental health and psychosocial considerations during the covid-19 outbreak news release: depression and anxiety spiked after lockdown announcement, coronavirus mental health study shows suicide risk and prevention during the covid-19 pandemic living in our isolation bubbles can bring great rewards the lockdown paradox: why some people's anxiety is improving during the crisis available online at: www.theguardian.com/society/2020/may/30/ shortage-of-ppe-may-force-reopened-dentiststo-limit-treatments news release: ddu launches new employee wellbeing helpline for dental members british dental association. coronavirus: live updates. available online at available online at: www.mind.org.uk/informationsupport/coronavirus/coronavirus-and-your-well being/#takingcareofyourmentalhealthandwell being dentistry and mental health: what next? available online at: www.gdc-uk. org/docs/default-source/standards-for-thedental-team/standards-printer-friendly-colour. pdf?sfvrsn=98cffb88_2 key: cord-318136-2skr13gc authors: jevon, phil; shamsi, shaam title: using national early warning score (news) 2 to help manage medical emergencies in the dental practice date: 2020-09-11 journal: br dent j doi: 10.1038/s41415-020-2024-6 sha: doc_id: 318136 cord_uid: 2skr13gc if a medical emergency occurs in the dental practice, members of the dental team must be able to respond promptly, effectively and safely. fundamental to this response is knowing when it is necessary to call 999 for an ambulance and communicating effectively with the ambulance service to ensure the timely arrival of the emergency services and timely transfer to hospital. this can be helped by using the royal college of physicians' (rcp's) national early warning score (news) 2, widely used by the ambulance service and in hospitals it reliably detects deterioration in adults, triggering review, treatment and escalation of care. although news2 hasn't yet been validated for use in primary care, nhs england is encouraging its widespread use in this sector. using news2 in the dental practice will help the dental team to effectively, confidently and safely manage medical emergencies, including sepsis, should they arise. this will facilitate effective teamwork and help to ensure enhanced patient outcomes. this article provides an overview of news2, including benefits for using it in the dental practice and guidance on how to implement it. members of the dental team are expected to be able to effectively and safely manage medical emergencies in the dental practice. 1 fundamental to achieving this is recognising when patients are ill and communicating effectively with the ambulance service to ensure the timely arrival of the emergency services and timely transfer to hospital. the royal college of physicians' (rcp's) national early warning score (news) 2, 2 widely used in the healthcare setting both in the uk and abroad, reliably detects deterioration in adults, triggering review, treatment and escalation of care. 3 although news2 has yet to be validated for use in primary care (research is ongoing), nhs england is encouraging its use in this sector. 3 the aim of this article is to understand how news2 can help members of the dental team manage a medical emergency in the dental practice. news was developed in 2012 by the rcp to improve detection of, and response to, clinical deterioration in patients who are acutely ill. 2 news2, released in 2017, 2 has been endorsed by nhs england and nhs improvement for use in both the ambulance service and in acute hospitals. 3, 4 three-quarters of acute trusts and all ambulance trusts are currently using it. 3 news has standardised how acute illness is assessed and responded to and, in hospitals alone, it is estimated that close to 2,000 deaths a year will be prevented. 2 with news2, a simple scoring system is used whereby a score is allotted to each of six physiological measurements (box 1), which are commonly undertaken in healthcare settings. 3 it has been validated for use in adults (>16 years of age) but not in pregnant women or children (<16 years of age). 2, 3 the scores are calculated using the news2 observation chart (fig. 1) . a score is allocated to each of the physiological measurements (box 1); the higher the score, the more abnormal the measurement. 3 the score is aggregated and, if the patient requires supplementary oxygen, it is increased. an elevated news score doesn't provide a diagnosis, but helps to identify patients who are sick, requiring urgent clinical review following a standardised approach. 3 the news thresholds and triggers chart (fig. 2) can then prompt an appropriate response. another chart providing guidance on the recommended clinical responses to news trigger thresholds is available, particularly for use in hospital settings. the news2 observation chart (fig 1) incorporates a number of improvements made to the first news chart published in 2012, 2 including: • the familiar and systematic 'airway breathing circulation disability exposure' (abcde) approach advocated by the resuscitation council uk to assess (and treat) the acutely ill patient • a list of ranges for the boundaries of each measurement score • a specific section (spo2 scale 2) to be used when the patient has hypercapnic respiratory failure (usually copd) who has a clinically recommended oxygen saturation measurement of 88-92% • a new 'confusion' (disorientation, delirium or any new alteration to mentation) component has been incorporated into the familiar avpu assessment tool, which is now acvpu (where 'c' represents confusion). this can help to identify suspected sepsis • improved section for the administration of oxygen • the importance of considering sepsis is emphasised in patients who are known to have an infection, suspected to have an infection or are at risk of infection; in these patients, a news2 score of 5 or more is the key trigger threshold. the rcp hopes that news2 will be validated for use in primary care, assisting triage and communication of acute-illness severity to ambulance and hospital services. 2 nhs england encourages the use of news2 to assist clinical assessment in the primary care setting, as work continues to collect reliable evidence to validate its use. 3 it has shown that the use of news in the pre-hospital setting may facilitate earlier recognition of deteriorating patients, earlier involvement of senior emergency department staff and more appropriate levels of critical care. 5 unsurprisingly, very high and very low news scores are reliable indicators to identify patients who are and are not likely to deteriorate in the pre-hospital setting. 6 higher news scores have been shown to be associated with decreased time from referral to arrival for patients conveyed by ambulance, together with decreased time from arrival in hospital to doctor review. 7 a number of doctors' surgeries (west of england, liverpool and wessex) have found the use of news helpful as an adjunct to decision-making, a prompt to do a complete set of observations and an aid to communication with the rest of the healthcare pathway, including the ambulance service, regarding deteriorating patients. 3 this enables colleagues in other settings (for example, ambulance service and emergency department) to plan, prioritise and place patients safely and appropriately. in summary, what news2 offers is a prompt to encourage the reliable taking of physiological observations, an adjunct to clinical decisionmaking and a very clear, easily communicated and well-understood physiological score that the rest of the care pathway understands. 8 although news2 has not yet been validated for use in the dental practice setting, there are a number of reasons why dental practices should seriously consider introducing it as an adjunct to help them respond to a medical emergency: • news2 can provide an objective assessment of a patient's physiological state, adding to and reinforcing clinical judgement; it can help reinforce dental teams' clinical findings and flag up patients who are more likely to deteriorate when having a medical emergency in the dental practice (particularly when consecutive news2 scores display an upward trend) • the news2 observation chart (fig. 1) reinforces the abcde approach to assess (and treat) the acutely ill patient • news2 can improve the objective assessment of patients with a medical emergency such as suspected sepsis, acute asthma attack and anaphylaxis • news2 can help with communication when calling 999 for an ambulance (every ambulance service in the uk now use it) 3 because the news2 score enables the dental team to communicate vital signs data in a common language • news2 can empower the dental team to be listened to; for example, when calling 999 for an ambulance, if they have concerns about a patient 3 • the earlier a complete set of observations is done (for example, in the dental practice), the sooner a patient can be placed on a track and trigger score, enabling deterioration to be tracked and resources prioritised 9 • in the current nhs climate where 'ambulance stacking' seems to be becoming more common, every bit of non-subjective information such as a high news score can improve the triage, speed up the arrival of the paramedics and guide the urgency of transfer to the emergency department 8 • news2 can be used for communication and handover when patients are transferred to and from acute hospitals it is important to remember that news2 does not replace clinical judgement. 9 clinical judgement should always be used, even if the news2 score is normal. the dental team should escalate deteriorating patients for review whenever they are concerned, even if the news2 appears to be reassuring. a good example of this is a patient with chest pain. a patient could be having an acute coronary syndrome (heart attack) but have a normal news2 score. guidance and advice on implementing news2 are freely available on the rcp's website (www. rcp.org.uk). in addition, some basic equipment together with appropriate staff training will be required. the following equipment/resources will be required: • blood pressure monitor: at present, only dental practices that use sedation are required to have a blood pressure monitor (fig. 3) for oxygen saturation monitoring. 11 some other dental practices already have one on the premises, but for those that don't, basic affordable devices are widely available • thermometer: dental practices should already have a thermometer (fig. 4) because, according to nice guidance, the confirmation of fever in a patient with a dental abscess is one indication for prescribing antibiotics. 12 also, due to the current crisis, a thermometer would be useful even more so now, and highly indicated in recording the temperature in a patient with suspected covid-19 infection and managing our patients effectively • pulse oximeter: at present, only dental practices that use sedation are required to have a pulse oximeter (fig. 5) for oxygen saturation monitoring. 11 however, affordable fingertip pulse oximeters can be purchased and these devices are particularly useful in monitoring patients with medical emergencies such as sepsis, acute asthma attack and respiratory difficulties that can complicate covid-19 • news2 charts: freely available from the rcp's website. they are free to use, but it is not permitted to alter them and the charts need to be printed out in colour. 2 as well as having training in the use of the above devices, staff training and familiarisation with news2 will be required. the rcp provides information relating to news2 training resources on its website. the e-learning course ('standardising the assessment of acute-illness severity in the nhs') is free for nhs staff with an nhs e-mail address (nhs.net or nhs.uk). a training document together with webbased educational tools in varying formats to support news2 being implemented at local level are available at http://tfinews. ocbmedia.com. 2 these resources include using supplementary oxygen, the importance of new confusion and how news2 can be used to recognise sepsis. 2 in addition, news2 refresher/awareness training can be simply included in annual medical emergencies training undertaken in dental practices. using news2 in the dental practice will help members of the dental team effectively, confidently and safely manage medical emergencies, should they arise. this will facilitate effective teamwork and ensure enhanced patient outcomes. ultimately, in line with gdc principle 1, the dental team will be working in the best interests of patients. 13 this article has provided an overview to news2 as well as some guidance on how to implement it. general dental council. scope of practice news) 2: standardising the assessment of acute-illness severity in the nhs national early warning score (news) (news) 2 to improve detection of acutely ill patients validation of the national early warning score in the prehospital setting can early warning scores identify deteriorating patients in prehospital settings? a systematic review association between national early warning scores in primary care and clinical outcomes: an observational study in uk primary and secondary care news 2: an opportunity to standardise the management of deterioration and sepsis the updated national early warning score and its use with suspected sepsis royal college physicians. news2 and deterioration in covid-19 dental mythbuster 10: safe and effective conscious sedation general dental council. standards for the dental team key: cord-326413-rhvsdpyk authors: nuzzolese, emilio; pandey, hemlata; lupariello, francesco title: dental autopsy recommendations in sars-cov-2 infected cases date: 2020-05-04 journal: forensic science international doi: 10.1016/j.fsisyn.2020.04.004 sha: doc_id: 326413 cord_uid: rhvsdpyk abstract unidentified human remains with unknown medical history can always pose biological hazards to forensic pathologists and odontologists, including hepatitis c, hiv infection, middle east respiratory syndrome (mers), hemorrhagic fever viruses such as ebola, meningitis and now sars-cov2. the pandemic of the new coronavirus disease (covid-19) has reached 185 countries with an increasing number of deaths. forensic pathologists and odontologists may find themselves having to perform an identification autopsy to confirmed or suspected sars-cov2 positive deaths. by respecting the entire set of universal precautions and recommendations the highlighted risks can be minimized, and best practice in human identification should always be a priority for human rights of the dead. the following article is a summary of the recommendations for conducting dental autopsies and management of suspected covid-19 cases. coronaviruses are a large family of zoonotic rna betacoronaviruses that mainly circulate among animals including mice, pigs, bats and avian hosts [1] , but it has been known since the 1960s that they can infect humans too. they belong to the family of coronaviriade and have a large genetic diversity which, during viral replication, generate sub-genomic rnas leading to an increase in the coronavirus species [2] . also, human to human transmission has been reported [3] . novel viruses are often associated with human outbreaks. there are already seven coronaviruses known to infect humans: oc43, sars (severe acute respiratory syndrome coronavirus), hku1, 229e, nl63, and mers (middle east respiratory syndrome coronavirus) [4, 5] . the seventh strain emerged in china, whose epidemic started in wuhan, on december 12th, 2019, from a local fresh seafood market [1] and was designated severe respiratory syndrome coronavirus 2 (sars-cov2-2) which causes the coronavirus decease 19, covid-19 [3, 6] . cadavers can always pose biological hazards to forensic scientists, including hepatitis c, hiv infection, middle east respiratory syndrome (mers), hemorrhagic fever viruses such as ebola, meningitis and now also sars-cov2. the pandemic of the new coronavirus decease, as of april 14, 2020, has reached 185 countries with 1,920,918 deceased [7] . according to our best knowledge, there are no cases reported of an infected medical examiner after an autopsy of a covid-19 [8] , and no identification autopsy has yet been reported with suspected or confirmed sars-cov2 positive human remains. nevertheless, considering the covid-19 outbreak and the declaration of a pandemic on the march 11, 2020 by the world health organization and the increasing number of deaths, we have to consider this potential infectious risk for forensic pathologists and odontologists. this short report provides specific recommendations to forensic odontologists in terms of biosafety and infection control practices during the post mortem dental data collection of unidentified human remains without any known medical history data. a dental autopsy should be performed when identity is unknown, limiting the number of personnel working on the autopsy room to three people: three odontologists or two odontologists and one dental hygienist with forensic background. alternatively, a forensic pathologist, may assist the dental autopsy, too. immunosuppressed or high-risk autopsy personnel should not participate. the authors advise odontologists to always discuss the case with the forensic pathologist in charge before starting the dental autopsy. the infectious nature of case should be determined before any post mortem dental data collection, starting from the available history given by the police on the circumstances of the recovery of the body and as per centers for disease controls and prevention, 2020, the collection by the medical examiner of specimens for sars-cov-2 testing: nasopharyngeal swab and oropharyngeal swab [9] . it is well known that infection can be spread either by aerosol or directly through cuts and puncture wounds. when such cases are unsuspected or undiagnosed before death, it can be hazardous to the forensic pathologist, odontologist, technicians, and other personnel present in the mortuary. the most important aspect of protection for dental autopsy personnel is the correct use of personal protective equipment and training prior to conducting any autopsy and dental autopsy [9e12]. full ppe and necessary equipment should be to hand in order to avoid leaving the mortuary area. these are the universal precautions and ppe recommended: -wear surgical uniform; -over the scrubs wear a long-sleeved waterproof or fluidresistant gown to protect chest, arms and legs; -a disposable apron covering chest and legs over the waterproof gown; -double non sterile gloves (preferably nitrile gloves); gloves must extend to cover wrists; the second nitrile gloves can be changed frequently, if needed; -wear heavy-duty gloves over the first nitrile gloves (if post mortem dental data collection involves checks' cuts); -consider using a whole-body suit; -use goggles and a plastic face shield or face mask to protect the face, eyes, nose, and mouth; -class 3 or class 2 filtering face masks (certified disposable n-95 respirator or higher, ffp2, ffp3). surgical masks do not provide adequate protection but can be worn over the an ffp2 mask, but ffp3 masks are preferred; -rubber boots and waterproof shoe protectors; -surgical cap. the precautions listed above may exceed the capabilities of under-staffed or overwhelmed forensic facilities. in this event, forensic odontologists must protect at least eyes, mouth and hands with two physical barrier (two pairs of gloves; googles or glasses and a face shield; multiple filtering masks). where there is nonavailability of ppe, the dental autopsy must not be performed and postponed. to prevent exposure of the eye mucosa by any accidental splashing, goggles or face shield should fit the contours of the user's face. ears and nose orifices and wound openings, like tracheostomy opening, should be packed using cotton or gauze dipped with disinfectant [13, 14] . the splashing of water or fluids is to be strictly avoided while performing dental autopsy. when necessary, wipe the shield with a wet gauze to enhance visibility. dental autopsies have no aerosol-generating procedures, but require instruments, photographic and radiographic equipment. caution should be exercised while using any sharp instruments, and only one odontologist must be allowed to perform any cuts on the human remains. dental radiography with portable equipment must be performed but should limit the potential for staff exposure to covid-19 [15] . to reduce the time of the dental autopsy, periapical xrays should be limited to sound teeth for age estimation, treated teeth, teeth with decay, edentulous areas and any region with unique findings. all photography and radiography equipment should be covered with waterproof material such as plastic sheets to minimize contamination. the disinfection of such equipment is paramount. gloves should be changed before using any photography or xray equipment. to make the process convenient, it is highly recommended that a clean (uncontaminated) ppe protected personnel assist in photography and radiography. this will allow the odontologist to complete dental examination without any break during the process, also minimizing the risk of skin contamination while removing and wearing gloves multiple times. when the case is sars-cov-2 confirmed is highly recommended to avoid any dental specimen collection, unless otherwise requested by the medical examiner for dna sample. after the dental autopsy, keep the ventilation active and remove all ppe before leaving the autopsy suite, then follow appropriate waste disposal requirements. after removing ppe, hands and contaminated skin surfaces should be thoroughly washed with soap and water for 20 s avoiding any splashing, whenever changing gloves and before leaving the autopsy room. if water is not available, an alcohol-based hand sanitizer that contains 60%e95% alcohol must be used and avoid touching the face with unwashed hands. as per guidelines issued by the indian ministry of health & family welfare, 2020 [14] , reusable clothing can be removed from the autopsy suite and will be laundered according to routine procedures. besides washing and cleaning other dental autopsy instruments, all the surfaces, and transport trolleys should be properly disinfected with soap and water, and then disinfected with a disinfectant for at least 20 min in concentration of 0.5e1% sodium hypochlorite solution is to be followed by autoclaving of instruments. other common effective hospital disinfectants are ethanol (62e71%) or hydrogen peroxide (0.5%). cameras, telephones, laptops and x-ray portable devices once the protection film is removed, should still be treated as if they are contaminated and handled with gloves. all these items must be wiped with appropriate disinfectant. it is known that sars-cov-2 persist on surfaces for days [16] , and persist in the nasal cavity for 3 days after death [17] and for this reason it is the possible that the virus persists on the bodies of the deceased, too. as a consequence, unidentified human remains must be handled safely during transportation, storage, autopsy and burial/cremation [18] . it must be stressed that an autopsy of unidentified person whose dead is due to covid-19 should be performed only for forensic reasons [19] or identification purposes. on the other hand, identification process of covid-19 cases should always follow proper management and humanitarian principles, adopting the entire set of universal precautions and recommendations described. the respecting of safety precautions can minimize risks, and it is unethical to refuse to perform a dental autopsy where requested by the medical examiner, except when there is non-availability of ppe or the odontologist himself is at high risk due to health issues. the identification process relies not only on dental post mortem data but also on dna collections, which has been collected by the forensic pathologist. these two primary identifiers, dna and dental, should both be considered when performing an identification autopsy, but when a dental autopsy is too risky and/or too labor intensive, dna can be considered a stronger substitute for the identification [20] . given the current spread of covid-19, all autoptic procedures, including dental autopsies, must assume human remains are potentially infected [21] . odontologists should be aware that the ppe will inevitably reduce the ability to perform fine motor skills and if there is a lack confidence or inadequate training, dental post mortem collection should be performed by a more experienced colleague. forensic dental identification process of suspected or positive covid-19 cadavers should balance the protection of the personnel involved and the need of ensuring dignity to the human remains, but best practice in human identification requires the collection dental and dental radiology data [22, 23] . forensic odontologists and dental hygienists involved in autoptic procedures of unidentified human remains infected with covid-19 must be well trained in infection prevention control practices and for the task of managing the dead in challenging circumstances [12, 14] . the preparation of the body for funeral must finally be discussed with the medical examiner in charge, also considering cultural and religious practices. this should be in line with the directives issued by governing body in the relevant country. it is recommended that processed human remains shall be disposed without any embalming and preferably as soon as practicable directly from the mortuary to the burial or cremation. for best management of human remains, single burial should be preferred to cremation [12] . the current spread of covid-19 all autoptic procedures, including dental autopsies, must assume human remains are potentially infected. risk should not prevent us from applying best practice in human identification through the collection of primary identifiers, fingerprint, dna and dental data. to balance safety and the respect of the human rights of the dead, strict infection and safety protocols must be applied through planning, training, preparation and experience of all personnel entering the autopsy suite. forensic odontologists and dental hygienists involved in autoptic procedures of infectious human remains should always be well trained in infection prevention control practices and management of the dead in challenging circumstances. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. the emerging of the novel coronavirus 2019-ncov virus taxonomy: the database of the international committee on taxonomy of viruses (ictv) genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding hosts and sources of endemic human coronaviruses isolation of a novel coronavirus from a man with pneumonia in saudi arabia identification of a novel coronavirus causing severe pneumonia in human: a descriptive study covid-19 in forensic medicine unit personnel: observation from thailand collection and submission of postmortem specimens from deceased persons with known or suspected covid-19 recommendations to perform autopsies in patients with sars-cov-2 infection. iss working group on causes of death assessment covid-19 2020 (in italian), ii, 7 pp. rapporti iss covid-19 n briefing on covid-19: autopsy practice relating to possible cases of covid-19 (2019-ncov, novel coronavirus from china 2019/20), the royal college of pathologists international committee of the red cross (icrc): general guidance for the management of the dead related to covid-19 the turkish neonatal society proposal for the management of covid-19 in the neonatal intensive care unit, turk pediatri ministry of health & family welfare, covid19 guidelines on dead body management, directorate general of health service, government of india infection prevention and control for the safe management of a dead body in the context of covid-19, world health organization aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 guide to forensic pathology practice for death cases infection prevention and control for covid-19 in healthcare settings autopsy in suspected covid-19 cases dna commission of the international society for forensic genetics, recommendations regarding the role of forensic genetics for disaster victim identification management of the corpse with suspect, probable or confirmed covid-19 respiratory infection e italian interim recom-mendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures and during autopsy practice missing people, migrants, identification and human rights human identification and human rights through humanitarian forensic odontology key: cord-333588-3krh1xzx authors: sharma, amita; jain, megha b title: pediatric dentistry during coronavirus disease-2019 pandemic: a paradigm shift in treatment options date: 2020 journal: int j clin pediatr dent doi: 10.5005/jp-journals-10005-1809 sha: doc_id: 333588 cord_uid: 3krh1xzx coronavirus disease-2019 (covid-19) pandemic has affected the world in an aggressive manner and the healthcare fraternity has been at the forefront in this fight. dental professionals are at a larger risk to get afflicted owing to the proximity to the oral cavity. along with other verticals of dentistry, pediatric dentistry too has to adapt quickly keeping in mind the newer protocols so as to limit the increase of the global epidemic and the commencement of cross-infections. the purpose of this article is to present different treatment options for a pediatric dentist so as to achieve positive dental outcomes. how to cite this article: sharma a, jain mb. pediatric dentistry during coronavirus disease-2019 pandemic: a paradigm shift in treatment options. int j clin pediatr dent 2020;13(4):412–415. coronavirus disease-2019 (covid-19) has affected the world in an unprecedented fashion. 1 the world health organization (who) on january 30, 2020, confirmed the extensive increase in covid-19 cases a public health crisis. thus, there has to be a paradigm shift in the way healthcare procedures are done across the world in accordance with the guidelines set by who. 2, 3 dentistry is unique in the sense that not only the operator and the patient are in close immediacy during the examination and the procedure but also the main source of infection is the actual area of operation-the oral cavity. in dental settings, oral fluids like blood and saliva from the patient or infected dental instruments can create a possible way of distribution of the virus to the dentist, assistant, and to the patients. customary dental procedures that include the use of rotating instruments such as the high-speed turbine handpiece and the use of ultrasonic scalers for oral prophylaxis are allied with the production of large quantity of aerosols and droplets from the saliva and blood of the patient. before settling on the environmental surfaces and on the medical instruments, these can remain suspended in the air for a long period and can penetrate the respiratory tract through the nose and mouth. 4 hence, it is apparent how the aerosols generated during dental treatment can render the operators and patients to the menace of cross-infection. this review aims to discuss alternate ways in which the pediatric dental interventions can be done, which can be a great way of restoring the pediatric patient back to health. these options are aerosol-free and thus can contain the contagion. dental management of pediatric patients in the period of pandemic should be based on the severity of the case, the degree of invasiveness of the procedure, and the risk involved. for initial patient screening and evaluation of the problem, teledentistry is the best method. 5 a detailed travel, medical, and dental history should be taken over phone to understand the problem and needs of the patient. this shall help in reduced patient and dentist contact time and proper appointment scheduling. pediatric dentist should use various "social" digital platforms on which they can circulate and propagate behavioral guide for the safety of the dental health of children. child patients requiring regular checkups and follow-ups with no eventful history should be completely deferred for some time. preventive care instructions like (1) brushing twice daily with fluoridated toothpaste, (2) minimal consumption of sweet and sticky food, (3) rinsing after every meal, and (4) more of fruits and healthy food in the diet can be explained over the phone or social media applications. dental management of cases requiring restorative care should be carefully evaluated taking a proper history and clinical examination. the cavitated tooth not involving the pulp can be treated by following methods: atraumatic restorative technique (art) is a time-tested technique making restorative care accessible for pediatric patients and has high success rates. 6 this technique is highly advantageous for young children who are fearful to the conventional drill and local anesthesia. it has found special relevance in times of the pandemic as it promotes no aerosol dentistry. the main indications are that it can be carried out only in small and shallow cavities. the technique involves the scooping out of spongy, demineralized tooth tissue using manual instruments alone (spoon excavator) and then filling the cavity with adhesive curative material, generally glass ionomer cement (gic). 7 silver diamine fluoride can arrest dental caries and prevents its progression. it was originally used in japan in 1970s but soon fell out of favor due to the unaesthetic discoloration. now, many countries have recommended the use of 38% silver diamine fluoride (sdf) solution for caries prevention as well as for caries arrest. 8 silver diamine fluoride is a colorless liquid that combine the remineralizing property of fluoride and the antibacterial effects of silver. for managing carious lesions in young children and those with special care needs, it is therefore a potentially capable remedial agent. 9 the oral cavity is inspected for cavitated lesion and it is advisable to probe the lesion to check for the extent. silver diamine fluoride should not be used in case the carious lesion is approaching the pulp or is found to be too deep. the carious lesion is completely dried using cotton rolls and the solution is applied over it using an applicator tip. the application time is 1 minute. a clear-cut discoloration of the carious lesion to black shall be seen, signaling the end of application. for cavitated lesions on coronal or root surfaces that are not suspected to have pulp involvement, are not symptomatic, and are cleansable, sdf is indicated. 9 it is suggested that sdf primarily acts by three mechanisms. first, it may cause the obturation of dentinal tubules. the second mechanism is the cariostatic action of the resultant products between sdf and mineral constituent of the tooth. the third proposed way is the anti-enzymatic actions of the reaction yield between ag(nh 3 ) 2 f and organic component of the tooth. 8 the biggest advantage with sdf is that there is no cavity preparation; hence, it eliminates the usage of airotors/micromotors completely. there is control of pain, infection, and minimal armamentarium is needed. the biggest disadvantage is the obvious discoloration of the tooth to black. however, this can be overcome to some extent by placing layer of gic over the cavitated lesion. 9 the hall crown technique using preformed metal crowns was introduced by dr norna hall from scotland in 2006. 10 they are stainless steel crowns that are used in the cavitated lesions. just like sdf, there is no cavity preparation involved here. indication involves class i or class ii cavitated or noncavitated primary molar tooth. orthodontic separators are put in the place for 3-7 days on the proximal sides of the tooth to be restored. once optimal space is created, the crown is cemented into place using a luting agent. 11 the crown gives full veneering advantage and prevents the progression of caries to the pulp as well as to the neighboring tooth. the patient is thereafter kept on a regular follow-up. it is a newer noninvasive technique of removing carious infected dentin via a chemical agent. it is of caries elimination based on dissolution. instead of drill, this method uses a chemical agent along with an atraumatic mechanical force to get rid of soft carious structure. it complies with the theory of the minimal invasive dentistry (mid). 12 the procedure involves applying of solution/gel to the carious dentin, allowing it to soften the tissue, and thereafter scraping it off with specialized hand instruments. the two most currently sought agents are cariosolv and papacarie. carisolv consists of: • syringe 1: sodium hypochlorite (0.5%) • syringe 2: pink viscous gel having three amino acids: leucine, glycine, and lysine. when the components of two syringes are mixed as one, the amino acids bind with chlorine and form chloramines. this results in the breakdown of degraded collagen found in the demineralized part of carious lesion. the gel softens only carious tissue, which is then removed with special hand instruments. 12 papacarie consists of papain enzyme (which is an extract of the fruits and the latex of leaves of the green adult carioca papaya tree), toluidine blue, chloramine, a thickener, salts, stabilizers, preservatives, and deionized water. the mechanism of action depends on the papain enzyme, which is a proteolytic enzyme that causes degradation of proteoglycans in the dentinal matrix. it has bactericidal and anti-inflammatory actions. chloramine enhances the removal of denatured tissues. 13 in a deciduous tooth with reversible pulpitis lacking evidence of radicular pathology, the pulpotomy procedure can be performed. by use of low-speed micromotor handpiece, access can gained be into coronal pulp. the coronal pulp is removed while the residual vital radicular pulp tissue is maintained and the surface is treated with a clinically proven medicament such as buckley's solution of formocresol. 14 mineral trioxide aggregate (mta) and calcium hydroxide are materials used for pulpotomies with an elevated rate of success. 15 in young permanent teeth with reversible pulpitis, partial or cvek's pulpotomy can be done. it is a procedure in which the inflamed pulp tissue underlying an exposure is removed to a depth of 1-3 ml or further to reach the healthy tissue. pulpal hemorrhage is controlled using bactericidal irrigants such as chlorhexidine or sodium hypochlorite thereafter which the site is covered with calcium hydroxide or mta. it is preferred in teeth with immature roots to continue apexogenesis and usual root development. 14 pulpectomies in primary teeth should be avoided as it might require multiple sittings depending on the clinical condition of the tooth and extensive instrumentation during biomechanical preparation shall increase patient and dentist's contact time. therefore, extraction of the affected tooth is recommended in such a case. extraction followed by space maintainers would ensure prevention of adjoining tooth moving in to occupy the space. 16 in young immature teeth, full or cervical pulpotomy can be done unless the pulp is found to be necrotic after entering the pulp chamber. the remaining pulp will heal as long as hemorrhage is controlled. thereafter, biocompatible materials like calcium hydroxide or mta are applied. when pulpotomies are performed in young permanent teeth, the tooth may require reentry in future for root canal treatment, if signs and symptoms of pulpal necrosis appear. 14 in case the swelling is related to a carious tooth indicated for extraction, extraction under proper antibiotic coverage should be the treatment of choice. if the swelling involves facial spaces then incision and drainage along with proper antibiotic coverage and pain management should be the mode of treatment. 5 in case of soft tissue injury, the patient should be first evaluated over telephone by taking a detailed history and assessing the site of lesion through the photographs via digital applications. parents should be advised to control the bleeding through pressure pack or cold compression. in case bleeding does not stop, the patient should be asked to report to the dental operatory so that suitable management can be done. in case of mobile deciduous tooth, splinting should be done using self-etch composite resin material with minimal postprocedure finishing. in case of avulsion of primary tooth, control of bleeding should be the main mode of treatment followed by pain management of the child. if case of avulsed permanent tooth, the patient should be directed to get the tooth immediately to the dental clinic wherein the tooth should be reimplanted followed by splinting the tooth to maintain the repositioned tooth in correct position, provide comfort to the patient, and maintain function. other facial traumatic injuries should be attended on emergency basis and guidelines of the international association of dental traumatology (iadt) 17, 18 should be followed as far as possible. these include functional appliances and retainers. growing children are given functional appliances to correct the growth of jaws and the dentoalveolar complex. if the patients has noticeable discomfort wearing the appliance or breaks it, the use of the appliance should be temporarily suspended. a retainer appliance can be frequently lost by the patient or broken down; in such a case, it is advised that the clinicians take new impressions or digital scans and remake the retainer. 19 a bracket may lose its metallic or elastic ligature or become loose as a result of eating sticky or hard food. if the bracket remains flush with the tooth, it can be left as it is, if it seems to drop from the archwire, the patient can cautiously try to remove it with eyebrow tweezers. if there is a metallic ligature that causes soft tissue pain or injury, the patient should aim to push it back with the small eraser on the back of a pencil. in case that it is not possible, then orthodontic relief wax can be applied. 19 the covid-19 pandemic presents unique challenges to dentistry. with newer ways of working and added stress on disinfection, the fraternity has to adapt quickly. following are general precautionary measures to be followed at all dental operatories: • mandatory use of rubber dam in all procedures. 20 • using 0.23% povidone-iodine mouthwash for at least 15 seconds or 0.5-1% hydrogen peroxide mouth rinse before the procedure is recommended as it can reduce the viral load in the patient's saliva. 21 • extraoral dental radiographies, such as panoramic radiography and cone-beam ct, are suitable alternatives through the spread of covid-19 pandemic. 5 • personal protective equipment kits involving gown, goggles, face shield, etc., to be worn by the dentist and assistant at all times during the procedure. 5 • use of throwaway (single-use) devices such as mouth mirror and syringes to avert cross-contamination is adviced. 5 conclusion dental professionals have the responsibility to guard the patient, auxiliary staff, and themselves and also uphold high standards of care and infection control while delivering the treatment. with multiple options present to deal with the different clinical scenarios, it is up to the dentist to make a judicious call. critical preparedness, readiness and response actions for covid-19 centers for disease control and prevention. recommendations for putting on and removing personal protective equipment persistence of corona viruses on inanimate surfaces and their inactivation with biocidal agents coronavirus disease 19 (covid-19): implications for clinical dental care atraumatic restorative treatment and interim therapeutic restoration: a review of literature the atraumatic restorative treatment approach: an "atraumatic" alternative silver diamine fluoride: a review and current applications stretching new boundaries of caries prevention with silver diamine fluoride: a review of literature hall technique for carious primary molars: a review of the literature the hall technique in paediatric dentistry: a review of the literature and an "all hall" case report with a-24 month follow up chemomechanical caries removal (cmcr) agents: review and clinical application in primary teeth chemomechanical caries removal: a conservative and pain-free approach american academy of pediatric dentistry. pulp therapy for primary and immature permanent teeth. the reference manual of pediatric dentistry mta pulpotomy in primary molars: a prospective study space management in paediatric dentistry guidelines for the management of traumatic dental injuries: 1. fractures and luxations of permanent teeth guidelines for the management of traumatic dental injuries: 2. avulsion of permanent teeth management of orthodontic emergencies during 2019-ncov the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment in vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens key: cord-314492-483rn3aw authors: gallagher, jennifer e.; johnson, ilona; verbeek, jos h.; clarkson, janet e.; innes, nicola title: relevance and paucity of evidence: a dental perspective on personal protective equipment during the covid-19 pandemic date: 2020-07-24 journal: br dent j doi: 10.1038/s41415-020-1843-9 sha: doc_id: 314492 cord_uid: 483rn3aw the global covid-19 pandemic, caused by the sars-cov-2 virus, has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. this is a really important issue for dentistry, where we place great emphasis on infection control and universal precautions, given the nature of care provided. cochrane have recently updated their review of ppe for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. it examined evidence on which type of full body ppe and which method of donning (putting on) or doffing (removing) are most effective, while having the least risk of contamination or infection for healthcare workers, as well as which training methods increase compliance with ppe protocols. the objective of this paper is to raise awareness of the above review of ppe, its findings and their relevance to dentistry as outlined in the cochrane oral health website. the available evidence comes from healthcare generally, mostly involving simulation exercises, and is of low or very low certainty. none of the evidence specifically comes from dentistry. the findings in relation to the nature of ppe, methods of donning and doffing, and the importance of training are all of practical relevance to dentistry. research is critically important to provide evidence for future decision making in support of patients and staff. the global covid-19 pandemic, caused by the sars-cov-2 virus, 1 has highlighted the importance of personal protective equipment (ppe) for health and social care personnel. it is important to acknowledge from the outset that ppe has proved a contentious issue across health and social care generally across the united kingdom (uk), and beyond, and is one that will need to be resolved practically moving forwards. this is of critical importance to dentistry, where we have historically placed great emphasis on infection control and universal precautions, given the nature of care provided. based on evidence to date, the world health organisation suggests that transmission of the sars-cov-2 virus is mainly via respiratory droplet and contact routes, with transmission being possible through aerosol generating procedures (agps). 2 droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (for example, coughing or sneezing) and is therefore at risk of having his/her mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. person-toperson transmission routes for covid-19 disease can involve direct and indirect contact, 2 and it is important to recognise that this coronavirus is present in saliva. 3, 4, 5 sars-cov-2 is a novel coronavirus and, because of the nature of their occupation, healthcare workers (hcws) are often at greater risk of infection than the general population. 6 deaths of colleagues across healthcare have highlighted these risks, leading to concern and calls for greater protection for staff. appropriate ppe offers an important way of reducing the risk of infection during the provision of healthcare. highly infectious diseases due to exposure to contaminated body fluids, in healthcare staff ' . 8 it reviewed contemporary evidence on 'which type of full-body ppe and which method of donning (putting on) or doffing (removing) ppe have the least risk of contamination or infection for hcw, and which training methods increase compliance with ppe protocols' . 8 the evidence from this review is of great importance where there is a risk of highly infectious diseases, and even though covid-19 is no longer considered to be a high consequence disease in the uk, 9 its findings remain relevant to the current pandemic 10 and continue to be updated. the objective of this paper is to raise awareness of the findings of the above review of ppe 8 and explore their relevance to dentistry, building on our commentary presented on the cochrane oral health website. 10 cochrane synthesises the best available evidence using rigorous methodology to answer specific research questions, thus drawing on the body of evidence available to inform decision-making, 11 using thorough methods. 12 the covid cochrane group are prioritising questions related to covid-19, 13 reviewing the literature and synthesising wide-ranging data in a matter of weeks rather than the usual extended period of at least two years. 14 groups have prioritised this task and are collaborating where interventions are common across profession groups or health conditions. it involves rapid peer review of protocols and search strategies, working many extra hours to complete them as quickly as possible without compromising their quality, with final peer review and editing before publication. one example is the fast-tracking of this review of ppe for all hcws. 7,8 current work by cochrane oral health includes rapid reviews of mouthwashes and nasal sprays, and methods to reduce aerosols produced during agps, as well as a rapid review of international dental guidelines for return to dental services. 15 the ppe review questions for hcws are relevant to the practice of dentistry and all dental professionals working in clinical settings, including dentists, dental hygienists, dental nurses, dental therapists, orthodontic therapists, dental technicians and clinical dental technicians, along with reception and cleaning staff and practice managers. 10 clinical members of the dental team work in close proximity, usually face-to-face, with patients and often for sustained periods of time. over and above the risk associated with proximity to potentially infected individuals, during routine care, they are exposed to saliva and blood and carry out agps (for example, use of high-speed air rotors and ultrasonic scalers). for covid-19, personal protection entails preventing droplets from entering their mouth, nose or eyes and preventing them from contaminating the skin elsewhere. this makes the findings of the review highly relevant to the dental profession. although there is no evidence to say that dental procedures increase the likelihood of patients coughing, if they do, clinicians are in close proximity. this further increases the chance of aerosol and droplet generation, as well as infected material settling on environmental surfaces and on ppe. while the search included a broad range of hcws, only 24 studies (controlled studies, either randomised or non-randomised) were included, most from simulation exercises and none directly associated with dentistry. 8 in the midst of an acute situation where the primary evidence is difficult, and probably impossible to generate with enough speed to be useful, a judgement has to be made on how confident we are that the findings of this review can be applied to the dental care setting. however, in the absence of direct evidence from studies situated in a dental setting, we have to take note of, and realistically apply, the general evidence. it is important to note that 'the certainty of the evidence presented in the review, 8 across all comparisons, was judged to be low or very low' 10 for a range of reasons. this related to the paucity of research addressing each of the questions, together with the fact that much of the available research involved simulations of exposure rather than research in real-life conditions, small sample sizes, high or unclear risk of bias and insufficient detail on whether the ppe used fitted international standards for protective clothing. 8, 10 furthermore, most of the research understandably used harmless microbes or fluorescent markers rather than microbes or viruses of concern. 8,10 nonetheless, its key findings, against which the questions were relevant to dentistry, are important given the above caveats (box 1). while it is important to acknowledge that 'members of the dental team are very experienced in the use of standard ppe, most work within primary care settings, and may be less familiar with the more extensive forms of ppe' , 10 although this is rapidly changing. the cochrane review suggests that 'covering more of the body' leads to 'better protection.' 8 this included gowns providing better protection than just an apron. 8 the evidence suggests that added coverage provided by a coverall (one-piece suit) when compared with a gown comes at a cost in terms of increased 'difficulty in doffing' such ppe. 8 while there were initial concerns that challenges with doffing increased the risk of contamination, current evidence suggests that, in 'more recently introduced full-body ppe ensembles, there may be no difference in contamination' . 8 the review also suggests that 'ppe made from more breathable material may help increase user satisfaction, with little impact on contamination. ' 10 the head and neck areas of the dental team are particularly at risk for hcws during clinical dental procedures. 10 thus, ensuring ppe coverage is adequate to protect these areas is an important aspect of its effectiveness; in addition, 'better fitting ppe' in this region, 'sealed gown and glove combinations' to protect wrists, and certain design features such as 'tabs to "grab" during doffing and donning' may help to reduce the risk of contamination. 8, 10 overall, ppe should provide full coverage but not be too cumbersome. it is important not to make the mistake of assuming that just 'having' face masks and other elements of enhanced ppe is 'good enough' . dental professionals also need to be aware of the risks of contamination associated with donning and, in particular, doffing ppe. space for these processes will need to be considered as part of dental surgery organisation where care is being delivered, as well as the time involved. training in donning and doffing is particularly important for dental teams who may not wear this type of ppe for routine practice or who may need to learn new, safer habits carefully. the presence of an observer, in particular for doffing ppe, should be considered. teams should consider face-toface training opportunities as they may reduce the likelihood of errors, alongside computer simulation or videos which may also support these skills. 8,10 the cochrane review makes a strong case for building evidence to inform decisions on the 'most appropriate manageable protection' , 8 including 'modifications for hcws' . 8 we concur that this is essential for dentistry, if dental teams are to deliver care safely. 10 it also 'provides helpful insights on the research required, and the importance of registering and coordinating research with comparable outcomes' . 10 we need to consider how we can best do this across the four nations of the uk and connect with our global partners who are also facing the same issues. there is an opportunity, during this covid-19 outbreak, to use the natural experimental setting that dental care centres provide to create the evidence we need on health outcomes and personnel involved. 10 these opportunities include, but are not limited to, the issues of viral transmission rates, those related directly to the training, education and use of ppe, as well as how this affects patient care. 8, 10 trials in dental care settings safe provision of dental care requires a deep understanding of pathogen transmission and how it relates to the various types of care provided; for example, agps and non-agps. 10 trials using high-quality and standardised methodology considering the spread and settle of demonstration pathogens or surrogate measures in dental settings are key, and these should consider the array of different procedures that are considered to generate aerosols. it is worth noting that fluorescent dyes or harmless bacteria and viruses have been used for much of the higher quality simulated research in the past. 8 they should include all relevant settings and consider single and multiple surgeries as well as laboratories and domiciliary care. 10 studies should be well-designed and of sufficient sample size, with agreed outcomes. 8 crossover studies should be conducted where possible. details of education and training, fit testing, equipment used (including standards), dental examination and special investigations and procedure(s), length of appointment, nature of patient(s), technique of dental care, donning and doffing processes, environment and a range of outcomes should be recorded. 10 we need to know the most appropriate type of ppe for clinical encounters with different potential exposure levels. for example, it would be helpful to confirm whether standard ppe is adequate for an oral examination while more elaborate ppe, even with its drawbacks, is necessary for treatments where aerosols are actively generated during the procedure. also, are the types of ppe required for dental professionals carrying out routine care during peak phases of the covid-19 pandemic still required for the post-peak phase? in addition, there needs to be an understanding of the amount of time that recommended ppe can be worn comfortably. simulation exercises involving comparison of different levels of ppe will be particularly helpful to inform standard requirements for different aspects of dental care. 10 this includes the effect of masks, face shields and goggles. 10 furthermore, we will also need to consider shielded patients and the best way of affording them the necessary protection as well as staff. while we have considered the review in a dental context, we currently lack critical knowledge on whether viral load and shedding are similar in asymptomatic individuals 16 and to what extent this presents a risk in dentistry. 17 evidence in these areas would allow better understanding of appropriate ppe. we also need to deepen our understanding of aerosol generation generally, 18 as well as specifically in relation to viruses in dental settings. given the burden of oral disease 19 and the evidence that transmission of sars-cov-2 by seemingly well individuals (pre-symptomatic and asymptomatic), we need to seriously consider how our patient and population needs are best met for the future. models indicate that pre-symptomatic individuals alone may account for 30-62% of events (confirmed covid cases). 20, 21, 22, 23 it is important to remember that most patients attending for dental care will be covid-negative. important questions are being debated regarding the nature and extent of universal precautions, and whether we should adopt a precautionary principle to protect our dental teams and patients until more is known and these can be confidently relaxed. measures such as self-isolation and testing are now being suggested to reduce risk associated with planned and urgent care in key findings: • coverage: there is better protection from covering more parts of the body, but this has to be balanced against the possible increase in risk of contamination associated with difficulty donning or doffing, as well as less user comfort hospital settings. 24 ppe should be considered after risk assessment and as just one issue in a larger preventive approach, including aerosol, droplet and splatter reduction and ventilation. risk reduction must be considered along with other major challenges to our staff 's health and wellbeing, including the nature of care and the complex business of dentistry. we do not have all the answers about universal precautions for the future, but all dental professionals will need to take action in identifying and managing risk in line with national guidance and learning from our colleagues around the world. we have to be able to justify our actions in managing risk, and collect evidence and be prepared to adapt where necessary. having ppe is important, but so is wearing it properly and removing it safely; it is important to remember that ppe is just one way of protecting dental professionals and patients, all of which require careful consideration and research to inform our journey back to what may become a 'new normal' . naming the coronavirus disease (covid-19) and the virus that causes it modes of transmission of virus causing covid-19: implications for ipc precaution recommendations temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sarscov2: an observational cohort study consistent detection of 2019 novel coronavirus in saliva human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) epidemiology of and risk factors for coronavirus infection in health care workers personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff high consequence infectious diseases (hcid) -status of covid-19 personal protective equipment: a commentary for the dental and oral health care team about cochrane reviews cochrane handbook for systematic reviews of interventions half of cochrane reviews were published more than two years after the protocol available at https:// oralhealth.cochrane.org sarscov2 viral load in upper respiratory specimens of infected patients bacterial aerosols in dental practice -a potential hospital infection problem? editor's commentary: rapid reviews of ppe -an update global burden of oral conditions in 1990-2010: a systematic analysis quantifying sarscov2 transmission suggests epidemic control with digital contact tracing substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) estimating the generation interval for covid-19 based on symptom onset data temporal dynamics in viral shedding and transmissibility of covid-19 operating framework for urgent and planned services in hospital settings during covid-19 professor a. m. glenny, cochrane oral health. key: cord-315116-u7btx7nt authors: cabrera-tasayco, fiorella del pilar; rivera-carhuavilca, juana mercedes; atoche-socola, katherine joselyn; peña-soto, claudio; arriola-guillén, luis ernesto title: biosafety measures at the dental office after the appearance of covid-19: a systematic review date: 2020-07-27 journal: disaster medicine and public health preparedness doi: 10.1017/dmp.2020.269 sha: doc_id: 315116 cord_uid: u7btx7nt the purpose of this research was to determine biosecurity measures at the dental office after the appearance of coronavirus disease 2019 (covid-19). a search was conducted in the main databases of the scientific literature using the words “covid-19, coronavirus, sars-cov2, biosecurity, disinfection and dentistry.” we analyzed biosecurity and disinfection standards at the dental office and dental health personnel to date, and their adaptation to the needs and way of working of each. as a result, according to the information collected the following procedure was identified: a telephone appointment must be made and a questionnaire should be given before dental care; at arrival to the appointment, the temperature of the patient should be taken and proper cleaning and disinfection of the waiting room should be maintained. panoramic radiography and cbct are the auxiliary methods of choice. absolute isolation and atraumatic restorative therapy techniques are a good alternative to decrease fluid exposure. the removal of protective clothing and accessories must follow a specific order and washing hands before and after is essential. in conclusion, the efficient biosecurity for dentists and patients in all dental care processes before, during, and immediately after the appointment reduces the risk of covid-19 infection and allows healthy dental care environments. i n december 2019, several cases of pneumonia of unknown origin accompanied by high fever, dry cough, fatigue, and respiratory distress were reported in wuhan city, china. 1 this disease was diagnosed as coronavirus disease 2019 and is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) of zoonotic origin (derived from bats). covid-19 spread rapidly among humans worldwide, leading to its classification as a pandemic by the world health organization (who) on march 19, 2020. 2,3 it has been shown that many patients may be carriers of the virus while remaining asymptomatic or presenting only mild symptoms, mainly among children. 4 the incubation period is between 5 and 14 d, and the elderly and individuals with systemic problems are the most likely to present severe complications. 3 the contagion can be caused by direct (bodily fluids) or indirect transmission (by contact with surfaces). 5 the population at large may become infected, however, health professionals and especially dentists are at increased risk due to direct contact with the mouths of their patients and constant exposure to fluids, such as saliva and blood. 6, 7 in march 2020, the who published biosecurity measures to be taken by health professionals during patient care, seeking to reduce the high risk to which they are exposed. 8 in addition, in early april, the american dental association (ada) published guidelines for protective measures in dental offices to maintain biosecurity and thereby minimize the risk of covid-19 transmission before, during, and after dental care. 9, 10 one of the protective measures recommended is related to the usual clothing of dentists in patient care. disposable gowns over long-necked jacket and trousers are required. the use of protective lens, respiratory masks such as the n95 or ffp2, face visors, surgical caps, and disposable footwear covers are also recommended for personal and patient protection. 11 the guidelines also emphasize the need to not leave dental care with protective clothing. 12 studies related to biosecurity standards in dental surgery and by health governing entities are needed. among the standards proposed, a variety of methods of protection and disinfection must be elucidated, taking into account the cost benefits and the essential need for compliance to avoid unwanted contagion. therefore, this literature review aims to determine the biosecurity measures required in dental offices after the appearance of covid-19, seeking to provide dental health personnel with updates on the biosecurity and disinfection standards recommended to date, and their adaptation to the needs and ways of working of each. the bibliographic search carried out included articles published in the medline databases by means of pubmed, scopus, ebsco, science direct, scielo, and lilacs from their beginnings until may 31, 2020, and without language restriction. the keywords used were covid-19, coronavirus, sars-cov-2, biosecurity, disinfection, and dentistry (table 1 ). in addition, institutional guides from the who and the ada were taken into account. observational, descriptive, longitudinal, and systematic review studies were included. in contrast, articles such as letters to the publisher, books, publishers, and case reports were excluded from this review. on review of the literature, the following biosafety measures were identified. all patients requiring dental care must request an appointment by phone in advance. during the call the patient's risk should be assessed with questions regarding the presence of possible symptoms such as fever, cough, respiratory distress, and if the patient has been any contact with any suspicious or person confirmed as having covid-19. 13 appointments should be staggered to avoid patients accumulating in the waiting room. the whole environment should be considered as being of high risk. therefore, it is recommended that the dental office provide masks, disinfectant alcohol, and that magazines, ornaments, and objects that may spread the virus contagion be removed. 9, 14 in addition, the temperature of the patient should be taken with a contact-free infrared digital thermometer. 15 a questionnaire should be given to identify patients with potential covid-19 infection before dental care (table 2 ). patients answering "yes" to the questionnaire but without a temperature higher than 98.6°f or 37°c are to be instructed to remain quarantined at home and under surveillance for 14 d. in the case of symptomatic patients, these must promptly contact the nearest health center for evaluation. in the event of any symptoms, the appointment is postponed until after 14 d and the patient is advised to undergo a medical evaluation. patients answering "yes" to the questionnaire and with a temperature higher than 100.4°f or 38°c should be immediately quarantined and the nearest health center should be contacted. if patients answer "no" to the questionnaire, dental care will proceed. 3, 14 biosafety measures during dental care dental health personnel must take measures to protect both the patients and themselves. before any procedure, the clinician must perform hand washing and use different garments to (coronavirus or covid-19 or 2019-ncov) and dentistry (coronavirus or covid-19 or 2019-ncov) dental and coronavirus and (dentistry or dentist or dental) covid-19 and (dental hygiene or dental care or oral health) (dentistry or dentist or dental) and covid-19 (dentistry or dentist or dental) and (covid-19 or coronavirus or 2019-ncov) scielo (covid-19) and (dentistry) ((covid-19) and (dentistry)) or (dental) ((((covid-19) and (dentistry))) or (sarscov 2) (coronavirus) and (dentistry) (covid-19) and (dental) and (dental) lilacs coronavirus and dentistry and (db:("lilacs")) tw:(sarscov 2 dentistry) and (db:("lilacs")) tw:(coronavirus and dental) and (db:("lilacs")) tw:(covid-19 and dental) and (db:("lilacs")) tw:(covid-19 and disinfection and dental) and (db:("lilacs")) enhance biosecurity in the following order: disposable surgical cap, breathing mask (n95 or ffp2), disposable long-sleeved gown with elasticized wrist cuffs, lenses, facial visor, disposable gloves, and boots. 13, 14 dental units and work tables must be covered with single-use plastic (film) for each patient. 16 the patient should be given a hydrogen peroxide rinse with 1% distilled water to decrease the salivary viral load and should be fitted with disposable boots, a disposable cap, and protective glasses. 6 handpieces, micromotors, and ultrasound parts must be disinfected with 96% alcohol, sodium hypochlorite. rotary systems must have an anti-return system. 9, 15 to minimize the spread of aerosols, a rubber dam should be used in all procedures in addition to performing minimally invasive techniques, such as atraumatic restorative therapy. 17, 18 when auxiliary exams such as x-rays are needed, panoramic x-rays or ct scans are recommended, and if a surgical suture procedure is performed, a resorbable material should be chosen to reduce clinical appointments. 4, 6 in addition to following these measures, a disinfection method should be used for any material extracted from the mouth and sent to the laboratory (eg, prints, bite register, and prosthesis) to prevent cross-contamination. 18, 19 suspected fluid exposure when there is suspicion of exposure, microbiological testing should be performed, and if the diagnosis of covid-19 is confirmed, the patient should be quarantined and supervised. 20 following any dental procedure, clothing and accessories should be removed in the following order: disposable surgical gown, gloves, face protector, and finally, the mask. the mask should be removed from the back, without contact with the front. it is recommended to place the mask in a plastic bag and immersed in boiling water for 5 min for proper disinfection. immersion in sodium hypochlorite can also be used for disinfection purposes. 14,21-23 it is recommended that the handpiece, micromotor, and any equipment that can be removed from the unit be sterilized and/or autoclaved between each patient, depending on the manufacturer's specifications, and the same considerations should be taken with nondisposable instruments. in addition, x-ray equipment, lights, and the dental chair must be disinfected according to the manufacturer's instructions. 24 surfaces such as door handles, chairs, desks, elevators, and bathrooms, among others, must be frequently cleaned and disinfected. disinfectants such as 0.1-0.5% sodium hypochlorite, 62-71% ethanol, or 2% glutaraldehyde can be used for surface decontamination, as well as 62% ethanol or 2% glutaraldehyde in freshly prepared solutions and adequate concentrations. 25 protective barriers should be used to cover clinical contact surfaces, especially those that are difficult to clean such as switches on dental chairs, computer equipment, screens. these barriers should be changed between each patient. 26 in relation to the residue discarded, this should be disinfected with a 0.5% sodium hypochlorite solution and then placed in a double-layered bag with a "swan neck" knot which should only be filled to 80% capacity to allow proper closure. sharp objects should be placed in a double bag. 18, 23 all waste originating from the care process is to be considered as dangerous, and disposable personal protection elements should also be considered as hazardous waste. for biocontaminated waste, red bags should be used, while common waste should be discarded in black bags, and special residue should be placed in yellow bags (table 3) . 27,28 this research was carried out to describe the biosafety guidelines in all dental care processes after the appearance of biosafety at the dental office after covid-19 disaster medicine and public health preparedness 3 covid-19 especially because the full practice of dentistry has been reopened in different cities and because the dental urgencies and emergencies cannot be postponed in most of the cases. due to the increase in infection worldwide, protective measures have been recommended for health personnel including dentists and dental auxiliary personnel who have more direct contact with patients and require the implementation of protective measures in the dental office before, during and immediately after dental care. thus, this literature review was performed to evaluate the biosecurity standards published for dental care in the main sources of information in the scientific literature. because some people are asymptomatic and do not present specific signs and/or symptoms of the sars-cov-2 virus, every patient should be considered as a potential carrier. for this reason, it is necessary for the temperature of the patient to be taken and a questionnaire should be given previously to identify any possible risk factor of the disease. in addition, biosafety protocols should be implemented in dental procedures to reduce the risk of infection. 3, 4, 14, 15 the protection of dental personnel must be adequately addressed, because this health area is the most exposed to cross-contamination, 1 of these reasons is for the use of dental aerosols (released particles less than 50 microns in diameter) that is produced from dental instruments, such as ultrasonic scalers, air-water syringes, dental handpieces when using rotating systems, which are a source of emission of microorganisms and even droplets (particles smaller in dimension than aerosols) can be produced and could generate a risk of contagion. even inhaled droplets and aerosol particles have different sites of deposition, inhaled droplets are deposited in the upper regions of the respiratory tract, in contrast, inhaled aerosolized particles can penetrate to the depths of the lungs, where they may be deposited in the alveoli. 29 therefore, the use of these systems should be minimized and conventional alternative techniques should be used to reduce bacterial dissemination. in addition, it has been shown that the use of n95 masks is essential for medical personnel. however, daily and continuous use can lead to skin lesions especially on the nose; therefore, it is recommended to optimize their use times among the staff. on the other hand, an alternative to disinfection is the use of ultraviolet light, the use of which, however, is limited due to its high cost. 9, 15, [30] [31] [32] surfaces and objects used after care must be constantly disinfected to reduce the risk of cross-contamination. a large number of studies have shown that sodium hypochlorite at 0.1%-0.5%, 62-71% ethanol, and 2% glutaraldehyde are able to disinfect surfaces by decreasing virus load. [24] [25] [26] 33 direct contact with disinfectants, such as alcohol and hypochlorite, may cause skin reactions, such as peeling, cracking, stinging, bleeding, and dermatitis; therefore, the use of protection is recommended for surface disinfection. 31 in addition, it is important to follow adequate waste management after dental consultation, categorizing the different types of waste into the corresponding packaging, providing better management by the staff responsible for waste disposal. 18, 23, 27, 28 moreover, because the appearance of covid-19 is a recent phenomenon, more research is necessary to clarify the doubts remaining in relation to biosafety for dental offices and procedures and to establish definitive protocols. in the meantime, dentists must reinforce biosafety measures to ensure adequate protection to both the dental professionals and their patients. therefore, it is of great importance to follow all the stages of structured protocols, [34] [35] [36] such as carrying out a questionnaire and taking the temperature of patients before care, as well as disinfection of waiting rooms and offices, and wearing protective clothing. moreover, it must be kept in mind at all times that hand washing is essential between each patient. finally, there must be a protocol of maximum protection that avoids contact with exposed areas after dental care and to perform adequate management of waste after care. only in this way will the dental care environment have a safe protocol to reduce the risk of infection by this new virus which has led to radical changes worldwide. efficient biosecurity before, during, and immediately after dental care reduces the risk of covid-19 infection in dentists and patients and allows greater confidence in the management of the dental environment. what we know so far: covid-19 current clinical knowledge and research coronavirus disease (covid-19): characteristics in children and considerations for dentists providing their care coronavirus and the dental office coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice considerations for emergency dental care and measures preventive for covid-19 (sars-cov 2) disaster medicine and public health preparedness a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster who. laboratory biosafety guidance related to coronavirus disease 2019 (covid-19 covid-19 outbreak: an overview on dentistry interim guidance for minimizing risk of covid-19 transmission personal protective equipment and covid 19-a risk to healthcare staff? measures and suggestions for the prevention and control of the novel coronavirus in dental institutions. front oral maxillofac med biological and social aspects of coronavirus disease 2019 (covid-19) related to oral health coronavirus disease 19 (covid-19): implications for clinical dental care masks and thermometers: paramount measures to stop the rapid spread of sars-cov-2 in the united states pediatric dentistry management guidelines during the confinement or quarantine stage of the covid-19 pandemic covid-19: present and future challenges for dental practice what dentists need to know about covid-19 protecting dental manpower from covid 19 infection covid-19 transmission in dental practice: brief review of preventive measures in italy decontamination of face masks with steam for mask reuse in fighting the pandemic covid-19: experimental supports perioperative care provider's considerations in managing patients with the covid-19 infections prevention and control of infection in subjects suspected of infection with the new coronavirus mers-cov in military units oral healthcare during the covid-19 pandemic persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents tracking and controlling soft surface contamination in health care settings the dental solid waste management in different categories of dental laboratories in abha city, saudi arabia waste management in dental office droplets and aerosols in the transmission of sars-cov-2 analysis of bacterial contamination produced by aerosols in dental clinic environments covid-19 pandemic and personal protective equipment shortage: protective efficacy comparing masks and scientific methods for respirator reuse covid-19 epidemic: skin protection for health care workers must not be ignored protection and disinfection policies against sars-cov-2 (covid-19) covid-19 and its impact on peruvian dentistry guidance for dental settings osha. dentistry workers and employers key: cord-348358-dg3sa9ho authors: yüce, meltem özden; adalı, emine; kanmaz, burcu title: an analysis of youtube videos as educational resources for dental practitioners to prevent the spread of covid-19 date: 2020-07-23 journal: ir j med sci doi: 10.1007/s11845-020-02312-5 sha: doc_id: 348358 cord_uid: dg3sa9ho background: coronavirus disease (covid-19) was first reported on 31 december 2019 and has rapidly been spreading day by day. dental patients and professionals have a high risk of the coronavirus infection and also have a huge responsibility to prevent its spread during emergency dental treatment over the period of the covid-19 outbreak. aim: informing patients and dental practitioners about the novel coronavirus in an accurate and effective way is very important. therefore, this study aimed to evaluate the quality of dentistry-related medical information about covid-19 on youtube as educational resources for dental practitioners. methods: youtube was queried for the search phrases ‘covid-19 and dental practice’, ‘sars-cov-2 and dental practice’ and ‘2019-cov-2 and dental practice’. the first 100 videos for each term were viewed and analysed by 3 independent investigators. the scope was limited to videos in english. results: the search phrases yielded 1102 videos, among which 802 videos were excluded and 300 videos screened. fifty-five videos were included in the final analysis. of the 55 videos, only 2 videos (3.6%) were found to be of good quality, while 24 videos (43.6%) were found to be of poor quality. conclusion: youtube is a popular video broadcast site and can provide both relevant educational information and the spreading of misinformation. health professionals should play a more active role with regard to educative information given on social media, especially youtube, during global disease outbreaks. a novel pneumonia named coronavirus disease 2019 (covid19) was first reported in the chinese city of wuhan on 31 december 2019. the transmission routes of this virus include direct transmission by coughing, sneezing and droplet inhalation and contact transmission by coming into contact with the oral, nasal and eye mucous membranes. dental patients receive dental treatment through a high-speed handpiece or ultrasonic instruments which make their secretions, saliva or blood aerosolise to the surroundings and clinic environment, and the dental apparatus could be contaminated [1] . unfortunately, symptoms of this disease are non-specific, ranging from asymptomatic to severe pneumonia [2] [3] [4] . dental practitioners who have to treat patients who are in incubation period and unaware if they are infected or patients who need an emergency dental treatment, often ask the following question: 'are the standard protective measures in daily clinical practice effective enough to prevent the spread of covid-19 (sars-cov-2)?' there is yet no consensus and guideline regarding infection prevention for dental clinics. however, in almost every country, dentistry communities have issued reports about possible transmission routes and the measures to be taken during the covid-19 outbreak in dental clinics to prevent and control the infection. currently, youtube is a popular online public communication platform with more than 2 billion registered users, who receive information about infection control measures during the outbreak periods [5, 6] . dental practitioners play an important role in preventing the transmission and spread of the infection. a recent study has reviewed various practical strategies to prevent the transmission of the 2019-ncov during dental diagnosis and treatment, including patient evaluation, hand hygiene, personal protective measures for dental practitioners, mouth rinse before dental procedures, rubber dam isolation, anti-retraction handpiece, disinfection of the clinic settings and management of medical wastes [2] . therefore, youtube could be a valuable tool to convey this information to dental practitioners during the covid-19 outbreak. however, unregulated and misleading information taken from youtube videos can result in the spreading of inaccurate or false information [7] . therefore, this study aimed to evaluate the usefulness of youtube videos as an informative tool for dental practitioners regarding additional preventive measures that need to be taken during the covid-19 outbreak. to attain the aim of our study, we designed and implemented a cross-sectional study. the study material was composed of all youtube videos containing information about covid-19 control procedures for dental practice on 31 march 2020 between 9 am and 6 pm. youtube was accessed using the search terms 'covid-19 and dental practice', 'sars-cov-2 and dental practice' and '2019 ncov-2 and dental practice'. the search term 'covid-19 and dental practice' yielded 554 results, and the 'sars-cov-2 and dental practice' term yielded 443 results, while the term '2019 cov-2 and dental practice' showed 105 results. it has been shown that most youtube users search the first 60-200 videos and only the first 30 videos [8] . in our study, the first 100 videos for each term were viewed. exclusion criteria were as follows: non-english videos, duplicate videos and irrelevant videos like other medical field advertisements, financial advice videos and videos about work hours of dental practice. the remaining 55 videos were analysed by three researchers (moy, ea, bk). all the reviewers were blinded to each other's responses. the researchers did not see the number of likes, dislikes or comments before completing their reviews for objective assessment (fig. 1) . as this study required analysis of publicly available information, institution review board approval was not required. for each video, we recorded the number of views; total video duration; total numbers of comments, 'likes' and 'dislikes'; date of upload and country of origin. viewers' interactions were calculated based on the interaction index ([number of likes − number of dislikes]/total number of views × 100%) and the viewing rate (number of views/number of days since upload × 100%). also, all videos were classified according to the source of upload, categorised as american dental association (ada), dental health professionals (general dentists, specialists), dental health centres, news and information websites. videos were classified as quality if they contained scientifically correct information about infection control methods for covid-19 in dental practice. we evaluated the included videos using the global quality scale (gqs) [9] for the presence of 5 contents: (1) characteristics of 2019-ncov, (2) treatment and outcome, (3) possible transmission routes, (4) possible transmission routes for dental practice and (5) 2019-ncov infection controls for dental practice [2] . after the five contents were scored from 1 to 5, the total score was adapted to the gqs score. lastly, the overall quality of the videos was scored subjectively using a 5-point likert-type gqs that awarded a score as follows: 1. poor quality: poor flow of the video, most information missing, not at all useful 2. generally poor quality and poor flow: some information listed, but many important topics missing; of very limited use 3. moderate quality: suboptimal flow; some important information adequately discussed, but other information poorly discussed; somewhat useful 4. good quality and generally good flow: most of the relevant are information listed, but some topics were not covered; useful 5. excellent quality and flow; very useful the reliability of each video was evaluated by means of the modified discern instrument [10] , a five-item questionnaire for assessing health information (scoring: 1 to 5). the items were as follows: (1) are the aims clear and achieved? (2) are reliable sources of information used (i.e. publication cited, speaker is specialist in dentistry)? (3) is the information presented both balanced and unbiased? (4) are additional sources of information listed for patient reference? (5) are areas of uncertainty mentioned? statistical software (spss inc. version 21, ibm, chicago, il) was used to analyse the data. the inter-observer agreement was calculated as a kappa score. descriptive statistics were calculated for each variable. variables were tested for normality using the shapiro-wilk test. continuous variables were analysed using kruskal-wallis tests. after the kruskal-wallis test, if a significant difference was found, comparisons were evaluated using the mann-whitney u test and bonferroni correction. categorical variables were analysed using the chi-square test. correlations were determined using pearson-spearman tests. statistical significance level was set at p < 0.05. the first 100 videos of each term searched were screened for relevance based on our inclusion criteria. after the initial screening, 245 videos were excluded (fig. 1 ) and the remaining 55 videos were analysed in this study. videos were classified based on the source. more than half of the videos (58.2%, n = 32) were uploaded by dental health professionals (general dentists, specialists), whereas 23.6% (n = 13) were uploaded by ada, 5.5% (n = 3) by dental health centres, 10.9% (n = 6) by the news and 1.8% (n = 1) by information website (fig. 2) . most videos (54.5%, n = 30) were uploaded by users in the usa and 21.9% (n = 12) by users in other countries (canada, uk, australia, united arab emirates, india, trinidad and tobago). the source of 13 videos was not specified (fig. 3) . the mean number of comments was 5.56 ± 16.09. the mean video duration was 10 min 11 s ± 15 min 30 s (range, 54 s to 73 min 37 s). the mean number of views of the videos was 3988.62 ± 7434.14. the mean numbers of likes and dislikes were 37.51 ± 69.97 and 3.82 ± 13.55, respectively. viewers' interaction with videos was generally positive; the mean interaction index score was 1.99% ± 3.24% (range, 0.00 to 3.24%). the mean viewing rate was 3.55% ± 5.53%. the mean global quality score was 2.03 ± 1.06 and the mean modified discern score was 2.77 ± 0.99 (table 1) . fifty-five videos selected were evaluated with the gqs. it was determined that 43.6% of youtube videos on covid-19 infection control in dental practice were of poor quality. the remaining 32.7% of the videos were of a generally poor quality, 12.7% of them were of moderate quality, 7.3% of good quality and only 3.6% of them were of excellent quality ( table 2) . when we compared the content analysis of the videos based on the general quality scale (gqs) scores between the groups, 'characteristics of 2019-ncov' and 'treatment and outcome' values were found to be significantly different between the groups. in the 'characteristics of 2019-ncov' gqs value mean, dental health centres were significantly higher than ada (p = 0.003) and news (p = 0.006). in the 'treatment and outcome' gqs value mean, dental health centres were significantly higher than ada (p = 0.004), dental health professionals (p = 0.004) and news (p = 0.006) ( table 3 ). in the comparison of the gqs means, it was found that there is no significant difference between the groups (p > 0.05) ( table 4 ). the kruskal-wallis test was used to compare the characteristics of videos between the sources of uploads. significant differences were found in number of comments, number of views, video duration, interaction index and view rate between the groups (p < 0.05). in the mean number of comments, dental health professionals were significantly higher than ada (p = 0.000). on the other hand, in the mean number of views, ada was significantly higher than dental health professionals (p = 0.000) and news (p = 0.005). in the video duration mean, news was found to be significantly lower than dental health professionals (p = 0.004). in the mean of interaction index, ada was significantly lower than dental health professionals (p = 0.000) and news (p = 0.001). it was also found that ada was significantly lower than dental health professionals (p = 0.000) in the mean of view rates (table 5 ). in comparison with modified discern question value means and score mean, only the 4th question (are additional sources of information listed for patient reference?) was found to be significantly different between the groups (p < 0.05). ada's fourth question value mean was significantly lower than for dental health professionals (p = 0.000) ( table 6) . pearson's correlation analysis showed a significant correlation between like and dislike, view rate, number of comments and viewing rate (p < 0.05). there was a positive correlation between dislike and view rate (p < 0.05). several positive correlations were observed between total video duration and detailed contents of videos, gqs score and modified discern question 4 and question 5 (p < 0.05). there were positive correlations between video contents and gqs, modified discern question value and discern mean scores (p < 0.05). the overall inter-observer agreement calculated as weighted kappa score was 0.87 (range: 0.84-0.90). in late december 2019, covid-19 started in wuhan city and rapidly spread to other countries. on 30 january 2020, the world health organization (who) declared the covid-19 outbreak as a 'public health emergency of international concern'; on 11 march 2020, as a pandemic and according to who situation report of 31 march 2020, 750,890 cases had been confirmed and 36,405 cases died globally [11, 12] . everyone has a huge responsibility to prevent the spread of the infection; nevertheless, both dental patients and professionals have a high risk of covid-19 infection due to the face-to-face treatment, exposure to body fluids such as saliva and blood and the handling of sharp instrument procedures during the interventions [1, 2] . therefore, it is important to inform the patients and dental practitioners about the novel coronavirus in an accurate and effective way and our study provides a detailed analysis of youtube videos as a source of dentistry-related medical information about covid-19. as known, youtube is a popular video broadcast site; it is free and easy to access [13] . the use of youtube may mann-whitney u test with bonferroni correction: † p < 0.008 significantly higher than ada; ‡ p < 0.008 significantly higher than dental health professional; § p < 0.008 significantly higher than dental health centres; ‖ p < 0.008 significantly higher than news have a positive impact on professional and public education; during the outbreaks in the past such as ebola outbreak in 2014 and zika virus epidemic in 2016 and h1n1 influenza pandemic in 2009, youtube videos have been reported to be watched millions of times [14] . covid-19 epidemic has captured the attention of social media users globally, and in comparison with previous disease outbreaks, the viewership of content related to covid-19 epidemic appears higher [5, 6, 13, 15] . covid-19 is reported as transmitted person to person through bodily fluids by cough, sneeze and droplet inhalation or through contaminated objects [1, 2] . although good hand hygiene is reported and considered to be the most critical measure to reduce the risk of transmitting the microorganism, it is known that covid-19 is stable for several hours to days in aerosols and on surfaces [16] . a recent study has reported that covid-19 could be airborne through aerosols during medical procedures [17] . therefore, the reliability of youtube videos as a source of information about preventing the spread of covid-19 for dental practitioners is very important. in the present study, despite 58.2% of the videos were uploaded by dental health professionals, it has been determined that 43.6% youtube videos on covid-19 infection control in dental practice were unfortunately in a poor quality. nevertheless, according to content analysis of videos based on gqs, despite no significant difference between groups in the comparison on gqs means, 'characteristics of 2019-ncov' and 'treatment and outcome' mean values were found significantly higher in dental health centres than the other groups. covid-19 is rapidly spreading and researches recommend suspending routine dental practices and to treat only dental emergency cases [1, 2] . it is reported that a large number of medical staff get infected until now, so the use of personal protective equipment such as masks, gloves, gowns and face shields to protect skin and mucosa from infected or potentially infected blood or secretion may not be enough to protect patients and dentists from transmission [2, 18] . in the scientific literature, there are some suggestions about infectious diseases in addition to personal protection measures for dental practitioners such as the following: (a) extraoral dental radiographies should be preferred in order to prevent intraoral radiographs' stimulating saliva secretion; (b) patients should be asked to use anti-microbial mouth rise before dental intervention; (c) aerosol-generating procedures should be minimised; (d) if dental intervention is urgently required, rubber dams and high-volume saliva ejectors should be used to minimise aerosol and patients should be treated in a well-ventilated room [2, 19, 20] . in the present study, we analysed the source and quality of dentistry-related scientifically based medical information given by professionals about covid-19 on youtube for dental practitioners as demonstrated above. in accordance with the mean modified discern score (2.77 ± 0.99), the mann-whitney u test with bonferroni correction: † p < 0.008 significantly higher than ada; ‡ p < 0.008 significantly higher than dental health professional; § p < 0.008 significantly higher than dental health centres; ‖ p < 0.008 significantly higher than news reliability of the videos was potentially important but has shortcomings. only 2 of the 55 videos were in a good quality; this finding demonstrates the substantial need for improving the quality and reliability of information to achieve better outcomes during outbreak period. however, as a limitation of this study, the information which is available about dentistryrelated medical information about covid-19 on youtube is only during the initial phase of the covid-19 pandemic. the epidemic is increasing day by day and youtube content may have shifted over time and as mentioned in previous studies during epidemics/pandemics, users may be more vulnerable to misinformation, due to the acute effect of infection. professional societies should be encouraged to provide useful and reliable information for dental professionals. health professionals should play a more active role about educative information given on social media, especially youtube, during global disease outbreaks. also, further studies are needed to evaluate the videos changes with time of the available youtube videos during and after the period of the covid-19 outbreak. ethical approval since the present study is an observational study as it involved the use of public access data only, there is no need for approval of the ethics committee. the authors declare that they have no conflict of interest. informed consent since the present study is an observational study as it involved the use of public access data only, there is no need for informed consent. coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa coronavirus covid-19 impacts to dentistry and potential salivary diagnosis youtube videos as a source of medical information during the ebola hemorrhagic fever epidemic are internet videos useful sources of information during global public health emergencies? a case study of youtube videos during the 2015-16 zika virus pandemic panic, paranoia, and public health-the aids epidemic's lessons for ebola is content really king? an objective analysis of the public's response to medical videos on youtube youtube for information on rheumatoid arthritis: a wakeup call? youtube as source of patient information on abdominal aortic aneurysms situation report 71 st public health measures to slow community spread of covid-19 youtube as a source of information on the h1n1 influenza pandemic social media and outbreaks of emerging infectious diseases: a systematic review of literature youtube as source of information on 2019 novel coronavirus outbreak: a cross sectional table 6 comparison of discern scores according to source of upload. all data were expressed as median are additional sources of information listed for patient reference? test: *p < 0.05 significant difference between groups u test with bonferroni correction: † p < 0.008 significantly higher than ada aerosol and surface stability of hcov-19 (sars-cov-2) compared to sars-cov-1 practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients the novel coronavirus pneumonia emergency response epidemiology team (2020) the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china centers for disease control and prevention. guidelines for infection control in dental health-care settings modern dental imaging: a review of the current technology and clinical applications in dental practice publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-302379-jh6jxwyn authors: jevon, phil; abdelrahman, ahmed; pigadas, nick title: management of odontogenic infections and sepsis: an update date: 2020-09-25 journal: br dent j doi: 10.1038/s41415-020-2114-5 sha: doc_id: 302379 cord_uid: jh6jxwyn the management of odontogenic infections has improved over recent decades, but further improvements are still required. the ongoing education of gdps and their dental teams on this issue continues to be important, especially during the current covid-19 pandemic, where remote triage poses additional difficulties and challenges. odontogenic infections can lead to sepsis, a potentially life-threatening condition caused by the body's immune system responding in an abnormal way. this can lead to tissue damage, organ failure and death. a patient with non-odontogenic-related infection could also present with sepsis at a dental practice. early recognition and prompt management of sepsis improves outcomes. gdps and their dental teams should be trained in the recognition and management of sepsis. age-specific sepsis decision support tools have been developed by the uk sepsis trust to help dental staff recognise and manage patients with suspected sepsis. the aim of this article is to provide an update on the management of odontogenic infections and sepsis. although the management of odontogenic infections has improved over recent decades, further improvements are needed and the ongoing education of gdps and their dental teams on this issue is essential. in addition, the covid-19 pandemic has imposed new difficulties and challenges; for example, telephone triage and prescription of antibiotics, and it is important to be up-to-date with current guidelines. 1, 2 odontogenic infections can lead to sepsis, 3,4 a potentially life-threatening condition caused by the body's immune system responding abnormally. this can lead to tissue damage, organ failure and death. 5 a patient with nonodontogenic-related infection could also present with sepsis at a dental practice. early recognition and prompt effective treatment of sepsis improves outcomes. 5 the dental team should be trained in the principles of the management of sepsis. 6 agespecific sepsis decision support tools have been developed by the uk sepsis trust 7 to assist the dental team to recognise and manage patients with suspected sepsis. the aim of this article is to provide an update on the management of odontogenic infections and sepsis in the dental practice. the morbidity and mortality rate of odontogenic infections has dropped significantly over the past 70 years. 8, 9, 10 this dramatic drop is undoubtedly linked to the discovery of antibiotics, the improvement of the general population health standards, and a better understanding of appropriate medical and surgical management of these cases. further improvements are needed and ongoing education of the dental team on this issue is very important. odontogenic infections pass through three key stages: 11 • stage 1: 1-3 days; soft and mildly tender swelling • stage 2: 2-5 days; hard, red and severely sore swelling • stage 3: 5-7 days; abscess formation. there is a strong belief that once the abscess has formed, surgical drainage is mandatory to achieve resolution. 12 medical management has a role in selected cases. 13 seven principles have been proposed to achieve the best outcome in managing odontogenic infections: 11 1. establish the severity of the infection 2. assess host defences 3. elect the setting of care 4. surgical intervention 5. medical support 6. antibiotic therapy 7. frequently evaluate the patient. a careful history and thorough clinical examinations are essential to determine the severity of any infection. history-taking will highlight factors like immune system competence and the level of systemic reserves to fight infections. a physical examination can identify clinical observations outside normal limits. several clinical and haematological parameters have been used as prognostic indicators for the severity of the infection. c-reactive protein (crp), fever and anatomical locations have been investigated for the assessment of the extent of odontogenic infections and presumed duration of hospital stay. 14 additional factors must be considered to establish the infection severity: • anatomical location • airway compromise. there are a number of potential spaces between the musculoskeletal head and neck structures and the regional fasciae and organs better known as fascial spaces. a summary of these spaces and their level of risk 11, 12 is found in table 1 . in healthy and systemically well patients without trismus, infections of low-risk spaces can be initially treated in a primary care dental practice, while infections spreading to higher risk spaces should be managed more aggressively and may need to be treated in a secondary care centre. ludwig's angina was described by karl friedrich wilhelm von ludwig in 1836 as a rapidly and frequently fatal progressive gangrenous cellulitis and ooedema of the soft tissues of the neck and floor of the mouth. 15 thankfully, mortality rates have reduced significantly with the introduction of antibiotics, improved oral and dental hygiene, and timely surgical intervention. 15 the majority of ludwig's angina infections are odontogenic; 16 peritonsillar or parapharyngeal abscesses, mandibular fractures, oral lacerations/piercing and submandibular sialoadenitis are other recognised causes. 15 a compromised airway is synonymous with ludwig's angina and the initial assessment of a patient with ludwig's angina should follow the familiar 'airway, breathing, circulation, disability, exposure' (abcde) approach. signs of a compromised airway in these patients could include noisy (gurgling) breathing with drooling saliva, stridor, dyspnoea, tachypnoea, tachycardia, dysphagia and trismus. the initial immediate management usually includes positioning the patient in an upright position and administering oxygen 15 litres/minute, 15 while colleagues call 999 for an ambulance. a healthy immune system is essential to the maintenance of host defence against infection. multiple medical conditions can affect it. 17 box 1 summarises the common factors that can cause immune system compromise. the concept of 'physiologic reserve' represents a significant driver of outcome in patients fighting infection. this can be defined as the capability of an organ to carry out its activity under stress. 18 age is an essential factor that is inversely related to the physiologic reserve; that is, decreased respiratory, cardiovascular and metabolic reserve. 19 elect the setting of care an uncomplicated localised dental abscess in a healthy young person, who does not show signs and symptoms of a worsening immune response, can be safely treated in a dental practice. early and adequate intervention is essential in order to prevent avoidable deterioration with invasion of adjusted anatomical spaces and symptoms of sepsis ( fig. 1) . similarly, severe neck infection in an immunocompromised elderly person warrants treatment in a secondary care setting. the clinical decision to choose the setting of care is not always straightforward though, prompting the need for clear secondary care referral criteria. although there are no agreed national guidelines on when to admit to a secondary care setting, criteria for hospital admission have been proposed 2,20 (box 2). a careful history, thorough clinical examinations and a high index of suspicion will enable the gdp to diagnose and appropriately manage patients presenting with odontogenic sepsis. early surgical intervention has been advocated to improve the clinical outcome of odontogenic infection. the dramatic improvement in the outcome of sever odontogenic infection is directly linked to the immediate establishment of a safe airway, followed by early surgical intervention. once the airway has been deemed patent and not at risk of being compromised, in either a hospital setting or dental practice, the principles of management are very similar. thorough knowledge of head and neck anatomy will enable the surgeon to access the abscess cavities using incisions in safe places without damaging any vital structures like blood vessels or nerves. most of the odontogenic infections can be drained through intraoral access. five principles must be followed: 11 21 although abscess formation takes place between the fifth and seventh days, early elimination of the infection source and surgical intervention will decompress the involved anatomical spaces. 14 relying on antibiotics only in relieving dental infection is likely to be less effective and can cause antimicrobial resistance. 22 two of the challenges to performing adequate drainage of any odontogenic infection in dental practice are: 23 1. achieving adequate local anaesthesia 2. risk of spreading the infection to other anatomical spaces. the ability to deliver safe, adequate local anaesthesia is essential for any dental procedure. the mechanism of action of the local anaesthetic solution depends on the tissue ph. in the presence of infection, tissue ph becomes more acidic, which slows down the degree of ionisation, resulting in less optimal or failed anaesthesia. 23 to overcome this problem, the injection of the anaesthetic solution at a distance from the inflammatory site is required (nerve blocks). it will also avoid infection spread to different tissue spaces. although surgical drainage is the classic approach to most of the odontogenic infection, medical support has a critical role in controlling the disease. 24 adequate hydration, nutrition and control of fever are essential to optimise the medical care for patients presenting with odontogenic infections. stabilisation of any underlying systemic disease (for example, uncontrolled diabetes) is extremely important. 24 box 2 criteria for referral to secondary care 2, 20 • difficulty in swallowing and dehydration first-line antibiotics for dental abscess in dental practices (adults and children more than 12 years) odontogenic infections are multi-microbial with a combination of facultative and anaerobes species. facultative streptococcus viridans group are commensal gram-positive bacteria and include s. anginosus, s. intermedius and s. constellatus. these organisms are abundant in the mouth and most frequently associated with orofacial cellulitis and abscess. after a few days, the anaerobes (prevotella and porphyromonas) predominate. the majority of the facultative streptococci that cause odontogenic infections are sensitive to penicillin. 25 approximately a quarter of strains of prevotella and porphyromonas are penicillin-resistant. 26 the scottish dental clinical effectiveness programme (sdcep) has published evidencebased guidance on antibiotic prescription in dental practice. penicillin-based antibiotics remain the first line for the treatment of odontogenic infections. metronidazole is effective against anaerobic bacteria. 1, 27, 28 the antibiotic doses recommended in the sdcep's guidance are based on the doses recommended by the british national formulary (bnf) 13 (table 2 ). in secondary care settings, the antibiotics are prescribed in accordance with the local hospital antimicrobial therapy. consultation with the on-call microbiologist is a common practice for severe cases and cases which are not responding to first-line treatment. the last principle, but as vital as the previous ones, is the periodic re-evaluation of these patients. in outpatient settings, the recommended follow-up is after two days. 29 forty-eight hours will allow the drainage to cease and the immune system to overcome the initial insult from the infection. if no improvement or deterioration of symptoms is noted, further escalation in care must be provided. the review interval, however, depends on the clinical course of the infection. a patient with a rapidly developing swelling and mild temperature may need review within 24 hours, but a patient with a chronic abscess and no systemic symptoms will need to be reviewed at the end of the antibiotic treatment. causes of treatment failure include: • failure to remove the source of infection • underlying systemic disease; for example, uncontrolled diabetes • antibiotic-related factors -patient non-compliance, drug not reaching site secondary to inadequate drainage, wrong antibiotic choice or incorrect dose. in hospital settings, more frequent evaluations are essential as the disease is expected to be more aggressive. the covid-19 pandemic has dramatically changed dental practice since march 2020. guidance on the management of acute dental problems is available. 2, 30 this is likely to change as the situation evolves. advice, analgesia and antimicrobials (when indicated) should form the basis of primary care dental triage when using remote consultation (telephone call or video call). 1 while assessing the patient, covid-19 status should be established and documented, as this will determine how the patient's care will be managed should referral to an urgent dental care centre or secondary care be required. patients should be advised that dental treatment options are currently severely restricted and that they should call back in 48-72 hours if their symptoms have not resolved. 2 the sdcep's flowchart (fig. 2) helps the remote management of patients by guiding the gdp to categorise the patient into one of three management groups. 2 the sdcep has also recently updated their drugs for the management of dental problems worryingly, there has been a rise in anecdotal reports of antibiotics apparently being overprescribed for dental pain since the outbreak of covid-19. 31 this pandemic has demonstrated the havoc a pathogen can unleash when we have no protection against it. inappropriate use of antibiotics increases the likelihood that resistant bacteria will evolve 31 and it is essential that gdps remain guardians against antimicrobial resistance. 1,32 antibiotics should only be prescribed if it is likely that the patient has a bacterial infection, and the principles of prescribing and follow-up (as detailed earlier) should be followed. it is estimated that 234,000 patients develop sepsis in the uk every year, 5 with 70% of sepsis cases originating in the primary care setting. annually, there are approximately 44,000 deaths from sepsis in the uk 5 and six million deaths worldwide. 33 although deaths from sepsis due to odontogenic infection are very rare, they have been reported. 34 the incidence of sepsis is on the increase, possibly due to: 35 • a growing elderly population • an increased use of invasive surgery • an increased incidence of bacterial resistance • an increased number of immunocompromised patients. a localised infection which progresses into an uncontrolled systemic response is usually the cause of sepsis. progression to acute physiological deterioration with the risk of multiple organ failure and death can be swift. • pneumonia: 50% • urinary tract: 20% • abdomen: 15% • skin, soft tissue, bone and joint: 10% • endocarditis: 1% • device-related infection: 1% • meningitis: 1% • others: 2%. in normal circumstances, the body's immune system will prevent or fight infection (bacteria, viruses, fungi). however, the immune system can sometimes go into overdrive, resulting in vital organs and other tissues being targeted. this can result from any injury or infection in the body. although a wide variety of different microorganisms (for example, streptococcus, e. coli, mrsa or clostridium difficile) can cause sepsis, it is usually caused by common bacteria that don't normally make patients ill. 36 any infection can lead to sepsis (box 3), though pneumonia (commonly referred to as chest sepsis) is the cause in half of the cases. 5 the national institute for health and care excellence (nice) 6 the uk sepsis trust has developed age-specific sepsis decision support tools to assist the dental team to assess both adult and paediatric patients who may have sepsis. 7 utilisation of these sepsis decision tools will help determine if red flag sepsis (see below) is present, prompting appropriate timely action. the prompt transfer of patients presenting with orofacial infections suspected of sepsis to an acute hospital setting for early treatment should ultimately improve sepsis survival rates. 37 the care quality commission (cqc) 38 endorses these sepsis decision tools and, ideally, all three should be readily available in the dental practice. the 'gdp sepsis decision support tool for primary dental care' (fig. 3) should be applied to all adults and young people aged 12 years and over with fever (or recent fever), symptoms presenting with a source of orofacial/dental infection (including post-operative infection) or have clinical observations outside normal limits. 7 it details what to look out for if the patient has presumed infection and, in particular, what constitutes red flag sepsis. red flag sepsis is a definition from the uk sepsis trust which lists a set of easyto-assess clinical parameters, the presence of one of which in the context of infection identifies sepsis with a high risk of death and a requirement for urgent treatment (fig. 3) . 7 if red flag sepsis is present: there are two paediatric sepsis decision tools, one for children aged 5-11 years (fig. 4) and one for children <5 years (fig. 5) . these should be used in children who have a suspected source of orofacial/dental infection (including post-operative infection) or have clinical observations outside the normal range. 7 the paediatric sepsis decision tools take into account paediatric considerations, including differences in paediatric physiology. covid-19 infection can cause sepsis on its own. 5 unfortunately, the sepsis signs and symptoms for a number of initial conditions can be very similar. this stresses the importance for dental teams to be familiar with sepsis and the decision tools described here for safe management of such patients. in addition, evidence suggests that, for a period of time following sepsis, patients may be vulnerable and develop further infections including covid-19; therefore, they have an increased risk of readmission with infective complications (including sepsis). 5 the nice advises that patients with suspected sepsis are assessed following a structured set of observations to stratify the risk of acute illness or death. 6 the royal college of physicians' national early warning score (news) 2 is widely used by the ambulance service and in hospitals, and reliably detects deterioration in adults, triggering review, treatment and escalation of care, particularly sepsis. 41 although news2 hasn't yet been validated for use in primary care, nhs england is encouraging its widespread use in this sector. 42 the cqc has created a webpage titled 'dental mythbuster 25: sepsis' on its website, 38 providing helpful information relating to the management of sepsis in the dental practice, including online links to professional guidelines (nice and uk sepsis trust) as well as what to expect from the cqc, relating to sepsis, when they review dental practices to determine whether they are safe and well-led. when reviewing dental practices, the cqc will ask dental staff what systems and processes are in place to manage a patient with a bacterial infection, including procedures for follow-up and referral for specialist care when necessary. this will include treating patients who: • are not responding to conventional oral antibiotic treatment • cannot have their infection drained at an initial appointment. the cqc will also ask what advice is given to patients, including when they should seek emergency advice or treatment, if symptoms worsen or when the dental surgery is closed. odontogenic infections can lead to sepsis, which can result in tissue damage, organ failure and death. this article has outlined the management of odontogenic infections, including the latest covid-19 guidelines. drugs for the management of dental problems during covid-19 pandemic management of acute dental problems during covid-19 pandemic severe odontogenic infections with septic progress -a constant and increasing challenge: a retrospective analysis medical emergencies: sepsis in primary dental care professional resources sepsis: recognition, diagnosis and early management nice guideline uk sepsis trust. clinical tools. 2020. available online at changing trends in deep neck abscess. a retrospective study of 110 patients deep neck abscesseschanging trends life-threatening oro-facial infections peterson's principles of oral and maxillofacial surgery deep space neck infection: principles of surgical management prescribing in dental practice increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management ludwig's angina ludwig's angina management of head and neck infections in the immunocompromised patient organ reserve, excess metabolic capacity, and aging influence of aging and environment on presentation of infection in older adults criteria for admission of odontogenic infections at high risk of deep neck space infection irrigating drains for severe odontogenic infections do not improve outcome antibiotic selection in head and neck infections pharmacology of local anaesthetics used in oral surgery is conservative treatment of deep neck space infections appropriate? evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility severe odontogenic infections. part 2. prospective outcomes study management of acute dental problems: guidance for healthcare professionals sdcep. drug prescribing for dentistry: dental clinical guidance deep neck infection covid-19 guidance and standard operating procedure when to prescribe antibiotics royal college of surgeons, faculty of general dental practice (uk) & bda. open letter on prescribing antibiotics during covid-19 assessment of global incidence and mortality of hospital-treated sepsis. current estimates and limitations death from overwhelming odontogenic sepsis: a case report sepsis guidance implementation advice for adults sepsis decision support tool for primary dental care dental mythbuster 25: sepsis resuscitation council uk. the abcde approach basic guide to medical emergencies in the dental practice: second edition news) 2: standardising the assessment of acute-illness severity in the nhs national early warning score (news) the recognition and management of sepsis in the dental practice has also been discussed, including the age-specific sepsis decision support tools developed by the uk sepsis trust. key: cord-253682-pwrojqju authors: yakubov, dorin; ward, max; ward, brittany; raymond, george f.; paskhover, boris title: opinion: an increase in severe late-dental complications may result from reliance on home dental remedies during the covid-19 pandemic date: 2020-05-15 journal: j oral maxillofac surg doi: 10.1016/j.joms.2020.05.016 sha: doc_id: 253682 cord_uid: pwrojqju nan the global pandemic resulting from the covid-19 outbreak has caused significant limitations in the publics access to routine dental and medical care. availability of appointments at private medical and dental practices, particularly on the east coast, have been severely curtailed as practices have shut their doors and laid off workers in response to stay-at-home orders and reduced clinical volume. 1 even larger academic practices have been forced to close for all but the most severe emergencies. 2, 3 despite this, routine dental issues continue to occur. data from google trends shows that while united states searches for "dentist appointment" are at a one year low, searches for "dental emergency" are at a 1 year high ( figure 1a ). this also coincides with the massive spike in interest for the terms "covid-19" and "stay at home", as well as the growing awareness covid-19 in the united states ( figure 1b) . unfortunately, routine dental conditions may rapidly evolve to emergencies if not promptly handled, and these data suggest that while patients decreasingly looking for dental appointments, they are increasingly using internet searches to see if their dental condition is an emergency in order to avoid leaving the house. patients may even attempt to treat themselves at home in extreme circumstances. 4 clinically, the consequences of this are becoming increasingly apparent. at our hospital system, we have begun to see increasing numbers late dental complications, specifically ludwig's angina, an end-stage infection of the floor-of the mouth often resulting from untreated mandibular infections or trauma. 5 this condition has become exceeding rare in the age of modern dentistry, and therefore this increase is alarming. we believe this may be the direct result of decreased routine dental care, as patients begin to ignore signs of increasingly severe dental conditions in an effort to remain home. we believe that this is likely the result of a failure to directly communicate with patients the circumstances under which they should seek dental care despite the covid-19 pandemic. in cases of severe dental pain, persistent oral bleeding, or increasing difficulty with breathing or swallowing, patients should still be urged to seek dental care. while the risks associated with covid-19 are significant, the risks of untreated dental emergencies may prove immediately life-threatening. as such, it is our belief that when public agencies and policy makers communicate the situations under which citizens may leave their residences, there should be greater emphasis placed on non-covid related medical and dental emergencies. patients in pain, dentists in distress: in a pandemic, the problem with teeth new york state dental association. practice guidance people are pulling their own teeth while dentists are on coronavirus lockdown statpearls. treasure island (fl) key: cord-340138-u8hxyfml authors: seneviratne, chaminda jayampath; lau, matthew wen jian; goh, bee tin title: the role of dentists in covid-19 is beyond dentistry: voluntary medical engagements and future preparedness date: 2020-10-06 journal: front med (lausanne) doi: 10.3389/fmed.2020.00566 sha: doc_id: 340138 cord_uid: u8hxyfml the emergence of the highly infectious novel coronavirus sars-cov-2 has led to a global covid-19 pandemic. since the outbreak of covid-19, worldwide healthcare systems have been severely challenged. the rapid and explosive surge of positive cases has significantly increased the demand for medical care. herein we provide a perspective on the role dentists can play in voluntary medical assistance and future preparedness for a similar pandemic. though dentists and physicians have different scopes of practice, their trainings share many similarities. hence, dental professionals, with their knowledge of basic human science and sterile surgical techniques, are an invaluable resource in the covid-19 pandemic response. overall, it is commendable that many dentists have risen to the challenge in the fight against covid-19. for example, in singapore, national dental centre singapore (ndcs) deployed dental clinicians as well as volunteers from research laboratories to screen for suspected cases, provide consultations as well as conduct swabbing operations. dental practice will be considerably changed in the post-covid-19 era. there is a greater need to have refresher courses for practicing dentists on new infection control strategies. moreover, the curriculum in dental schools should be expanded to include competencies in pandemic and disaster relief. in addition, voluntary medical work should be made a part of the community dentistry curriculum. this volunteerism will leave a positive impact on developing the careers of young dentists. hence, the contribution of dentists beyond dental practice in this pandemic situation will be appreciated by future generations. the emergence of the highly infectious novel coronavirus sars-cov-2 has led to a global covid-19 pandemic. since the outbreak of covid-19, worldwide healthcare systems have been severely challenged. the rapid and explosive surge of positive cases has significantly increased the demand for medical care. herein we provide a perspective on the role dentists can play in voluntary medical assistance and future preparedness for a similar pandemic. though dentists and physicians have different scopes of practice, their trainings share many similarities. hence, dental professionals, with their knowledge of basic human science and sterile surgical techniques, are an invaluable resource in the covid-19 pandemic response. overall, it is commendable that many dentists have risen to the challenge in the fight against covid-19. for example, in singapore, national dental centre singapore (ndcs) deployed dental clinicians as well as volunteers from research laboratories to screen for suspected cases, provide consultations as well as conduct swabbing operations. dental practice will be considerably changed in the post-covid-19 era. there is a greater need to have refresher courses for practicing dentists on new infection control strategies. moreover, the curriculum in dental schools should be expanded to include competencies in pandemic and disaster relief. in addition, voluntary medical work should be made a part of the community dentistry curriculum. this volunteerism will leave a positive impact on developing the careers of young dentists. hence, the contribution of dentists beyond dental practice in this pandemic situation will be appreciated by future generations. keywords: covid-19, dentistry, voluntary work, preparedness, infection control background the emergence of the highly infectious novel coronavirus has led to a global pandemic in a span of just 3 months. it was only on 31 december 2019 that first reports of pneumonia of an unknown cause detected in wuhan, china, began to surface to the world health organization (who). provisionally named as 2019 novel coronavirus (2019-ncov), there was evidence of exponential human-to-human transmission in the early outbreak stage (1) (2) (3) . consequently, on 30 january 2020, the who declared the outbreak a public health emergency of international concern (pheic). subsequently, assessment by the coronavirus study group (csg) of the international committee on taxonomy of viruses found that sars-cov-2 clusters phytogenetically with the species severe acute respiratory syndrome-related coronavirus (sars-covs) and genus betacoronavirus, and formally designated it as severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (4). csg also emphasized that the name sars-cov-2 has no relationship to the name of the sars disease caused by sars cov-1. in fact, the sars cov-2 genome shares only 79.6% similarity to that of sars-cov-1 (5) . the initial sequencing of the new coronavirus revealed that it is closely related to betacoronaviruses of bat origin i.e., bat-sl-covzc45 (87.99% similarity) and bat-sl-covzxc21 (87.23% similarity) (5) . more recent genome sequencing showed that a bat coronavirus batcov ratg13 originally found in the bat rhinolophus affinis from yunnan province, china has 96.2% genome similarly to that of sars cov-2 (6) . these foregoing studies indicate that the bats are the likely zoonotic reservoir host for sars cov-2. although bats may be the original source of the new coronavirus, it is assumed to be transmitted to humans via an intermediate host, possibly pangolins or wild animals currently yet unknown (7). on 11 february 2020, the who announced coronavirus disease 2019 to be the disease caused by sars-cov-2. subsequently, many countries continued to experience clusters of cases and community transmissions. this led the who to declare the covid-19 outbreak a pandemic on 12 march 2020. as of 26 july 2020, more than 15.78 million confirmed cases of covid-19 and 640,016 associated deaths have been reported worldwide (8) . with the number of infected cases surging each day, researchers are racing to understand what makes it spread so easily. from the evidence so far, the transmission of sars-cov-2 can occur via respiratory droplets, contact and aerosols (9) . a major factor facilitating the transmission of covid-19 is the high level of sars-cov-2 shedding in the upper respiratory tract, even among pre-symptomatic patients (10) . it has been reported that pharyngeal virus shedding of sars-cov-2 reaches its peak on day 4 of symptoms onset, and it can be over 1,000 times higher than sars-cov-1 (11) . numerous cases have been reported wherein patients who had positive test results were asymptomatic at testing (12) . moreover, the asymptomatic incubation period for infected individuals could be ∼1-14 days in general, although longer incubation periods as long as 24 days have been reported. thus, symptom-based screening alone may have failed to detect a high number of covid-19 positive cases and most likely contributed to the rampant transmission. since the outbreak of covid-19, worldwide healthcare systems have been severely challenged. the rapid and explosive surge of positive cases have led to a significant increase in the demand for medical care. on the infrastructure front, hospitals have actively scaled up their capacity of basic and critical care beds. however, global medical manpower resources are finite. consequently, many hospital-based healthcare workers have had to work overhours and take on extra shifts. such stressors have been associated with reduced job performance and fatigue-related errors which could harm patients (13) . in responding to this crisis with a multi-sectorial, equitable and human-rights focused approach, the united nations entities have called for voluntary support from professionals with medical backgrounds for various job capacities to manage the pandemic (14) . though dentists and physicians have different scopes of practice, their trainings share many similarities. the dental student, like his medical counterpart, has to attain proficiency in his understanding of the basic sciences such as anatomy, physiology, pharmacology, and microbiology. this is essential given that dentists are expected to competently manage dental issues of medically compromised patients. moreover, dentists must be able to expeditiously and effectively manage medical emergencies that may arise in routine dental practice. to this end, many dental practitioners would have undergone basic cardiac life support training. thus, the robust training of clinical medicine in dentistry strengthens the candidature of dentists to volunteer services for covid-19 control and spread. the outbreak of covid-19 has significantly affected the practice of dentistry. dental treatment can generate large amounts of aerosols and droplets mixed with the patient's saliva or blood (15) . this poses a risk to dental professionals as sars-cov-2 has been detected in saliva of infected individuals (16) . many dentists have therefore discontinued the provision of elective dental treatment, in accordance with guidelines released by national-level government healthcare authorities such as the centers for disease control and prevention (cdc) in the us and national health service (nhs) in the uk. only limited cases that require urgent or emergency dental care continue to be seen. the significantly reduced workload during this time, coupled with robust training in a medical setting, makes the dentist a prime candidate to volunteer in the fight against covid-19. dental professionals, with their knowledge of basic human science and sterile surgical techniques, are an invaluable resource in the covid-19 pandemic response. licensed dentists are eligible to administer covid-19 diagnostic tests such as nasopharyngeal and oropharyngeal swabs. with their detailed understanding of head and neck anatomy, dentists are well placed to perform such procedures accurately and atraumatically. this is imperative as irritation to the oral or nasal mucosa while swabbing risks the patient sneezing or coughing, potentially releasing contaminated droplets and aerosols to the environment. unlike negative-pressure rooms, many makeshift medical screening facilities are unable to limit the aerosol spread of sars-cov-2. this may lead to contamination of open-air healthcare facilities. in this context, dental clinics that are well equipped with facilities to control aerosol spread of infections, such as negative pressure rooms and high-volume excavators, can offer help to augment the capacity for covid-19 screening. in this regard, global health authorities as well as health ministries from the respective countries have provided clear standard infection control procedures for dentists (17) (18) (19) . dentists can also assist their medical counterparts in the inpatient setting. such duties include patient triage, monitoring vital signs, administering oxygen and injectables, and writing prescriptions. should emergency procedures need to be performed, dentists are capable of administering local anesthesia and suturing. in addition, oral surgeons and dentist anesthesiologists are competent in performing intubation, deep sedation and general anesthesia services (20) . the covid-19 outbreak as well as harsh lock down practices worldwide have created a stressful environment for many people globally. such stressful situations have been shown to lead to poor oral health (21, 22) . therefore, oral healthcare professionals should consider developing online platforms to provide information on oral hygiene and oral health maintenance. digitalized healthcare services can be implemented with a qualified team of dentists being available online to provide reliable oral healthcare solutions in an accessible, affordable and appropriate manner and allay patients' dental concerns during the lockdown period. oral healthcare professionals can also engage in voluntary service for residents in community housing to promote good oral health. the recommendations on how the dental fraternity can play their part in the current crisis are summarized in table 1 . in singapore, while limited community transmission of covid-19 remains, there has been a rapid surge in the number of infected cased among foreign workers living in dormitories. such facilities become conducive for rapid spread of sars-cov-2 as residents are housed in close proximity and share many common amenities. in a whole-of-government approach to isolate and eradicate the virus, the singapore government implemented aggressive mass-scale testing for covid-19 for foreign workers residing in dormitories. this major operation was undertaken by multiple agencies including singapore health services (singhealth), singapore police force and singapore armed forces. supporting this move, national dental centre singapore (ndcs) deployed dental clinicians as well as volunteers from research laboratories to the foreign worker dormitories to conduct swab operations. all patients were treated as suspect cases, and all volunteers observed universal precautions and donned appropriate personal protective equipment (ppe). the use of specially manufactured swab booths further minimized the risk of cross-infection between patients and volunteers (figure 1) . in this massive operation, ndcs staff worked collaboratively with colleagues across various professional backgrounds including clinicians, nurses, pharmacists, radiographers, and medical social workers (figure 2) . without the cohesive and coordinated effort, it would have been a considerable task to successfully establish and staff the field swab clinics within a short period of time. in the uk, dentists, dental support teams as well as clinical academics have played a vital role in supporting the nhs (23). for instance, there are news reports that dental staff from bath health nhs trust and qmul institute of dentistry are helping in maternity, critical care, and emergency units. dental hospitals have undergone reconfiguration to support medical care. in the us, dentist volunteers in states such as virginia and california have responded to appeals to assist with critical emergency care needs, and have been redeployed to the frontlines. importantly, states such as california have made changes to their law to allow greater flexibility in scope and licensure in the time of a catastrophic emergency. the law provides immunity from liability for care provided "in good faith" during an emergency for a person who "voluntarily and without compensation or expectations of compensation, and consistent with the dental education and emergency training that he or she has received, figure 1 | dental clinicians from national dental centre singapore were trained to conduct swab procedure using swab booths manufactured in singapore (photo credit: national dental centre singapore). a team of singapore health services (singhealth) volunteers assigned to manage a medical clinic at a foreign workers' dormitory in singapore. this team included a neurologist, a dental scientist, a pharmacologist, a cancer patient service associate, a radiographer and nurses (photo credit: national dental centre singapore). frontiers in medicine | www.frontiersin.org provides emergency medical care to a person during a state of emergency." this would be an important consideration for other countries to follow. covid-19 has been an unprecedented experience for mankind. the scale and extent of the pandemic has forced many governments to take drastic and decisive action, resulting in considerable disruption in daily life and damage to global economies. this episode has revealed the need to be better prepared for future pandemics. to this end, educational institutions can take the lead. dental schools should revise and strengthen education on infection control measures in dental practice. some areas where universal precaution protocols can be re-evaluated and strengthened include hand hygiene, donning and doffing of ppe, respiratory hygiene/cough etiquette, sterilization of instruments and devices, and disinfection of workplaces. additionally, with the growing evidence of asymptomatic transmission of covid-19, infection control practices should be re-examined and improved to prevent crossinfection in a dental setting. notwithstanding, recent attempts have been made to review the current literature on precautions when providing dental care during the current pandemic, and make recommendations for dental practitioners (24, 25) . the curriculum in dental schools should also be expanded to include competencies in pandemic and disaster relief. such exposure enable dentists and their dental auxiliaries to augment the existing medical professionals in response to declared medical emergencies. dentists have already been trained to undertake oral swab procedures and biopsies as part of oral cancer screening. however, in the wake of a pandemic outbreak, dental students should be additionally trained to perform nasopharyngeal and oropharyngeal swabs, as well as saliva sampling procedures. dentists can also be a part of an effective surveillance network by notifying public health authorities about unusual oral symptoms or clinical presentations detected in questionable frequency in a population. thus, dentists can facilitate the early detection of a disease outbreak or bioterrorism attack, and prevent mass casualties by prompt interventions. in addition, voluntary medical work should be made a part of the community dentistry curriculum. in dentistry, clinical outreach programs during undergraduate training are still in their infancy. such programs should be quickly scaled up. several studies have reported that overseas voluntary outreach programs are a fulfilling and life-changing experience for dentists (26) , and that community-based learning experience brings significant positive outcomes in terms of productivity and higher professional standards of dental students (27) . with the expanded level of contact with patients from various strata of society, students will have additional opportunities to see the complexities of social and cultural aspects of their future patients. in addition, students are likely to gain appreciation for alternative career paths in public health as well as volunteer work. these experiences also have a positive impact on their understanding of ethical and social issues related to oral health care (28). some dental schools have already included community engagement programs as a part of the dental curriculum. such engagements instill a sense of voluntarism in the minds of the dental graduates and prepare them to contribute in future disease outbreaks. a study looking at stony brook university's humanitarian dental mission to rural madagascar found that all dental students who participated gained experience and confidence in their clinical ability and increased their speed in performing procedures under demanding conditions (29) . beyond medical training, such programs also nurture team work, communication skills and leadership qualities in young dentists. moving forward, it is likely that dental practice will be considerably changed in the post-pandemic era. therefore, there is a greater need for refresher courses for practicing dentists on infection control in order to adjust with patients' apprehension in the post-covid-19 world. dental authorities and dental schools should urgently look into this need and appoint taskforces to develop protocols and appropriate courses for dental practitioners. concurrently, research on infection control in the dental setting needs to be advanced. in order to formulate best practices, new research should be conducted across all disciplines of dentistry covering all procedures and their respective infection control strategies. the field of public oral health should find new research avenues on community oral health that can provide an insight on the perception and apprehension of patients during hospital visits. such information would help to revive the financial viability of public hospitals and private clinics. the recommendations for dental implementation in the post-covid-19 era are summarized in table 1 . volunteers are being selfless in providing services amid crisis. however, it should be borne in mind that similar with medical staff, volunteers are also a vulnerable group. preparation and medical support for volunteers during their placement is a significant aspect of any overseas voluntary work. lack of understanding and preparation may expose volunteers to certain diseases during community engagement as well as subject them to psychological problems (30). hence, it is highly advisable that proper training is provided to the volunteers. volunteers should be trained on proper donning and doffing of ppe. it is important not just to minimize cross-infection but to keep it to zero. therefore, strict infection control measures such as correct use of gloves and hand hygiene steps should be practiced. volunteers working in close contact with covid-19 positive patients should check for proper fit and size of n95 masks. it is very likely for cross-contamination to occur during public mass-scale swabbing operations. a single breach of the chain of infection control will put the whole team in jeopardy leading to quarantine of its members and closure of the medical facility. not all volunteers have the same physical and mental strength and the amount of volunteering work that one can engage must be monitored by group leaders and higher level authority. frequent breaks in between and off days are necessary, in particular for a longer engagement, to support mental and psychosocial well-being of the volunteers. it is also important to provide an understanding of the precautionary safe-distancing measures to be taken with family during and after engagement in risk activities. it is essential that volunteers are mindful of their own and their family's health while serving others. overall, it is commendable that many dentists have risen to the challenge in the fight against covid-19. the role of the dentist in a pandemic can be beyond dentistry. by virtue of their training and practical experience, dentists can provide services in various ways to reduce the strain on the healthcare sector. volunteerism in such a time also leaves a positive impact on the individual. pandemics rarely occur, and practical experience gained will be a lifelong lesson for the volunteer. in fact, the fighting spirit of a volunteer working in risky operations instills a high moral esteem and self-confidence. the rejuvenated personality of the volunteer can prove to be valuable in developing his career in future. the selfless voluntary service will be appreciated by the larger community and future generations. together we will be able to pull through this crisis and emerge stronger than before. written informed consent was obtained by the ministry of health singapore for the publication of any potentially identifiable images or data included in this article. clinical features of patients infected with 2019 novel coronavirus in wuhan early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study severe acute respiratory syndrome-related coronavirus: the species and its viruses -a statement of the coronavirus study group genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding a pneumonia outbreak associated with a new coronavirus of probable bat origin identifying sars-cov-2 related coronaviruses in malayan pangolins coronavirus disease (covid-19) situation report -188 transmission routes of 2019-ncov and controls in dental practice asymptomatic transmission, the achilles' heel of current strategies to control covid-19 virological assessment of hospitalized patients with covid-2019 presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility negative impacts of shiftwork and long work hours volunteers for novel coronavirus (covid-19) pandemic response aerosols and splatter in dentistry: a brief review of the literature and infection control implications saliva is a reliable tool to detect sars-cov-2 covid-19 guidance and standard operating procedure gradual resumption of dental services after covid-19 circuit breaker period dentists can register to help with state's covid-19 pandemic response the importance of family functioning, mental health and social and emotional well-being on child oral health. child care health dev dentistry and coronavirus (covid-19) -moral decisionmaking possible aerosol transmission of covid-19 and special precautions in dentistry precautions when providing dental care during coronavirus disease 2019 (covid-19) pandemic dental mission for children-vietnam comparing fourth-year dental student productivity and experiences in a dental school with community-based clinical education a questionnaire study of voluntary service overseas (vso) volunteers: health risk and problems encountered cjs and ml contributed to the conception. cjs, ml, and btg drafted and critically revised the manuscript. all authors contributed to the article and approved the submitted version. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 seneviratne, lau and goh. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-352862-2q4h3bwj authors: goswami, mridula; sharma, sadhna; kumar, gyanendra; gogia, monica; grewal, monika; garg, aditi; bhardwaj, sakshi; vignesh, ramanand p; narula, vashi; bidhan, ravita title: dealing with “coronavirus pandemic”: a dental outlook date: 2020 journal: int j clin pediatr dent doi: 10.5005/jp-journals-10005-1757 sha: doc_id: 352862 cord_uid: 2q4h3bwj an emergent pneumonia outbreak, denoted as coronavirus disease-2019 (covid-19) by the world health organization (who) originated in wuhan city, in late december 2019 and spread at an alarming rate to become a pandemic affecting more than 200 countries. the covid-19 is caused by a novel coronavirus (2019-ncov), which is highly contagious and is associated with a high mortality rate. the current covid-19 outbreak has created a major havoc among every strata of the society with a detrimental impact on healthcare professionals, including dentists limiting their capabilities at large. the transmission of virus through aerosols produced by highand low-speed handpieces, ultrasonic scalers, air/water syringes, or an infected patient coughing, and even when taking intraoral radiographs has made it difficult for dental personnel to provide even the most basic services to the needful. the virus survives on environmental surfaces for extended periods of time, including metal and plastic surfaces commonly found in dental offices making it utmost necessary to follow the precautions and recommendations issued by various organizations in order to contain its spread. this article aims to provide the latest knowledge encompassing the various aspects of covid-19 to pediatric dentists in india. how to cite this article: goswami m, sharma s, kumar g, et al. dealing with “coronavirus pandemic”: a dental outlook. int j clin pediatr dent 2020;13(3):269–278. the human body is prone to a plethora of infections caused by various microorganisms, which damage the tissues by different mechanisms. 1 these infectious agents can be broadly classified into viruses, bacteria, fungi, protozoa, and helminths. 1 amongst these five groups, viruses hold special significance due to their ability to manipulate the host-cell machinery in a unique manner and evolve continuously to thrive and survive in all species. 1 nearing by the end of 2019, a group of pneumonia cases occurred in wuhan, a city in the hubei province of china with the causative agent being identified as a novel coronavirus. it spread at a rapid pace in china culminating into an epidemic with widespread involvement of other countries across the globe. the world health organization (who) declared the outbreak as a 'public health emergency of international concern' on 30 january, 2020, and subsequently designated the disease as 'covid-19', which stands for coronavirus disease 2019. 2 the number of covid-19 cases in areas other than china increased multifold and the global burden of the disease rose to an alarming 118,000 cases in 114 countries with a loss of 4,291 lives. this led who to ultimately declare covid-19 as a pandemic on 11 march, 2020. 3 the cases are still increasing at an alarming rate involving a total of 209 countries with 1,136,851 confirmed cases and 62,955 reported deaths till 6 april, 2020. 4 it is also designated as 2019 novel coronavirus acute respiratory disease or novel coronavirus pneumonia. this is the first ever pandemic to be initiated by a coronavirus and a situation of this gravitas has not been experienced by the world post the second world war (ww ii: 1939 -1945 . the second world war with nearly 85 million causalities including more than 30 countries was undoubtedly the most dangerous event in human history. at that time, all the countries diligently utilized their entire scientific and economic capabilities in order to strengthen their position on the war front. 5 mirroring this to the present scenario, all the countries must diagnose, isolate, provide treatment, locate, and mobilize the people to the maximum extent. this approach can prevent the conversion of a few cases into clusters and further limit the spread via community transmission. even countries with widespread involvement can turn the tide on this virus by coming together as one unit and effectively screening, isolating, and tracing all the possible cases. 3 major events have been canceled, rescheduled, or modified to curb the transmission of this deadly disease. the grand slam tennis tournament at wimbledon scheduled for 29 june-12 july, 2020 has been canceled for the first time since world war ii on 1 april, 2020. the tournament has been rescheduled between 28 june and 11 july, 2021. another mega event, such as, the 2020 summer olympics to be held in tokyo has been postponed until 23 pandemic as a word should be used cautiously and the intensity of using this word must be understood carefully. an inappropriate use of this word can either lead to undue fear or create a false impression of the fight being over. 3 also, delineation of a situation as a pandemic should not alter the course of estimation of its danger and should strengthen the efforts to control the disease. the who propagates that in order to contain the spread and minimize the impact, every country must adopt a comprehensive approach involving both the governing bodies and the societies at large. 3 viruses are miniature organisms which can multiply only inside a living cell. they contain nucleic acid, such as, rna or dna surrounded by a protein shell. viruses are generally classified by the organisms they infect including animals, plants, or bacteria. 1 coronaviruses are single-stranded rna viruses surrounded by an envelope, belonging to the family coronaviridae. 6 they mostly affect mammals including humans and birds. 6 they possess unique crown-like projections on their surface which correspond to large spike proteins as seen on electron microscopy. coronaviruses have been classified into three groups based on serology and genetic characteristics with the human coronaviruses (hcovs) belonging to groups 1 and 2. 1 in humans, coronaviruses are implicated for causing common cold as well as more severe respiratory infections including both severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). 7 the world health organization (who) has classified 2019 novel coronavirus (2019-ncov) as a beta-coronavirus (β cov) of group 2b belonging to subfamily orthocoronavirinae. 8 the genetic attributes of the 2019-ncov are highly identical to sars-cov and mers-cov with their source of origin being bats. 8 another piece of evidence, which supports that 2019-ncov is of bat origin, is the existence of a high degree of homology of the angiotensin converting enzyme-2 (ace-2) receptor amongst different species of animals causing them to either act as intermediate hosts or be utilized for research-oriented studies for 2019-ncov infections. 9 the epithelial cells of lungs have been hypothesized as the primary targets of 2019-ncov. the first step of infection with the virus involves binding with a host-cell receptor and subsequent union with the host-cell membrane. 9 thus, there is a strong evidence, which points toward human-to-human transmission of 2019-ncov via binding between viral surface spike proteins and host ace-2 receptor. 9 in wuhan city, the wet animal markets being a source of live animals were largely implicated for a high number of positive cases, strongly pointing at the zoonotic origin of 2019-ncov. 10 efforts were made to identify the reservoir host transmitting the infection to humans with preliminary evidence suggesting two species of snakes as possible reservoirs of 2019-ncov. 10 however, there is still a lack of concrete data, which identifies any coronavirus reservoir other than birds and mammals. 10 the high degree of genetic similarity between 2019-ncov and two sars-like coronaviruses indicates mammals as the mode of transmission of 2019-ncov to humans. the cause of spread of 2019-ncov infection has been identified as person-to-person transmission. 8, 10 the basis of this observation lies with the fact that a large number of cases were identified among those families who had never visited wuhan's wet animal markets. direct contact with an infected individual and spread of infection via droplets either by sneezing or coughing are the two most important modes of person-to-person transmission. 10 also, no definitive vaccine is yet available against the virus with trials underway for the same. coronavirus disease-2019 (covid-19) was first seen in wuhan, china, in the end of 2019 and spread at an alarming speed to involve a large number of countries, culminating into a deadly pandemic. in december 2019, a group of pneumonia cases of unknown cause was linked to a local seafood market in wuhan. following this, a total of five patients with acute respiratory distress syndrome were hospitalized from 18 december, 2019 to 29 december, 2019 with one reported fatality. as of 6 april, 2020, a total of 1,136,851 cases of covid-19 have been reported in 209 countries and territories, resulting in nearly 62,955 deaths. more than 264,843 people have recovered. 11 the large variations in number of these cases are dependent upon their region of origin, time since initial outbreak, degree to which diagnostic tests are being conducted, healthcare infrastructure and services, treatment facilities, and various other population parameters. amongst the six who regions including the western pacific, european, south-east asia, eastern mediterranean region, region of the americas and african region, local transmission has been reported in several countries. 12 in western pacific region, china reported highest number of cases (81,589) followed by south korea (9,976), australia (5,136), malaysia (2,766), and japan (2, 178) . in european region, italy had highest cases (110,574) followed by spain (104,118), germany (78,027), france (56,325), uk (29,474), and switzerland (17, 785) . iran had reported 47,593 cases followed by pakistan (2,291) and saudi arabia (1,563) in eastern mediterranean region. usa reported the highest cases (216,362) among the region of americas followed by canada (9,731), brazil (6,836), and chile. in african region, south africa reported 1,380 cases followed by algeria. in south-east asia, indonesia reported 2,291 cases followed by india (2,094), thailand (1,771), sri lanka (143), bangladesh (54), and maldives (18). 13 in india, first case was reported on 30 january, 2020 in kerala. as of 2 april, 2020, there were approximately 2,094 cases among which 150 recovered with 50 casualties. maharashtra had reported the highest number of cases (325) followed by kerala (265), tamil nadu (234), delhi (219), and uttar pradesh (121). 14 the total number of confirmed covid-19 cases, deaths, and summary of cases among different countries till 6th of april, 2020 can be summarized as depicted in tables 1 to 3, respectively. the increase in confirmed covid-19 cases and deaths among different countries till 6 april, 2020, has been depicted in figures 1 and 2 , respectively. the current covid-19 outbreak has created a major havoc amongst healthcare professionals, including dentists. since dental professionals perform procedures which create aerosols and are in direct contact with saliva and blood, the exposure risk is high among dentists. as a result, the entire dental team is highly vulnerable, facing a high possibility of direct exposure to the virus, which also implies a major negative psychological impact. due to this emergent outbreak and difficulty in screening the patient for covid-19, dentists are mostly uncertain of encountering a positive patient. seasonal flu is common among children, and with the changing weather conditions, cold and cough have become extremely prevalent. these may present with overlapping signs and symptoms of covid-19, complicating all elective dental procedures and provision of noncritical dental care. the centers for medicare and medicaid services (cms) 17 recommend that all nonessential dental examinations and procedures must be postponed until further notice. since the announcement of a total lockdown in india on 25 march, 2020, a vast number of private and government dental colleges and hospitals along with private clinics have been completely shut so as to prevent the exposure. the indian dental association (ida) has recommended that all the private dental clinics must not perform any type of nonemergency dental care. 18 the indian society of pedodontics and preventive dentistry (isppd) also issued an advisory for oral health professionals and pediatric dentists including c (clean, cover, and confine), o (observe, online, or telephonic consultation as possible), r (restrict to emergency treatment only and all elective treatment to be postponed as far as possible), o (obey), n (no aerosol), and a (avoid). 19 the declarations issued by these various organizations prove the threatening nature of the current situation for dental professionals. with the closure of various private dental clinics, provision of essential services has become difficult with the dentists incurring economic losses of varying magnitudes. despite these guidelines, hospitals, such as, maulana azad institute of dental sciences, (maids) new delhi, centre for dental education and research (cder) aiims, new delhi, and dental department at ram manohar lohia hospital, new delhi along with various other hospitals across the country, still continue to provide emergency dental services to the needful. even in grave circumstances, such as, todays, a patient reporting with a dental emergency is being effectively treated by dental professionals at such hospitals. the covid-19 pandemic has continued to unfold dramatically all over the world, bringing us to the current state of an international emergency. the cases have seen an exponential rise and so has they have been continuously trying to reinforce the precautionary guidelines for all, time and again. to ensure everyone's safety and following the restrictions laid on travel and large gatherings, the scheduled international conferences have also been postponed. the dental practices have been limited to emergency services only and our entire dental fraternity has been challenged academically, professionally, and financially. to cope up with academic loss, continuous efforts are being made to provide high-quality educational content. social platforms are being used to conduct webinars in an effort to connect people all around the world with the experts, in various interactive learning sessions. surveys are being conducted to evaluate the stress and future implications of this pandemic on dental professionals in order to seek solutions to deal with it on a wide spectrum. efforts are being made by various dental organizations and societies to not connect 'physically' but 'digitally'. the current situation has created a severe negative psychological impact among dental professionals. though all precautionary measures are taken and no procedure is performed without the use of personal protective equipment (ppe), the risk of being exposed and carrying the infection to home is still a major concern. also, the limited availability of ppes is becoming a matter of great concern among health professionals largely restricting their capabilities for providing emergent health services. though the responsibilities are major and expectations are high, dental professionals are at the forefront to provide with whatever best they can! the covid-19 pandemic, caused by 2019 novel coronavirus, has caused a major disruption in the indian healthcare system including both medical and dental facilities. the risk of infection is particularly high among the dental professionals due to a variety of reasons. the covid-19 virus may spread through handpiece-generated aerosols, aerosols produced while using ultrasonic scalers, use of air/water syringes in different dental procedures, or via infected droplets through coughing and sneezing. 20 this virus has a high tendency to survive on exposed environmental surfaces, such as, those found in dental offices for extended periods of time. 20 also, it has been seen that asymptomatic individuals infected with the virus may shed the virus via various body secretions, such as, saliva and transmit the disease. 20 the risk is even higher in pediatric dentistry as children may be asymptomatic but infectious posing a high risk not only to the dentist but also to the parents or guardians accompanying the patient. 20 due to the impending danger of spreading the infection, various dental organizations, such as, american dental association (ada), american dental hygienists' association (adha), indian dental association (ida), indian society of pedodontics and preventive dentistry (isppd), and many others have advised the dental professionals to undertake only essential and urgent dental procedures. 15, 16, 18, 19 present scenario it is important that the dental professionals must carefully weigh the risk associated with provision of nonessential treatment and emergency care to the needful against the availability of personal protective equipment (ppe) for limiting the transmission of infection. the ada, isppd, centers for disease control and prevention (cdc) and occupational safety and health administration (osha) have proposed various measures and guidelines for the safety of both the patients and dental professionals. 15, [19] [20] [21] the following measures should be taken to minimize risk during dental treatment 15,19-21 : • dentists should follow appropriate hand hygiene practices and proper usage of personal protective equipment (ppe). • while treating patients in close approximation to their respiratory system, usage of n95 masks, with proper sealing of areas around the nose and mouth, together with a full-face shield and goggles should be worn. • rinsing the oral cavity with 0.2% povidone-iodine prior to any dental procedure can cause significant reduction in salivary viral load. • use of disposable mouth mirror, syringes, and blood pressure cuff to prevent cross contamination. • take extraoral radiographs whenever possible; intraoral techniques may induce coughing. • while taking intraoral radiographs, double barriers must be used for protection of sensors and to further limit the chances of cross infection. • use of hand instruments should be preferred over aerosolgenerating procedures and high-speed suction facility must be available. • use of dental dam must be encouraged during various dental procedures in order to limit splashing of saliva. also, covering the nose with rubber dam sheet can provide additional benefit to the patient. • dental treatment of patients with suspected or confirmed covid-19 disease must be carried out in negative pressure treatment rooms or airborne infection isolation rooms. • proper disinfection of all the inanimate surfaces must be carried out daily by mopping with a linen/absorbable cloth soaked in 1% sodium hypochlorite and must maintain a dry environment. during the active covid-19 crisis and lockdown period: • creating awareness among people regarding the disease, transmission, and protective measures to be taken (table 4 ). • it is also essential to impart knowledge to them regarding the importance of social distancing. • in this crucial time, it is mandatory to make the patients understand what is dental emergency and to realize the pros and cons of providing unnecessary exposure. • screening for patients with dental emergencies with a history of contact. • using teledentistry in order to limit the spread of infection. • clean your hands often: • with soap and water for at least for 20 seconds. • with sanitizer having 60% alcohol. • avoid touching your eyes, nose, and mouth with unwashed hands. • avoid close contact with people who are sick. • social distancing with other people due to asymptomatic cases (at least 6 feet). • cover your mouth and nose with a cloth face cover when around others. • cover coughs and sneezes. • throw used tissues in the closed bin and immediately wash your hands. • clean and disinfect frequently touched surfaces daily by the following: • diluting household bleach. • alcohol solutions with at least 70% concentration. • other common epa-registered household disinfectants. if surfaces are dirty, clean them: use detergent or soap and water prior to disinfection. the cases of covid-19 seem to be rising at an alarming rate across the world. if the conditions continue to deteriorate, the healthcare professionals will have to face the grave challenge of balancing the treatment needs with the available workforce. in such circumstances, dental professionals with their basic knowledge of human body and vast usage of aseptic techniques can prove to be highly indispensable to the healthcare workforce. this will certainly provide an opportunity for the local hospitals facing the highest demand to utilize dentists' skills in the time of need. some of the ways dentists can provide their assistance may include: • primary screening of patients with history regarding symptoms of covid-19. • recording the four primary vital signs, i.e., body temperature, blood pressure, heart rate, and respiratory rate. • performing diagnostic tests for covid-19 detection. • triaging to determine the priority of treatment. • providing emergency dental care. • oxygen administration along with provision of essential vaccinations. • writing prescriptions. • provision of services including deep sedation or general anesthesia along with intubations by dental anesthesiologists. • donating spare ppe, n95, and surgical masks, face shields, gowns, gloves, and hand sanitizers to hospitals in order to meet the increased treatment demands. in this way, the dental healthcare professionals can accomplish their role as healthcare workers and help in serving the nation. the anticipated difficulties in the future can be rationally divided into immediate implications, which would be observed after completion of lockdown period and before the availability of a therapeutic drug or vaccine, and extended implications may be seen after the availability of a therapeutic drug or vaccine and hence emerge over an extended period of time thereafter. 22, 23 anticipated immediate implications social front: even after india overcomes the disaster stage of the pandemic, the viral infection would still prevail and should not be overlooked. hence, preventive measures and use of safety equipment would be necessary till a potential vaccine or therapeutic drug is made to overpower the covid-19 virus. measures at the public front would include the following: 22, 23 • wearing masks in public places • social distancing • good hygiene measures • continued screening for covid-19 at all potential places involving airports, railway stations, hotels, and hospitals. • limited social gatherings/conferences • limited international travel • immediate consultation on appearance of symptoms and quarantining the healthcare sector's active participation on following the current protocol for disease screening, evaluation, and treatment is necessary. measures adopted: 22, 23 impacts on dental sector: • detailed past medical and traveling history should be taken from the patients with elaborated discussion on symptoms for the infection -continuing screening of patients. • all patients should be treated under universal precautions. • use of masks and personal protective equipment (ppe) while treating a patient should be mandatory. • patients with symptoms of covid-19 should be referred and elective dental treatment deferred till recovery. • minimizing aerosol production to avoid infection from asymptomatic patients. the present time is proving to be difficult for every strata of the society but it is expeditiously arduous for healthcare professionals design principles in virus particle construction world health organisation world health organization, director-general's opening remarks at the media briefing on covid-19 -11 world health organization, coronavirus disease (covid-19) pandemic. world health organisation coronavirus pathogenesis symmetry in virus architecture origin and evolution of pathogenic coronaviruses receptor recognition by the novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars coronavirus a novel coronavirus from patients with pneumonia in china coronavirus update (live) available from: www.worldometers.info/ coronavirus situation report -59. world health organisation ministry of health and family welfare ada recommending dentists postpone elective procedures. american dental association. 2020 [last accessed on adha covid-19 updates for dental hygienists. american dental hygienists' association. 2020 [last accessed on cms adult elective surgery and procedures recommendations. centers for medicare and medicaid services. 2020 [last accessed on advisory by isppd head office to all the oral health professioanls & pediatric dentists. indian society of pedodontics and preventive dentistry summary of ada guidance during the covid-19 crisis interim infection prevention and control guidance for dental settings during the covid-19 response preparedness and lessons learned from the novel coronavirus disease the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? international journal of clinical pediatric dentistry, volume 13 issue 3 (may-june 2020) 278 including dental personnel. although all the necessary precautions are being diligently followed at various dental hospitals, providing services even to most needful has become a tedious expedition. with so much uncertainty and peculiarly precarious nature of the present situation, we can only hope to contribute in the best of our capabilities without overlooking the need for adopting all the necessary steps to prevent and limit the spread of this deadly disease at large. key: cord-295720-eeqv5xa4 authors: umeizudike, kehinde adesola; isiekwe, ikenna gerald; fadeju, adeyemi dada; akinboboye, bolanle oyeyemi; aladenika, emmanuel temitope title: nigerian undergraduate dental students’ knowledge, perception, and attitude to covid‐19 and infection control practices date: 2020-09-21 journal: j dent educ doi: 10.1002/jdd.12423 sha: doc_id: 295720 cord_uid: eeqv5xa4 purpose/objectives: the current coronavirus disease 19 (covid‐19) pandemic has affected most countries. infection, prevention, and control training is important in mitigating the spread of covid‐19. the closure of universities by the nigerian government has hampered academic activities of dental students. our objectives were to assess the knowledge, perception, and attitude of undergraduate dental students in nigeria to the covid‐19 pandemic and infection control practices. methods: this was a cross‐sectional study of undergraduate clinical dental students from the dental schools in nigeria. self‐administered questionnaires were distributed to participants using an online data collection platform. correct responses to the 45‐item questionnaire on covid‐19 knowledge were scored to determine their knowledge level. a likert scale of 1‐5 was used to assess the 13‐item perception and attitude questions. the level of significance was set at p values ≤ 0.05. results: a total of 102 undergraduate clinical dental students participated in the study. males represented 54.9%, and mean age was 25.3 ± 2.4 years. fifty percent of the students had adequate knowledge of covid‐19. final‐year students (58.1%) demonstrated more adequate knowledge of covid‐19 than penultimate‐year students (28.6%, p = 0.008). most (95.1%) respondents had positive attitudes towards infection control practices against covid‐19. conclusion: although the clinical dental students had a positive attitude to infection control practices against covid‐19, the overall knowledge of covid‐19 was barely adequate. guidelines on covid‐19 from reputable health authorities should be reviewed by dental school authorities and disseminated to the students to suit their clinical practice. the new coronavirus infection was first identified in a cluster of patients admitted into hospitals for suspected pneumonia of an unknown cause, later linked to a seafood and wet animal market in wuhan city, hubei province, china, in december 2019. 1 this coronavirus has been identified as the severe acute respiratory syndrome coronavirus (sars-cov-2). 2 this infection was named the novel coronavirus disease 19 (covid-19) on february 11, 2020 by the who. 3 as the disease began to spread rapidly across several countries, the covid-19 outbreak was declared a global pandemic by the who on march 11, 2020. 4 since the initial cases, covid-19 has affected more than 27 million people globally with over 880,000 deaths in about 216 countries and territories 3 as of september 7, 2020, thus posing a serious and alarming public health concern. since the index confirmed case in nigeria on february 27 th , 2020, the number of confirmed cases have risen to 55,160 with 1061 covid-19 related deaths, as of september 8, 2020. 5 the increase in the number of confirmed cases led the federal government of nigeria (fgn) in march 2020 to effect the immediate closure of all educational institutions including universities, airports, land borders, and religious and recreational centers, amongst others, as major efforts to curb the spread of the infection. 5 the nigeria centre for disease control (ncdc) in partnership with the ministry of health and state governments has been actively involved in contact tracing, testing, isolation, and treatment of covid-19 cases in nigeria. 5 numerous campaigns have been embarked upon through the media for preventive measures such as hand hygiene, respiratory etiquette, social/physical distancing, noncontact temperature screening, and facemask wearing in public places to limit the spread of the disease. the covid-19 pandemic has also affected dental training schools and dental clinics all over the world, with initial restrictions to emergency and urgent dental care. [6] [7] [8] the nigerian dental association also issued some guidelines on covid-19 protocol for dental clinics in nigeria to postpone elective procedures in april, 2020. 9 this is due to the reported high risk of infection amongst dental professionals as a result of the large amounts of aerosols generating procedures and their close proximity to patients in confined treatment offices/clinic. the coronavirus has also been found in the saliva of infected persons, 10 and shown to survive in aerosols for hours and on surfaces for days. 11 the closure of universities by the fgn in a bid to limit the spread of covid-19, has hampered the academic activities of dental schools and clinical training of dental students in nigeria. the pandemic also affected the training activities of dental students in countries such as china 12 and canada. 13 dental students in china had to continue learning online after the chinese spring festival and were told not to return to school until further notification at the onset of the pandemic. 12 also in canada, many third-and fourth-year undergraduate dental students within a dental geriatric module in the university of british columbia, vancouver, were unable to participate in the clinical geriatric care activities due to the covid-19 pandemic. 13 the ongoing industrial strike action embarked by the academic staff union of universities in nigeria has further worsened the situation as all forms of training in federal universities have been grossly affected. the impact on the effective training of dental students in nigerian universities is likely to be severe, further worsened by the highly contagious nature of the covid-19 infection in clinic settings by the time dental schools in nigeria reopen. previous studies among nigerian dental students had highlighted the importance of feedbacks from students on the factors that affecting their training and how these could be overcome. [14] [15] [16] the covid-19 pandemic presents with a new range of challenges for undergraduate dental training, not only in nigeria, but worldwide which include infection control practices in the clinic. understanding these challenges will assist and guide dental faculties in assisting dental students through these very difficult times. the aim of this study was therefore to assess the knowledge, perception and attitude to the covid-19 pandemic and infection control practices among undergraduate clinical dental students in nigeria. ethical approval for this study was obtained from the health research ethics committee of the lagos university teaching hospital. the ethical approval number for the study is luthhrec/erev/0420/12. this was a descriptive cross-sectional study in which the study population was made up of undergraduate clinical dental students in their penultimate (year 5) and final years (year 6) from 9 out of the 12 accredited dental schools in nigeria. the estimated population of undergraduate clinical dental students in nigeria is 400, as they constitute a smaller segment of all undergraduate dental students in the country. the sample size of the participants for the study was determined to be 102 using a confidence level of 98% within a 10% margin of error. informed consent was obtained from all respondents in the study. self-administered questionnaires were distributed and sent out repeatedly to participants using an online data collection platform (google forms), between april 30 and june 6, 2020 using a purposive sampling technique. the respondents were accessed through their whatsapp general dental students' platform and direct whatsapp messages. the questionnaire had 3 sections. section 1 documented the participants' sociodemographic characteristics while section 2 recorded participants' knowledge of covid-19. correct responses were assigned 1 point while incorrect answers were assigned 0. forty-five (n = 45) questions were used to assess the students' knowledge of covid-19. the total knowledge score was derived based on the total sum of correct responses and converted to percentage scores. the level of knowledge of covid-19 was categorized into 2: adequate and inadequate, using a cut off value of 60% considering the fact that covid-19 is still a novel disease. the third section appraised their perception and attitude towards infection control practices in the dental clinic using 13 questions. participants' attitudes were assessed using a 5-point likert scale (1 = strongly disagree; 2 = disagree; 3 = indifferent; 4 = agree; 5 = strongly agree). all the scores were summed up and converted to percentages. the average percentage perception score was then computed. scores ≥60% were graded as positive attitude towards infection control. data analysis was carried out using the statistical package for social sciences version 20. descriptive statistics was used for categorical variables that were expressed as frequencies and percentages, while student's t test was used to compute the means and standard deviation of continuous variables such as the age. the 5 likert scales were collapsed into 3 categories: disagree (scales 1,2), neutral (scale 3), and agree (scales 3,4) for purpose of the statistical analysis. differences between categorical variables were compared using the chi-square or fisher's exact where indicated. the level of statistical significance was set at p ≤ 0.05. a total of 102 undergraduate clinical dental students participated in the study. males were slightly more (54.9%) than females (45.1%). the mean age of the respondents was 25.3 ± 2.4 years (range of 21-31 years). majority (72.6%) of the respondents were in their final year. students in 9 out of the 12 dental schools participated in the study and distribution is as follows: university of lagos-35 (34.3%); obafemi awolowo university-20 (19.6%); university of maiduguri-15 (14.7%); university of nigeria nsukka, enugu-12 (11.7%); university of benin-6 (5.9%); lagos state university-5 (4.9%); university of ibadan-5 (4.9%); university of medical sciences, ondo-2 (2%); and bayero university of kano-2 (2%). the mean overall knowledge score was 70.17 ± 10.0. overall, 51(50%) demonstrated adequate knowledge of covid-19. a significant proportion of the respondents (78.4%) reported that they were up to date on the case definition for covid-19. figure 1 shows the source of infor-f i g u r e 1 sources of information about covid-19 among the respondents in the present study mation about covid-19, which is the primary data collected among the respondents during the present study. their source was mostly from the social media (99%), television (81.4%), friends/family (45.1%), colleagues (42.2%), and text message (39.2%), while the least source of information came from academic training courses (8.8%). the social media in this study included twitter, facebook, instagram, youtube, etc., while the text message was the short message service (sms) through phone which was utilized mainly by the nigerian center for disease control (ncdc) to disseminate covid-19 related information. academic training courses on covid-19 that were freely organized by health organizations/bodies, locally and internationally, were accessible to the respondents in this study through different online platforms. table 1 shows the responses of the respondents to the questions on covid-19. nearly 60% of the students correctly identified sars-cov 2 virus as the cause of covid-19 while majority (95.1%) knew the average incubation period as 1-14 days. only 30.4% of the respondents knew that mild to moderate symptoms occurred in 80% of those infected with covid-19, while 96.1% knew that asymptomatic people could spread the coronavirus. transmission routes of covid-19 were reported as respiratory droplets from coughing, sneezing, and talking (99%), and airborne (52.9%). some of the symptoms of covid-19 known by the respondents included shortness of breath (100%), cough (99%), fever (97.1%), loss of smell or taste (49%), joint/muscle pain (44.1%), chills (42.2%) and diarrhea (25.5%). the sample collection methods to diagnose covid-19 was reported by 85.3% as real-time pcr with nasopharyngeal swab/sputum and 23.5% as real time pcr with endotracheal aspirate. only 16.7% of the respondents knew the (figure 2) . table 2 shows their perception/attitude towards infection control. their responses included the perception that the current standard of infection control measures in their dental schools were effective in preventing the spread of covid-19 (24.5%). majority (95.1%) agreed that aerosol-generating procedures in dentistry carried a high risk of spreading covid-19. regarding their attitude, 92.2% were willing to undergo an infection control training in dentistry for covid-19 while only 39.2% were willing to personally procure extra personal protective equipment (ppe) for use in the dental clinic to prevent the spread of covid-19. table 3 shows the association between knowledge of covid-19 and sociodemographic characteristics, and perception/attitude towards infection control practices against covid-19. only the year of study was significantly associated with the knowledge of covid-19, as the final-year students (58.1%) demonstrated more adequate knowledge of covid-19 than the penultimate-year students (28.6%) (p = 0.008). the rapid surge in the number of cases during the covid-19 pandemic has placed enormous strain on health care systems and significantly impacted educational systems globally, including dental training institutions in health care settings of undergraduate dental students. there are currently about 12 accredited dental schools in nigeria. prior to the covid-19 pandemic, studies by isiekwe et al. 14-16 among undergraduate dental students in nigeria observed a lack of satisfaction with the quality of their clinical training. this study sought to provide an overview of dental students' knowledge of covid-19 and attitude to infection control during this pandemic, which could serve as guidelines in preparation for school resumption and clinical training of the students. the present study revealed that generally, only half of the students had adequate covid-19 related knowledge. on the contrary, majority had a positive attitude 17 who reported a large proportion (82.3%) of university students in china with good knowledge of covid-19. a possible reason for the differences observed may be the fact that fewer questions were used in that survey (5 questions) 19 compared to our present survey which had many more questions on covid-19 (45 questions). it is thus most likely that more information was required from the students in the present study. clinical dental students are expected to possess an in-depth knowledge particularly due to their access to the social media and television which were their most frequent source of information in the present study. the proportion of respondents with adequate knowledge of the diagnosis, case definition, symptoms (like diarrhea, joint/muscle pain, loss of smell, chills, headache), and at-risk persons was observed to be low. this could be ascribed to the novelty of the infection and the rapidly evolving information concerning its epidemiology. in this study 97% of the participants knew the correct incubation period of covid-19, which is contrary to the findings of khader et al., who reported that only 36.1% of dentists in jordan knew the correct incubation period. 18 the news media in nigeria has been flooded with regular and continuous information from the ncdc (nigerian centre for disease control) on the need for self-isolation for a period of 14 days for people who developed specific symptoms such as cough, fever, and breathing difficulties. this would no doubt have increased the respondents' awareness about these common symptoms, as the news media was bombarded by campaigns to identify these symptoms. besides, the jordanian study 18 was conducted at an earlier stage of the pandemic, which might have accounted for the disparity in knowledge level of the correct incubation period. the majority of the dental students knew the early and common features of the infection; this finding is crucial as students should be able to easily identify a suspected ta b l e 3 association between knowledge and socio-demography, perception, and attitude towards infection control practices against covid-19 case and take the necessary immediate action and respond appropriately. this was also the case in a jordanian study amongst dentists. 18 the respondents in the present study indicated good knowledge of the preventive strategies for covid-19. however, it was surprising to observe that the minimum social/physical distance of 1 m (equivalent to 3 feet) recommended by the who 19 was unknown by the majority in the present study. a distance of at least 2 m (about 2 arms' length) between people has also been advocated by other health authorities such as the u.s. centers for disease control and prevention. 20 it is important to maintain the recommended distance to prevent a person from inhaling droplets from someone with covid-19 who may be either asymptomatic or with symptoms of coughing, sneezing, or speaking. knowledge of bronchoalveolar and endotracheal aspirate for diagnosis was poor, however. this finding may be attributed to the most frequently used methods in this environment, which are oropharyngeal and nasopharyngeal swabs. although nasopharyngeal swabs have typically been used to confirm clinical diagnosis of covid-19, a chinese study found bronchoalveolar fluid to have the highest positivity (93%), followed by sputum (72%), nasal swabs (63%), pharyngeal swabs (32%). 21 the respondents' knowledge of hydrochloroquine/azithromycin and remdisivir was particularly impressive compared to that of pluristem and ivermectin. this may be due to the several controversies that have been generated regarding the effectiveness of these drugs, especially the antimalarial drug chloroquine and its derivative hydroxychloroquine, which the who is testing in some clinical (solidarity) trials 22 in which nigeria is participating. the higher knowledge demonstrated by the final-year compared to the penultimate-year students could stem from a greater urge to learn more about the coronavirus and a deeper concern, eagerness, and anticipation amongst the final-year students to complete their clinical procedures upon school resumption in order to write the qualifying exams. it would therefore not be unexpected by them to want to learn more about covid-19. these findings highlight the need to improve the knowledge span of undergraduate clinical dental students about covid-19 in order to mitigate its spread. this should be included in the curriculum for dental students all over the world. 17 this is crucial, as the current approach to covid-19 is to control the routes of infection and to conduct extensive infection prevention and control (ipc) trainings with preventive measures to lower the risk of transmission. 18 surprisingly, knowledge did not influence the attitude of the students significantly in this study. however, it was noted that there was a lack of will by most students to personally procure extra ppe to prevent the spread of covid-19, when they recommence their clinical procedures. these materials are currently scarce in the market and quite expensive too, and many students may lack the funds to procure them. besides, there could be a notion that the school authorities are to provide these items. undergraduate dental education in nigeria is heavily subsidized by the government, with almost all the dental schools located in either federal or state government-owned universities. thus, students pay very minimal tuition, however, they are expected to purchase most of the bench items required for training. furthermore, since the dental schools are dependent on the government for most of their funding, they often have restrictive finances due to limited funding from the government. the provision of ppe by the dental school may therefore be an additional financial burden; in this context, without additional help from the government, the dental schools may be constrained to ask the students to procure their own ppe for training. this underscores the critical need by stakeholders to make appropriate ppe available for all undergraduate clinical dental students to curtail the spread of covid-19 particularly in resource restricted countries like nigeria. government and all stakeholders in the health and educational sectors must cooperate to fight this deadly scourge ravaging the whole world. majority of respondents (74.5%) agreed that wearing of face masks, gloves, goggles, and face shields while performing dental procedures will protect against covid-19. this observation is similar to effective infection control advocated in china by meng et al. 12 it was encouraging to note that most of the respondents recognized that it was not advisable to wear the same clothing and footwear between the clinic and their hostels. approximately 61% of respondents strongly agreed that wearing clinical scrubs with protective footwear without their personal clothes when treating patients or observing procedures in the clinic gives better protection against covid-19 than wearing clinical white coats on top of their personal home clothing. this is in keeping with standard infection protocols to avoid transmitting infections. the role of health care worker's uniforms on the horizontal transmission of pathogens in hospital settings is controversial. 23 in the study by munoz-price et al., 23 they found an association between the contamination of providers' hands and contamination of white coats, yet they found no association between providers' hands and scrubs although this was mainly attributed to the reduced frequency of laundering white coats than the scrubs. prior to the pandemic, white clinical coats were worn over personal clothes by clinical dental students in nigeria during school hours in the dental clinics. this may however not be appropriate nor sufficient particularly with the highly infectious nature of covid-19 and might change when the students resume to school. advocating the wearing of clinical scrubs and foot wears was supported by most of the students in the present study. it would also equally important to emphasize the frequent laundering of the scrubs and foot wears. of note is the significant proportion of students supporting the need to change and wash their clinical white coat after daily use. thus, it should be performed regularly and thoroughly as it is a simple but effective measure that dissolves the lipid coat surrounding the virus and kills or inactivates the virus if the hands have been contaminated. 12, 19, 24 in addition, in the present study, the perception held by many of the students was to pause the dental treatment of patients who start sneezing or coughing persistently in the dental clinic and refer them for further screening and possibly a covid-19 test. this is in tandem with the who policy that procedures which are likely to induce coughing should be avoided (if possible) or performed cautiously. 6, 15, 24 the importance of hand hygiene as one of the most critical factors for reducing the risk of transmission of covid-19 has been previously reported. 12, 19 thus, it should be performed regularly and thoroughly as it is a simple but effective measure that dissolves the lipid coat surrounding the virus and kills or inactivates the virus if the hands have been contaminated. 12, 19 concerning the dental management of covid-19 patients, 83.3% supported their treatment in a wellventilated room or in a negative pressure room. it is better and advised to encourage good air flow whilst ensuring physical distancing as much as possible. meng et al., 12 proposed that based on their experience, relevant guidelines, and research, dentists are to take strict personal infection control measures that are effective and avoid or minimize operations that can produce droplets or aerosols. four-handed technique is considered beneficial for controlling infection coupled with the use of saliva ejectors with high volume to reduce the production of droplets and aerosols. the nonprobability sampling method employed in the study may be subject to selection bias as participants were approached via online platforms. environmental factors in each dental school may have influenced the responses recorded as each dental school has its own peculiarities. notwithstanding, this study has provided a national perspective on the knowledge and attitudes/perceptions of undergraduate clinical dental students towards the covid-19 pandemic and infection control practices in nigeria. this study determined that only half of the undergraduate clinical dental students had adequate general knowledge of covid-19. the students were not abreast of current updates on covid-19, particularly the confirmed case definition and less common symptoms. the students however had a good perception and positive attitude towards infection control practices against covid-19. our recommendations are that guidelines from reputable health institutions/authorities on covid-19 be reviewed by the dental school authorities and included in the dental school curricula. the government should also make more ppe available for clinical dental students. the authors declare no conflict of interest. kehinde adesola umeizudike bds, mph, fmcds https: //orcid.org/0000-0003-4893-872x outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak covid-19) situation report 129. world health organization web site covid-19) situation report 51. world health organization web site nigeria centre for disease control web site covid-19 guidance for dentistry. california department of public health web site cdc guidance for providing dental care during covid-19 general dental council web site nda recommendations on covid-19 protocol for dental clinics. nigerian dental association web site salivary glands: potential reservoirs for covid-19 asymptomatic infection aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine covid-19 pandemic: students' perspectives on dental geriatric care and education nigerian dental students' perspectives about their clinical education. unilag undergraduate dental education in nigeria: perceptions of dental students and recent dental graduates perception of dental students and recent graduates of a nigerian dental school on the quality of undergraduate training received. unilag knowledge, attitude and practice associated with covid-19 among university students: a cross-sectional survey in china dentists' awareness, perception, and attitude regarding covid-19 and infection control: cross-sectional study among jordanian dentists health topics: coronavirus world health organization (who) web site covid-19) social distancing, quarantine, and isolation. centers for disease control and prevention web site detection of sars-cov-2 in different types of clinical specimens effectiveness of use of chloroquine/ hydroxychloroquine in covid-19 case management. 2020. world health organization web site differential laundering practices of white coats and scrubs among health care professionals nigerian undergraduate dental students' knowledge, perception, and attitude to covid-19 and infection control practices key: cord-256528-sbbkqirv authors: obisesan, o.; akintola, o.; bryant, c.; patel, j.; shah, a.; tagar, h. title: the rapid development of an urgent dental care hub in an oral surgery unit—key learning points date: 2020-05-01 journal: br j oral maxillofac surg doi: 10.1016/j.bjoms.2020.04.031 sha: doc_id: 256528 cord_uid: sbbkqirv nan we would like to bring to the attention of your readers working in oral surgery and oral and maxillofacial surgery units some of the salient lessons we have learnt whilst establishing and developing an urgent dental care hub at king's college hospital in response to the covid-19 crisis. king's college dental institute was in the fortunate position of having an established telephone triage and appointment booking service for its existing "acute dental care" service. at the time that our outpatient and elective operating activities were cancelled, the unit became inundated with calls from patients from across greater london, the home counties, and as far as the south coast seeking urgent dental treatment as their local dental services began to close down. in order to prioritise clinically urgent cases and to ensure social distancing consultant-led telephone triage was introduced. a strict triaging process was adopted so that only those with genuine dental emergencies such as acute orofacial infections, severe uncontrolled pain, dental trauma, and uncontrolled bleeding were given appointments; these were usually on the same or next day. "covid-19 screening" was incorporated into the telephone triage call, this allowed patients to be categorised into one of three streams: "covid-19 asymptomatic", "covid-19 symptomatic" or "vulnerable". the latter group included those with medical comorbidities, the over 70s, and pregnant patients, whom we wished to isolate from other patients, should they be booked an appointment. the appointments for booked patients were spread throughout the day and we developed a new covid-19 period standard operating procedure for use across the dental institute. the only treatment we currently provide are dental extraction, and pulpotomy. both are carried out in closed surgeries using ppe recommended in baoms/baos guidance 1 by ffp3 mask fit-tested staff. members of our team are assigned appropriate roles including telephone advice and triage, patient assessment in acute dental care, and operating within the oral surgery department. now into week 4 of our covid-19 urgent dental care service, we have received calls from up to 290 patients a day, there are a number of repeat callers who contact us again having failed to secure dental care in their locality as we advised. whilst many gdp's are taking calls, providing advice and prescriptions where appropriate this is not universally the case. there is a clear need for more urgent dental care hubs to become operational with immediate effect. not applicable. guidance ppe for patients with emergency oral and dental problems of unknown covid status tagar department of oral surgery, kings college dental institute we have no conflicts of interest. key: cord-350990-tywbe4o2 authors: checchi, vittorio; bellini, pierantonio; bencivenni, davide; consolo, ugo title: covid‐19 dentistry‐related aspects: a literature overview date: 2020-07-05 journal: int dent j doi: 10.1111/idj.12601 sha: doc_id: 350990 cord_uid: tywbe4o2 a new coronavirus (sars‐cov‐2) was detected in china at the end of 2019 and has since caused a worldwide pandemic. this virus is responsible for an acute respiratory syndrome (covid‐19), distinguished by a potentially lethal interstitial bilateral pneumonia. because sars‐cov‐2 is highly infective through airborne contamination, the high infection risk in the dental environment is a serious problem for both professional practitioners and patients. this literature overview provides a description of the clinical aspects of covid‐19 and its transmission, while supplying valuable information regarding protection and prevention measures. at the end of 2019, the first cases of a pulmonary disease of unknown aetiology were detected in wuhan city, china. in the following months, this new pathogen spread throughout europe and then worldwide; in march 2020, the world health organization (who) officially declared a pandemic alert. this new virus, highly infective especially through airborne transmission, is responsible for an acute respiratory syndrome, distinguished by an often asymptomatic, but potentially lethal, interstitial bilateral pneumonia 1 . this virus, initially named 2019-ncov and subsequently renamed sars-cov-2, belongs to the coronoviridae family, along with the middle east respiratory syndrome (mers-cov) and the severe acute respiratory syndrome (sars-cov) viruses 2 . the most updated epidemiological and genetic studies performed on infected chinese patients revealed that this pandemic originated from a zoonosis, after a single transmission event between an animal and a human, followed by subsequent, rapid interhuman diffusion 1, 3 . sars-cov-2 expresses membrane proteins that permit adhesion between it and specific receptors expressed on the surface of host tissue cells 4 . the most common receptor involved in the virus-cell interaction is angiotensin-converting enzyme 2 (ace-2), which is present at high concentrations in lungs, myocardial cells and kidney, as well as on oral mucosa (especially of the salivary glands and tongue) 5, 6 . these structures have been considered as early targets of sars-cov-2, with infection causing a disease in humans known as corona virus disease 19 (covid19) 7 . the main infection pathways of sars-cov-2 are air and direct contact 1 . airborne infection occurs through droplets released by coughing, sneezing, exhalation or speech 1, 8 ; direct-contact infection occurs through contact with contaminated surfaces and subsequent touching of the eyes, nose or mouth 8 ( figure 1 ). saliva also plays a crucial role in the spread of infection, through both airborne and direct-contact pathways 1 . the incubation period of sars-cov-2 varies between 3 and 14 days; however, a 24-day incubation period has also been reported 9 . in most instances, the infection brought on by this new coronavirus is asymptomatic or causes few symptoms 2 . infected patients mainly exhibit night fever, dry cough, sore throat and asthenia; patients with more severe disease can exhibit dyspnea. the most severe symptoms occur in 15%-25% of infected patients, with a relevant impairment of respiratory function that leads to hospitalisation and assisted ventilation 2 . from a clinical perspective, this infection presents as a bilateral interstitial pneumonia, detected radiographically as bilateral ground-glass opacity 10, 11 . covid-19 diagnosis is based on clinical symptoms (e.g., asthenia, dyspnea, headache and hyperpyrexia) and epidemiological aspects, particularly involving the english in this document has been checked by at least two professional editors, both native speakers of english. for a certificate, please see: http://www.textcheck.com/certificate/pe03md. patients who had previous contact with potentially infected individuals or who travelled through/resided in areas with high concentrations of infected people in the 2 weeks prior to symptom onset 9 . recently, a sudden loss of smell (anosmia) and/or taste (ageusia) has been encountered in many sars-cov-2-positive patients. anosmia has been reportedly observed in most sars-cov-2-positive german, swiss and italian patients; data from korea suggest that 30% of sars-cov-2-positive patients exhibited anosmia as the primary presenting symptom 12 . a high-resolution chest computed tomography scan can show bilateral impairment of lung parenchyma 13 . biomolecular diagnosis is performed through reverse transcription-polymerase chain reaction (rt-pcr) of samples taken from the upper airways; thus far, this procedure is the gold standard for correctly diagnosing sars-cov-2-positivity 3 . no vaccine is yet available; infected patients are mostly treated with assisted ventilation, oxygen administration (2-15 l/min) and fluid maintenance 14 . promising results have been reported concerning the development of recombinant monoclonal antibodies for a specific viral antigen, as previously tested on patients with sars-cov 15 . this literature overview focuses on publications regarding this new coronavirus and supplies valuable indications to dental professionals concerning protective and preventive measures that can be adopted. pubmed, embase, scopus, web of science and cochrane databases were used to identify publications on covid-19 and covid-19 dentistry-related aspects, which had been published from the beginning of january 2020 to the end of april 2020. the terms used for the identification of keywords were: covid-19, 2019-ncov, sars-cov-2, covid-19 transmission, coronavirus pneumonia, coronavirus infection, severe acute respiratory syndrome, atmospheric contamination, droplets, aerosol, ppe/dpi, covid-19 guidelines, airborne contamination, masks and respirators, and covid-19 dental-related aspects. the inclusion criteria used for screening were papers written in the english language or in the italian language with an english abstract, which reported on covid-19 and dentistry-related aspects of covid-19. the exclusion criteria were: papers in a language other than english or italian with no english abstract; and studies not reported in the above-mentioned databases. studies were first screened according to titles and abstracts and examined by two reviewers (v.c. and d.b.); studies that fulfilled the inclusion criteria were selected and their full texts were obtained. the contents were analysed and results were extracted if the papers provided original data regarding sars-cov-2. citations in each article selected during the main search were reviewed for potential relevance. dentists, dental hygienists, dental assistants and patients have always been at high risk of cross infections because of their exposure to pathogenic microorganisms and viruses derived from the oral cavity and airways 16, 17 . these groups of professionals face daily risks of contagion and infection transmission because the dental environment typically involves dangerously high levels of microbes 18 as a result of close contact with the patient's oral cavity and the presence of bacteria and viruses in the aerosols created by dental instrumentation 1, 16 . a study performed on a mannequin fitted with phantom jaws, and seated on a dental chair, showed that the highest levels of aerosol contaminants can be found within 60 cm from the patient's head, mainly on the right arm of the dentist, on their mask, and around their nose and eyes. moreover, the aerosol generated by an ultrasonic device can remain suspended in the air for 30 minutes after the procedure 19 . therefore, dental procedures can be considered as one of the most probable causes of sars-cov-2 infection because such procedures require close proximity to the patient's mouth, possess a risk of contact with saliva, blood and other biological fluids and involve the use of instrumentation that creates large aerosols 4, 19, 20 . an in vitro study showed that sars-cov-2 maintained viability in the air for at least 3 hours and that its viability half-life was nearly 1 hour 21 . moreover sars-cov-2 demonstrates persistent adherence, for a maximum of 9 days, to various surfaces 1, 21 ; therefore, all surfaces and instruments in a dental clinic should be considered as potential sources of virus transmission because infected droplets from saliva or aerosols could land on any exposed surface 16, 19, 22 . although it remains unclear which devices are most effective for protection against sars-cov-2 infection, all dental patients should be considered as potentially infected 4 . therefore, the use of personal protective equipment (ppe), such as disposable waterproof scrubs and bonnets, gloves, eyewear protection, face shields, disposable shoe-covers and masks, is highly recommended 1,23 . thus far, many doubts remain regarding the type of mask that best protects against covid-19. different types of mask have been developed in recent decades; each mask offers a different degree of protection. surgical masks were conceived with a one-way protection designto capture bodily fluids leaving the wearerthus protecting the patient from the risk of contamination by healthcare personnel 17, 24 . however, a study performed on mannequin heads showed that surgical masks were also able to provide a filtration effect for the operator, in that they filtered an artificial aerosol made of water and sodium bicarbonate. two different types of surgical masksrectangular and shell-shaped were tested; these showed filtering efficiencies of 92% and 96%, respectively 24 . in dentistry, the most indicated ppe for airway protection is the filtering face-piece (ffp) mask, which can also block virus particles. ffp masks are designed to protect the wearer and are divided into the following different categories based on their filtration efficiency towards powders ≥0.3 µm in diameter: ffp1 (80% minimal total filtration efficiency); ffp2 (94% minimal total filtration efficiency); and ffp3 (99% minimal total filtration efficiency) 17, 25 . these ffp scores are determined in accordance with en standard 149:2001 and en 143, maintained by the european committee for standardisation. by contrast, us standards are determined by the national institute for occupational safety and health (niosh), which classifies oral respirators as n95 (95% minimal total filtration efficiency), n99 (99% minimal total filtration efficiency) and n100 (99.97% minimal total filtration efficiency). comparing european and us classifications, an ffp2 respirator corresponds to an n95 mask, while an ffp3 respirator corresponds to an n99 mask ( table 1) . because air droplet covid-19 particles are estimated to be 0.06-0.14 µm in diameter 26 , the most efficient masks are presumed to be ffp2/n95, ffp3/n99 and n100. surgical masks, however, remain valid devices for all procedures that do not create an aerosol. in addition to the filtration efficacy, facepieces can be further distinguished as valved or non-valved respirators. valved respirators facilitate air exhalation, leading to less moisture buildup inside the mask; thus, they can filter the entering air, but do not filter the wearer's exhaled air. non-valved respirators provide good two-way protection by filtering both inflow and outflow of air 25, 27 . ffp3/n99 and n100 facepieces without valves seem to be the devices primarily indicated to guarantee the highest level of protection for both operator and patient, but it is quite challenging to achieve normal air exhalation when these facepieces are used for an extended period of time 23 . in dental procedures, the mask should be considered as disposable and the mean surgical period does not exceed 2 hours; therefore, it is suggested to use a mask with the highest filtration efficacy without a valve, or a valved mask covered by a surgical mask. in the dental field, eye protection has been consistently indicated to minimise contact of the eyes with mechanical (e.g., slivers and foreign bodies), chemical (e.g., acids and disinfectants) and biological (e.g., saliva, blood, oral fluids) agents 18 . the ocular pathway is known to be one of the most frequent routes of infection with sars-cov-2 1 . eyewear with enveloping frames should be used, and should have wide lenses to cover the face as much as possible. alternatively, plastic shields may be preferred to glasses because of their greater capacity to protect the face from aerosol droplets. these shields can be worn directly on the forehead or can be included in the surgical mask 17 . from a practical point of view, the use of a shield is compatible with wearing glasses or magnification loupes; it is much more difficult to achieve proper eye protection while using a microscope. during the pandemic, updated local guidelines have suggested avoidance of dental treatments, except for patients with emergencies. each dental professional must understand the transmission pathways of sars-cov-2 and must perform all essential procedures in a manner that prevents the spread of infection. all patients should be regarded as potentially infected because only symptomatic individuals exhibit fever and breathing symptoms. as a general rule, patients affected by covid-19 with a body temperature of >37.5°c (99.5°f) cannot be treated in a dental clinic, and should be confined to their home or hospitalised if they exhibit severe symptoms. a triage area is mandatory for initial evaluation of patients, and this area should be set up in such a way that close contact between individual patients and between patients and healthcare personnel is avoided 4 . preliminary evaluation of patients should consist of body temperature measurement and a brief survey to investigate possible fever, respiratory issues, cough or dyspnea in the past 14 days, as well as contact with individuals who could have been potentially infected 1 . patients answering 'yes' to any of the survey questions and who have a body temperature of >37.5°c (99.5°f) should be confined to their home or hospitalised 1 . patients answering 'yes' to any of the survey questions to the survey and who have a body temperature of <37.5°c (99.5°f) should not be treated for at least 14 days. patients who have recovered from covid-19 can be treated 30 days after symptom remission 4 . patients answering 'no' to the survey questions and who have a body temperature of <37.5°c (99.5°f) can be treated, but procedures that cause aerosol production should be avoided. each potentially contaminated surface should be cleaned and then disinfected with hydro-alcoholic disinfectants containing an alcohol concentration of >60% 1,4,28 . a recent review of 22 selected studies evaluated the persistence of human coronavirus on various surfaces and the effects of multiple disinfectant agents on virus inactivation. this review revealed that coronaviruses can persist on plastic, glass and metal surfaces and remain infective for a maximum of 9 days, with a mean infective period of 4-5 days. the authors found that coronavirus could be effectively eliminated in 1 minute when the surfaces were disinfected with 62%-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite 22 . more recently, the sars-cov-2 survival rate was studied in aerosols, as well as on copper, cardboard, stainless steel and plastic. sars-cov-2 was viable in aerosols, with a progressive reduction of its infectious titre within the first 3 hours and a median half-life of approximately 1.1 hours 21 . moreover, sars-cov-2 appeared to be more stable on plastic and stainless steel than on cardboard or copper; the following differences were found regarding the duration before sars-cov-2 became inactive: 72 hours for plastic, 48 hours for stainless steel, 24 hours for cardboard and 4 hours for copper 21 (table 2) . thus, for environmental disinfection, it may be useful to place a dispenser containing an alcoholic gel (with an alcohol concentration of 60%-85%) in the waiting room, for hand cleansing. a valid method to reduce the microbial load in the oral cavity is rinsing before dental procedures. there remains controversy regarding the effectiveness of chlorhexidine against coronavirus 1, 29 . because sars-cov-2 is sensitive to oxidation, mouthrinses containing 1% hydrogen peroxide or 0.2% povidone-iodine have been proposed 1 . hand hygiene is considered the most important preventive measure to reduce the risk of transmission of microorganisms between dentists and patients 4 . soap and cleansers must be rubbed extensively on both hands, until the appearance of abundant foam. this foam has been shown to dissolve the lipid sheath around the viruses, causing dispersion and decomposition of viral molecules. this action is mediated by the surfactant agents in soaps and cleansers, which can enter the virus lipid membrane through hydrophobic interactions, eventually causing it to lyse 30 . at concentrations greater than 60%-65%, alcohol can dissolve fatty molecules of the external lipid layer of the virus, which leads to disruption of the virus particle; therefore, friction with an alcoholic hand sanitiser is suggested after handwashing. when possible, it is recommended to avoid dental procedures that could cause cough and regurgitation. orthopantomography (opg) or cone beam computed tomography (cbct) are preferred; periapical x-rays should be avoided because they could provoke hypersalivation, coughing or vomiting 4 . when handpieces or ultrasonic devices must be used, the use of a rubber dam is indicated as this significantly reduces the amount of aerosol containing saliva and/or blood, providing a 70% reduction of droplets around the surgical field 31 . when isolation using a rubber dam is not possible, manual instrumentation is preferred over high-speed handpieces 1 . considerable reduction of droplet spread during dental procedures can be achieved using either high-speed saliva ejectors or surgical ejectors, and the use of such devices is therefore highly recommended 31 . simultaneous assembly of two ejectors (e.g., a high-speed ejector and a high-volume evacuator) may also be useful. handpieces generally used in dentistry can draw and then expel biological fluids and contaminants that can become deposited on the patient or the dentist, leading to cross infection 1, 32 . because it has been shown that anti-retraction handpieces effectively reduce the return of bacteria and viruses into the tubing system, the use of handpieces without an anti-retraction system should be avoided during the covid-19 pandemic 16, 28 . although there is a lack of information concerning environmental sanitation related to coronaviruses, some options are always useful for reducing bacterial and viral loads in dental clinics. common sense-based guidelines suggest an adequate air change after each dental procedure by opening the windows in surgical rooms and in the waiting room. safe distances must be maintained between patients in the waiting room. in the early 1990s, the air quality in a dental clinic was shown to become extremely polluted by aerial microbiota after the most common dental procedures 16 . when no aerosol is created, most sars-cov-2 droplets precipitate and deposit on surfaces. when handpieces or ultrasonic devices are used, the aerosol generated can transmit the virus into the air where it can persist, viable, for more than 3 hours 21 . currently, there is no evidence regarding sanitation devices that are especifically effective against sars-cov-2. the following air sanitation systems were developed in the past and are commonly used in medical settings. air depuration systems have been developed to filter and recirculate the air of surgical rooms and medical and health clinics. air is drawn through different filters: the first stops bacteria and larger droplets; the second reduces gas components; and the third reduces the numbers of the smallest droplet particles and the smallest microorganisms. these systems can filter droplet particles smaller than 0.01-0.3 µm, with a filtration efficiency of 85%-99% 16, 33 . ozone is a natural gas, and one of the most effective systems for environmental sanitation. it provides highly reactive free radicals that can oxidise bacteria, viruses and organic and inorganic compounds, thereby effecting bactericidal action towards air contaminants. because ozone is heavier than oxygen, it precipitates on tissues and disinfects both air and surfaces 34 . germicidal ultraviolet (uv) radiation also represents a valid sterilisation option: uv light can damage microbial dna and rna, thus preventing reproduction of microbes and reducing the harmful effects of infectious organisms. these uv lights can be installed with a filtration apparatus and used in water-and aircirculation systems to eliminate powders, bacteria and viruses 35 . this literature overview was intended to collect all relevant published data in the dental field since the identification of the new coronavirus, sars-cov-2. it aimed to supply practical information to dental professionals, through analyses of the indications for contamination protection and prevention. however, since this literature search, researchers and scientists may have found and presented new strategies, products and technologies that are more effective against covid-19. transmission routes of 2019-ncov and controls in dental practice epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study a pneumonia outbreak associated with a new coronavirus of probable bat origin coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa structural basis for the recognition of sars-cov-2 by full-length human ace2 epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) covid-19, modern pandemic: a systematic review from front-line health care providers' perspective clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china point-of-care lung ultrasound findings in patients with novel coronavirus disease (covid-19) pneumonia a new symptom of covid-19: loss of taste and smell ct imaging and differential diagnosis of covid-19 treatment of covid-19: old tricks for new challenges adverse effects of human immunoglobulin therapy atmospheric contamination during dental procedures management rules of the dental practice: individual protection devices management rules for a dental practice: biological risk and safety at work dissemination of aerosol and splatter during ultrasonic scaling: a pilot study epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia aerosol and surface stability of sars-cov-2 as compared with sars-cov persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff efficacy of three face masks in preventing inhalation of airborne contaminants in dental practice n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial a novel coronavirus from patients with pneumonia in china surgical mask vs n95 respirator for preventing influenza among health care workers: a randomized trial rules for managing a dental practice: waste disposal, disinfection, and sterilization stability of sars-cov-2 in different environmental conditions using effective hand hygiene practice to prevent and control infection the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination contamination of the turbine air chamber: a risk of cross infection respiratory protection against bioaerosols: literature review and research needs water and air ozone treatment as an alternative sanitizing technology role of ultraviolet (uv) disinfection in infection control and environmental cleaning how far droplets can move in indoor environments -revisiting the wells evaporation-falling curve none. none. key: cord-293180-f1ulk9ce authors: li, r w k; leung, k w c; sun, f c s; samaranayake, l p title: severe acute respiratory syndrome (sars) and the gdp. part ii: implications for gdps date: 2004-08-14 journal: br dent j doi: 10.1038/sj.bdj.4811522 sha: doc_id: 293180 cord_uid: f1ulk9ce the transmission modes of sars-coronavirus appear to be through droplet spread, close contact and fomites although air borne transmission has not been ruled out. this clearly places dental personnel at risks as they work in close proximity to their patients employing droplet and aerosol generating procedures. although the principle of universal precautions is widely advocated and followed throughout the dental community, additional precautionary measures — termed standard precaution may be necessary to help control the spread of this highly contagious disease. patient assessment should include questions on recent travel to sars infected areas and, contacts of patients, fever and symptoms of respiratory infections. special management protocols and modified measures that regulate droplet and aerosol contamination in a dental setting have to be introduced and may include the reduction or avoidance of droplet/aerosol generation, the disinfection of the treatment field, application of rubber dam, pre-procedural antiseptic mouthrinse and the dilution and efficient removal of contaminated ambient air. the gag, cough or vomiting reflexes that lead to the generation of aerosols should also be prevented. in the first part of this two-part article an account of the epidemiology, virology, pathology and management of severe acute respiratory syndrome (sars) was provided together with public health issues and general aspects of infection control. in this concluding part we describe in detail the implications of sars for the general dental practitioners together with infection control guidelines that may be applied in a primary dental care setting in the event of such an outbreak. the suggested guidelines have been modulated based on the promulgations by the british and north american infection control agencies, and our own close encounters with the sars outbreak in hong kong. sars patients are unlikely to seek dental treatment in the early acute phase of the disease owing to the rapid course of the disease and the onset of fever as a primary symptom. indeed, the observation that maximum infectivity coincides roughly with the presence of high fever, when the patients would be seeking medical rather than dental care, 1 appears to be the major reason for the absence of sars infection in dental settings thus far. nonetheless, due to the highly infectious nature of the disease, and as the modes of transmission and infectivity are not fully understood, especially in the prodromal and convalescent stages of the disease dental healthcare workers maybe at risk of exposure to sars-cov. this is particularly the case as in dentistry the care provider has to operate in close proximity to the patient using droplet and aerosol generating procedures. the fact that the droplet spread mainly occurs within a 3 feet radius of the infective focus emphasizes this danger further. as discussed earlier, sars is likely to be transmitted via droplets, close contact and fomites. when an individual coughs or sneezes, or when aerosol generating procedures are used particles of varying size (from 0.001 µm to up to 10,000 µm) are produced. particles or droplets with a diameter greater than 100 µm, as most are, called splatter or spatter are then propelled through the air for short distances, generally 3 ft or less and settle rapidly on either animate or inanimate surfaces. transmission of infection via droplets thus requires close contact with an index case. on the other hand smaller droplets (or aerosols, generally under 10 µm in size) or small-particle residue of evaporated droplets are usually airborne and are entrained in the air for a lengthy period • sars is a highly infectious disease and dental personnel are likely to be at risk because of the nature of their profession, working in close proximity to the patient. • management protocol may be modified to minimise public health risks. this includes the identification, isolation, management and report of possible and probable cases and contacts. • the principles of standard precautions should be followed. • effective infection control and treatment planning should include measures aimed at minimising the generation of, or contact with infectious droplets and aerosol. • modified universal infection control recommendations (now termed standard precautions) relevant to sars is provided, based on different clinical scenarios. and, may carry infectious microbes. they may be dispersed widely by air currents and the disease transmission thus become airborne. 2 it is salutary to note that the microbe-laden aerosol may also settle in surrounding areas in the clinic/office devoid of any clinical activities. the infective dose of the organism is another important consideration that should be borne in mind when considering airborne infection. an influenza virus particle or a few spores of the aspergillus fungus may have widely differing potentials for causing respiratory infection as is the viability of the microbes and the general health of the person inhaling them. the foregoing risks to the dental professionals posed by airborne particles have been assessed and precautionary measures recommended elsewhere. 3, 4 the measures for controlling droplets and aerosols will be discussed later in this article. we describe in detail below the management protocols recommended for different clinical scenarios one may encounter in sars-affected areas: 1. possible and probable sars cases. 5 the concept of 'standard precautions' should be applied regardless of the management protocols suggested below. as is the routine, infection control measures begin with a thorough medical history questionnaire. the most recent case definition 5,6 for sars should be used for screening purposes and special emphasis should be placed on the course of events 10 days prior to the dental appointment. the health protection agency (hpa) of the uk has given guidelines 7 on patient assessment which includes a detailed travel history from patients with symptoms and a contact history with those who have had similar signs and symptoms of sars. specifically, the patient should also be asked, or temperature taken as the case may be, if he or she is running a fever (> 38 ºc) or suffering from flu-like symptoms, myalgia, unproductive cough or diarrhoea. once a sars case is suspected, the dentist must immediately inform the health authorities. in the unlikely event of a sars patient, in the early phase of the disease, attending for a dental appointment priority should be given to minimising disease transmission. the patient should be immediately provided with a surgical mask and transferred to a secluded private area away from other patients or personnel. 7 the patient should be referred to hospital for assessment as directed by local health authority regulations, after rescheduling the dental appointment. ideally, the health authority should arrange transport to hospital or a sars clinic and all personnel involved must be informed and wear suitable protective garments. 7, 8 dental management should be limited to the control of pain and infection in consultation with the patient's physician if indicated. no confirmed sars cases with active infection should be treated in a general dental practice. laboratory data indicate that the sars-cov survives at room temperature for up to 2 days provided the conditions are optimum. for instance in cell-culture supernatants only one log reduction in viral load was noted at ambient temperature after 2 days. 9 therefore, if informed by a physician or the local health authority that a patient recently treated at the dental surgery has been confirmed to have sars, the following measures should be adopted: 1, 7, 8, 10 • notify all persons (contacts) who were in the office within a 48-hour period from the time when the sars patient was present. hpa advises that these contacts should stay indoors and keep contact with other people to a minimum for a period of 10 days from the time of last contact with the case. • advise all 'contacts' to inform their general practitioner (gp) immediately. they should keep in touch with the gp daily and seek medical advice as soon as symptoms develop or when recommended by the gp. the contacts should be monitored but need not to be in isolation unless symptoms appear. • the dental office should be thoroughly disinfected using hospital grade germicide, and remain closed for at least 48 hours from the time when the sars patient was present before re-opening 3. dental personnel following unprotected exposure to sars patient hpa has recommended that exclusion from duty is not necessary for healthcare personnel after exposure if they remain asymptomatic or have followed normal infection control procedures 11 (the same rule applies to personnel who have travelled to a highrisk area). they should be monitored daily for fever and respiratory symptoms. exclusion from duty is recommended if symptoms develop during the 10 days following unprotected exposure to sars patients (or visit to high-risk areas), and for 10 days after the resolution of symptoms. 12 these personnel should always wear protective surgical masks irrespective of whether they are treating patients or not, during the 10-day observation period. close contact with sars patients within the past 10 days hpa considered 'close contacts' to be family, friends or healthcare workers who lived with, or who had direct contact with respiratory secretions, body fluids and/or excretions (eg faeces) of possible or probable cases of sars (see below), while that case was symptomatic. 7 examples of close contact include kissing or embracing; sharing utensils, close conversation, physical examination and physical contact. 5 they should be managed by pharmacological means over the 10-day isolation (incubation) period. any acute symptoms that require immediate attention (eg temporisation or emergency endodontics) should be treated only if aerosol and splatter generation can be prevented or minimised by measures outlined below. otherwise the patient should be rescheduled. in high-risk areas where there is a current or recent sars outbreak, a person may have contracted the sars infection leading to sub-clinical infection. further, individuals who have recovered from sars may carry the virus beyond the 10-day isolation period. 13 the infectivity of these patients is unknown. 14 there is a dilemma regarding dental management of these symptomless individuals. on one hand, aerosol generating or potentially cough or vomit inducing dental procedures increases the risk of cross-infection whilst on the other, patients' well-being is compromised if treatment is not delivered. some may consider this as unethical and ostracisation of those who have suffered sars. treatment planning and work practice should therefore be modified as stated above to minimise aerosol generating procedures and, according to some authorities, to take into considerations an approach to cohort convalescent cases for up to 3 weeks from the onset of illness. 15 corticosteroids are used in many centres for the treatment of sars. as even a short-term use may interfere with adrenal cortical responses 16 steroid cover may have to be considered as appropriate. a comprehensive review of dental procedures that incorporate universal and standard precautions is beyond the remit of this article as many recent reviews are available on this subject. 17, 18 rather we outline below special precautions that may be taken in dentistry to minimise droplet and aerosol production including the prevention of the gag, cough or vomiting reflexes leading to aerosols. all the measures outlined below need not be implemented at all times. rather the practitioner should be cognisant of these and implement them appropriately as dictated by the clinical scenario. • proper patient positioning and behaviour management is important. the patient should be relaxed and comfortable. sedation may be considered and hypnosis has been reported to be useful for some patients. 19 • retraction and suction must be performed with care • intra-oral radiographs, especially bite wing and posterior films, may stimulate the gag reflex and one may consider using extra-oral views for screening purposes eg the opg or the oblique lateral views instead of bite wings. 20 • trays may need to be adjusted for impression taking. very sensitive patients may require anaesthesia of the oral mucosa before impression taking. 21 the use of topical spray for subduing the gag reflex is contraindicated to avoid the risk of an aerosol being generated. lozenges may be used instead but its effect is not fully studied. 19 cad-cam technology, may be useful in some cases, to obviate conventional impression taking. 22 • patients suffering from traumatic injuries may have a significant amount of blood in the oral cavity. the reflexes may be induced if blood is swallowed or aspirated so effective evacuation is important. to minimise the likelihood of airborne disease transmission via droplets or aerosols, the dental team adopts the following: 1. reduction or avoidance of droplet/ aerosol generation 2. use of rubber dam isolation 3. use of pre-procedure mouthwash 4. dilution and efficient removal of contaminated ambient air 5. disinfect air/aerosol generated 6. adoption of contact precautions 33 although these results cannot be directly translated to include sars-cov, care should be exercised when these units are used. rubber dam effectively isolates the operating field and its use is well known to prevent or minimise the generation of potentially infectious splatter and aerosol. 34, 35 for the majority of restorative procedures, eg operative and endodontic treatments, the application of rubber dam and the use of high volume evacuation will significantly reduce the risk of droplet transmission and help control the reflexes. • for crown and bridgework, treatment planning may be altered to incorporate rubber dam application. for example, crown margins may be placed supragingivally or a split-dam procedure used. • rubber dam can be applied during tooth preparation for dentures. • adjuncts such as light-cured block out resin (eg opal dam ultradent) can be used where effective isolation by rubber dam cannot be achieved (eg repairing a conventional bridge). a pre-procedural 0.12% chlorhexidine mouth rinse can reduce the microbial load of saliva, and by implication a resultant aerosol due to instrumentation. 36 although the effect of chlorhexidine gluconate on human coronavirus is unknown it is effective against many respiratory viruses, like herpes and hiv. 37 this could be performed through using one or more of the following measures, namely: high volume evacuation (hve), improving the general ventilation and effectively controlling the airflow patterns and filtration of the circulating air. in clinics where air-conditioning is not available all windows should be kept open to encourage natural ventilation as much as possible. high volume evacuation (hve). hve prevents or minimises the dispersion of infectious droplet nuclei into the air by removing them at the source as they are emitted. it is important that the filters in the suction apparatus are cleaned daily in order to maintain its efficacy and the exhaust air vented outside to prevent recirculation. extra-oral evacuation devices and special aerosol reduction devices (ard) designed for use in conjunction with ultrasonic scalers are now available and are considered useful in further reducing the amount of droplets and aerosols. 36, 38 general ventilation. the air quality may be improved by controlling the airflow patterns. the ventilation systems should be designed such that fresh incoming air mixes with and dilutes the contaminated ambient air and the mixture is then removed by an exhaust system. air stagnation or short-circuiting of air directly from the supply to the exhaust is thus prevented. an optimal pattern of airflow (eg air movement from the ceiling towards the floor area) with a minimum of three air changes per hour (ach) is generally recommended for dental surgery settings. [39] [40] [41] air filtration. air filtration could be effectively performed by using high efficiency particulate air (hepa) filters that achieve a particle removal efficiency (pre) of 99.97% at 0.3 µm. although aerosols may have a smaller diameter, testing has shown that smaller particles do not penetrate as readily as 0.3 µm particles. 42 hepa filters may therefore be used in exhaust ducts or any fixed or portable room-air cleaners. 43 its use in dentistry may still be controversial as: • it is difficult to efficiently direct the flow of aerosol towards the filter. • the amount of aerosol filtered is limited per unit time and dental procedures generate a large amount of aerosols in a relatively short period of time thus overloading the device. • filters have to be leak-proof to be effective. • the air inlet and exhaust are adjacently situated in small units (eg those suggested for use in relatively small spaces as in dental clinics) thus causing 'shortcircuits' and reducing the filtration efficacy. 41 a number of new air disinfection systems are commercially available. however, the technologies used are varied and their efficacy in dental clinic settings or indeed against the sars-cov are as yet unproven. these are outlined below: ultraviolet germicidal irradiation (uvgi). ultraviolet radiation is produced by using mercury vapour arc lamps at a wavelength of 253.7 nm, within the uv-c bandwidth of the electromagnetic spectrum. it damages the dna of microbes rendering them non-infectious and is effective against a wide range of airborne pathogens. 41 the efficacy of uvgi depends on: • energy generated ie the intensity of uvgi. 44 • air movement ie amount of aerosol passing the device per unit time. 44 • whether microorganisms are protected by moisture or particulates, and • the duration of the exposure. at present these devices are primarily used as wall-mounted fixtures in some health institutions. they are thought to offer effective filtration against fungi, viruses and bacteria including tubercle bacilli and anthrax spores. 41 their installation, use and maintenance have to be closely monitored to prevent occupational hazards. 45 the use of uvgi in dental surgeries is unproven. photocatalytic oxidation (pco). photocatalytic oxidation (pco) is based on the principle that irradiated titanium dioxide (tio 2 ) produces reactive oxidising radicals that disinfect adsorbed aerosols by oxidising their volatile organic content. 46 this technology has been incorporated in room air decontamination devices although their performance is significantly affected by the water content of the air stream. other factors that may affect its efficiency include temperature, initial contaminant concentration, flow rate and the light intensity. 47 ozone air purification. the high oxidation potential of ozone is used in a number of air purification products although it is not used in dentistry for this purpose. the action of ozone against microorganisms and its use in treating root caries lesions has been described. 48 however, the level of ozone has to be monitored as excessive levels may cause inflammation and impaired lung function and patients with respiratory problems such as asthma may be particularly sensitive. 49, 50 molfino et al. 51 showed that even low ozone concentrations could increase the bronchial responsiveness to allergens in atopic asthmatic subjects. aerosols containing the sars-cov may be deposited on dental surgery surfaces especially in close proximity to the surgical areas. further, the sars-cov has been shown to survive for up to 2 days on fomites (much longer than the influenza virus or hiv) and, contact with sars-cov particles-laden organic or inorganic debris is considered a significant mode of transmission of sars-cov. 13, [52] [53] [54] the established practices of universal/ standard precautions already include protocols that effectively deal with this issue. the following points are highlighted for the prevention of sars-cov infections: • thorough hand washing should be done frequently and after treatment, contact with patient or fomites and before or after handling protective gear. it is a critical measure in controlling the spread of infection 55 a note on personal protection equipment (ppe) • masks have been shown to be useful against nosocomial transmissions of sars. 54 as the most penetrating particulate size is 0.3 µm, a mask with a specification of pfe (particle filtration efficiency) 99% (or above) at 0.1 µm may be more useful although it is uncomfortable to wear for a prolonged period. • hpa recommends the use of usa standard n-95 respirator or the european standard en149:2001 ffp2 for routine airborne isolation precautions. use of higher levels of respiratory protection may be considered for certain aerosolgenerating procedures when treating confirmed or highly suspected sars cases. • masks or respirators must be changed according to the manufacturer's recommendations. furthermore, the filtering efficiency of a mask is only as good as its fit or the moisture content. therefore masks and respirators should be fit checked and always discarded if moist/ wet. • eye protection and face shields are also recommended when there is a potential for splattering or spraying respiratory secretions. 40 • long cover gowns should be worn and sleeves secured under the gloves to prevent exposure of any part of the forearm. re-usable garments should be changed when visibly soiled or penetrated by fluids and placed in marked containers after use. contaminated garment should be laundered using a normal laundry cycle. 57 it is the duty of all dental professionals to maintain a safe practice environment free from infectious hazards. the principles of universal precautions is widely advocated and followed throughout the dental community. however it is believed that in the wake of the sars crisis, practitioners should pay heed to additional precautionary measures now termed standard precautions discussed in this paper in order to help control the spread of this highly contagious disease, as well as other respi-ratory diseases such as tuberculosis. it is likely that a vaccine would be available against sars in the not too distant future, but until then prevention is the only weapon available against this disease. american dental association. severe acute respiratory syndrome (sars) hospital infection control practices advisory committee, centres for disease control and prevention. guideline for isolation precautions in hospitals bacterial aerosols in the dental clinic: a review microbial aerosols in general dental practice updated interim u.s. case definition for severe acute respiratory syndrome (sars) guidance on identification, reporting, and management of sars patients in the uk in the postoutbreak period. london: health protection agency (hpa) guidance for primary care practitioners on investigation, management and reporting of sars cases and contacts (including community infection control). london: health protection agency (hpa) population and public health branch. infection control guidance for health care workers in outpatient settings: severe acute respiratory syndrome (sars) first data on stability and resistance of sars coronavirus compiled by members of who laboratory network. geneva: world health organisation bulletin: advice to members about severe acute respiratory syndrome (sars) guidance for hospital on the prevention of spread of sars. london: health protection agency (hpa) interim domestic guidance for management of exposures to severe acute respiratory syndrome (sars) for health-care settings. atlanta: centres for disease control and prevention sars-associated coronavirus apartment complex holds clues to pandemic potential of sars hospital authority. hospital authority guidelines on severe acute respiratory syndrome. hong kong: hospital authority oxford handbook of dental patient care guidelines for infection control 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(aerosol) the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination reduction of bacteria-containing spray produced during ultrasonic scaling the action of three antiseptics/ disinfectants against enveloped and non-enveloped viruses the usefulness of the modified extra-oral vacuum aspirator (eova) from household vacuum cleaner in reducing bacteria in dental aerosols infection control for the dental team. p112 copenhagen : munksgaard additional precautions for tuberculosis and a self assessment checklist the application of ultraviolet germicidal irradiation to control transmission of airborne disease: bioterrorism countermeasure national institute for occupational safety and health. guide to the selection and use of particulate respirators certified under 42 cfr 84. atlanta: centres for disease control and prevention guidelines for preventing the transmission of mycobacterium tuberculosis in health-care facilities estimation of tuberculosis risk and incidence under upper room ultraviolet germicidal irradiation in a waiting room in a hypothetical scenario occupational risk from ultraviolet germicidal irradiation (uvgi) lamps photocatalytic oxidation of bacteria, bacterial and fungal spores, and model biofilm components to carbon dioxide on titanium dioxide-coated surfaces photocatalytic oxidation of gaseous chlorinated organics over titanium dioxide antimicrobial effect of a novel ozone-generating device on microorganisms associated with primary root carious lesions in vitro the effect of ozone exposure on the ability of human surfactant protein a variants to stimulate cytokine production repeated ozone exposures enhance bronchial allergen responses in subjects with rhinitis or asthma effect of low concentrations of ozone on inhaled allergen responses in asthmatic subjects identification of severe acute respiratory syndrome in canada a major outbreak of severe acute respiratory syndrome in hong kong effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) healthcare infection control practices advisory committee (hicpac) -centres for disease control and prevention, society for healthcare epidemiology of america (shea), the association of professionals in infection control and epidemiology (apic), the infectious disease society of america guideline for hand hygiene in healthcare settings -2002. last revised september managing sars amidst uncertainty epidemiology program office. recommendations for prevention of hiv transmission in health-care settings. atlanta: centres for disease control and prevention key: cord-287633-31pxa5rv authors: harrel, stephen k.; molinari, john title: aerosols and splatter in dentistry a brief review of the literature and infection control implications date: 2004-04-30 journal: the journal of the american dental association doi: 10.14219/jada.archive.2004.0207 sha: doc_id: 287633 cord_uid: 31pxa5rv abstract background aerosols and droplets are produced during many dental procedures. with the advent of the droplet-spread disease severe acute respiratory syndrome, or sars, a review of the infection control procedures for aerosols is warranted. types of studies reviewed the authors reviewed representative medical and dental literature for studies and reports that documented the spread of disease through an airborne route. they also reviewed the dental literature for representative studies of contamination from various dental procedures and methods of reducing airborne contamination from those procedures. results the airborne spread of measles, tuberculosis and sars is well-documented in the medical literature. the dental literature shows that many dental procedures produce aerosols and droplets that are contaminated with bacteria and blood. these aerosols represent a potential route for disease transmission. the literature also documents that airborne contamination can be minimized easily and inexpensively by layering several infection control steps into the routine precautions used during all dental procedures. clinical implications in addition to the routine use of standard barriers such as masks and gloves, the universal use of pre-procedural rinses and high-volume evacuation is recommended. t he production of airborne material during dental procedures is obvious to the dentist, the dental team and the patient. an aerosol cloud of particulate matter and fluid often is clearly visible during dental procedures. this cloud is evident during tooth preparation with a rotary instrument or air abrasion, during the use of an air-water syringe, during the use of an ultrasonic scaler and during air polishing. this ubiquitous aerosolized cloud is a combination of materials originating from the treatment site and from the dental unit waterlines, or duwls. it is common for the patient to comment on this cloud of material. with the advent of severe acute respiratory syndrome, or sars, questions concerning the potential for the spread of infections from this aerosol may arise. in this article, we review relevant literature that has addressed the presence and makeup of dental aerosols and splatter. we also assess the threats that may be inherent in this airborne material, including risk potential to patients and the dental team. we make recommendations for the control of dental aerosols and splatter. the potential routes for the spread of infection in a dental office are direct contact with body fluids of an infected patient, contact with environmental surfaces or instruments that have been contaminated by the patient and contact with infectious particles from the patient that have become airborne. 1 there is a long history of infections that have been transmitted by an airborne route. even before the discovery of specific infectious agents such as bacteria and viruses, the potential of infection by the airborne route was recognized. in historical reports of the bubonic plague-the "black plague"-the pneumonic form of the disease was recognized as the most deadly. historical accounts have noted that the pneumonic form of the plague, characterized by severe coughing, has been spread from patients who had the pneumonic form of plague to those who surrounded the patient but were not necessarily in direct contact. apparently, because the bacteria that cause plague (yersinia pestis) were inhaled, the pneumonic form of the disease was reported to progress more rapidly than other forms of plague, and historical reports indicate that it was almost universally fatal. 2 there are more recent examples of the spread of disease by an airborne route. in one published report, a number of people were exposed to tuberculosis, or tb, while on a commercial airline flight. a patient with active tb boarded an airplane in chicago en route to honolulu. during the flight, the patient coughed repeatedly, aerosolizing the tubercle bacillus, which then entered the airplane's ventilation system and subsequently spread to other parts of the airplane cabin. after it was confirmed that the patient had active tb, it was determined that 15 of the 55 passengers in the cabin who were tested had been exposed to tb, as confirmed by a positive tuberculin test. passengers seated within two rows of the source patient had a higher probability of a positive skin test than did those seated elsewhere in the cabin. 3 another published example occurred in a medical office where the measles virus was spread through the ventilation system to multiple people. the source patient was a 12-year-old boy who was coughing. of the seven people who had secondary cases of measles that were associated with him, three were never in the same room with the source patient and one entered the office an hour after he had left. 4 more common is the apparent spread of cold and influenza viruses by airborne routes. however, the actual documentation of an airborne route for transmission of cold and influenza viruses is difficult to verify. because cold and flu viruses can be transmitted by contact, contaminated objects and an airborne route, in a flu outbreak it often is difficult to know the exact route by which the virus is transferred. sars recently has been reported in china, canada and other countries. this severe flulike illness appears to be caused by a new form of coronavirus, a family of viruses usually associated with the common cold. the exact mechanisms by which sars is spread remains uncertain, but it is clear that the primary method is through aerosolized droplets produced by coughing or other means. in a hong kong apartment complex outbreak, it appeared that the disease may have been spread through ventilation systems by airborne viruses that were independent of larger droplets. 5 the centers for disease control and prevention, or cdc, and the ada have recommended that aerosol-producing procedures should be avoided in patients with active sars. the ada has pointed out that it is unlikely that any dental treatment will be performed on a patient with active sars, owing to the fact that these patients are extremely ill and should not undergo any elective procedures. 6,7 the terms "aerosol" and "splatter" in the dental environment were used by micik and colleagues [8] [9] [10] [11] [12] in their pioneering work on aerobiology. in these articles, aerosols were defined as particles less than 50 micrometers in diameter. particles of this size are small enough to stay airborne for an extended period before they settle on environmental surfaces or enter the respiratory tract. the smaller particles of an aerosol (0.5 to 10 μm in diameter) have the potential to penetrate and lodge in the smaller passages of the lungs and are thought to carry the greatest potential for transmitting infections. splatter was defined by micik and colleagues as airborne particles larger than 50 μm in diameter. micik and colleagues stated that these particles behaved in a ballistic manner. this means that these particles or droplets are ejected forcibly from the operating site and arc in a trajectory similar to that of a bullet until they contact a surface or fall to the floor. these particles are too large to become suspended in the air and are airborne only briefly. the consensus has been that the greatest airborne infection threat in dentistry comes from aerosols (particles less than 50 μm in diameter) due to their ability to stay airborne and potential to enter respiratory passages. 13, 14 with the resurgence of tb, however, splatter droplets also must be considered a potential infection threat. the usual method for transmission of tb is through the formation of droplet nuclei. 15 these form when a droplet of sputum or saliva containing mycobacterium tuberculosis is projected from the patient by coughing or potentially by splatter from a dental procedure. as the droplet begins to evaporate, the size of the droplet becomes smaller, and it then has the potential to stay airborne or to become reairborne as a dust particle. thus, splatter droplets also may be a potential source of infection in a dental treatment setting. splatter and droplet nuclei also have been implicated in the transmission of diseases other than tb, such as sars, measles and herpetic viruses. some diseases known to be spread via an airborne route are listed in table 1 . there are at least three potential sources of airborne contamination during dental treatment: dental instrumentation, saliva and respiratory sources, and the operative site. contamination from dental instrumentation is the result of organisms on instruments and in duwls. routine cleaning and sterilization procedures should eliminate contamination of all dental instruments except those being used with the current patient. the use of ada-recommended methods to treat the duwl also should minimize or eliminate airborne contamination from the duwl. because contamination from these sources is controlled relatively easily by following standard procedures, we do not discuss them in detail. 16 the oral environment is inherently wet with saliva that continuously replenishes the fluid in the mouth. the fluids in the mouth are grossly contaminated with bacteria and viruses. dental plaque, both supragingival and in the periodontal pocket, is a major source of these organisms. it should not, however, be overlooked that the mouth also is part of the oronasal pharynx. as part of this complex, the mouth harbors bacteria and viruses from the nose, throat and respiratory tract. these may included various pathogenic viruses and bacteria that are present in the saliva and oral fluids. any dental procedure that has the potential to aerosolize saliva will cause airborne contamination with organisms from some or all of these sources. the most serious potential threat present in aerosols is m. tuberculosis, the organism that causes tb. in the past, tb was viewed as an occupational hazard of dentistry. 17, 18 while the number of active tb cases in the united states is relatively small, certain populations such as the homeless, prisoners and recent immigrants have a higher percentage of tb infection. 19 patients known to have active tb should be treated using special respiratory precautions so that the aerosols produced during treatment can be controlled. patients with undiagnosed, active, infectious tb, however, remain a risk for the dental team and other patients. the saliva and nasopharyngeal secretions also may contain other pathogenic organisms. these may include common cold and influenza viruses, herpes viruses, pathogenic streptococci and staphylococci, and the sars virus. the use of universal precautions with all patients initially jada, vol. 135, april 2004 431 c l i n i c a l p r a c t i c e it also should be assumed that all patients may have an infectious disease that has the potential to be spread by dental aerosols; thus, universal precautions to limit aerosols also should be in place. most dental procedures that use mechanical instrumentation will produce airborne particles from the site where the instrument is used. dental handpieces, ultrasonic scalers, air polishers and air abrasion units produce the most visible aerosols. each of these instruments removes material from the operative site that becomes aerosolized by the action of the rotary instrument, ultrasonic vibrations or the combined action of water sprays and compressed air. the water spray usually is the portion of the aerosol that is most visible to the naked eye and is noticed by the patient and dental personnel. figure 1 and figure 2 show the coolant water aerosol and splatter produced by an ultrasonic scaler and air polisher. one study, however, showed that when an ultrasonic scaler was used in vitro without any coolant water, there still was a large amount of aerosol and splatter formed from small amounts of liquid placed at the operative site to simulate blood and saliva. 20 this airborne material was spread for a distance of at least 18 inches from the operative site. despite the amount of splatter and the distance it was spread, no visible aerosol was detected during the use of the ultrasonic scaler, and it could only be detected as settled droplets on the environmental surfaces. figure 3 shows that aerosols and splatter from an ultrasonic scaler can arise both from a coolant water source and directly from the patient. qualitative and quantitative analysis of the makeup of dental aerosols would be extremely difficult, and the composition of aerosols probably varies with each patient and operative site. however, it is reasonable to suppose that components of saliva, nasopharyngeal secretions, plaque, blood, tooth components and any material used in the dental procedure, such as abrasives for air polishing and air abrasion, all are present in dental aerosols. in the past, studies usually concentrated on the number of bacteria present in dental aerosols; several recent studies have analyzed the presence of blood components in dental aerosols. 21, 22 multiple studies have been conducted to determine which dental procedure produces the most airborne bacterial contamination. 23 studies, researchers have measured the number of bacteria that settle on growth media plates over a specific period. in almost all instances, a nonselective bacterial growth media such as blood agar has been used. when an aerobic bacterium settles on the plates and grows as a colony, it will be counted as a colony-forming unit, or cfu. most results have been reported as the total cfus produced during the various dental procedures. this method gives a good picture of the increase in total airborne bacterial cfus from a particular procedure, but it does not provide any differentiation between whether the bacteria are relatively benign or a pathogenic species. any bacteria that require special media or growth conditions, such as mycobacteria or strict anaerobes that are common in periodontal pockets, will not grow on media used in these tests and therefore are not counted. also, because they do not grow on the type of media used for bacterial studies, no viral particles such as influenza, rhinoviruses and sars coronovirus would be measured. table 2 lists the dental instruments and procedures that produce the greatest amount of aerosols. because of the methods used, bacterial growth studies give only a partial picture of the airborne contamination that occurs during dental procedures. however, in relative terms these studies can be viewed as providing a good comparative index of the amount of airborne material that is generated during various dental procedures. using the bacterial growth method, the ultrasonic scaler has been shown to produce the greatest amount of airborne contamination, followed by the air-driven high-speed handpiece, the air polisher and various other instruments such as the airwater syringe and prophylaxis angles. 12,23-28 to date, no studies have been performed on the bacterial contamination produced by air abrasion. investigations have evaluated the presence or absence of blood contamination in the aerosols produced during root planing when an ultrasonic scaler is used. 21, 22 these studies have shown that blood is present universally in ultrasonic scaler aerosols during root planing. while the presence of blood has not been directly studied, it would seem logical that blood also would be present in any dental aerosol that is produced by an instrument in a blood-contaminated field. this would include restorative procedures that extend subgingivally, as well as periodontal and oral surgery procedures. as noted previously, if the ada's recommendations for sterilization of instruments and treatment of duwls are followed, these major sources of potentially contaminated dental aerosols can be controlled. however, it should be recognized that the aerosol created by the interaction of coolant water and ultrasonic vibrations or by compressed air and a rotary motion are visible to patients and dental personnel. it is important that this aerosol cloud be controlled to the greatest extent possible to reassure patients and dental personnel. it also should be recognized that contaminated aerosols are produced during dental procedures when there are little or no visible aerosols. as has been shown in the study of aerosol production by ultrasonic scalers when no coolant water was used, even in the complete absence of coolant water there is aerosolization of material from the operative site. 20 during routine dental treatment, there is a strong likelihood that aerosolized material will include viruses, blood, and supra-and subgingival plaque organisms. at this time, it is impossible to determine the exact infection risk represented by aerosolized material. the potential for the spread of infection via an almost invisible aerosol, however, must be recognized and minimized or eliminated to the greatest extent feasible within a clinical situation. the use of personal barrier protection such as masks, gloves and eye protection will eliminate much of the danger inherent in splatter droplets arising from the operative site. 29 infectious material that is present in a true aerosol form (particles less than 50 μm in diameter) or splatter that becomes reairborne as droplet nuclei has the potential to enter the respiratory tract through leaks in masks 30 and contact mucus membranes by going around protective devices such as safety glasses. a true aerosol or droplet nuclei may be present in the air of the operatory for up to 30 minutes after a procedure. 13 this means that after a dental procedure, if the operator removes a protective barrier such as a face mask to talk to a patient when a procedure is completed, the potential for contact with airborne contaminated material remains. also, there is a potential for an airborne contaminant to enter the ventilation system and spread to areas of the facility where barrier protection is not used. one method of reducing overall bacterial counts produced during dental procedures is the use of a preprocedural rinse. the use of a .01 percent chlorhexidine or essential oil-containing mouthwash for one minute before a dental procedure has been shown to significantly reduce the bacterial count in the air of the operatory. 31, 32 chlorhexidine is an effective antiseptic for freefloating oral bacteria such as those found in the saliva and those loosely adhering to mucus membranes. chlorhexidine, however, does not affect bacteria in a biofilm such as established dental plaque, does not penetrate subgingivally, will not affect blood coming directly from the operative site and is unlikely to affect viruses and bacteria harbored in the nasopharynx. while preprocedural rinses will reduce the extent of contamination within dental aerosols as routinely measured on agar plates, they do not eliminate the infectious potential of dental aerosols. during many dental procedures, the use of a rubber dam will eliminate virtually all contamination arising from saliva or blood. if a rubber dam can be used, the only remaining source for airborne contamination is from the tooth that is undergoing treatment. this will be limited to airborne tooth material and any organisms contained within the tooth itself. in certain restorative procedures such as subgingival restorations and the final steps of crown preparation, it often is impossible to use a rubber dam. the use of a rubber dam also is not feasible for periodontal and hygiene procedures such as root planing, periodontal surgery and routine prophylaxis. this is of particular concern owing to the fact that periodontal procedures always are performed in the presence of blood and instruments such as the ultrasonic scaler, which has been shown to create the greatest amount of aerosol contamination, are used. two methods are available to reduce airborne contamination arising from the operative site. one method involves using devices that remove the contaminated material from the air of the treatment area after it has become airborne. the other is to remove the airborne contamination before it leaves the immediate area surrounding the operative site. the most frequently mentioned methods of removing airborne contamination from the air of the treatment room are the use of a high efficiency particulate air, or hepa, filter and the use of ultraviolet, or uv, chambers in the ventilation system. while both of these systems appear to reduce airborne contamination, they are somewhat expensive; the uv system is costprohibitive for most dental offices at this time. considered the greatest source of aerosol contamination; use of a high-volume evacuator will reduce the airborne contamination by more than 95 percent bacterial counts indicate that airborne contamination is nearly equal to that of ultrasonic scalers; available suction devices will reduce airborne contamination by more than 95 percent bacterial counts indicate that airborne contamination is nearly equal to that of ultrasonic scalers; high-volume evacuator will reduce airborne bacteria by nearly 99 percent bacterial contamination is unknown; extensive contamination with abrasive particles has been shown both approaches also have the problem that it takes an extended period for the air in the treatment room to cycle through the filter or uv treatment system. from a practical point of view, it is easiest to remove as much airborne contamination as possible before it escapes the immediate treatment site. the use of a high-volume evacuator, or hve, has been shown to reduce the contamination arising from the operative site by more than 90 percent. 8, 23, [33] [34] [35] it should be emphasized that for a suction system to be classified as an hve, it must remove a large volume of air within a short period. an evacuator that pulls a high vacuum but does not remove a large volume of air, such as is used routinely for hospital suction, is not considered an hve. the usual hve used in dentistry has a large opening (usually 8 millimeters or greater) and is attached to an evacuation system that will remove a large volume of air (up to 100 cubic feet of air per minute). the small opening of a saliva ejector does not remove a large enough volume of air to be classified as an hve. during restorative dentistry, the hve often will be used by an assistant who is able to guide and aim the vacuum in a manner that eliminates or greatly reduces the visible water spray produced during dental procedures. it has been shown that the number of cfus produced during dental procedures is reduced greatly when an assistant uses an hve. 8 a problem arises when the operator is working without an assistant. this often is the case during delivery of periodontal treatment by a dental hygienist. several options are available to operators working without an assistant. they include using the operating instrument in one hand and the hve in the other hand, hve devices that attach to the operating instrument and various "dry field" devices that attach to an hve. for air polishing and air abrasion, devices are available that combine a barrier device to help contain the abrasive material and a vacuum to remove the abrasive material and the airborne particles created by the procedures. 28, 36 all of these instruments are available commercially from multiple sources. it must be emphasized that no single approach or device can minimize the risk of infection to dental personnel and other patients completely. a single step will reduce the risk of infection by a certain percentage, another step added to the first step will reduce the remaining risk, until such time as the risk is minimal. this can be described as a layering of protective procedures. this layering of infection control steps needs to be followed in reducing the potential danger from dental aerosols. the dental team should not rely on a single precautionary strategy. in the reduction of dental aerosols, the first layer of defense is personal protection barriers such as masks, gloves and safety glasses. the second layer of defense is the routine use of an antiseptic preprocedural rinse with a mouthwash such as chlorhexadine. the third layer of defense is the routine use of an hve either by an assistant or attached to the instrument being used. an additional layer of defense may be the use of a device to reduce aerosol contamination that escapes the operating area, such as a hepa filter. the first three layers of defense are found routinely in most dental operatories, are inexpensive and can be made part of routine infection control practices easily. unfortunately, many operators appear to use only the first layer of defense (personal protection barriers) without following the other simple steps. all three simple and inexpensive steps should be followed routinely for adequate protection. table 3 lists the available methods of reducing aerosols and splatter contamination, as well as their relative effectiveness and costs. the ada and cdc have recommended that all blood-contaminated aerosols and splatter should be minimized. 29 occupational safety and health administration regulations state that "all procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of the these substances." 37 in the guidelines for infection control in dental health-care settings that was published recently by the cdc, all of these recommendations were retained. the use of rubber dams and hves are considered to be "appropriate work practices"-precautions that always should be followed during dental procedures. 38 jada, vol. 135, april 2004 435 c l i n i c a l p r a c t i c e no single approach or device can minimize the risk of infection to dental personnel and other patients completely. by following the simple and inexpensive recommendations for controlling aerosols and splatter outlined in this article, dental practitioners will be in compliance with these recommendations and will minimize any legal or regulatory risks that may exist. the aerosols and splatter generated during dental procedures have the potential to spread infection to dental personnel and other people in the dental office. while, as with all infection control procedures, it is impossible to completely eliminate the risk posed by dental aerosols, it is possible to minimize the risk with relatively simple and inexpensive precautions. we feel that the following procedures are appropriate as universal precautions whenever an aerosol is produced: duniversal barrier precautions should be followed; da preprocedural rinse should be used before treatment; da rubber dam should be used where possible; dan hve should be used for all procedures. the use of these precautions should reduce the risk of an aerosolized spreading of infection to a minimal level. further, the universal application of these infection control strategies will reduce the employer's legal exposure to the lowest possible level. ■ c l i n i c a l p r a c t i c e preprocedural rinse with antiseptic mouthwash such as chlorhexidine part of "standard precautions," inexpensive reduces the bacterial count in the mouth, saliva and air; inexpensive on a per-patient basis will reduce the number of bacteria in the air and remove most of the material generated at the operative site such as bacteria, blood and viruses; inexpensive on a per-patient basis effective in reducing numbers of airborne organisms masks will only filter out 60 to 95 percent of aerosols, subject to leakage if not well-fitted, do not protect when mask is removed after the procedure tends to be most effective on freefloating organisms; it will not affect biofilm organisms such as plaque, subgingival organisms, blood from the operative site or organisms from the nasopharynx when an assistant is not available, it is necessary to use a high-volume evacuator attached to the instrument or a "dry field" device; a small-bore saliva ejector is not an adequate substitute only effective once the organisms are already in the room's air, moderate to expensive, may require engineering changes to the ventilation system device advantages disadvantages guideline for isolation precautions in hospitals. the hospital infection control practices advisory committee. infect control the black death: natural and human disaster in medieval europe transmission of multidrug-resistant mycobacterium tuberculosis during a long airplane flight measles outbreak in a pediatric practice: airborne transmission in an office setting cdc. interim domestic infection control precautions for aerosolgenerating procedures on patients with severe acute respiratory syndrome (sars) american dental association. severe acute respiratory syndrome (sars) studies on dental aerobiology, i: bacterial aerosols generated during dental procedures studies of dental aerobiology, ii: microbial splatter discharged from the oral cavity of dental patients studies on dental aerobiology, 3: efficacy of surgical masks in protecting dental personnel from airborne bacterial particles studies on dental aerobiology, iv: bacterial contamination of water delivered by dental units air pollution and its control in the dental office aerosol technology: properties, behavior, and measurement of airborne particles practical infection control in dentistry comparison of dental water quality management procedures intraoral and pulmonary tuberculosis following dental treatment spread of organisms from dental air rotor another challenge from the microbial world aerosol and splatter contamination from the operative site during ultrasonic scaling the effectiveness of an aerosol reduction device for ultrasonic scalers bacterial airborne contamination with an air-polishing device evaluating spatter and aerosol contamination during dental procedures aerosol generation by two ultrasonic scalers and one sonic scaler: a comparative study assessing the clinical effectiveness of an aerosol reduction device for the air polisher clinical use of an aerosol-reduction device with ultrasonic scaler blood contamination of the aerosols produced by the in vivo use of ultrasonic scalers efficacy of face masks in preventing inhalation of airborne contaminants assessing pre-procedural subgingival irrigation and rinsing with an antiseptic mouthrinse to reduce bacteremia jacks me. a laboratory comparison of evacuation devices on aerosol reduction reduction of bacteria-containing spray produced during ultrasonic scaling occupational exposure to bloodborne pathogens: osha-final rule guidelines for infection control in dental health-care settings key: cord-341661-sokoghh1 authors: ahmed, muhammad adeel; jouhar, rizwan; ahmed, naseer; adnan, samira; aftab, marziya; zafar, muhammad sohail; khurshid, zohaib title: fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak date: 2020-04-19 journal: int j environ res public health doi: 10.3390/ijerph17082821 sha: doc_id: 341661 cord_uid: sokoghh1 an outbreak of novel coronavirus disease (covid-19) in china has influenced every aspect of life. healthcare professionals, especially dentists, are exposed to a higher risk of getting infected due to close contact with infected patients. the current study was conducted to assess anxiety and fear of getting infected among dentists while working during the current novel coronavirus diseases (covid-19) outbreak. in addition, dentists’ knowledge about various practice modifications to combat covid-19 has been evaluated. a cross-sectional study was conducted using an online survey from 10th to 17th march 2020. the well-constructed questionnaire was designed and registered at online website (kwiksurveys) and validated. a total of 669 participants from 30 different countries across the world responded. after scrutiny, completed questionnaires (n = 650) were included in the study. statistical analysis was performed using spss version 25. chi-square and spearman correlation tests were applied to control confounders and assess the relation of dentists’ response with respect to gender and educational level. more than two-thirds of the general dental practitioners (78%) from 30 countries questioned were anxious and scared by the devastating effects of covid-19. a large number of dentists (90%) were aware of recent changes in the treatment protocols. however, execution of amended treatment protocol was recorded as 61%. the majority of the dentists (76%) were working in the hospital setting out of which 74% were from private, and 20% were from government setups. individually we received a large number of responses from pakistan and saudi arabia, but collectively more than 50% of the responses were from other parts of the world. despite having a high standard of knowledge and practice, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the covid-19 pandemic impact on humanity. a number of dental practices have either modified their services according to the recommended guidelines to emergency treatment only or closed down practices for an uncertain period. an outbreak of novel coronavirus disease in china has influenced every aspect of life [1] . within a few months, covid-19 has spread globally and on 11th march 2020, the world health organization (who) declared it as a controllable pandemic disease [2, 3] . the latest strain of coronavirus is believed to have originated in a seafood market in wuhan, china [1] . on 11th february 2020, who used the term covid-19 to describe the latest strain of coronavirus [4] . structurally, covid-19 is an ss-rna, enveloped virus with a size of~350 kilobase-pair (kbp) [5] . covid-19 has the potential to cause severe acute respiratory tract infection among infected humans and is commonly transmitted from person to person via hands, saliva, nasal droplets, and surface contacts [3, 6] . the average incubation period ranges of covid-19 from 4 to 14 days [7] . the infected person usually presents with upper respiratory tract infection (rti) and complaints of high-grade fever, a dry cough, and dyspnea [8] . it is highly recommended to keep any suspected individuals in quarantine (isolation) and under observation until further investigation by the real-time polymerase chain reaction (rt-pcr) can take place [9] . unfortunately, there is no antiviral vaccine available on the market, but on 16th march 2020 the first clinical trial was initiated by the national health institute (nhi), usa [3] . therefore, patients have to rely on supportive therapy such as vitamins a, c and d; chloroquine phosphate; and general healthcare until the body's immune system can eradicate the infection [10] . considering the vital role of the body's immune system, elderly patients with chronic debilitating diseases have a higher risk of getting infected compared to young, healthy individuals with a strong immune system [11] . to date, three quarter of a million cases have been reported, and more than thirty-three thousand patients have died around the world (source who situation report-70). although the mortality associated with covid-19 is low, it has a high spreading potential [12] . since the covid-19 outbreak is so fast and devastating, many countries have shut down teaching institutions, social gatherings, sports activities, events, airports, and even banks in an attempt to control the spread of the infection. besides this, several individuals went into self-quarantine in order to play their part in society by limiting the spread of disease. on the other hand, healthcare facilities are necessarily required for any society and are rarely closed under such pandemic conditions. healthcare professionals are exposed to a higher risk of getting infected due to their close contact with infected patients [13] . in particular, dentists perform their duties not only in close contact with patients but also while exposed to aerosol and droplets splashing out of patients' oral cavity [13, 14] . therefore, dentists have a high risk of getting infected from patients and potentially spreading it to their peers, families, and other patients. under these circumstances, it may be natural for dentists to develop a fear of being infected by their patients. fear and anxiety are powerful emotions that may be associated with the overwhelming reports on the covid-19 pandemic by social, electronic, and print media. mild anxiety is natural and fosters preventive and safeguarding behavior [15] . at the current juncture, people with persistent anxiety may panic and are more likely to make mistakes leading to irrational decisions and behavior. being on the list of high-risk professions, dentists are very much expected to develop severe anxiety about the current pandemic situation [16] . considering the current rapid spread of infection, the american dental association (ada) highlighted key steps to be taken by dentists in addition to the standard universal precautions such as taking patients' recent travel history; assessing signs and symptoms of rti; recording patients' body temperature; mouth rinsing with 1% hydrogen peroxide prior to commencement of any procedure; using a rubber dam and high volume suction during procedures; and frequently cleaning and disinfecting public contact areas including door handles, chairs and, washrooms [13] . although the ada has published preventive guidelines, the majority of dentists are still reluctant and feel fearful of treating patients in such a situation (source ada-covid-19 resources for dentists). in fact, most dentists may not be aware of the recent guidelines. therefore, we have conducted a questionnaire-based study to evaluate dentist response globally. the present study aimed to assess anxiety and fear of getting infected among dentists working during the current viral outbreak. in addition, dentist knowledge about various practice modifications to combat the novel coronavirus disease (covid-19) outbreak has been evaluated. the present cross-sectional study was conducted using an online survey questionnaire from 10th to 17th march 2020. for this purpose, a well-constructed questionnaire was designed at www. kwiksurveys.com and validated through intra-class correlation with a strong relation of 0.74. the online survey link was circulated through social media and an e-mail to dental professionals and received a response through an online survey submission. any paramedical staff and dental students were not included in this survey. the questionnaire was comprised of a total of 22 closed-ended questions, which were divided into two sections. the first section focused on the fear among dentists about getting infected with covid-19 and the second section was designed to gather information about their practice modifications to combat covid-19 outbreak in accordance with the centers for disease control and prevention (cdc) and ada practice guidelines. a total of 669 participants from 30 different countries across the world participated and submitted the questionnaire, excluding 19 unfilled or partially filled forms ( figure 1 ). an ethical review board approved the study (aidm/ec/03/2020/20) and statistical analysis was done on spss version 25. a chi-square and spearman correlation test were used to control confounders and assess the relation of dentist response with respect to concerning gender and education level. we have conducted a questionnaire-based study to evaluate dentist response globally. the present study aimed to assess anxiety and fear of getting infected among dentists working during the current viral outbreak. in addition, dentist knowledge about various practice modifications to combat the novel coronavirus disease (covid-19) outbreak has been evaluated. the present cross-sectional study was conducted using an online survey questionnaire from 10th to 17th march 2020. for this purpose, a well-constructed questionnaire was designed at www.kwiksurveys.com and validated through intra-class correlation with a strong relation of 0.74. the online survey link was circulated through social media and an e-mail to dental professionals and received a response through an online survey submission. any paramedical staff and dental students were not included in this survey. the questionnaire was comprised of a total of 22 closed-ended questions, which were divided into two sections. the first section focused on the fear among dentists about getting infected with covid-19 and the second section was designed to gather information about their practice modifications to combat covid-19 outbreak in accordance with the centers for disease control and prevention (cdc) and ada practice guidelines. a total of 669 participants from 30 different countries across the world participated and submitted the questionnaire, excluding 19 unfilled or partially filled forms ( figure 1 ). an ethical review board approved the study (aidm/ec/03/2020/20) and statistical analysis was done on spss version 25. a chi-square and spearman correlation test were used to control confounders and assess the relation of dentist response with respect to concerning gender and education level. a total of 650 participants from 30 countries worldwide submitted the completed questionnaire with a total of 22 questions comprising of two sections about fear or anxiety level and practice modification due to covid-19. the responses were recorded from various countries as follows: saudi arabia (80) the demographic information of the participants is presented in table 1 . out of a total of 650 participants, 160 were male and 490 female, with a common age bracket between 20 and 40 years (92.84%). by designation, 511 were general dentists, 97 specialists, and only 42 were from the consultant category. similarly, 511 were graduates and 139 postgraduates by qualification while 482 dentists were from a private setup, 37 were semiprivate and 131 from a government work setting. the majority of participants (495) were working in a hospital while 155 were working in clinics ( table 1 ). the present study reported no significant relationship (rho-0.2), (p 0.06) between dental care professionals' responses with gender and their education level. (20) in table 2 there is a description of the fear and anxiety levels of dental care professionals towards covid-19; 87% of participants were afraid of getting infected with covid-19 from either a patient or a co-worker. while treating a coughing or a patient suspected to be infected with covid-19, 90% were anxious. more than 72% of participants felt nervous when talking to patients in close vicinity, 92% were afraid of carrying the infection from dental practice to their families, and 77% were afraid of getting quarantined if they got infected. the anxiety rate concerning the cost of treatment if they the demographic information of the participants is presented in table 1 . out of a total of 650 participants, 160 were male and 490 female, with a common age bracket between 20 and 40 years (92.84%). by designation, 511 were general dentists, 97 specialists, and only 42 were from the consultant category. similarly, 511 were graduates and 139 postgraduates by qualification while 482 dentists were from a private setup, 37 were semiprivate and 131 from a government work setting. the majority of participants (495) were working in a hospital while 155 were working in clinics ( table 1 ). the present study reported no significant relationship (rho-0.2), (p 0.06) between dental care professionals' responses with gender and their education level. (20) in table 2 there is a description of the fear and anxiety levels of dental care professionals towards covid-19; 87% of participants were afraid of getting infected with covid-19 from either a patient or a co-worker. while treating a coughing or a patient suspected to be infected with covid-19, 90% were anxious. more than 72% of participants felt nervous when talking to patients in close vicinity, 92% were afraid of carrying the infection from dental practice to their families, and 77% were afraid of getting quarantined if they got infected. the anxiety rate concerning the cost of treatment if they got infected was 73%, while 86% felt afraid while they learnt about mortalities because of covid-19. a considerable number of dentists (66%) wanted to close their dental practices until the number of covid-19 cases start to decline. in table 3 there is a description of the knowledge of dental care professionals about covid-19; 97% were aware of its mode of transmission, and 90% were updated with the current cdc or who guidelines for cross-infection control. accordingly, 82% preferred asking about the patient's travel history, 81% recorded every patient's body temperature before performing dental treatments, and 78% deferred dental treatment of patients who disclosed suspicious symptoms. in terms of using personal protection, 85% believed that a surgical mask is not enough to prevent cross-infection of covid-19. in comparison, 84% favored the use of n-95 masks for routine dental procedures during the current outbreak. on the contrary, 90% reported not wearing an n-95 mask while treating a patient. although the majority (89%) recommended routine universal precautions of infection control, 84% did not use rubber dam isolation for every patient. seventy-six percent of participants used high-volume suction for every patient. however, 74% did not ask patients to rinse the mouth with antibacterial mouthwash before dental treatment. ninety-four percent of participants practiced washing hands with soap and water or sanitizer before and after treatment of patients, while 80% of participants were aware of the proper authority to contact if they came across a patient with a suspected covid-19 infection. table 3 . knowledge and practice of dentists about covid 19 n = 650. the present cross-sectional study reported the anxiety and fear of getting infected among dentists while working during the current viral outbreak. for this purpose, a questionnaire focusing on closed-ended questions was used to gather information about dentist's fear and any practice modifications to combat the covid-19 outbreak epidemic. questionnaire-based studies are proven for gathering information regarding preferences, attitudes, opinions, and experiences of participants; however, careful data collection and interpretation is required [17] . the questionnaire used in the present study collected information objectively and validated through intra-class correlation with a strong relation of 0.74. any incomplete questionnaires were excluded. psychological implications such as fear and anxiety are natural in pandemics, especially when the number of infected individual and mortality rates are increasing sharply. studies on previous outbreaks of similar infectious diseases such as severe acute respiratory syndrome (sars) demonstrated various factors leading to psychological trauma in healthcare workers including the fear of getting infected while treating an infected patient, or infecting a family member [18, 19] . the repercussions of the current rapid spread of covid-19, which has affected millions of people worldwide, ranging from being isolated and quarantined to fatality has resulted in considerable psychological stress and fear. with the prolonged incubation period of the coronavirus (as long as 14 days), it is virtually impossible to pinpoint an individual's exposure to the virus [20] . in addition, there is no vaccine or approved treatment, which further enhances anxiety upon the thought of getting infected. healthcare workers dealing with sick patients continuously are at a higher risk of acquiring infectious diseases, adding a tremendous psychological toll [21] . since it has been established that the primary route for transmission of coronavirus is through droplets and aerosols [22] , this enhances the likelihood of dentists and dental healthcare workers of getting infected and further spreading the virus. the current study found that a large number of dentists fear getting infected by their patients or co-workers. the response is similar to the perception of rest of the population where people are terrified of getting infected from other individuals in the community in the presence of a rapidly developing epidemic [23] . the majority of the dentists are fearful of providing treatment to any patient reporting suspicious symptoms. since covid-19 has rapidly infected such a large number of individuals in almost every country, the fear of getting infected by a patient is justified. the high level of anxiety was reflected as a large proportion of dentists wanted to close down their practices which may have significant economic implications for dentists and dental healthcare workers. in addition, patients suffering from dental pain and/or undergoing a multi-visit treatment plan may have to experience delays in dental care in such circumstances. the current guidelines on the covid-19 outbreak have recommended deferring all non-essential dental treatment, and only patients suffering from pain, swelling, bleeding, and trauma are advised to undergo treatment [14, 24] . in the current scenario, all elective or non-essential dental treatment for all patients should be deferred until the situation is regressing or under control [14] . there is a study conducted at a dental emergency department in beijing, china [25] , where they have observed an impact of the covid-19 pandemic on the reporting of dental treatments, which has declined in the emergency department as compared to reporting pre-covid-19. due to the covid-19 pandemic, less dental trauma has been reported and the proportion of dental and oral infection has increased while those of dental trauma and non-urgency have decreased [25] . another genuine fear that dentists have is of carrying infections from their dental practices to their families. the coronavirus can last on various surfaces for a few hours to a few days [26] . this, combined with its prolonged incubation period before symptoms develop, are factors that make it particularly difficult to limit its transmission. the trepidation of getting quarantined as a result of suspected disease or actual infection is also a legitimate fear when one thinks about how the rest of the family members are likely to suffer due to various aspects. the burden on the healthcare system and cost incurred during treatment also puts one's mind at stress. health facilities may not be state-sponsored globally and hence can result in a significant financial burden. the screening and testing for covid-19 have been greatly subsidized by the government bodies in many countries worldwide, which is encouraging residents to get tested for covid-19 in cases of suspected infection. a positive aspect reposted by the present study was that the majority of the participants were aware of the covid-19 mode of spread and transmission. as a part of infection control measures, such information is essential during dental practice. it is crucial in the face of this pandemic to further follow the procedures and guidelines focusing on reducing the amount of aerosol generated and deal with it effectively. similarly, it was encouraging that a large number of dentists were aware of the current guidelines issued by the center for disease control (cdc) and who for cross-infection control in the dental practice including asking patients' travel history and recording patients' body temperature [8] . understandably, both these facts may provide a fair idea of potentially infected patients and their precautionary management in dental practice. of course, the routine universal precautions already recommended and endorsed by various regulatory and infectious control authorities worldwide for the prevention of cross-infection in dental practice should be rigorously adhered to in the current circumstances. although the majority of dentists agreed that these precautions should be practiced for every patient, unfortunately, a large number of participants reported not using basic cross-infection measures like the rubber dam for every patient. use of a rubber dam is an effective way to control cross-infection by limiting the spread of aerosols with good patient acceptance for dental procedures [24] . considering the benefits, there is no excuse for not using rubber dam during dental procedures, especially while using rotary instruments that generate a large quantity of aerosols and droplets. the use of high-volume suction is also considered an essential means to control aerosols evacuation during dental procedures and should be used for the majority of patients [22] . at the start of any dental procedure, rinsing with an antimicrobial mouthwash also significantly reduces the microbial load [27, 28] . this practice is recommended in the current pandemic, however the majority of dentists reported ignoring it. at present there is no available evidence addressing the effects of commonly used antimicrobial mouth rinses on covid 19. hence, this recommendation could be based on the fact that gargling has been reported to decrease the viral load and spread by removing oropharyngeal protease and associated viral replication [29] . in addition, mouthwashes containing agents with anti-viral activity such as povidone-iodine have exhibited effectiveness against various respiratory viruses [30, 31] . during the outbreak of covid-19, the importance of hand hygiene has been emphasized repeatedly and this is even more important in the case of dental practitioners. studies have shown that proper hand hygiene, including handwashing with soap and water and cleaning using alcohol-based sanitizers, is an essential measure in controlling the spread of respiratory illness including sars [32, 33] . therefore, who recommends frequent hand washing or using an alcohol-based hand sanitizer in the dental practice. the use of a particulate respirator such as the n-95 mask has been recommended for treating patients suspected of covid-19. otherwise, at least a surgical mask must be used while treating all patients when the distance between the dental healthcare worker and the patient is less than 1 m [22] . currently, recommendations are based on experiences and pertinent guidelines in addition to universal precautions applied to all dental patients. additionally, the intra-oral radiographs may be replaced by extra-oral radiographs such as orthopantomogram, and cone beam computed tomography where possible. periodontal procedures utilizing ultrasonic scalers should be substituted with hand scalers aiming to reduce the production and spread of aerosol and splatter. besides the regular use of a rubber dam, high-volume suction helps to keep aerosols in check and prevent droplets originating in the patient's oral cavity and respiratory tract from spreading and potentially transmitting infection. currently, around the world, dental regulatory authorities such as the ada are urging dentists to conduct only emergency dental treatments. further recommendations for dental treatment can be found elsewhere in relevant documents [6] . it is crucial in the face of the fear and anxiety shown by the dental community towards covid-19 that psychological coping mechanisms and strategies are practiced in order to remain calm and function efficiently. the fear that dentists have regarding getting infected from covid 19 could be greatly curtailed if dentists and dental healthcare workers meticulously follow the relevant recommendations issued by the regulatory authorities. these include the universal cross-infection control protocols along with some additional precautions in cases where patients present with any suspicious symptoms. some of the limitations of this study is data was collected in a concise duration of time, keeping in mind the rapid effect this outbreak was having on the psychology and practices of dental health practitioners. it may be argued that the attitudes and knowledge of dentists may alter with the emerging research and possible treatment of covid-19. furthermore, we did not receive responses from all countries that have been affected by the outbreak. hence, the generalizability of the study is limited. although the present study included participants from various countries across the globe, every country may have variable information, policies, and guidelines regarding covid-19 that may directly influence participant responses. similarly, some countries are more affected than others which may affect administrative, precautionary, and healthcare measures taken by a specific country that can also influence the outcome of a survey. therefore, the findings of the present study should be interpreted carefully and not be globalized. even though the questionnaire was sent to dentists almost all over the world, there was a lack of response mainly from european and african countries and resultant small sample size. the reason for this could be that the current panic may have diverted the attention of potential respondents towards other priorities, possibly related to the continuing or imminent lockdown conditions in many countries. due to the cross-sectional nature of the study plan, we couldn't conclude a cause-effect relationship. despite having high standards of knowledge and practices, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the covid-19 pandemic impact on humanity. currently, the effects of covid-19 around the globe are worsening day by day. several dental practices have either modified their services according to recommended guidelines to emergency treatment only, or closed down practices for an uncertain period. it is essential that in the present scenario, priority is given to dental procedures labeled as emergencies by the who and that all dental treatments are deferred until a time when the outbreak goes into recession. this would be an appropriate step in attempts to curtail the further spread of covid-19. return of the coronavirus: 2019-ncov. viruses potential impact of seasonal forcing on a sars-cov-2 pandemic al human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) covid-19): a perspective from china emerging coronaviruses: genome structure, replication, and pathogenesis transmission routes of 2019-ncov and controls in dental practice incubation period of 2019 novel coronavirus (2019-ncov) 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workers active quarantine measures are the primary means to reduce the fatality rate of covid-19 factors associated with mental health outcomes among health care workers exposed to coronavirus disease possible aerosol transmission of covid-19 and special precautions in dentistry fear and stigma: the epidemic within the sars outbreak dental-dam for infection control and patient safety during clinical endodontic treatment: preferences of dental patients the impact of the covid-19 epidemic on the utilization of emergency dental services aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review antimicrobial effects of chlorhexidine, matrica drop mouthwash (chamomile extract), and normal saline on hospitalized patients with endotracheal tubes in vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens great cold investigators-i. can we prevent influenza-like illnesses by gargling? the action of three antiseptics/disinfectants against enveloped and non-enveloped viruses effectiveness of handwashing in preventing sars: a review interventions for the interruption or reduction of the spread of respiratory viruses this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-315246-b477kabe authors: dziedzic, arkadiusz title: special care dentistry and covid-19 outbreak: what lesson should we learn? date: 2020-05-09 journal: dent j (basel) doi: 10.3390/dj8020046 sha: doc_id: 315246 cord_uid: b477kabe the recent outbreak of coronavirus disease 2019 (covid-19) caused by the emerging severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and the declaration of pandemic by the world health organization have made an enormous impact on medical and dental care across the world. the current covid-19 situation may teach dental teams a better approach and optimal ways concerning the management of patients with special needs, by bringing people together to discuss and optimize standards of care, as often happens in challenging situations. we can always learn new things that turn out to be valuable and useful even in exceptionally difficult times, and in addition, dental services can benefit from enabling positive attitudes and introducing constructive changes. clinicians just need to keep in mind that adjustment to a new future reality appears inevitable for both patients and professionals who provide care. the covid-19 pandemic is undoubtedly posing the greatest challenge that special care dental services ever had to face, but we can learn from this situation and benefit from this challenge. in fact, we should realize that this is an opportunity for constructive change, toward becoming more patient-centered and, more importantly, more adaptive providers, equipped with a strategy for positive change [1] . it is the right time to re-define and re-think our role, trying to learn the lesson that the current situation is teaching us and prepare well for the future, by changing our mindset and widening our resources. the "3r" principle, (r)edefinition, (r)econsideration and (r)eflections, addresses well these challenges in the dental sector, recommending clinicians to demonstrate a professional commitment and be 'slicker and quicker', displaying critical decision-making skills. one of the positive aspects of the current covid-19 outbreak is the fact that dental teams all over the world and their patients have instantly understood in a profound way the important role of primary, community, and hospital services [2] , which continually contribute, despite some interruption, to the maintenance of patients' wellbeing. without the essential urgent and emergency dental care provided by dental services, a large number of patients would be deprived of appropriate help [3] . nowadays, we might clearly realize that dental care constitutes a crucial element in the whole healthcare system and public health maintenance, and, more importantly, that basic 'impactful dental interventions' are critical for pain management in general [4] . despite the fact that relevant key expressions such as triaging, prioritizing, compromising, and making difficult choices have become a daily reality in this pandemic time, these actions can bring an 'added value' and improve our service. we can definitely enhance our communication skills for tele(video) consultations, providing comprehensive advice to patients in needs. in addition, and more importantly, we have a great opportunity to create a unique, professional relationship with our patients, based on our commitment and profound understanding of clinical problems. as the impact of covid-19 on wellbeing and mental health appears to be significant, dental services will need to be able to provide some sort of 'psychological counselling and reassurance' prior to dental care to vulnerable individuals with complex pre-existing conditions and special requirements. this is why improving our skills is essential. from the pragmatic and clinical perspective, questions are arising on a daily basis; for instance, how can we help our phobic patients when most of sedation and dental general anesthesia services are currently suspended and these patients are known not to tolerate any form of standard local anesthesia? a broader implementation of non-pharmacological pain and anxiety control measures would be inevitable and the only available option [5] . this is definitely the proper time to expand our panel of treatment and/or 'psychological' methods and learn/revise in depth alternative techniques, regardless of patient's age, e.g., gradual exposure, hypnotherapy, behavioral management, professional cognitive behavioral therapy (cbt), the use of virtual goggles for distraction, desensitization methods, etc. [6] [7] [8] . this would be particularly useful when treating individuals with learning disabilities, young patients with attention deficit hyperactivity disorder (adhd), phobic children. nowadays, we also need to change our standard way of dealing with severe cases of medically compromised patients, trying to balance and weight our clinical decisions and reviewing service capacity and patient's safety on a regular basis. therefore, we must act as effectively as we can, trying to 'alter our mindset' by adapting it to the new reality and setting up far more adjustable dental services. undoubtedly, the recently implemented strict cross infection control measures and the awareness of infectious diseases transmission have affected dental services management in a positive way, as they are leading to a better level of infection prevention control and better personal protective measures. in the field of special care dentistry, even basic advice may have a huge impact on clinical outcome. a patient with acute/chronic oral medicine problems would vastly benefit from professional recommendations, provided over the phone, regarding treatment planning [9] . after all, it is vitally important to reassure our patients, encouraging them to continue taking their prescribed medications, as any sudden change in pharmacotherapy regimen may have a detrimental effect on patients' outcome [10] . we must encourage our patients to continue to access health systems, particularly in case of emergency problems, and ensure that dental care is able to support them. this is a primary role of reorganized dental services to minimize an indirect impact of covid-19 on oral health; therefore, preparation seems to be another key word for special dental care 'evolution' in the nearest future. the overall impact of sars-cov-2 on general health is deemed to be far more profound, with significant effects on various systems and functions, including the respiratory and cardiovascular systems, hemostasis, cognitive and renal functions [11] [12] [13] [14] [15] . when the pandemic crisis is finally over, special care dentistry teams should be well prepared to tackle increased numbers of patients with unresolved medical and dental problems or unfinished treatment courses, as a consequence of deferred services. for some of them, restorative care will no longer be an option, and more radical planning will be necessary. consequently, we should expect oral health deterioration and increased incidence of oral diseases. moreover, patients who were treated in intensive care units due to covid-19 serious complications may require special attention as a group at high risk for oral health deterioration [16] . nevertheless, the lesson we all need to learn is simple: be adaptable, be empathetic, and always try to provide the best care to your patients, while learning from challenges. preparedness and lessons learned from the novel coronavirus disease health services provision of 48 public tertiary dental hospitals during the covid-19 epidemic in china urgent dental care for patients during the covid-19 pandemic dentistry and coronavirus (covid-19)-moral decision-making an overview of dental anxiety and the non-pharmacological management of dental anxiety non-pharmacological interventions for managing dental anxiety in children dental anxiety-how would you manage it? saad dig psychological treatment of fearful and phobic special needs patients. spec. care dent emergency measures for acute oral mucosa diseases during the outbreak of covid-19 covid-19 the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients impact of the covid-19 pandemic on therapeutic choices in thrombosis-hemostasis potential effects of coronaviruses on the cardiovascular system: a review acute renal impairment in coronavirus-associated severe acute respiratory syndrome nervous system involvement after infection with covid-19 and other coronaviruses the impact of coronavirus infectious disease 19 (covid-19) on oral health funding: this research received no external funding. the author declares no conflict of interest. key: cord-307285-bxy0zsc7 authors: dar odeh, najla; babkair, hamzah; abu-hammad, shaden; borzangy, sary; abu-hammad, abdalla; abu-hammad, osama title: covid-19: present and future challenges for dental practice date: 2020-04-30 journal: int j environ res public health doi: 10.3390/ijerph17093151 sha: doc_id: 307285 cord_uid: bxy0zsc7 covid-19 was declared a pandemic by the world health organization, with a high fatality rate that may reach 8%. the disease is caused by sars-cov-2 which is one of the coronaviruses. realizing the severity of outcomes associated with this disease and its high rate of transmission, dentists were instructed by regulatory authorities, such as the american dental association, to stop providing treatment to dental patients except those who have emergency complaints. this was mainly for protection of dental healthcare personnel, their families, contacts, and their patients from the transmission of virus, and also to preserve the much-needed supplies of personal protective equipment (ppe). dentists at all times should competently follow cross-infection control protocols, but particularly during this critical time, they should do their best to decide on the emergency cases that are indicated for dental treatment. dentists should also be updated on how this pandemic is related to their profession in order to be well oriented and prepared. this overview will address several issues concerned with the covid-19 pandemic that directly relate to dental practice in terms of prevention, treatment, and orofacial clinical manifestations. covid-19 was declared a pandemic by the world health organization (who), with substantial numbers of infected cases and deaths reported in many countries. among these countries, italy, the united kingdom, and spain had a high fatality rate ranging 4-8% [1] . the disease is caused by one of the coronaviruses, which are a large family of viruses that may cause severe illnesses, such as severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). these viruses are common in animals with the potential of transmission to humans. they are composed of an envelope, a lipid layer, and single-stranded large rna. the name "corona" ("crown" in latin) is attributed to the spherical shape and surface projections. four subfamilies have been identified: alpha-, beta-, gamma-, and delta-coronaviruses. beta-coronaviruses seem to originate from mammals, namely bats; it was found that the genome sequence of sars-cov-2, the virus responsible for covid-19, is >90% identical to a bat coronavirus ratg13. in fact, bats represent a natural reservoir for a wide variety of coronaviruses including sars-cov-like and mers-cov-like viruses. sars-cov-2 is closely related to the sars-cov virus, and it belongs to the b lineage of the beta-coronaviruses, which are known to cause severe disease and fatalities. the origin of sars-cov-2 is still unclear, however, initial transmission from animals to humans has probably occurred in the huanan seafood market in wuhan, china in december 2019, where a cluster of pneumonia cases, caused by a newly identified β-coronavirus, were diagnosed in this city. the main clinical manifestations are respiratory in nature, and they manifest after a mean incubation period of five days (range: 0-24 days). an increased risk of infection was found in patients with certain co-morbidities mainly including hypertension, diabetes, and ischemic heart disease. a possible explanation for this association could relate to the nature of these diseases and the types of medications used for treatment. in hypertensive and diabetic patients, circulating amounts of angiotensin converting enzyme-2 (ace2) are increased. moreover, some drugs including some types of antihypertensive drugs act as ace inhibitors which further increase ace2, and as sars-cov-2 binds to the host cell's membrane via ace2, an increased risk to infection is noticed [2] . there is a wide variation between countries in the numbers of deaths and positive asymptomatic cases, with some reports indicating that approximately 80% of infected cases are asymptomatic [3] . initial symptoms consist of fever, cough, nasal congestion, fatigue and other signs of upper respiratory tract infections. in approximately two thirds of the cases, the infection can progress to severe disease with dyspnea and severe lung congestion. multi-organ failure may eventually result in the form of respiratory failure, shock, acute respiratory distress syndrome, arrhythmia, acute myocardial injury, acute liver injury, and sepsis [4] . as of 26 april 2020, there have been more than 2.9 million cases, and more than 205,000 deaths globally. in response to this challenging pandemic, the center for disease control and prevention (cdc), american dental association (ada), the national health service (nhs), as well as other health regulatory bodies have provided advice to dentists to regulate dental services and to provide them with guidance in order to protect themselves, their co-workers, and their patients from this infection. dentists are among the highest risk categories for transmission and contraction of the coronavirus, with many routine dental procedures having the potential to transmit the virus through aerosols. asymptomatic (carrier) patients as well as patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. while it is important to provide treatment for patients who present with urgent or emergency dental procedures, the primary goal should be to prevent transmission of infection to patients and dental healthcare personnel. the growing fear of cross-infection, and the possible role of dental practice in spreading the infection, have obliged dentists to step aside and to confine themselves in home quarantine similar to other non-healthcare sectors of the population. in addition, there has been an increased demand for personal protective equipment (ppe), which consists of garments to protect healthcare workers or any other persons to get infected. the standard ppe consist of gloves, mask, and gown. however, in case of airborne infections like covid-19, additional equipment should be utilized including face protection, goggles, mask, face shield, gloves, gown or coverall, head cover, and rubber boots [5] . dentists are now providing emergency dental procedures only, during which they have to follow the recommended cross-infection control protocols. therefore, the main bulk of published research directed to dentists has mainly focused on giving a background on the pandemic and what the recommended cross-infection control measures are. there are many aspects of covid-19 that are related to dental practice in addition to infection control, including prevention and treatment. there are also a number of clinical manifestations that affect the orofacial region and that dentists should be familiar with. this overview addresses the medical-dental aspects of covid-19 infection. it is directed to dental healthcare personnel to update them on the recommended guidelines for provision of dental health services during this critical period, and to explain important aspects of the covid-19 infection with relevance to the orofacial region and oral healthcare. these aspects are divided into three sections: prevention, treatment, and oral manifestations. the ada has maintained a consistent stand since the pandemic was recognized. they called upon dentists to postpone elective dental procedures for all dental patients, and to provide dental treatment only for urgent or emergency cases [6] . the main aims were to minimize potential for healthcare transmission of covid-19, and to avoid shortage of ppe for healthcare personnel caring for those with covid-19, or dental healthcare personnel providing urgent dental care in emergency cases. they further clarified the meaning of dental emergencies as "potentially life-threatening conditions that require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain, or infection"; therefore, the emergency conditions indicated for treatment include cellulitis, uncontrolled bleeding, or trauma [7] . within this context, provision of urgent dental treatment is to be done in regular dental clinics, and not to direct patients to emergency rooms even afterhours unless a life-threatening emergency is encountered. types of urgent dental care was also clarified in detail to include: severe dental pain; certain infections such as pericoronitis, postoperative osteitis, dry socket, or abscess/cellulitis; trauma such as symptomatic fractured tooth or avulsion/luxation; as well as certain urgent restorative procedures [7] . the nhs, on the other hand, has initially provided advice to dentists to perform routine dental care only for patients with no symptoms of covid-19, provided that no aerosol-generating procedures are undertaken. recommendations of the nhs were updated according to the evolving situation of the pandemic so that the most recent recommendation was in concordance with that of the ada. so far no definitive treatment is adopted for covid-19. a number of antiviral drugs as well as other drug categories were used so far with variable success rates. some of these drugs have direct relevance to dental practice including analgesics, hydroxychloroquine, and azithromycin. azithromycin is a macrolide antibiotic that is particularly important in dental practice. it is a recommended antibiotic in the empiric treatment of odontogenic infections mainly in penicillin-allergic patients [8] . it is also among the top five antibiotics prescribed in the dental setting in some countries including the usa, brazil, and belgium [9] [10] [11] . the long half-life of azithromycin make it a favorable antibiotic for children who lack compliance and for whom a once daily oral dosage is recommended. further, it is effective in the management of respiratory infections in young children [12] . hospitalized patients usually receive the intravenous form of the drug for the treatment of community-acquired pneumonia. this antibiotic is considered relatively safe in adults, children, and pregnant women [13] . however, a number of side effects have been identified especially with intravenous administration, which may be associated with gastrointestinal disturbances, ototoxicity, and pain and inflammation of the injection site [14] the development of resistant bacteria, [15] and its association with proarrhythmic events [16] have also been reported. the latter risk has been attributed to qt prolongation (summation of action potential of ventricular myocytes), which can lead to a life-threatening arrhythmia; however, susceptible patients usually have other co-factors such as old age, heart disease, and exposure to other qt prolonging drugs [17] . in vitro studies have shown that azithromycin is active against zika and ebola viruses, [18] [19] [20] and is able to prevent severe respiratory tract infections when administrated to patients suffering viral infection [12] however, the efficacy of azithromycin in combination with hydroxychloroquine in the treatment of covid-19 patients has not been confirmed yet [21, 22] , and more studies are needed to further investigate its clinical effects. in light of the current shift of dental services towards the provision of emergency treatment only, and the possible increase in antibiotic prescriptions for severe orofacial infections, the use of azithromycin in dentistry should be monitored, especially that its use in dental practice as a favorable antibiotic is reported in countries with a high toll of covid-19 infections. alternative antibiotics such as amoxicillin or clindamycin (in penicillin-allergic patients) should be considered for indicated cases, provided that no contraindications are present. an important example is patients who has a history of pseudomembranous colitis or ulcerative colitis, and hence cannot use clindamycin [23] . dentists and physicians working in the treatment of emergency dental cases should be vigilant in prescribing antibiotics only for indicated cases and should consider the use of analgesic alternatives to control dental pain. avoiding the development of side effects and antibiotic resistance should be considered among the goals of treatment. chloroquine is an antiparasitic drug that is primarily used as antimalarial drug since the 1930s. it has recently attracted a lot of attention due to its use in the treatment of covid-19. however, its use in the treatment of some oral diseases has been recognized for a long time. it was noticed to possess efficacy towards autoimmune diseases and has been implemented since the 1980s in the treatment of systemic lupus erythematosus (sle), a disease that may have oral manifestations like ulcers. its use in the treatment of primary sjögren's syndrome has been suggested by some scientists [24] , and it is also recommended for the treatment of chronic ulcerative stomatitis [25] . it had been suggested for the treatment of oral squamous cell carcinoma due to its role in cell protection by eliminating excessive proteins and injured/aged organelles in the microenvironment of tumors with subsequent acceleration of tumor cell death [26] . the antiviral activity of the drug has long been recognized. in the current epidemic of covid-19 many countries announced its use in their trials to eradicate this disease. scientists stated that the drug, which has established antiviral activity over the past 40 years, inhibited sars-cov-2 viral replication in vitro and human clinical application indicated apparent efficacy [27] . hydroxychloroquine is a derivative of chloroquine with significantly higher solubility, and lower toxicity, therefore fewer side effects are anticipated [28] . pharmacological modelling based on observed drug concentrations and in vitro drug testing suggest that prophylaxis with hydroxychloroquine at approved doses could prevent sars-cov-2 infection and ameliorate viral shedding [29] . the combination of antiviral drugs, such as remdesivir and chloroquine, has been considered highly effective in the control of infection in vitro and has been suggested in the treatment of covid-19 due to its safety profile [30] . however, clinical trials conducted so far are limited in sample size and their lack of randomization cast doubt on reported outcomes. it is still unknown how this drug exerts its anti-viral activity, but some researchers believe it can inhibit the development of an acidic media in endosomes that transport it from the cell membrane to cytoplasm. alkaline media in endosomes is believed to prevent viral transfer to cytoplasm and can thus limit the replication of several viruses [31] . the activity of the drug against autoimmune diseases, such as sle, is believed to be due to its action to prevent production or release of il-6 and tnf-α, and due to its inhibitory action on autophagy [32] . this activity of hydroxychloroquine has been demonstrated in vitro against influenza and coronaviruses, however, clinically in humans and on animals the therapeutic activity was less successful. the drug is generally safe, with poisoning being associated with the dangerous side-effects of retinopathy and immunosuppression [33] . however, it is contraindicated in pregnancy. during the current pandemic of covid-19, and due to increased demand, severe shortages of the drug were reported and adversely affecting on the regular autoimmune disease patients with countries banning its export. dentists have to be aware that shortages of chloroquine may influence their patients who are dependent on this drug especially sle and sjogren's syndrome patients who have oral manifestations. they also should be aware of the possible oral complications caused by the drug, namely melanotic pigmentation of the oral mucosa [34] and lichenoid reaction [35] . since the recognition of the covid-19 pandemic, professional regulatory bodies advised against provision of dental treatment except for emergency cases. it became essential that dental patients will rely on supportive therapy such as analgesics, and non-steroidal anti-inflammatory drugs (nsaids) for the control of dental symptoms of pain. among these patients, some may be asymptomatic for covid-19. furthermore, supportive analgesic, antipyretic therapy remains the backbone for the treatment of mild to moderate cases of covid-19. this may eventually lead to the increased demand on analgesics. there was a warning against the use of ibuprofen in the treatment of covid-19 due to the increased expression of angiotensin-converting enzyme-2, which is believed to be the binding receptor of the virus to the cells. consequently, the accelerated expression of this protein would theoretically potentiate and enhance the infection. this argument may be based on mechanistic or theoretical pharmacology rather than evidencebased clinical trials [36] . covid-19 can be such a severe infection in about 20% of the cases, forcing patients to choose ibuprofen as a more effective drug compared to paracetamol. thus, the clinical manifestations potentially emanate from this fierce infection itself rather than the theoretical potentiating action of the drug. further, there is no strong epidemiological evidence to suggest a harmful effect of ibuprofen on covid-19 patients [36] . the who recommendation in this case is to use paracetamol as first line treatment, while ibuprofen comes as second line treatment [37] . recently, the national institute for health and care excellence (nice) said that there is no evidence from published scientific studies to determine whether acute use of nsaids is related to increased risk of developing covid-19 or increased risk of a more severe illness [38] . this was confirmed by the nhs england in their recent commissioning policy for acute use of nsaids for people with or at risk of covid-19 [39] . dentists should remain updated as more information emerges on the topic and should weigh any benefits against harm when prescribing analgesics for patients with dental pain. paracetamol can be used as a first line analgesic, however, if it is not effective, they can prescribe ibuprofen or other nsaids unless there is a contraindication. the genome of covid-19 virus has been detected in saliva in the majority of patients with this disease [40] , indicating the potential infection of salivary glands [41] . it is interesting to know that in some cases, covid-19 was only detected in saliva, with no evidence for its presence in the nasopharynx [42] . positive salivary tests indicate possibility of transmission through the spread of saliva as respiratory viruses usually spread via direct contact or spatter and aerosol production from mouth and nose i.e., sneezing or coughing [41] . furthermore, respiratory droplets containing influenza virus have been detected even during normal breathing [43] . although it is possible to detect the virus in saliva with viral culture, this should be interpreted with caution since saliva may contain secretions that originate from the nasopharynx or the lungs through the action of cilia [41] . however, this can be ascertained by choosing the correct method of saliva collection; to collect saliva from a particular salivary gland (the parotid gland for example) rather than obtaining the sample directly from the mouth [44] . the detection of virus in saliva is being used for monitoring saliva virus load during serial viral load monitoring instead of nasopharyngeal or oropharyngeal sources to reduce patient discomfort and health hazards to the operator during successive sampling [41] . conducting covid-19 tests on saliva is easier for the patient and operator and the process bears less risk of cross contamination. specimens can be provided by asking the patient to spit into a sterile container, and the operator stands little chance of exposure with such a non-invasive procedure [41] . saliva collection is more comfortable for patients than venipuncture as well as being more cost-effective with minimal required instruments [45] . this finding is of particular interest to dentists. the initial recommendation by the nhs was to provide treatment to all patients except those with symptoms of infection. also, all dental treatment was allowed except procedures that are associated with aerosolization. however, it is established now that there is a proportion of asymptomatic patients who may transmit infection, and the presence of the virus in saliva means that even non-aerosol producing dental procedures can be a source of infection. another important aspect of this finding is that dentists who are engaged in tobacco cessation efforts should disseminate awareness among their smoker patients of the possibility of salivary virus transmission via social sharing of tobacco smoking instruments namely the electronic cigarettes and waterpipe [46] . loss of taste and smell have been recognized lately as one of the symptoms of covid-19 [47] . an italian team reported that 20 out of 59 covid-19 patients who were interviewed (33.9%) had at least one taste or olfactory disorder and 11 (18.6%) had both [47] . most of the patients with these symptoms (91%) reported the occurrence of taste alterations before being hospitalized. taste and smell disorder in this case could be explained by the fact that sars-cov-2 has been known for its interaction with angiotensin converting enzyme 2 (ace2) receptor, to facilitate its penetration into the cell, and this receptor is widely expressed on the epithelial cells of oral mucosa and the brain [48] . in fact, expression of ace2 was found to be higher in tongue, where the taste buds are most abundant, than gingiva or buccal mucosa [48] . another possibility is that sars-cov-2 could also be detected in saliva and infection of salivary glands is also possible [40] , which increases the availability of virus in the oral cavity and its uptake by the epithelial cells. dentists should be aware of this symptom since they may encounter patients with taste abnormalities in the form of dysgeusia or burning mouth syndrome. this is particularly important because these symptoms may precede the onset of respiratory diagnostic manifestations of the disease. however, reporting of this symptom should be interpreted with caution as the affected patients are known to be of the old age group who are already susceptible to taste and smell disorders. dental practitioners have an important role in the global fight against pandemics like covid-19. they are experienced in cross-infection control procedures and barrier techniques. they are competent in suture placement, hemostatic procedures, and in many countries, they can perform parenteral drug administration. they are also constructive members in multidisciplinary professional groups and experienced in managing patients in pain. they are well adapted to management of vulnerable patients including children, pregnant women, and elderly people. on the other hand, dentists should recognize the importance of following the regulations for delivery of oral healthcare so as to protect their patients and members of the dental healthcare team. practicing dentists should ensure that all members of the oral healthcare team are well acquainted to the covid-19 transmission and preventive measures. provision of dental services should take into consideration the availability of ppe, and that only emergency cases are admitted for treatment. cross-infection control measures should be applied meticulously at all times, and social distancing should be adopted in the practice unless advised otherwise. dental procedures in general are categorized into two groups according to aerosol generation. most dental procedures generate aerosol; preparing cavities for fillings, use of rotary instruments for root canal treatment, scaling and polishing of teeth, dental implantation, and surgical removal of teeth are only some examples. asymptomatic covid-19 patients may present for emergency dental treatment. these patients are expected to have saliva contaminated with the virus and they are a confirmed source of infection. moreover, the conjunctiva mucosa and upper respiratory tract are connected by the nasolacrimal duct, and they share ace2 on the cell membrane [49] . this exposes dental healthcare personnel to the risk of infection via direct exposure of conjunctiva (eyes) to droplets from patients during dental treatment. there are now restrictions for the work of dentists in many countries, however, some countries like austria and jordan will start to ease the lock down. in jordan, for instance, dentists will be permitted to work in their practices as of 27 april 2020, even though complete eradication of the virus has not been accomplished yet. considering that neither treatment nor vaccination is available for covid-19, it would be wise for dentists to rely more on non-aerosol generating procedures for treatment of their patients. excavation of caries rather than drilling and conventional root canal treatment rather than rotary instruments, for example, should be the mainstay of treatment at this point of time. researchers should focus on developing barrier techniques and negative pressure procedures to contain and isolate the aerosol so that dental procedures are safe for dental healthcare personnel and patients alike. furthermore, dentists should be aware that covid-19 patients may present with oral symptoms that are suspected to be linked to the virus such as taste abnormalities. while home confinement is considered the mainstay for populations to prevent transmission of the virus, dentists should not be confined by the society within the borders of their specialty. they have many roles to play. following the recommended cross-infection control procedures, spreading awareness based on evidence and not misconceptions, identifying emergency cases indicated for dental treatment, and practicing effective tele-dentistry when needed can all be helpful for dental patients and community as a whole. dentists should give drug prescription particular attention. when advising patients to use medications for treatment of dental problems it is important to consider the indicated clinical conditions for analgesics, anti-inflammatory drugs, and antibiotics, and patients should be advised against using antibiotic self-medication to relieve dental pain. it is certainly the right time for dental schools to expand the learning outcomes of their courses to include additional roles of dentistry that take into consideration natural disasters and pandemics. furthermore, dentists should be prepared to be active members in healthcare teams dealing with pandemics. professional dental associations should contemplate continuing educational courses for practicing dentists that reinforce their role in the healthcare team by delivering courses on essential aspects of acute healthcare such as basic life support, phlebotomy, and drug prescribing. covid-19 in colombia endpoints. are we different, like antihypertensive drugs and risk of covid-19? covid-19: four fifths of cases are asymptomatic, china figures indicate clinical features of 85 fatal cases of covid-19 from wuhan: a retrospective observational study world health organization (who) american dental association. ada coronavirus (covid-19) center for dentists antibiotic prescribing for oro-facial infections in the paediatric outpatient: a review an evaluation of dental antibiotic prescribing practices in the united states antibiotic prescription for endodontic infections: a survey of brazilian endodontists antimicrobial prescribing by belgian dentists in ambulatory care early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial pharmacokinetic properties of azithromycin in pregnancy intravenous azithromycin-induced ototoxicity risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases electrophysiologic studies on the risks and potential mechanism underlying the proarrhythmic nature of azithromycin risk evaluation of azithromycin-induced qt prolongation in real-world practice zika virus cell tropism in the developing human brain and inhibition by azithromycin evaluation of ebola virus inhibitors for drug repurposing azithromycin inhibits the replication of zika virus hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection clostridium difficile isolated from faecal samples in patients with ulcerative colitis primary sjögren syndrome: an update on current pharmacotherapy options and future directions chronic ulcerative stomatitis: a comprehensive review and proposal for diagnostic criteria in vitro and in vivo antitumor effects of chloroquine on oral squamous cell carcinoma in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro bioavailability of hydroxychloroquine tablets in healthy volunteers remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro effects of chloroquine on viral infections: an old drug against today's diseases? quinoline-based antimalarial drugs: a novel class of autophagy inhibitors hydroxychloroquine in systemic lupus erythematosus (sle) chloroquine-induced oral mucosal hyperpigmentation and nail dyschromia pigmented lichenoid drug eruption secondary to chloroquine therapy: an unusual presentation in lower lip safety of ibuprofen in patients with covid-19; causal or confounded? chest 2020 says there's no evidence it can worsen covid-19 covid-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (nsaids) for people with or at risk of covid-19 acute use of non-steroidal anti-inflammatory drugs (nsaids) in people with or at risk of covid-19 (rps2001) covid-19: gastrointestinal symptoms and potential sources of 2019-ncov transmission consistent detection of 2019 novel coronavirus in saliva additional molecular testing of saliva specimens improves the detection of respiratory viruses infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community variations of some salivary antimicrobial factors in different disease states: a review. saudi dent human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) unconventional materials and substances used in water pipe (narghile) by smokers in central western region, saudi arabia self-reported olfactory and taste disorders in in patients with severe acute respiratory coronavirus 2 infection: a cross-sectional study high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa conjunctiva is not a preferred gateway of entry for sars-cov-2 to infect respiratory tract this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-272602-rywg9mek authors: allison, james r; currie, charlotte c; edwards, david c; bowes, charlotte; coulter, jamie; pickering, kimberley; kozhevnikova, ekaterina; durham, justin; nile, christopher j; jakubovics, nicholas; rostami, nadia; holliday, richard title: evaluating aerosol and splatter following dental procedures: addressing new challenges for oral healthcare and rehabilitation date: 2020-09-23 journal: j oral rehabil doi: 10.1111/joor.13098 sha: doc_id: 272602 cord_uid: rywg9mek background: dental procedures often produce aerosol and splatter which have the potential to transmit pathogens such as sars‐cov‐2. the existing literature is limited. objective(s): to develop a robust, reliable and valid methodology to evaluate distribution and persistence of dental aerosol and splatter, including the evaluation of clinical procedures. methods: fluorescein was introduced into the irrigation reservoirs of a high‐speed air‐turbine, ultrasonic scaler and 3‐in‐1 spray, and procedures were performed on a mannequin in triplicate. filter papers were placed in the immediate environment. the impact of dental suction and assistant presence were also evaluated. samples were analysed using photographic image analysis, and spectrofluorometric analysis. descriptive statistics were calculated and pearson’s correlation for comparison of analytic methods. results: all procedures were aerosol and splatter generating. contamination was highest closest to the source, remaining high to 1–1.5 m. contamination was detectable at the maximum distance measured (4 m) for high‐speed air‐turbine with maximum relative fluorescence units (rfu) being: 46,091 at 0.5 m, 3,541 at 1.0 m, and 1,695 at 4 m. there was uneven spatial distribution with highest levels of contamination opposite the operator. very low levels of contamination (≤0.1% of original) were detected at 30 and 60 minutes post procedure. suction reduced contamination by 67–75% at 0.5–1.5 m. mannequin and operator were heavily contaminated. the two analytic methods showed good correlation (r=0.930, n=244, p<0.001). conclusion: dental procedures have potential to deposit aerosol and splatter at some distance from the source, being effectively cleared by 30 minutes in our setting. the coronavirus disease 2019 (covid19) pandemic has had significant impact upon the provision of medical and dental care globally. in the united kingdom, routine dental treatment was suspended in late march 2020 [1] [2] [3] [4] , with care instead being provided through a network of urgent dental care centres 5 . during this period, it was advised that aerosol generating procedures (agps) were avoided unless absolutely necessary, leading to altered treatment planning and a negative impact on patient care 6 . as more routine dental services start to resume worldwide, the guidance in the uk and elsewhere is still to avoid or defer agps where possible [7] [8] [9] [10] [11] [12] [13] . this will have an effect both on patients attending for urgent and emergency care, as well as those requiring routine dental treatment for oral rehabilitation. standard operating procedures (sops) have been published by a number of organisations to inform practice, however many of these acknowledge a limited evidence base [14] [15] [16] [17] [18] . additionally, all face-to-face undergraduate and postgraduate clinical dental teaching in the uk is suspended at the time of writing 19 . various definitions exist for the terms "aerosol" and "splatter". for the purposes of this study we define particles which make up aerosols as having a diameter of less than 10 µm, 20 and splatter as comprising of particles larger than this; in reality, aerosols and splatter are made up of a spectrum of droplet sizes and this distinction is somewhat arbitrary. many dental procedures produce both aerosol and splatter contaminated with saliva and/or blood 21, 22 . saliva has been shown to contain severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in infected individuals 23, 24 , many of whom may be asymptomatic 25 , with the salivary gland potentially being an early reservoir of infection 26, 27 . equally, however, preliminary data suggest that in asymptomatic carriers, the viral load may be low in saliva and these individuals may have faster viral clearance 28, 29 . early data suggest that sars-cov-2 can remain viable and infectious in aerosol for hours, and on surfaces for days 30 . hence, dental aerosols and splatter are likely to be a high-risk mode of transmission for sars-cov-2, and it is highly likely that international clinical protocols across the spectrum of dental practice will need to be significantly modified to allow a safe return to routine care. a review of the impact of agps generally across healthcare (including dentistry) concluded that the existing evidence is limited 31 . the current literature regarding the risks posed by aerosols and splatter in dental settings is particularly limited. a number of authors have used microbiological methods to study bacterial contamination from aerosol and splatter following dental procedures, either by air sampling 21, 32, 33 , swabbing of contaminated surfaces 34, 35 , or most commonly, by collection directly onto culture media [36] [37] [38] [39] . these studies are limited in that they only detect accepted article culturable bacteria as a marker of aerosol and splatter distribution. a smaller number of studies have used various fluorescent [40] [41] [42] [43] [44] and non-fluorescent tracers 45, 46 to measure aerosol and splatter distribution, although some of these have significant methodological flaws and major limitations. many studies are small and report only one repetition of a single procedure, and some have only examined contamination of the operator and assistant; a number of studies which have measured spatial distribution of aerosol and splatter have only done so to a limited distance from the source. few studies have considered the temporal persistence of aerosol and splatter with sufficient granularity to inform clinical practice. open plan clinical environments such as those common in dental (teaching) hospitals with multiple patients and operators in close proximity are problematic. the current lack of robust evidence about dental aerosol and splatter distribution and persistence will be a barrier to the reintroduction of routine dental services and dental education, which is likely to have a negative impact on the availability of care for patients, and on the future dental workforce if not addressed expediently 19 . patients' oral healthcare will also suffer if routine care cannot be re-established, especially for those with high dental needs and active dental disease. the aim of the present study was to establish a robust, reliable and valid methodology to evaluate the distribution and persistence of aerosol and splatter following dental procedures. this can then be used in future work linking specifically to transmission of sars-cov-2, as well as other pathogens, in a dental environment. we present initial data on three dental procedures (high-speed air-turbine, ultrasonic scaler, and 3-in-1 spray use) and examine the effect of dental suction and the presence of an assistant on aerosol and splatter distribution. experiments were conducted in the clinical simulation unit (csu) at the school of dental sciences, newcastle university (newcastle upon tyne, united kingdom). this is a 308 m 2 dental clinical teaching laboratory situated within a large dental teaching hospital. the csu is supplied by a standard hospital ventilation system with ventilation openings arranged as shown in figure 1 ; this provides 6.5 air changes per hour and all windows and doors remained closed during experiments. the temperature remained constant at 21.5 °c. dental procedures were conducted on a dental simulator unit (model 4820, a-dec; or, usa) with a mannequin containing model teeth (frasaco gmbh; tettnang, germany). polyvinyl siloxane this article is protected by copyright. all rights reserved putty (lab-putty, coltene/whaledent; altstätten, switzerland) was added to the mouth of the mannequin to recreate the normal dimensions of the oral cavity as described by dahlke et al. 42 (figure 1). fluorescein solution (2.65 mm) was made by dissolving fluorescein sodium salt (sigma-aldrich; mo, usa) in deionised water, and this was then introduced to the irrigation reservoirs of the dental unit and ultrasonic scaler. the procedures investigated were as follows: anterior crown preparation -preparation of the upper right central incisor tooth for a full coverage crown using a high-speed air-turbine (synea ta-98, w&h (uk) ltd.; st albans, uk); full mouth scaling using a magnetostrictive ultrasonic scaler (cavitron select sps with 30k fsi-1000-94 insert, dentsply sirona; pa, usa); 3-in-1 spray (air/water syringe) use -washing of mesialocclusal cavity in upper right first premolar tooth with air and water from 3-in-1 spray. procedure durations were 10 minutes for anterior crown preparation and ultrasonic scaling, and 30 seconds for the 3-in-1 spray use with air and water (to represent removing acid etchant). irrigant flow rate was measured at 29.3 ml/min for the air-turbine, 38.6 ml/min for the ultrasonic scaler and 140.6 ml/min for the 3-in-1 spray. we also investigated dental suction (measured at 6.3 l of water per minute) and the presence of an assistant. having developed the methods reported by other investigators 37, 42, 44 , the present study used a reproducible, height adjustable rig. this rig was constructed to support cotton-cellulose filter papers spaced at known distances from the mannequin (figure 1). 30 mm diameter grade 1 qualitative filter papers (whatman; cytiva, ma, usa) were used to collect aerosol and splatter. before each procedure the mannequin, rig and filter paper platforms were cleaned with 70% ethanol and left to fully air dry. a period of 120 minutes was left between each procedure to allow for clearance of aerosol and splatter. following each procedure, the filter papers were left in position for 10 minutes to allow for settling and drying of aerosol and splatter, before being collected with clean tweezers and placed into a single-use, sealable polyethylene bag. for the anterior crown preparation without suction, additional filter papers were placed at 30 minutes and again at 60 minutes to examine persistence of aerosol and splatter. at both of these time points, the risk of fluorescein transfer was minimised by placing the new filter papers on new platforms, and filter papers were then left for 10 minutes before collection. all experimental conditions were repeated three times. filter papers were placed on a glass slide on a black background, covered by a second glass slide, and illuminated by two halogen dental curing lights (qhl75 model 503; dentsply, nc, usa) with 45 mw/cm 2 output at 400-500 nm; these were positioned at 0 and 180 degrees, 5 cm from the centre of the sample horizontally, and 9 cm vertically, with both beams of light focussed on the centre of the sample. images were captured with a digital single-lens reflex (dslr) camera (eos 1000d, canon; tokyo, japan) at 90 mm focal length (sp af 90mm f/2.8 di macro, tamron; saitama, japan) with an orange lens filter, positioned 43 cm directly above the sample (sample to sensor). exposure parameters were f/10, 1/80 seconds and iso 400. image analysis was performed using imagej 47 (version 1.53b, u.s. national institutes of health; md, usa) in a darkened room by one of four examiners blind to experimental conditions and sample position (ja, cc, de, rh). images were converted into 8-bit images and the pixel scale set across the maximum diameter of the sample at 30mm. a manual threshold was used to create a mask selecting all high intensity areas. the "analyse particles" function was used to identify particles from 0-infinity mm 2 in area and 0-1 in circularity. the number of particles, total surface area, and average particle size were calculated. total surface area was selected as the primary outcome measure, representing contamination levels of the samples and most likely representing the larger splatter produced from the procedures. examiners underwent calibration prior to formal analysis by independently analysing 10 images and then discussing to reach consensus. following this, examiners then independently analysed 30 images to assess inter-examiner agreement. examiners re-examined the same 30 images one week later to assess intra-examiner agreement. this article is protected by copyright. all rights reserved for one experimental condition (anterior crown preparation without suction, samples from the initial, 30-, and 60-minute time points) we completed spectrofluorometric analysis to allow validation of the image analysis technique, and to also capture aerosol produced which may not be easily detected in image analysis. building on the methods reported by steiner et al. 48 , fluorescein was recovered from filter papers by addition of 350 µl deionised water. immersed samples were shaken for 5 minutes at 300 rpm using an orbital shaker at room temperature. the fluorescein was then eluted by centrifugation at 15,890 g for 3 min using a microcentrifuge. 100 µl of the supernatant was transferred to a black 96-well microtitre plate with a micro-clear bottom (greiner bio-one; nc, usa) in triplicate in order to measure fluorescence. fluorescence measurements were performed using a synergy ht microplate reader (biotek; vt, usa) at an excitation wavelength of 485 ± 20 nm and an emission wavelength of 528 ± 20 nm with the top optical probe. for background correction, negative controls (n = 26) were included in the measurements for all runs. these included fresh filter papers out of the box and filter papers that had been placed on platforms in csu for 10 minutes exposed to air. the negative control filter papers were processed for imaging and fluorescent measurements in the same manner as the remainder of samples. the negative control mean + 3sd (164 rfu; relative fluorescence units) was used as the limit of detection; hence a zero reading was assigned to values below 164 rfu. for readings above the detection limit of the instrument (>100,000 rfu), a value of 100,000 rfu was assigned. data were collected using excel (2016, microsoft; wa, usa) and analysed using spss (version24, ibm corp.; ny, usa) using basic descriptive statistics and pearson's correlation (to compare analytical techniques). heatmaps demonstrating aerosol and splatter distribution were generated using python 3 49 . a two-way mixed effects model was used to assess inter-and intraexaminer agreement by calculating interclass correlation coefficient (icc) using stata release 13 (statacorp; tx, usa). inter-examiner icc for 30 images showed excellent agreement for total surface area (icc 0.98; 95%ci 0.97-0.99), good agreement for total number of particles (icc 0.88; 95%ci 0.80-0.93), and moderate agreement for average particle size (icc 0.63; 95%ci 0.47-0.78). intra-examiner agreement at one week for the same 30 images was excellent for total surface area (icc 0.97-accepted article 0.99), good to excellent for total number of particles (icc 0.82-0.97), and good for average particle size (icc 0.75-0.97) 50 . aerosol and/or splatter deposition (assessed by surface area outcome) was highest at the centre of the rig and decreased with increasing distance from the centre (table 1) . most contamination was within 1.5 m but there were smaller readings up to 4 m for some conditions. the spatial distribution is shown in figures 2 and 3. for one experimental condition (anterior crown prep with no suction, representing a presumed worst-case scenario), at three time points, we also completed spectrofluorometric analysis (table 1). the particle count was weakly correlated with spectrofluorometric measurements (r=0.344, n=244, p<0.001), average particle size was moderately correlated (r=0.555, n=244, p<0.001) and the use of dental suction, held by the operator, reduced the contamination of filter papers at each distance (table 1) , although image analysis still detected contamination up to 2 m. between 0.5-1.5 m there was a 67-75% reduction (central site contamination was unaffected). the spatial distribution was altered as demonstrated in figure 2 . when an assistant was present and held the accepted article dental suction this further reduced contamination readings within the first 1m, however, we noted a marked increase at the 1.5 m reading behind the assistant (0°). three clinical procedures (anterior crown preparation, ultrasonic scaling, and 3-in-1 spray use) were assessed while the operator held dental suction. the highest readings were obtained from the anterior crown preparation, but each procedure gave a unique distribution (table 1, supplementary table 1 (table 1) . average particle size measurements (from photographic analysis, likely to represent splatter particles) were combined for the 0, 0.5, 1 and 1.5 m readings for each condition to give an indication of the nature of the particles in this area. the anterior crown preparation without suction produced the largest particles (mean ± sd: 0.49 ± 2.98 mm 2 ) which were similar to when suction was added by the operator (0.56 ± 3.34 mm 2 ). there was a size reduction when an assistant provided suction (0.11 ± 0.69 mm 2 ). the ultrasonic scaling produced the smallest particles (0.05 ± 0.24 mm 2 ) followed by the 3-in-1 spray (0.08 ± 0.25 mm 2 ). figure 5 presents images of all samples for one repetition of a single experimental condition to demonstrate the distribution of particles and size. when looking at all the experimental conditions combined the average particle size was largest closest to the source, decreasing with distance (mean ± sd): 0 m = 5.52 ± 8.88 mm 2 ; 0.5 m = 0.11 ± 0.28 mm 2 ; 1 m = 0.01 ± 0.00 mm 2 ; 1.5 -4 m = 0.00 ± 0.00 mm 2 . supplementary figure 2 presents the average particle size by distance for each separate experimental condition. this article is protected by copyright. all rights reserved dental aerosol and splatter are an important potential mode of transmission for many pathogens, including sars-cov-2. understanding the risk these phenomena pose is vitally important in the reintroduction of dental services in the current covid-19 pandemic. our study is novel in that we are the first to measure aerosol and splatter distribution at distances up to 4 m from the source, and the first to apply image and spectrofluorometric analysis to the study of dental aerosol and splatter. this has allowed us to gather urgently needed data relevant to the provision of dental services during the covid-19 pandemic, and more widely. specifically, we have demonstrated the relative distribution of aerosol and splatter following different dental procedures, the effect of suction and assistant presence, and the persistence of aerosol and splatter over time. importantly, our spectrofluorometric analysis demonstrates that some fluorescein contamination may occur beyond this on filter papers that appear clean by image analysis, representing aerosol which cannot be detected with image analysis alone. in addition, a dslr camera with a complementary metal-oxide-semiconductor sensor is likely to be limited to the detection of larger particles (i.e. splatter) using the methods we report in the present study. we therefore propose that studies which use dye tracers assessed by visual examination or image analysis techniques alone are assessing primarily splatter rather than aerosol; this is because in order for deposits to be visible to the eye or camera it has to be relatively large in size. previous research using these methods should therefore be interpreted in this context. it is, however, worth noting that larger particles are likely to contain a greater viral load, and given the risk of sars-cov-2 transmission through contact with mucosal surfaces 52 , from a cross infection perspective splatter is likely to be highly significant. reassuringly, in our study splatter was greatly reduced using suction. findings from both analytical techniques demonstrate contamination at a distance from the source although contamination was lower at greater distances; this shows the potential for pathogens to travel a similar distance, although our methods replicate a worst-case scenario. this article is protected by copyright. all rights reserved we demonstrated significant contamination of the operator, assistant and mannequin for all procedures, which is consistent with the findings of other investigators 34, 38, 41, 44 . this is unsurprising and underscores the need for adequate personal protective equipment (ppe), for the operator and assistant. of particular note is the importance of the full-face visor which was heavily contaminated in our study. this also highlights the importance of enhanced ppe 53 during the peak of a pandemic for agps, because of the likelihood of treating an asymptomatic carriers. coverage of the operator and assistant's exposed arms with a waterproof covering would protect against contamination, although scrupulous hygiene with an effective antiseptic (povidone-iodine or 70% alcohol 54, 55 ) would be a minimum requirement if this were not used. ppe for patients' clothes do not feature in dental guidelines relating to covid-19, and our findings would suggest significant contamination of the patient is likely during agps, presenting a risk of onward crosscontamination by contact with surroundings; it is therefore important to provide waterproof protection for patients' clothes. our findings demonstrate that use of a high-speed air-turbine, ultrasonic scaler and 3-in-1 spray are all agps. 3-in-1 use is not currently included in the list of defined healthcare related agps recently updated by health protection scotland 31 , which only details "high speed devices such as ultrasonic scalers and high-speed drills". the highest levels of contamination were from the airrotor, although the ultrasonic scaler demonstrated contamination at greater distances, in keeping with the findings of bennett et al. 21 . dental suction was effective at reducing fluorescein contamination, with reduction of 67-75% between 0.5-1.5m. this is consistent with the effect of suction demonstrated by other investigators 37, 56 . when dental suction was provided by an assistant this was more effective in reducing contamination, although increased readings were seen at 1.5 m, potentially indicating that an additional barrier in the form of an assistant may have a more complex aerodynamic effect. highvolume dental suction is recommended in most dental guidelines and sops relating to covid-19, as an essential mitigation procedure when conducting agps. however, we are not aware of any that provide a definition or basic minimal requirements for effective high-volume dental suction. national guidelines 57 classify suction systems based on air flow rate (high-volume systems: 250 l/min at the widest bore size of the operating hose). we did not have a suitable device available to measure air flow rate of the system used in the present study and hence we chose to use the term 'dental suction' as we were unable to confirm whether it met this definition. we did, however measure water flow rate (6.3 l/min) which we found to be similar to that this article is protected by copyright. all rights reserved reported by other investigators 39 . our findings highlight the importance of suction as a mitigation factor in splatter and aerosol distribution following dental procedures, and future research should examine the impact of this effect in relation to different levels of suction based on air flow rate. safe times following procedures, after which contamination becomes negligible have rarely been investigated robustly. in studies using tracer dyes we are only aware of a single paper reporting contamination at 30 minutes 44 . this conflicts with our findings of no contamination by image analysis at 30 and 60 minutes, and only very low levels by spectrofluorometric analysis (≤ 0.10% of original levels). it is unclear from the methods of veena et al. 44 whether new filter papers were placed immediately following the procedure and collected at 30 minutes, or placed at 30 minutes and collected thereafter; in the prior case, any contamination found on the samples could have arisen at any time from the end of the procedure up to 30 minutes, and it cannot therefore be determined when contamination actually occurred. in addition, the authors do not report whether the tape they used to support filter papers was replaced following the initial exposure, and if not, it is possible that existing contamination was transferred to filter papers placed subsequently. finally, the investigation reported by veena et al. 44 was a single experiment and did not use multiple repetitions. it is important to note that our findings relate to the environmental setting studied, with 6.5 air changes per hour. air exchange rates in dental surgeries are likely to vary which may affect translation. our study has several limitations and our results need to be interpreted in the context of these. our methods serve as a model for aerosol and splatter contamination, and further work is required to confirm their biological validity. as our knowledge of the infective dose of sars-cov-2 required to cause covid-19 develops, the clinical relevance of our findings need to be put into context; our understanding of this is still too basic to be able to draw definitive conclusions as to the risks posed by dental aerosol and splatter. the particle size analysis is likely to overestimate the size of the particles for two reasons: first, when fluorescein droplets are absorbed into the filter paper they will spread out creating an area with a diameter greater than that of the original droplet; second, when samples are heavily contaminated the droplets coalesce on the filter paper to produce larger areas of contamination and the software measures the total surface area of the fused droplets. our experimental set up incorporated the tracer dye within the irrigation system of the dental units and represents a worst-case scenario for distribution of biological material. in reality, a small amount of blood and saliva will mix with large volume of water irrigant creating aerosol and splatter with diluted pathogen concentration compared to blood or saliva, and a likely accepted article reduced infective potential 19 . it has been estimated that over a 15-minute exposure during dental treatment with high-speed instruments, an operator may be exposed to 0.014 -0.12 µl of saliva 21 . early data suggest a median sars-cov-2 viral load of 3.3 x 10 6 copies per ml in the saliva of infected patients 23, 24 ; taken together, this suggests that an operator without ppe at around 0.5 m from the source may be exposed to an estimated 46 -396 viral copies during a 15 minute procedure. these data were collected from hospital inpatients, and recent data suggest that asymptomatic carriers may have lower salivary viral loads 28, 29 ; similarly the average concentration of fluorescein detected by spectrofluorometric analysis past 2 m in the present study was almost two orders of magnitude lower than at 0.5 m, and so at distances beyond 0.5 m this risk is likely to be lower. importantly, we still do not yet know what the infective dose of sars-cov-2 required to cause covid-19 is. within the limitations of this study, dental aerosol and splatter have the potential to be a cross infection risk even at a distance from the source. the high-speed air-turbine generated the most aerosol and splatter, even with assistant-held suction. our findings suggest that it may be safe to reduce fallow times between dental agps in settings with 6.5 air changes per hour to 30 minutes. future research should evaluate further procedures, mitigation strategies, time periods and aim to assess the biological relevance of this model. this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved letter to all primary care dental teams in wales covid-19: outline strategic plan for general dental services and updated guidance for general dental practice letter to nhs dental services (ref: pol/33888) letter to general dental practices and community dental services (ref: 001559) the first six weeks -setting up a uk urgent dental care centre during the covid-19 pandemic the covid-19 effect: number of patients presenting to the mid yorkshire hospitals omfs team with dental infections before and during the covid-19 outbreak letter to all primary care dental teams and health boards plans for the restoration of general dental services remobilisation of nhs dental services in scotland resumption of dental services in england 19 management: adaptation and progressively increased dental activity danish health authority kenya dental association; 2020. accepted article this article is protected by copyright. all rights reserved 13. centres for disease control and prevention. guidance for dental settings: centres for disease control and prevention british endodontic society; of general dentistry, faculty of general dental practice. implications of covid-19 for the safe management of general dental practice: a practical guide. london: college of genreal dentistry urgent dental care guidance and standard operating procedure. london: nhs england; 2020. 17. office of the chief dental officer england. standard operating procedure transition to recovery. london: office of the chief dental officer england covid-19 -returning to student-led dental clinical treatments 2020 demystifying the mist: sources of microbial bioload in dental aerosols microbial aerosols in general dental practice characteristics of blood-containing aerosols generated by common powered dental instruments consistent detection of 2019 novel coronavirus in saliva saliva is more sensitive for sars-cov-2 detection in covid-19 patients than nasopharyngeal swabs spread of sars-cov-2 in the icelandic population tmprss2 and ace2 coexpression in sars-cov salivary glands: potential reservoirs for covid-19 asymptomatic infection the natural history and transmission potential of asymptomatic sars-cov-2 infection viral load dynamics in transmissible symptomatic patients with covid-19 transmission based precautions literature review: aerosol generating procedures. glasgow: health protection scotland measurement of airborne bacteria and endotoxin generated during dental cleaning dental aerosols: microbial composition and spatial distribution the effect of rubber dam on atmospheric bacterial aerosols during restorative dentistry use of atp bioluminescence to survey the spread of aerosol and splatter during dental treatments comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling studies on dental aerobiology: ii. microbial splatter discharged from the oral cavity of dental patients bacterial aerosols in dental practice -a potential hospital infection problem? atmospheric contamination during ultrasonic scaling evaluating spatter and aerosol contamination during dental procedures aerosol-generating procedures and simulated cough in dental anesthesia evaluation of the spatterreduction effectiveness of two dry-field isolation techniques dissemination of aerosol and splatter during ultrasonic scaling: a pilot study evaluation of minimum required safe distance between two consecutive dental chairs for optimal asepsis reduction of aerosols produced by ultrasonic sealers key: cord-309922-d4lor3a5 authors: arvind, ritvi; roma, m. title: risk of eye infections in dental personnel and the need for its prevention: a case report date: 2020-08-27 journal: j ophthalmic inflamm infect doi: 10.1186/s12348-020-00211-5 sha: doc_id: 309922 cord_uid: d4lor3a5 a lot of dentists and dental personnel are at high risk of contracting eye infections during operative procedures involving aerosols. as many may not be aware of it, they often ignore the precautions to be taken for prevention of such infections. this is one such case report of a dental intern where an eyelid infection arose shortly after she treated a patient with an infected tooth in an operative procedure. this case report emphasizes the importance of preventive barriers for the dentist, and that how special protective gear is required for doing restorative cases which involve dealing with infection. every occupation has its own risks and benefits, and safety concerns are of paramount importance. protection with proper safeguard is mandatory. with the advanced knowledge about infection control and personal protection, a lot of emphasis is required on eye protection. frequently executed restorative and operative procedures like caries excavation, restorations, oral prophylaxis, etc. are performed using high power-driven handpieces. during the dental procedures, a lot of particulate matter like spicules of caries, calculus, amalgam, blood etc. gets released which may get lodged into tissues. the working handpiece generates lot of aerosols which carry an array of microorganisms producing infections to respiratory tract, eyes, skin, etc. eye infections can arise due to a variety of organisms (bacterial, viral, fungal, helminths) and its severity can range from mild swelling of the eyelid to complete blindness. dentistry is one of the professions which is highly risked for ocular infections on a routine basis [1] . dental professionals are bound to take necessary precautions to prevent eye related injuries [2] . previously cases have been reported which have shown a connection between dental treatment and ocular irritation [3, 4] . tremendous effort has to be created between the medical and dental professionals to understand the need for eye care. certain national safety agencies, like occupational safety and health administration (osha), american national standard institute (ansi), centers for disease control and prevention (cdc), american dental association (ada) have set prompt guidelines for the proper usage of infection control measures and personal protective equipment (ppe) [5] . this case report delineates the relationship between ocular infections secondary to allergic reaction due to dental treatment among the dentists. this article aims at improving the knowledge of eye related injuries among the dental fraternity while emphasizing the need for protective measures. a 22-year old female dentist had treated a patient, with deep caries management under rubber dam isolation. during the treatment, the dentist got injured with a spicule from the cavity in the right eye. she rinsed her eyes with the water couple of times. in spite of regularly rinsing, the dentist developed irritation and foreign body sensation in the right eye immediately after the procedure. three days later, a full-blown infection was noticed. she developed redness, pain, inability to fully open the eye without discomfort, yellowish discharge which often sealed the eye shut during sleeping, and generalized malaise. the right eye had diffuse swelling of the upper lid with a normal anterior segment and mild pain and difficulty in opening ( fig. 1) . mild congestion was seen in the left eye ( fig. 1 ) and then she visited the ophthalmology department. upon consultation, the ophthalmologist performed slit lamp examination and was diagnosed with bacterial blepharitis. there was no blurring of vision, no dilation of pupils, and no abnormality was detected in the adjoining structures. she was prescribed antibiotic ointment (moxigram, moxifloxacin hydrochloride 0.5% w/v three times a day for a week) with topical eye drops (toba, tobramycin ophthamic solution, 0.3% w/v four times a day for 1 week) and normal lubricating eye drops (zyaqua, carboxymethyl cellulose sodium eye drops, 0.5% w/v) for one month for symptomatic relief. along with this, she was advised to apply warm compresses to the eyelids for several minutes, two to four times daily. she was counselled to take complete rest, to avoid any cosmetics and not to treat any patients till the symptoms resolve. after 4 days of the treatment, the eyelid swelling got resolved and there was no pain and redness. after a week, she treated another patient for direct pulp capping procedure and encountered similar infection again, but the severity of the infection was in a milder form. the right eye showed nodular swelling at the medial margin of the upper lid with normal anterior segment (fig. 2) . there was no associated redness or pain present. the patient was advised to continue the lubricating eye drops. she was informed to report back to the ophthalmologist if the symptoms persist. after a month of treatment, she had no redness, no eyelid swelling or pain and had complete recovery. dental procedures often cause ocular injury due to combination of insults which can be microbial, physical, chemical, etc. both the dentist and patient are at risk due to the use of power-driven handpieces which generate aerosols. operative procedures like caries removal use dental handpieces on a frequent basis which release a lot of aerosol matter into the atmosphere. the most likely cause for the eyelid swelling was microbial infection present in the carious lesion which was transmitted via the aerosols generated by the airotor during the cavity cutting procedure [3, 6, 7] . various surveys including those by ramos mf [8], stokes an [9] have emphasized that the awareness and eye protection for the dental staff is not up to the standards. most often, the particulate matter is lodged in the cornea or conjunctival sac which causes irritation and redness. in certain instances, serious eye injuries like perforation, irritation of lens might occur due to the particle getting penetrated into deeper tissues [10, 11] . eyes are vital and delicate structures, and hence they are easily affected with the infectious matter like aerosols without any contact [3] . once contacted, the infection can range from a mild to severe swelling to serious complications like retinal damage, or formation of scars and ulcers which can cause obstruction of vision [12] . in this case, though the clinician was wearing her normal custom spectacles, it was not enough to prevent the infection from happening. this suggests extra that precautionary measures while dealing with such cases should be recommended. a study by b.a.aydil et al. [13] demonstrated that ocular injuries reported were significantly at a higher rate among the participants without any eye protection and also suggested that there were major inadequacies in the eye/face protection protocols. with the present pandemic situation, eye protection is must and mandatory. it is interesting to note that on 15th march 2020, the new york times in their paper published that dentists are the highly risked and exposed healthcare workers of being affected by . in the course of dental procedures, aerosol inhalation generated by the instruments when working on covid-19 patients is considered as high risk [15] . despite the virus transmission routes, it is advised to adopt protective glasses and visors as safe and careful approach when performing the dental procedures [16] . ada and osha have demarcated the use of designated protective eyewear with side shield and the use of face shields while performing dental procedures (fig. 3) . osha recommended the use of glasses which meet osha standard 1910.133(a) (1) and must meet ansi standard (z87.1) to prevent the frontal entry route of the debris. they also highlighted the use of side shields which meet osha standard 1910.133(a) for the prevention of debris travelling sideways (www.osha.gov/sltc/ etools/eyeandface/ppe/impact.html). osha also suggested the use of bottom gaps in the eyewear to prevent the travelling of debris vertical and tangential to the face [17] . they also outlined the implementation of eye wash station within 7.62 m in the vicinity [5] . the awareness and knowledge about ocular injuries and the need for proper precaution should be emphasized at the undergraduate level and should be highlighted in all the clinical work-stations. this case report describes acute infection of the eyelid secondary to allergic reaction due to the restorative dental procedures. ocular injuries can be minimized by the application of standard guidelines. this further spotlights the importance of additional awareness and implementation of protective protection equipment such as a face shield along with protective eye wear. both rm and ra were actively involved in manuscript preparation, manuscript editing and manuscript review." statement by the authors: the manuscript has been read and approved by all the authors; the requirements for authorship in this document have been met, and each author believes that the manuscript represents honest work. funding self. data sharing is not applicable to this article as no datasets were generated or analysed during the current study. ethics approval and consent to participate taken from ethical committee of manipal college of dental sciences, mangalore, india. patient has given the consent for publication. informed consent form included. ocular health practices by dental surgeons in southern nigeria eye-related trauma and infection in dentistry dental infection in diseases of the eye infections of the mouth and their relation to diseases of the eye from the point of view of a general practitioner of dentistry ocular injury during scaling: are we protecting ourselves? intraorbital abscess: a rare complication after maxillary molar extraction report of a case and considerations on route of spread prevention of work related injuries: a look at eye protection use and suggested prevention strategies eye protection in dental practice work -related vision hazard in the dental office prevalance of ocular injuries, conjunctivitis and use of eye protection among dental personnel in riyadh, saudi arabia the acute orbit: etiology, diagnosis, and therapy ocular injuries among oral and maxillofacial surgeons: have high risk or not? an overview of a two-centered experience the workers who face the greatest coronavirus risk coronavirus covid-19 impacts to dentistry and potential salivary diagnosis 2019-ncov transmission through the ocular surface must not be ignored eye safety in dentistry competing interests "the authors declare that they have no competing interests" in this section.received: 5 may 2020 accepted: 30 july 2020 key: cord-285513-pkqos0s5 authors: stangvaltaite-mouhat, lina; uhlen, marte-mari; skudutyte-rysstad, rasa; szyszko hovden, ewa alicja; shabestari, maziar; ansteinsson, vibeke elise title: dental health services response to covid-19 in norway date: 2020-08-12 journal: int j environ res public health doi: 10.3390/ijerph17165843 sha: doc_id: 285513 cord_uid: pkqos0s5 we aimed to investigate the management of urgent dental care, the perception of risk and workplace preparedness among dental staff in norway during the covid-19 pandemic. an electronic questionnaire regarding the strictest confinement period in norway (13 march–17 april 2020) was distributed to dental staff. among the 1237 respondents, 727 (59%) treated patients, of whom 170 (14%) worked in clinics designated to treat patients suspected or confirmed to have covid-19. out of them 88% (143) received training and 64% (103) simulation in additional infection prevention procedures, while 27 (24%) respondents reported deviation. in total, 1051 (85%) respondents perceived that dental staff had a high risk of being infected, 1039 (84%) that their workplace handled the current situation well, 767 (62%) that their workplace had adequate infection control equipment and 507 (41%) agreed that their workplace is well equipped to handle an escalation. before an appointment, 1182 (96%) respondents always/often inquired per phone information if a patient experienced symptoms of covid-19, and 1104 (89%) asked about a history of travel to affected areas. twice as many patients on average per week were treated by phone than in a clinic. a lower proportion of dental staff in high incidence counties applied additional infection prevention measures compared to low and medium incidence counties. to conclude, urgent dental health care was managed relatively well in norway. additional training of the dental staff in adequate infection prevention and step-by-step procedures may be needed. these results may be used to improve the dental health service’s response to future outbreaks. coronavirus disease 2019 (covid-19) is a public health emergency of international concern announced by the world health organization on 30 january 2020 and declared a pandemic on 11 march 2020 [1, 2] . covid-19 is caused by a novel coronavirus named "sars-cov-2", which belongs to severe acute respiratory syndrome coronaviruses (sars-covs) [3] . this is the third outbreak of an infection caused by a coronavirus in less than 20 years. the severe acute respiratory syndrome (sars) outbreak in 2002-2003 resulted in more than 8000 cases in 26 countries, and had a mortality rate of approximately 10% [4] [5] [6] [7] . in 2012-2013 the outbreak of middle east respiratory syndrome (mers) spread, and up to date 27 countries reported 2500 confirmed cases with a 34% mortality rate [8] [9] [10] [11] . to date (10 august 2020), there have been 9468 confirmed cases of covid-19 and 256 deaths in norway [12] . sars-cov-2 can be transmitted by two main routes: respiratory and contact. respiratory droplets are generated when an infected person coughs or sneezes. transmission by direct contact occurs through skin contact followed by touching the oral, nasal or ocular mucous membranes. the virus may also be transmitted by indirect contact via objects and surfaces [13] . recent evidence suggests that sars-cov-2 is detected in saliva [14] , can be transmitted by aerosol-generated procedures [15] and from asymptomatic patients [16] . in norway, during the period of containment for covid-19 (13) (14) (15) (16) (17) april 2020) dental health services suspended routine non-urgent dental health care. public dental health services in norway correspond to around 30% of the total dental health service, and twice as many dentists work in private dental clinics. it is unknown how many private clinics complied with the recommendation to suspend non-urgent dental care. health care professionals in both public and private practice are required by the norwegian law to provide emergency health care to all patients. indeed, patients confirmed or suspected to have covid-19 have the same right to emergency care as non-infected patients. however, to provide dental care during the pandemic required an extra focus on protective measures and personal protective equipment (ppe). in the period between 13 march-17 april 2020 there was a shortage of ppe in the health service in norway; consequently, some dental clinics had to be closed or staffed down in this period. on the 14 march 2020, the directorate of health in norwayrequested the dental public sector to establish an emergency service for patients suspected or confirmed to have covid-19. this could be in collaboration with the private sector and/or the universities, however, to our knowledge, the majority of the counties selected a fewpublic clinics in each region that was prepared and designated for this purpose subsequently. dental staff may be at high risk of being infected by covid-19, as the practice of dentistry involves the use of rotary and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes. these instruments create a visible spray that contains droplets of water, saliva, blood, microorganisms and other debris. aerosols may also be generated [17] . dental staff may become potential carriers of the virus and, if adequate precautions are not taken, the dental office can potentially serve as a cross-infection location [18] . since dental settings have unique characteristics, they warrant specific additional infection control considerations. before the present study was launched, the us centers for disease control and prevention (cdc) had released interim infection prevention and control guidance for dental settings during the covid-19 response [17] and the world health organization (who) had released its guidance for health workers during coronavirus disease (covid-19) outbreak, without specifying dental settings [19] . due to lack of international guidelines, national recommendations had to be devised for additional infection control and urgent dental care. since norway has not been affected by previous coronavirus outbreaks (sars or mers), this emergency was unprecedented for norwegian dental staff. therefore, the aim of this case study was to investigate how urgent dental health care was managed in norway, what additional infection prevention and control measures were employed by dental staff and to assess the dental staff perception of risk and workplace preparedness. the present study comprised a cross-sectional questionnaire survey among dental staff in norway. the questionnaire was sent electronically via questback to chief dental officers in counties who were asked to distribute the questionnaire among dental clinics in norway. all dental staff, including specialists, general dental practitioners, dental hygienists and dental assistants were invited to fill in the questionnaire. invitations to dentists in the private sector were distributed via local associations of the norwegian dental association (nda). the questionnaire was sent out 4 may 2020 to the public sector and 15 of may 2020 to the private sector and asked information related to the strictest confinement period in norway(13 march-17 april 2020). reminder for participation was sent three times and the questionnaire was closed on 26 june 2020. the self-reported questionnaire was based on information provided by cdc, who, norwegian institute of public health, ministry of health in norway, and guidelines provided by the norwegian counties. the questionnaire consisted of four parts: (i) background characteristics, (ii) dental health service management, including treatment of patients suspected or confirmed to have covid-19, (iii) dental staff perception of risk and preparedness, and (iv) psychological impact. the present article intended to report the results from the first three (3) parts of the questionnaire. the background characteristics included information about sex, age, work experience in years, profession (specialist/general dental practitioner, dental hygienist, dental assistant), area of the dental clinic (urban, which had >50,000 inhabitants, peri-urban 5000-50,000 inhabitants, rural <5000 inhabitants), size of dental clinic (large, ≥7 employees and small <7 employees), sector of main workplace (public, private), and if the respondent worked clinically with patients during covid-19 outbreak (yes/no). dental health service management part asked information about triage of patients per phone, additional infection control measures, three (3) most common treated conditions, if a clinic was eligible to treat patients suspected or confirmed to have covid-19, and knowledge of where to refer patients with urgent needs who are suspected or confirmed to have covid-19. questions related to treatment of patients confirmed or suspected to have covid-19 inquired information about the number of patients treated, additional infection control measures and procedures, if dental staff were trained to follow them and if there was a deviation, if scientific information was available and from where. regarding perceptions, dental staff was asked on a 5-point likert scale (1_completely agree, 5_completely disagree) to assess four statements: dental staff risk to be infected; if workplace had adequate infection control equipment; how workplace handled the current situation; if workplace was well equipped to handle an escalation. for statistical analyses the responses were dichotomized into agree (points 1 and 2) and disagree (points 3-5). the questionnaire was face validated by several experts in the field and pre-tested by 10 dentists, which were not included in the analysis. the incidence of cases in counties was retrieved from norwegian institute of public health, and subsequently the counties were grouped into low incidence counties (<100 reported cases per 100,000), medium incidence counties (100-150 reported cases per 100,000) and high incidence counties (>150 reported cases per 100,000) for statistical analyses [20]. statistical package for the social sciences (spss) version 26.0 (ibm spss, armonk, ny, usa) was used for statistical analyses. the chi-square test and analysis of variance (anova) with tukey adjustment were used to identify differences in characteristics between strata. univariable and multivariable binary logistic regression analyses were used to assess the association between the perception of risk and workplace preparedness (four (4) outcomes) and potential determinants. variables significantly associated with the outcome in bivariate analyses at p-value < 0.2 were entered into the regression analyses as independent variables. the results were presented as odds ratios with 95% confidence intervals (ci). the statistical significance was set at p < 0.05. approval was obtained from the norwegian centre for research data (907304). voluntary participation was based on a signed written informed consent. there was an overrepresentation by females, 1106 (89%), and those working in public service, 1134 (92%). out of all the respondents, 590 (48%) were dental specialists/general dental practitioners, 235 (19%) were dental hygienists and 412 (33%) were dental assistants. seven hundred and twenty-seven (59%) respondents worked with patients during the strictest confinement period 13 march-17 april 2020, in norway (413 (70%) dental specialists/general dental practitioners, 66 (28%) dental hygienists and 248 (60%) dental assistants) ( table 1) . table 2 shows the results regarding organization of urgent dental care in oral health service and management of patients not suspected to have covid-19. the majority of the dental staff always/often inquired information per phone if a patient experienced symptoms of covid-19 or had a history of travel to affected areas (1182 (96%) and 1104 (89%), respectively). a significant difference was observed among county incidence categories. dental specialists/general dental practitioners on average per week treated five (standard deviation (sd) 4.6) patients not suspected to have covid-19. on average per week 11 (sd 13.0) patients were clarified per phone out of whom three (sd 4.3) received drug treatment. dental specialists/general dental practitioners were asked to rank three most common conditions the patients had during the period 13 march-17 april 2020. out of 440 (35%) clinicians who responded, the most common urgent conditions were severe dental pain from pulpal inflammation (321, 73%), abscess or localized bacterial infection resulting in localized pain and swelling (264, 60%) and pericoronitis or third-molar pain (233, 53%) (data not shown). when treating patients not suspected to have covid-19, 389 (88%) of dental specialists/general dental practitioners) reported to follow additional infection prevention and control measures. the most common disinfection product was 70% ethyl alcohol; there was a significant difference in the products for disinfection between counties the majority of respondents used mouth rinse and high-volume suction as an additional protective measure while treating patients, while less than half used rubber dam; a significant difference in use of these additional protective measure was observed among county incidence categories (see table 2 ). out of the respondents who were not from clinics designated to treat patients suspected or confirmed to have covid-19 (1067, 86%), 1064 (99%) were aware where to refer a patient suspected or confirmed to have covid-19 for emergency treatment, or where to find such an information; there was a significant difference among county incidence categories (see table 2 ). table 3 shows the results of the organization of urgent dental care for patients suspected or confirmed to have covid-19. out of all the respondents, 170 (14%) were from clinics designated to treat patients suspected or confirmed to have covid-19; out of them 72 (42%) were dental specialists/general dental practitioners, 28 (17%) dental hygienists and 70 (41%) dental assistants. very few patients suspected or confirmed to have covid-19 were treated in the designated clinics. the majority of the dental staff (67, 39%) reported to leave the room between 35 min and 3 h in between such patients; there was a significant difference among county incidence categories. out of the dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19, up to 20% reported not to have available respirators ffp2 or ffp3 standard or equivalent, gowns and aprons in their workplace; there was a significant difference among the county incidence categories. the majority of dental staff received training in additional infection prevention and control procedures either digitally or in a clinic, and mostly guidelines developed by county (84, 49%) and university (59, 35%) were followed. the majority of dental staff reported that their clinic developed step-by-step procedures for treatment; the significant difference observed among county incidence categories. while 88% (143) of dental staff received training in these step-by-step procedures, and 64% (103) in addition received a simulation, 24% (27) still reported deviations. the most popular disinfection product was 70% ethyl alcohol, used by 74% (125) of the respondents. the majority of dental staff did not use extraoral dental radiographs as an alternative to intraoral radiographs; a significant difference was observed among county incidence categories (see table 3 ). all dental staff were asked four attitudinal statements regarding dental staff perception of risk and preparedness. the majority of respondents (1055, 85%) completely agreed/agreed that dental staff were at high risk of being infected by covid-19. sixty-two percent (766) perceived that their workplace had adequate infection control equipment, 84% (1035) experienced that their workplace handled the current situation well, while 41% (501) agreed that their workplace was well equipped to handle an escalation. table 4 shows the results of the multivariable regression analyses exploring associations between perception of risk and preparedness statements and selected independent variables. less experienced dental staff, or 2.0 (ci 1.4; 3.0), and dental staff in public practice, or 2.4 (ci 1.3; 4.4), were more likely to perceive dental staff to have a high risk of being infected, while working in low incidence counties reduced odds, or 0.5 (ci 0.3; 0.8), to perceive this risk. dental staff in public sector, or 0.3 (ci 0.2; 0.5) and those working at clinics not designated to treat patients suspected or confirmed to have covid-19, or 0.6 (0.4; 0.9) were less positive to preparedness of their workplace regarding infection control equipment. dental staff in public sector, or 0.2 (ci 0.1; 0.5), were less positive to how their workplace handled the current situation. dental hygienists, or 1.5 (ci 1.1; 2.2) and dental assistants, or 1.4 (ci 1.0; 1.9), marginally, but statistically significantly associated with being positive to their workplace preparedness to handle an escalation, while dental staff at small clinics, or 0.6 (ci 0.5; 0.9), public sector, or 0.2 (ci 0.1; 0.4), and clinics not designated to treat patients suspected or confirmed to have covid-19, or 0.3 (ci 0.2; 0.4), were less positive to workplace preparedness. ii adjusted for variables that resulted in statistically significant associations according to univariable analyses. iii adjusted for variables that resulted in statistically significant associations according to univariable analyses. iv adjusted for variables that resulted in statistically significant associations according to univariable analyses. the covid-19 pandemic is an unprecedented situation that has affected the population globally, especially healthcare workers, including dental staff. to the best of our knowledge, there are up to date 8 questionnaire studies that investigated covid-19 outbreak and dentistry, summarized in table 5 . none of the questionnaire studies assessed the urgent dental health care management and perception of risk and preparedness among the complete dental team, which includes not only dentists, but also dental hygienists and dental assistants. the appropriate infection prevention and control in order to limit the infection spread is a result of the efforts of the whole dental team. in the present study, there was an over-representation of females and dental staff working in public sector, therefore the results should be interpreted with caution in this respect. in addition, the timing of a questionnaire is an important factor, because of the differences in pandemic peak in different countries and constantly changing guidelines. for example, in march 2020, cdc recommended that dental settings should prioritize urgent and emergency visits and delay elective visits. already in april, some practices in the usa started reopening and providing the full range of dental health care. in norway, from 16 march 2020 health authorities recommended to reduce "one to one contact" in the dental setting by prioritize urgent care and delay elective care. dental health service started gradual re-opening also for elective visits after national recommendations issued by the end of may 2020. the present questionnaire study was commenced 4/15 may 2020 and asked the information about the strictest confinement period in norway, 13 march-17 april 2020. therefore, the results of the present study may not be directly comparable with other studies, as for example the study by kamate and co-workers was conducted much earlier [21] . moreover, the respondents of the global surveys may have experienced different degrees of outbreak during the given survey time which possibly influenced their practices and perceptions. in the present study, the majority of the respondents completely agreed/agreed that dental staff had a high risk of being infected by sars-cov-2. the new york times magazine ranked dental staff among other healthcare workers to have the highest risk to be infected [29] . in italy as well, the majority of respondents agreed that dentistry is a profession at risk [26, 28] . on the contrary, only one out of five dentists perceived covid-19 as very dangerous in jordan [23] . it must be noted that the questionnaire among jordanian dentists was distributed early in the global covid-19 outbreak, when jordan did not have any local cases, in addition to the fact that dentists in jordan has experience with previous similar virus outbreaks. in the present study, the dental staff perception of a dental staff having a high risk of being infected positively associated with working in a public sector and having less professional experience, but negatively with working in low incidence counties. the majority of the dental staff perceived that their clinic handled the current situation well, which negatively associated with working in public sector. however, less than a half of the respondents agreed that their workplace was well equipped to handle an escalation, which negatively associated with small clinics, clinics not designated to treat patients suspected or confirmed to have covid-19 and also public sector. the differences in perceived preparedness between private and public sectors can be partly explained by differences in "locus of control"-while dentists working in private sector were solely themselves responsible for being prepared, while dental staff in public sector were part of a large organization andwere more dependent on decisions of others. as this was a questionnaire study, we do not know if they in fact were better prepared, but it seems they had a better confidence in perceiving their preparedness. there is reason to believe that the level of preparedness facing a virus outbreak like sars-cov-2 in a country or society is influenced by experience with earlier and similar epidemics, like mers and sars. norway has not had a similar virus outbreak in the past and did not even have national recommendations for infection prevention and control in dental practice before 2018. increased internationalization and prevalence of antibiotic resistance did then contribute to the development of recommendations, which were used as a foundation for organizing the activity in the dental health service during the covid-19 outbreak. to reduce the spread of sars-cov-2, the norwegian institute of public health recommended that all patients and accompanying persons should be clarified with regard to infection status and anamnesis per phone prior to their appointment [30] . the majority of the dental staff always/often inquired information per phone about symptoms and about history of travel, showing a high degree of compliance with the recommendations from the authorities. this finding is in line with the global questionnaire study [24] and a study from italy, where phone triage, together with spaced appointments was the most commonly adopted precautionary measure, while deferring treatment in elderly and detecting body temperature in staff and patients were less commonly adopted precautionary measures [26] . the jordanian study revealed limited comprehension of the extra precautionary measures, where a recommended procedure during the outbreak was to measure the temperature of staff and patients [23] . in the present study, the lower proportion of dental staff inquiring about symptoms and travel history were in high incidence counties. in addition, the lower proportion of dental staff in high incidence counties reported not to use prevention measures, such as mouth rinse before procedure, rubber dam and high-volume suction while treating a patient not suspected to have covid-19. these results are in line with the italian survey, where dentists from the highest prevalence areas reported to adopt preventive measures less frequently [26] . the authors suggested that the risk perception is lower in high incidence areas because it is more general. therefore, risk perception in a dental clinic in high incidence areas is also lower. on the other hand, in the present study dental staff working in low incidence counties versus high incidence counties perceived dental staff as having a lower risk of being infected. teledentistry has been proposed only for conditions that could be managed by advice and managed or postponed by medication. it seems to be a useful platform to offer consultations when social distancing is warranted, to minimize direct patient interactions, and to reduce the use of personal protective equipment (ppe) as well as other highly valuable clinical resources during a pandemic [31] . a study evaluating the urgent dental care in north east of england in the first six weeks of the pandemic concluded that the phone triage system used to handle emergency and urgent dental care was both essential and effective [32] . in the present study, on average per week, five patients were treated in a dental office and twice as many received treatment by per phone, out of them one third received drug treatment for their dental condition. thus, treatment per phone may be evaluated as effective also in norway. in the present study, the most common conditions were severe dental pain from pulpal inflammation, abscess, or localized bacterial infection resulting in localized pain and swelling and pericoronitis or third-molar pain. this is in line with a study in beijing, china, which reported that the utilization of emergency dental care decreased during covid-19 outbreak and the distribution of the oral health conditions changed; more dental and oral infections were recorded, but less dental traumas compared to pre-covid-19 period [33] . moreover, the results of the present study are in line with a study from england, where the most frequent dental emergency conditions reported were acute pulpitis or periapical symptoms [32] . during the treatment of these conditions, the most aerosol generating procedures can be avoided. in norway, during the strictest confinement period, several public dental clinics were designated to provide urgent treatment for patients suspected or confirmed to have covid-19. the number of private clinics that provided dental care to patients suspected or confirmed to have covid-19 in norway in this period is not currently known. designated clinics were also implemented in the uk, where local urgent dental care hubs were arranged [34] and in china [35] . this was not the case in italy where private sector provided much of the dental health service, and almost half of the private dentists reported to remain working during the outbreak [26] . in the present study, less than two thirds of the dental staff agreed that their workplace had adequate infection control equipment. dental staff in public sector and those working at clinics not designated to treat patients suspected or confirmed to have covid-19 were less positive to this statement. during the peak of the pandemic, the global stockpile of ppe was insufficient, and the demand for respirators and masks even for health care workers could not be met [36] . the majority of italian dentists reported to have difficulties in finding needed ppe [27] . in the present study, up to 20% of the dental staff working in the clinics designated to treat patients suspected or confirmed to have covid-19 reported not to have available ppe, such a respirators, gowns and aprons at their workplace. even when treating patients not suspected to have covid-19, 88% (389) of the dental staff working during the strictest confinement period in norway applied additional infection control measures, though the who guidelines released 29 june for the health care advise that for patients not suspected to have covid-19 standard precaution should be applied [37] . every fifth responding dentist in jordan reported that additional infection control measures, such as patients wearing masks and washing hands before getting into a dental chair, are not necessary and may create a panic [23] . the newly released (3 august 2020) who interim guidance for the provision of essential oral health services in the context of covid-19 advises that all patients are encouraged to use medical or non-medical masks and practice hand hygiene on arrival and throughout the visit [38] . in the present study, almost all dental staff working in clinics that were not designated to treat patients suspected or confirmed to have covid-19, knew where to refer a patient or where to find an information about it. the highest proportion of dental staff who did not know either clinics or where to find an information, were from high incidence counties. the majority of the respondents in the global survey were aware of the proper authority to contact in case a patient was suspected to have covid-19 [24] . this demonstrates that dental staff were well informed, and thus potentially minimize the risk of infection spread. in the present study, the majority of the dental staff working at the clinics designated to treat patients suspected or confirmed to have covid-19, reported to follow local guidelines for additional infection prevention and control developed by county and university. according to the global survey, 90% of the respondents were updated with the current cdc or who guidelines for infection prevention and control [24] . following guidelines is a crucial aspect in limiting infection spread. dental treatment involves droplets and aerosol generating procedures, such as high-speed drills, dental hand-pieces, ultrasonic and air-flow devices, air-water syringe, ultrasonic scaler and oral prophylaxis cups/rotating brushes. a review has identified that sars-cov-2 may persist in the air in closed unventilated indoor areas for at least 30 min without losing infectivity [39] . therefore, adequate time between patients in the dental office may minimize the risk of cross-infection. in the present study, 84% (144) of the dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19, reported to leave the room before the next patient for 35 min or more. droplets and aerosols may contaminate surfaces, and it has been shown that viruses can sustain on surfaces for various time periods, depending on temperature and humidity, sometimes even up to 28 days [40] . surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide and 0.1% sodium hypochlorite seem to be the most effective against coronaviruses [40] . in the present study, the most common disinfection agent was reported to be 70% ethyl alcohol. mouth rinse before dental procedures has been shown to reduce microorganisms' load in droplets and aerosols [41] . the most common mouth rinse is 0.02% chlorhexidine digluconate, which seems to be less effective against coronaviruses compared to hydrogen peroxide [40] . the majority of dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19 (93%, 50) reported to use mouth rinse (for example chlorhexidine digluconate or hydrogen peroxide) as an additional protective measure. high-volume suction was reported to be used by 85% (46) and rubber dam by 63% (34) of the dentists as an additional protective measure. according to the global survey, the majority of the respondents neither used mouth rinse nor rubber dam, but a proportion reported to have used high-volume suction [24] . rubber-dam and high-volume suction are considered valid infection control measures during dental procedures and are recommended by american dental association in order to reduce aerosols during dental procedures [42] [43] [44] [45] [46] . intraoral radiographic examination is the most common radiographic technique in dentistry, but as it may stimulate both saliva secretion and coughing, extraoral radiographs may be an appropriate alternative during a virus outbreak, but only a small proportion of dental staff working with patients suspected or confirmed to have covid-19 reported to use extraoral radiographs [35] . the majority of respondents received training in the guidelines either digitally or in the clinics, which included training in putting on and removing ppe. even though, 88% and 67% of the respondents reported to receive training and simulation, respectively, in step-by-step procedures for treatment, including ppe putting on and removing, 24% of the respondents working in clinics designated to treat patients suspected or confirmed to have covid-19 reported the deviation in these procedures. this finding demonstrates that additional infection prevention and control procedures for treatment may not be easy to follow and require extra training. this calls for additional dental staff training in step-by-step procedures for dental treatment during an outbreak in order to minimize infection spread. in general, urgent oral health care was managed relatively well in norway and the majority of the dental staff perceived that their clinic handled the current situation well. however, only less than a half of the respondents agreed that their workplace was well equipped to handle an escalation. in the clinics designated to treat patients suspected or conformed to have covid-19, lack of availability of several ppe was reported. mainly local guidelines developed at a county level or universities were followed. despite training and simulation in additional infection prevention and control step-by-step procedures, there were reported several deviations. fewer dental staff in high incidence counties applied additional infection prevention measures compared to low and medium incidence counties. the results of this study may be used to improve dental health service response to possible future outbreaks in norway and other countries. the results call for additional staff training in using appropriate ppe and applying additional preventive measures for patients without and with infection. funding: this research received no external funding. the authors declare no conflict of interest. china coronavirus: who declares international emergency as death toll exceeds 200 severe acute respiratory syndrome-related coronavirus: the species and its viruses-a statement of the coronavirus study group identification of a novel coronavirus in patients with severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome coronavirus as a possible cause of severe acute respiratory syndrome world health organization. summary of probable sars cases with onset of illness from 1 isolation of a novel coronavirus from a man with pneumonia in saudi arabia middle east respiratory syndrome middle east respiratory 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emerging and future challenges for dental and oral medicine advice on the use of masks in the context of covid-19 infection prevention and control during health care when coronavirus disease (covid-19) is suspected or confirmed considerations for the provision of essential oral health services in the context of covid-19 stability and infectivity of coronaviruses in inanimate environments persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review possible aerosol transmission of covid-19 and special precautions in dentistry severe acute respiratory syndrome (sars) and the gdp. part ii: implications for gdps severe acute respiratory syndrome and dentistry: a retrospective view dental-dam for infection control and patient safety during clinical endodontic treatment: preferences of dental patients as dental practices resume operations, ada offers continued guidance this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-316095-jzyb4jn5 authors: falahchai, mehran; babaee hemmati, yasamin; hasanzade, mahya title: dental care management during the covid‐19 outbreak date: 2020-09-19 journal: spec care dentist doi: 10.1111/scd.12523 sha: doc_id: 316095 cord_uid: jzyb4jn5 aim: the level of preparedness of the healthcare system plays an important role in management of coronavirus disease 2019 (covid‐19). this study attempted to devise a comprehensive protocol regarding dental care during the covid‐19 outbreak. methods and result: embase, pubmed, and google scholar were searched until march 2020 for relevant papers. sixteen english papers were enrolled to answer questions about procedures that are allowed to perform during the covid‐19 outbreak, patients who are in priority to receive dental care services, the conditions and necessities for patient admission, waiting room and operatory room, and personal protective equipment (ppe) that is necessary for dental clinicians and the office staff. conclusion: dental treatment should be limited to patients with urgent or emergency situation. by screening questionnaires for covid‐19, patients are divided into three groups of (a) apparently healthy, (b) suspected for covid‐19, and (c) confirmed for covid‐19. separate waiting and operating rooms should be assigned to each group of patients to minimize the risk of disease transmission. all groups should be treated with the same protective measures with regard to ppe for the dental clinicians and staff. the novel human coronavirus, recently named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), was first emerged in china in december 2019 and turned into a pandemic within a couple of months, leading to a global crisis. 1 the most common clinical features of the coronavirus disease 2019 (covid-19) include dry cough, fever, and dyspnea. 2 it has an estimated incubation period of 4-5 days, although a time lapse as long as 14 days from the time of exposure to the onset of signs and symptoms has © 2020 special care dentistry association and wiley periodicals, inc. also been reported. 3, 4 the patients have no signs or symptoms during the incubation period while they are potential carriers for the sars-cov-2 and may transmit the disease to other individuals. this property makes efficient control of this disease extremely difficult. 5 according to the reports by the world health organization (who), over 200 countries worldwide reported covid-19 outbreak until march 25, 2020. 6 since there is no confirmed treatment or vaccine for covid-19 so far, dental treatments must be provided to those in need until the termination of this global pandemic. considering the generation of high amounts of droplets and aerosols during routine dental procedures, the conventional protective measures that are routinely followed by dental clinicians are no longer efficient for prevention of covid-19 transmission. 7 according to a report by the new york times, dental clinicians have the highest risk of exposure, even higher than that of nurses, physicians, and pharmacists. 8 under such circumstances, dental management of patients requires some certain precautions, which have not been practiced before. covid-19 may last for a couple of months in many countries especially those with a poor healthcare system. thus, the precautions need to be taken seriously not only during the management period and the disease peak, but also during the remission period in order to prevent reinfection. this study sought to provide some safety precautions that need to be followed step by step from patient admission to completion of treatment to prevent covid-19 transmission. a literature search was performed in embase, pubmed, and google scholar to retrieve relevant articles with the following combination of words: (((("dent manage" [journal] or ("dental" [all fields] and "management" [all fields])) or "dental management" [all fields]) or (("dental care" [mesh terms] or ("dental" [all fields] and "care" [all fields])) or "dental care" [all fields])) and ( ). articles in english with no other restriction were applied for inclusion of the retrieved articles in order to prevent missing of any information. this paper focused on dental management during the covid-19 pandemic in order to answer the following four questions: • which procedures are allowed to perform during the covid-19 outbreak? • which patients are in priority to receive dental care services? • what are the conditions and necessities for patient admission, waiting room, and operatory room? • what personal protective equipment (ppe) is necessary for dental clinicians and the office staff? sars-cov-2 can be transmitted from person to person via direct contact. person-to-person transmission is very common among the family members and also healthcare workers who are in direct contact with covid-19 patients and carriers. sars-cov-2 can be transmitted via body fluids, salivary droplets, respiratory secretions (fomites), and aerosols. risk of transmission via these routes decreases by an increase in physical distance, in an orderly fashion. 9 droplets and aerosols are the most important routes of virus transmission in dental procedures. the reason is generation of aerosols and droplets of saliva and even blood, which is unavoidable in dental procedures. use of high-speed handpiece in the oral cavity creates significant amounts of droplets and aerosols that remain suspended in the air for up to 30 minutes prior to their deposition on surfaces or being sucked into the air conditioning system, due to their small size. 10, 11 also, dental clinicians are in direct contact with the body fluids such as saliva and contaminated dental instruments. on the other hand, sars-cov-2 can remain viable on metal, glass, and plastic surfaces for a couple of days and serve as a source of infection transmission. 12 it has been documented that the human coronavirus can remain viable at room temperature from 2 to 9 days. 10,12 also, it shows higher resistance in 50% humidity compared with 30% humidity. 13 a similar behavior may be expected from the sars-cov-2. 1, 12 evidence shows that this virus may be transmitted by asymptomatic individuals. 5, 14, 15 these individuals have positive polymerase chain reaction (pcr) test result for the virus nucleic acid but have no symptoms such as pain or respiratory problems. thus, all dental patients should be considered suspicious for covid-19. 5,14,15 according to the american dental association, dental procedures can be divided into two groups of emergency/urgent and routine/elective during the covid-19 pandemic. the american dental association added urgent dental care as part of the emergency guidance. 16 emergency situations are life-threatening and require immediate attention to stop bleeding, alleviate severe pain, or resolve the infection. these include the following: • uncontrolled bleeding, cellulitis or bacterial infection with intraoral or extraoral swelling that can potentially compromise the airways. • trauma to the facial bones that can potentially compromise the airways. urgent dental treatments include management of conditions that require immediate attention such as alleviation of severe pain with/without the risk of infection and balancing the patient load in the hospital emergency departments. such treatments should be minimally invasive (as much as possible) and include the management of the following issues: • severe dental pain due to pulpitis. • pericoronitis or third molar impaction. • postoperative osteitis, dry socket dressing change. • local bacterial abscess or infection that has caused pain and local swelling. • a fractured tooth that has caused pain or soft tissue trauma. • dental trauma associated with avulsion/luxation. • dental treatments required prior to critical medical procedures. • cementation of crowns or bridges when the temporary restoration is lost, broken, or has caused gingival irritation. • biopsy of abnormal tissue. • management of extensive dental caries or defective restorations that have caused pain with interim restorative techniques if possible (silver diamine fluoride, glass ionomers). • denture adjustment in patients under radiotherapy/chemotherapy. • denture adjustment or repair in case of impaired function. • exchange of temporary restoration of an endodontic access cavity in patients complaining of pain. • snipping or adjustment of orthodontic wires or appliances that have traumatized the oral mucosa. routine/elective or nonemergency dental treatments include the following points: • primary oral and dental examinations, periodic examinations, and recall visits that may include routine radiography. • cleaning and prophylaxis, and preventive treatments. • orthodontic procedures other than cases that may lead to acute complications (such as pain, infection, or trauma). • extraction of asymptomatic teeth. • restorative treatments such as restoration of asymptomatic carious teeth and cosmetic dental procedures. if yes, when did you first notice the swelling? 3 are you experiencing uncontrolled bleeding? if yes, when did it start? 4 what is your pain level on a scale of 1-10? (0 indicates no pain, and 10 is the worst pain possible) can pain or discomfort be tolerated or managed at home for 2-3 weeks? 5 do you need denture repair or adjustment prior to medical treatment or due to trouble eating? 6 do you need dental treatment required prior to medical treatment (e.g., radiotherapy)? 7 do you need biopsy of abnormal tissue? 8 do you need final crown/bridge cementation if the temporary restoration is lost or broken and the gingiva is irritated? during the covid-19 pandemic, routine dental treatments are contraindicated, and emphasis should be placed only on emergency and urgent treatments in all patients. 16 thus, dental clinicians should first ensure their own health, and the health of their office staff, and then the first step would be screening of patients, which can be performed in two steps. patient screening primary screening should be performed when scheduling an appointment online or over the phone. at this time, patient status regarding covid-19 can be evaluated by using a simple questionnaire. aside from asking for the routine demographic information and medical history, the main question should be the patient's chief complaint to determine whether he/she is a candidate for emergency/urgent dental treatment. other questions should be directed to determine the risk of covid-19. tables 1 and 2 are the designed questionnaires suggested for this purpose. different scenarios may be encountered at this phase: 1. the patient does not require emergency/urgent treatment; thus, a dental appointment is not scheduled for him/her. 2. the patient requires emergency/urgent treatment and is not suspected for covid-19 or recovered from covid-19. an appointment is scheduled for such patients for further examinations. 3. the patient requires emergency/urgent treatment and is also suspected for covid-19. 4. the patient requires emergency/urgent treatment and is confirmed for covid-19 with laboratory tests. the patients recovered from covid-19 based on following criteria can be considered as healthy and receive dental care following standard precautions. according to updated recommendation of center for disease control (cdc), people with mild to moderate covid-19 are not infectious if at least 10 days passed after their symptoms began and at least 24 hours have passed science resolution of fever without the use of fever-reducing medication and other symptoms have improved. patients with more severe illness or those who are severely immunocompromised remain infectious no longer than 20 days after their symptoms began. therefore, resolved patient according to this symptom-based strategy could be considered in the second category. 17, 18 if the patient has traveled intercity in the past 14 days, it is recommended to postpone the dental visit to an appropriate time after a 14day quarantine period, given that his/her dental condition can be alleviated remotely (at least temporarily). 7 in the current situation, it is suggested to cancel patient appointments without prior primary screening to prevent close contact of patients in the waiting room and subsequent increase in the risk of transmission. secondary screening should be performed when patients show up for a clinical in-office visit. a primary examination needs to be performed before the patient enters the operatory room. also, before entering the clinic, the patients should be requested to wear a surgical mask and follow the hygiene measures for the respiratory system (use of tissue when coughing or sneezing and disposing it in a closed-lid trash bin immediately after use) and hands (washing hands with water and soap or 70-90% alcoholbased hand rubs). 19, 20 since fever is the most common clinical feature of covid-19 (present in 88.7% of the cases), 2 measuring the body temperature by a noncontact forehead thermometer or infrared cameras with thermal sensors can greatly help for in-office patient screening. 19 at this time, the questionnaires filled out during the primary screening should be verified by interviewing the patients. dental treatment should only be performed if the emergency/urgent situation is confirmed. according to the data acquired from the screening questionnaires, patients who need emergency/urgent dental treatment can be divided into three groups of apparently healthy, suspected, and confirmed cases. separate waiting rooms and operatory rooms should be considered for each group of patients. standard central dental care clinics need to have these separate rooms for treatment of all patients. however, private offices may not be well equipped to provide emergency care to all three groups of patients. therefore, their services should be limited based on the available separate waiting and operating rooms. it should be noted that normal body temperature does not definitely rule out the disease, and other signs and symptoms as well as the filled out questionnaires should also be scrutinized. patients with underlying systemic conditions are believed to be at higher risk of covid-19. therefore, the authors believe that it may be preferred to schedule appointments early in a work day for such patients. some systemic conditions are exception including patients who have nocturnal asthma which should be scheduled for late-morning appointments, when attacks are less likely. moreover, management of stroke-prone patients or patients with a history of stroke includes the use of short, midmorning appointments that are free of stress and anxiety. 21 they should be the first patients visited by the dentist to minimize the risk of cross-contamination. also, procedures involving aerosol generation such as the use of high-speed handpiece should be preferably scheduled at the end of a work day to minimize the risk of contamination of other patients by the generated aerosols. although physical contact is the main route of transmission of covid-19, some concerns still exist regarding its airborne transmission. 10 thus, patient appointments should be preferably scheduled such that only one patient waits in the waiting room. nonetheless, three separate waiting rooms should be considered for apparently healthy, suspected, and confirmed patients. the waiting room for suspected or confirmed cases of covid-19 should have negative pressure. alternatively, airborne infection isolation rooms should be allocated to such patients. the waiting room for asymptomatic and apparently healthy dental patients should have adequate ventilation, which is 60 l/s/patient for rooms with normal ventilation. 22 in case of presence of higher number of patients in a waiting room, safe distance between the chairs should be considered (a minimum of six feet) or the patient can be asked to wait in the car or in open spaces till the time of scheduled appointment. 18, 23 all surfaces in the waiting room should be considered high-risk due to the possibility of contamination with droplets upon coughing or sneezing of patients or hand contact. thus, all surfaces should be periodically disinfected. 24 logically, the patient's chair and its surroundings (by up to six feet) should be disinfected after the patient leaves the waiting room for the operatory room. although symptomatic covid-19 patients are the main source of disease transmission, evidence shows that asymptomatic patients and those in the incubation period may also be sars-cov-2 carriers. 5, 25 on the other hand, the two more efficient diagnostic modalities to rule out covid-19 infection include multiple reverse-transcription pcr tests and computed tomography (ct), the latter being more easily available. 26 considering the existing limitations and shortage of diagnostic pcr kits and nonfeasibility of requesting ct for all patients, it would be wise to consider all patients as potential carriers, and additional infection prevention and control practices should be considered during the covid-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. these practices are intended to apply to all patients, not just those with suspected or confirmed sars-cov-2 infection. thus, emergency dental treatments should only be provided to all cases in a negative-pressure operatory room or airborne infection isolation rooms. also, it should be noted that separate operatory rooms should be considered for the three groups of patients. to enhance normal ventilation, the who recommends negative-pressure rooms with a minimum of 12 air changes per hour or 160 l/s/patient. also, mechanical ventilation should be started prior to treatment of the next patient. 27 given that air change occurs 14-18 times per hour, elimination of air pollutants and contaminants requires 18 minutes for 99% efficacy and 28 minutes for 99.9% efficacy. thus, a minimum of 30-minute interval should be considered between treatment of patients. 28 dental clinicians should strictly follow the standard precautions for the contact and airborne infections, which include the use of ppe and the hand hygiene protocols. 19 to protect the skin and mucosa against the infected secretions, it is recommended that the operatory room staff wear isolation gowns with surgical gloves, appropriate mask, safety glasses, and face shield prior to entering the operatory room. according to the recommendations of the cdc, the order of wearing ppe includes hand washing, wearing the hospital gown, mask, cap, safety glasses, and surgical gloves. the order of taking off the ppe is the opposite, and hand washing should be performed as the final step. 29 the west china hospital of stomatology, sichuan university has recommended the hand hygiene guideline of two-before-and-three-after. accordingly, dental clinicians should wash their hands prior to patient examination, prior to initiation of a dental procedure, after contact with the patient, after touching the nondisinfected equipment and instruments, and after touching the oral mucosa, skin, wounds, blood, body fluids, or other secretions. 10 a hospital gown is an important ppe required when taking care of patients especially if they are suspected for a contagious disease, and is a critical part of many disease control strategies. hospital gowns can be divided into two main groups for (a) blood-borne pathogens such as surgical gowns, surgical isolation gowns, and nonsurgical gowns, and (b) for airborne pathogens (coverall gowns and nuclear protective gowns). 30 thus, it seems that the coverall gowns that protect against airborne pathogens are the best choice for protection against the covid-19. 31 the coverall gowns should be disposed after use for each patient. the standard surgical mask, which is also known as the fluid resistant surgical mask, creates a protective barrier for the nose, mouth, and the respiratory system against splashes, large droplets, and other fluids. it is loosefitting and not resistant against smaller airborne particles. the respirators, referred to as n95 masks in the united states and filtering facepiece (ffp) in the united kingdom, protect the user against smaller airborne particles in aerosol-generating procedures. 32 the national health service guideline recommends the use of ffp-3 respirators for aerosel generating procedures. ffp-2 respirators are recommended for level 2 ppe during nonaerosolgenerating procedures. 32, 33 moreover, according to the cdc guidelines 34 : • a n95 respirator or a respirator that offers a high level of protection e.g. other disposable filtering facepiece respirators, powered air-purifying respirator, or elastomeric respirators should be used during aerosol-generating procedures on patients assumed to be noncontagious. • respirators should be used as part of a respiratory protection program that includes medical evaluation, training, and fit testing. it should be noted that it is not known whether respirators with exhalation valves provide source control. • if a respirator is not available for use during an aerosolgenerating procedure, both a surgical mask and a fullface shield should be worn. make sure that the mask is approved by the us food and drug administration as a surgical mask. use the highest level of surgical mask available. • aerosol-generating procedures should not be performed if a surgical mask and a full-face shield are not available. a surgical mask would suffice for the office staff working outside of the operatory room. 35 ideally, respirators should be changed after visiting each patient. also, they need to be changed if damaged, or contaminated with blood, respiratory or nasal secretions, or other body fluids. 36 long-term use of a mask is only allowed when all patients have the same type of virus, and risk of crosscontamination is nonexistent. however, this is not the case in a dental office, since some patients may be healthy. thus, reuse and extended use of a mask are not recommended in a dental office setting. 37 analysis of conjunctival samples of suspected and definitive cases of covid-19 revealed that the routes of transmission are not limited to the respiratory tract only, 38 and covid-19 can also be transmitted via contact with the ocular conjunctiva, 39 which can be easily contaminated by droplets. thus, safety glasses or face shields should be necessarily used during the treatment procedure and cleaned and disinfected between patients. additional points to remember surfaces should be effectively disinfected with appropriate hospital grade disinfectants such as sodium hypochlorite. regarding the hospital grade disinfectant, there are different concentrations proposed for different uses, and product manufacturer's directions should be followed regarding concentrations and exposure time. for example, a 1:10-1:100 dilution of 5.25-6.15% sodium has been recommended for decontaminating blood spills. 40, 41 it is imperative to disinfect the frequently touched surfaces such as the door knobs, tables, and light switches. several disinfecting agents are used for this purpose including alcohols, hydrogen peroxide, benzalkonium, or sodium hypochlorite. evidence shows that disinfecting agents containing 62-71% ethanol or 0.1% sodium hypochlorite can eliminate the coronavirus from the surfaces if used for 1 minute. 12 the standard cleaning protocol should include initial cleaning of contaminated or potentially contaminated surfaces by using a combination of water and irrigating solutions. this is performed to ensure elimination of organic materials from the surface. evidence shows that presence of organic residues compromises the optimal efficacy of disinfecting agents. after initial cleaning, surfaces should be disinfected with an environmental protection agency (epa)-registered, hospital grade disinfectant for sufficient time depending on the product. 42, 43 the instruments and equipment should be disinfected according to the manufacturers' instructions or the who instructions for reuse of medical and dental equipment. since coronavirus is not able to survive more than 30 minutes at temperatures above 56 • c, the common sterilization protocols are still effective for the prevention of cross-infection. 44 these protocols suggest sterilization of critical and heat-tolerated semicritical instrument. reusable semicritical items that are not sterilized should be processed with high-level disinfection and cleaning is enough for noncritical instruments; however, when a noncritical item is spattered with blood or touched with a contaminated glove or hand, it should be cleaned and disinfected. 45 the disinfection protocol for instruments and equipment includes the use of antiviral solutions containing 70% ethyl alcohol. however, use of disposable instruments and equipment should be prioritized especially for suspected and confirmed patients. if not possible, all equipment should be disinfected between patients as explained earlier. 42 rinsing antimicrobial mouthwashes preoperatively can decrease the microbial load in the oral cavity. 46 the mean salivary viral load is reportedly 3.3 × 10 6 copies per milliliter. 39 use of antiseptic mouthwashes can only decrease the viral load but cannot eliminate the virus from the saliva. 24 according to the national health commission of the people's republic of china, chlorhexidine, which is routinely used in dental procedures, may not be effective against the coronavirus. thus, since the coronavirus is sensitive to oxidation, mouthwashes containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone iodine are recommended to decrease the oral and salivary viral load. 47 evidence shows that sars and mers are highly sensitive to povidone mouthwash. 48 intraoral radiographs should not be requested due to the stimulation of saliva secretion and coughing. intraoral radiography can be replaced with extraoral radiography such as panoramic radiography or cone-beam ct. 7 dental clinicians are recommended to avoid procedures that generate droplets or aerosols such as the use of three-way syringes, high-speed handpiece, and ultrasonic scalers, as much as possible or minimize their application. 19 evidence shows that ultrasonic scalers, irrespective of their type, generate much higher amounts of aerosols compared with manual curettes. 49 also, novel caries removal modalities such as chemomechanical methods are preferred to minimize the generation of aerosols. use of such painless alternatives has gained the spotlight in the recent years. at present, materials such as carisolv, caridex, and papacarie are used for caries removal. no significant difference has been reported in caries removal efficacy of carisolv and the conventional rotary method, although the former method takes more time. considering the fact that children comprise a large portion of emergency cases, these modalities can be considered as the modality of choice for caries removal due to the painless nature of such treatments, and not generating aerosols. 50 the low-volume or high-volume saliva ejectors and rubber dam can decrease the generation of droplets and aerosols. 7, 24 use of rubber dam in aerosol-generating procedures (such as the use of high-speed handpiece and ultrasonic scalers) can significantly decrease the generation of saliva-or blood-contaminated aerosols. however, it should be noted that in case of placing a rubber dam, a high-volume saliva ejector should also be used along with a conventional saliva ejector. 44 evidence shows that use of rubber dam during cavity preparation can decrease the spread of microorganisms by 90%. 51 another effective measure is to use high-speed anti-retraction handpiece, 43 which can significantly decrease the backflow of oral bacteria and hepatitis b virus into the handpiece tubes and dental unit, compared with handpieces without anti-retraction. 52 pharmaceutical therapy, comprising antibiotics and analgesics, is recommended for patients suspected for covid-19 who are detected during the screening process to alleviate their symptoms to some extent. ideally, therapeutic interventions should be postponed until recovery. it should be noted that pharmaceutical therapy should be based on the most recent, updated information to use safer medications. there are some claims regarding the contraindication of ibuprofen for covid-19 patients due to its interference with the immune function. acetaminophen is recommended as an alternative for such cases. 19 the correlation of nonsteroidal anti-inflammatory drugs (nsaids) and respiratory and cardiovascular syndromes has been well confirmed. however, evidence is inconclusive regarding the contraindication of nsaids for covid-19 patients. thus, as a precautionary act, care must be taken not to use them as the first line medication. 53 another important topic is the administration of injectable steroids, which should be avoided as much as possible particularly for the elderly and patients with underlying conditions in covid-19 pandemic. 54 great advancements have been made in digital dentistry in the recent years particularly in restorative dentistry. digital dentistry has many strength points with regard to infection control as well. for instance, digital intraoral impressions eliminate the need for use of an impression tray or dental impression materials. resultantly, the risk of gag reflex and coughing of patient would be eliminated. digital impressions also eliminate the risk of contact with contaminated trays and minimize the risk of infection transmission and cross-contamination as such. also, they decrease the number of treatment sessions, which also lowers the risk of contracting a disease. during the covid-19 pandemic, digital dentistry can greatly help in emergency management of dental patients whose temporary restorations are lost. a new restoration can be easily fabricated for such patients within one session with minimal contact with the patient or even by using the previous scan of the patient, if available. the recent technological advances also led to the advent of robotic dentistry, which has greatly advanced in different fields such as endo micro robot, surgical robot, and robotic dental drilling. 55 in 2001, a teleoperated, humancontrolled robot successfully eliminated caries, performed a crown preparation, and performed an endodontic treatment. 56 also, in 2017, a robot successfully placed two dental implants with 0.2-0.3 mm accuracy for an actual patient under the supervision of a clinician. 56 some concerns still exist regarding the efficacy of digital technology to offer customized treatments based on individual patient needs. however, it appears promising for later use in certain circumstances such as global pandemics of infectious diseases. another promising field is the pharmaceutical treatment of dental pain. at present, nsaids are commonly prescribed for dental pain management, which can have side effects for many patients or drug interferences in case of pandemics. some novel medications such as nociceptive temperature-sensitive receptors-targeting drugs have shown promising results so far but require further clinical investigations. 57 thus, occurrence of events such as the covid-19 outbreak can encourage the dental researchers to focus on novel dental approaches. this can be done by benefitting from the other fields of science to come up with some strategies to provide dental care under such circumstances and minimize the impact of such occurrences on dental care of patients. this article comprehensively discussed all phases of patient management from admission to completion of treatment in detail. the emergency cases should be detected via a primary interview over the phone or online. next, the patients should be divided into three groups of (a) apparently healthy, (b) suspected for covid-19, and (c) confirmed for covid-19, by screening questionnaires for covid-19. separate waiting and operating rooms should be assigned to each group of patients to minimize the risk of disease transmission. moreover, the same protective measures with regard to ppe for the dental clinicians and staff should be considered for all groups. therefore, private offices can choose their target group/groups based on their equipment (i.e., separate waiting and operating rooms for each group). the authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical characteristics of coronavirus disease 2019 in china transmission of 2019-ncov infection from an asymptomatic contact in germany situation report -65 coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine the workers who face the greatest coronavirus risk a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) transmission routes of 2019-ncov and controls in dental practice aerosol technology: properties, behavior, and measurement of airborne particles persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents survival characteristics of airborne human coronavirus 229e presumed asymptomatic carrier transmission of covid-19 a systematic review of asymptomatic infections with covid-19 what constitutes a dental emergency discontinuation of isolation for persons with covid-19 not in healthcare settings shedding of infectious virus in hospitalized patients with coronavirus disease-2019 (covid-19): duration and key determinants coronavirus disease 19 (covid-19): implications for clinical dental care infection prevention and control during health care when novel coronavirus (ncov) infection is suspected: interim guidance dental management of the medically compromised patient natural ventilation for infection control in health-care settings transmission routes of respiratory viruses among humans covid-19 outbreak: an overview on dentistry a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster association between clinical, laboratory and ct characteristics and rt-pcr results in the followup of covid-19 patients clinical management of severe acute respiratory infection when novel coronavirus (2019-ncov) infection is suspected: interim guidance: world health organization infection control measures for operative procedures in severe acute respiratory syndrome-related patients perioperative care provider's considerations in managing patients with the covid-19 infections what is the efficacy of standard face masks compared to respirator masks in preventing covid-type respiratory illnesses in primary care staff? east region standard operating procedure for urgent dental care hubs (udch) during the covid-19 interim infection prevention and control guidance for dental settings during the covid-19 response when to use a face mask or ff£ respirator understanding the difference (surgical masks, n95 ffrs, and elastomerics) infographic recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings clinical features of patients infected with 2019 novel coronavirus in wuhan consistent detection of 2019 novel coronavirus in saliva chemical disinfectants guidelines for infection control in dental healthcare settings disinfection of environments in healthcare and non-healthcare settings potentially contaminated with sars-cov-2 cdc. interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 infection control in dental practice during the covid-19 pandemic compliance of sterilization and disinfection protocols in dental practice -a review to reconsider basics efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review dental considerations in corona virus infections: first review in literature in vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens aerosol and splatter contamination from the operative site during ultrasonic scaling how to make choice of the carious removal methods, carisolv or traditional drilling? a meta-analysis the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment risk of hepatitis b virus transmission via dental handpieces and evaluation of an antisuction device for prevention of transmission non-steroidal anti-inflammatory drugs and covid-19 the safety of corticosteroid injections during the covid-19 global pandemic future advances in robotic dentistry digital dentistry: the new state of the art-is it disruptive or destructive potential novel strategies for the treatment of dental pulp-derived pain: pharmacological approaches and beyond key: cord-339517-93nuovsj authors: consolo, ugo; bellini, pierantonio; bencivenni, davide; iani, cristina; checchi, vittorio title: epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia date: 2020-05-15 journal: int j environ res public health doi: 10.3390/ijerph17103459 sha: doc_id: 339517 cord_uid: 93nuovsj the outbreak and diffusion of the severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) and coronavirus disease 19 (covid-19) have caused an emergency status in the health system, including in the dentistry environment. italy registered the third highest number of covid-19 cases in the world and the second highest in europe. an anonymous online survey composed of 40 questions has been sent to dentists practicing in the area of modena and reggio emilia, one of the areas in italy most affected by covid-19. the survey was aimed at highlighting the practical and emotional consequences of covid-19 emergence on daily clinical practice. specifically, it assessed dentists’ behavioral responses, emotions and concerns following the sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20), as well as the dentists’ perception of infection likelihood for themselves and patients. furthermore, the psychological impact of covid-19 was assessed by means of the generalized anxiety disorder-7 test (gad-7), that measures the presence and severity of anxiety symptoms. using local dental associations (andi-associazione nazionale dentisti italiani, cao-commissione albo odontoiatri) lists, the survey was sent by email to all dentists in the district of modena and reggio emilia (874 practitioners) and was completed by 356 of them (40%). all dental practitioners closed or reduced their activity to urgent procedures, 38.2% prior to and 61.8% after the dm-10m20. all reported a routinely use of the most common protective personal equipment (ppe), but also admitted that the use of ppe had to be modified during covid-19 pandemic. a high percentage of patients canceled their previous appointments after the dm-10m20. almost 85% of the dentists reported being worried of contracting the infection during clinical activity. the results of the gad-7 (general anxiety disorder-7) evaluation showed that 9% of respondents reported a severe anxiety. to conclude, the covid-19 emergency is having a highly negative impact on the activity of dentists practicing in the area of modena and reggio emilia. all respondents reported practice closure or strong activity reduction. the perception of this negative impact was accompanied by feelings of concern (70.2%), anxiety (46.4%) and fear (42.4%). the majority of them (89.6%) reported concerns about their professional future and the hope for economic measures to help dental practitioners. from the beginning of 2020, a new pathogen spread from china to europe and around the globe, and in march 2020, the world health organization (who) had to officialize a pandemic alert. this highly infective new virus, named severe acute respiratory syndrome-coronavirus-2 (sars-cov-2), is a coronavirus responsible of an acute respiratory syndrome, often asymptomatic but potentially lethal [1] , named coronavirus disease 19 . sars-cov-2 has an incubation period of two weeks and covid-19 clinical manifestations mainly include cough, fever and dyspnea [2] , but also anosmia, ageusia and, in few cases, diarrhea have been reported [3] . recently, also cutaneous manifestations have been observed: acral areas of erythema with vesicles or pustules (often after other symptoms) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%) [4] . airborne and direct contact contamination are the major infection pathways of sars-cov-2 [1] . airborne contamination is due to droplets released through exhalation, cough or sneeze [1] ; direct infection instead is due to contact with contaminated surfaces and eye, nose or mouth mucosa [5] . the distance and length of time that particles remain suspended in the air is determined by particle size, settling velocity, relative humidity, and air flow. droplets that are >5 µm in diameter can spread up to 1 m. the nuclei of the droplets which have a diameter <5 µm, create an aerosol which has a diffusion capacity greater than 1 m [6] . moreover, it has been reported that virus spread can also happen in absence of clinical symptoms [7, 8] . the outbreak and diffusion of sars-cov-2 and covid19 have caused an emergency status in the worldwide health system. italy has seen a rapid and massive diffusion of covid-19 and, as of the 7th of april 2020, italy registered the third highest number of covid-19 cases and the second official number of deceased subjects worldwide. the number of italian cases accounted for 9.47% of total cases worldwide, with 183,957 cases. of this sample, 94,067 were currently infected (69.37%), 24,391 (17.99%) had recovered, and 17,127 (12.63%) had died [9] . health care workers are the category with the highest diffusion of the contagion, as the italian national institute of health reports 13,121 cases of infection [9] . due to droplet production and exposure to saliva and blood, dental practitioners are at high risk of contagion during their routine procedures [1, 8, 10, 11] . sars-cov-2 transmission during dental procedures can therefore happen through the inhalation of aerosol/droplets from infected individuals or direct contact with mucous membranes, oral fluids, and contaminated instruments and surfaces [8, 9, 12] . the aim of this study is to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic professional restrictive measures due to italian national administrative order of 10 march 2020 (dm-10m20). an online structured survey composed of 40 questions has been sent to dental practitioners in order to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20). the survey focuses mainly on a specific geographical area, the provinces of modena and reggio emilia (the relevant area of our academic institution), one of the areas most involved in the covid-19 epidemic in italy. through the lists of local dental associations (andi -italian dental association, cao -commissione albo odontoiatri) it was sent to all dentists in the area and 40% of them replied. the survey was created using the free-access google forms application and the link to the online survey was sent through an anonymous mailing list to all dentists registered in the dental board commission (cao) of modena and reggio emilia district. participants provided their informed consent before completing the survey. data collection took place in the time period from 2 april to 21 april 2020. the structured survey was composed of 40 questions, divided into five sections (table 1) . section 1 included questions aimed at gathering demographic data (age and gender), and assessing the type of activity and level of experience of the respondents. section 2 was composed of questions assessing whether practitioners closed their dental practice or reduced their clinical activity following the outbreak of the emergency, whether this occurred before or after the restrictive measures introduced by the italian government in 10 march 2020 (dm-10m20), which modalities were used to inform patients, and whether patients understood the reasons for the closure/activity reduction. section 3 was composed of questions investigating the impact of the covid-19 outbreak on dental practice, which were the most common protective personal equipment (ppe) used before the covid-19 outbreak and whether habitual ppe had been changed after the outbreak. section 4 assessed practitioners' direct or indirect contact with covid-19, the feelings and emotions experienced while thinking at the covid-19 outbreak, the dentists' perception of infection likelihood for themselves and patients. it also assessed the presence of symptoms of anxiety by means of the generalized anxiety disorder 7-item (gad-7) scale [13] , which is commonly used to assess the presence of general anxiety symptoms across various populations and settings. it consists of seven items assessing how often, considering the previous two weeks, individuals have been bothered by covid-19 related problems: (1) feeling nervous, anxious, or on edge; (2) being able to stop or control worrying; (3) worrying too much about different things; (4) trouble relaxing; (5) being restless; (6) becoming easily annoyed or irritable; (7) feeling afraid as if something awful might happen. finally, section 5 of the survey assessed the practitioners' main concerns about the professional future, which measures they considered as helpful to support practitioners during and after the emergency, which protective measures they intended to use in the future to prevent the risk of infection for themselves and patients, and whether they believed the emergency situation could lead to improvements. given the nature of our survey we computed descriptive statistics for most of the questions. for each question, we computed the percentage of respondents that gave a particular answer with respect to the number of total responses to the question. for the questions "how worried are you of contracting covid-19 during your clinical activity?", "in your opinion, how likely is it that a patient can contract covid-19 during a dental service?", "how much do you think your patients are worried of contracting covid-19 during a dental service?" and "how worried are you for your professional future?", response categories were assigned a score ranging from 0 to 4 (0 = "not at all"; 4 = "extremely"). for the question "which of the following emotions (fear, anxiety, threat, concern, sadness, anger) do you feel when thinking about covid-19?" response categories were assigned a score ranging from 0 to 4 (0 = "i do not feel it", 4 = "i feel it intensely"). for each of the 7 items of the gad-7 scale, we assigned the scores 0, 1, 2, and 3 to the response categories "not at all," "several days," "more than half the days," and "nearly every day", respectively. the scores for each item were then summed to obtain a total score ranging from 0 to 21. scores from 0 to 4, from 5 to 9, from 10 to 14 and from 15 to 21 are indicative of minimal, mild, moderate and severe anxiety, respectively. we computed the pearson correlation coefficient to investigate the association between general anxiety level, as indexed by the gad-7 general score, level of concern for the professional future, level of concern of contracting the covid-19, perceived patient's likelihood of contracting the infection, and the level of concern of contracting the infection attributed to the patient. we also investigated the association between the impact of covid-19 on dental practice and level of concern about the professional future. furthermore, to assess potential differences between age groups, we submitted the mean scores obtained in the questions reported above and the gad-7 score to a one-way analysis of variance (anova) with age group (<35 years, 35 and 55 years, and >55 years) as a between-participants factor. statistical analyses were performed using the spss version 26.0 statistical software. the survey was sent to 874 practitioners and 356 of them completed it. with this sample size, the margin error at a 95 level of confidence is lower than 5%. of the respondents, 60.4% were male and 39.6% were female. the majority of participants were aged between 35 and 55 (48.6%); 34.8% were over 55 years old, while only 16.6% of them were under 35 years old. consequently, most had been working for more than 15 years (61.2%), 28.4% had been working for 6-14 years, while 10.4% had been working for less than 5 years. a large number of dentists (226; 63.5%) reported working 30-40 h or more per week, while the remaining 130 (35.5%) reported working less than 30 h per week. the majority of the compilers were practice owners (64.3%), while the others were private (34.6%) or public (1.1%) structures employees ( table 2) . all of the respondents closed or highly reduced their activity to urgent procedures, 38.2% before and 61.8% after the dm-10m20. patients were contacted mainly by phone (95.8%), only 4.2% through social channels or websites. most of them understood the reasons for the closure of dental practices or for the reduction in clinical activity (93%). a high percentage of patients (92.7%) canceled their previously-taken appointments after the dm-10m20. a large number of dentists (342, 96.1%) guaranteed telephone availability for dental emergencies. almost the totality of compilers (321, 90.2%) reported the willingness to personally take care of emergency situations. when an emergency occurred, 45% of respondents took care of it alone, and 55% of them were helped by an assistant. approximately 70% of practice owners reported an average number of 6 to 15 patients a day before the pandemic, that shifted to 0 to 5 a week in 90% of the sample. each practitioner asserted a routinely use of the most common protective personal equipment (ppe), such as gloves, masks, disposable gowns and protective glasses before the sars-cov-2 pandemic (table 3) . however, they also admitted that they had to increase the use of ppe or to modify kinds of ppe during the covid-19 pandemic (77%), or that they were still awaiting directives to do so (12.9%). only 10% have not changed their ppe, probably because they were already applying maximal ppe before the pandemic. since the beginning of coronavirus pandemic, 86% of the respondents reported difficulties in finding ppe, and 57.9% reported problems in the delivery time of dental materials. most of the interviewees (279, 78.4%) report having held information sessions dedicated to the staff on the correct use of ppe, 13.2% did not, but 8.4% said that they will soon. fortunately, only four (1.1%) respondents contracted covid-19, while 68.6% knew at least one person who has been infected. in total, 20.8% did not know anyone who has contracted the disease. for 74.4% of the respondents, covid-19 was having a highly negative impact on their professional activity (mean (m) = 3.7, standard deviation (sd) = 0.7) and the majority of them (89.6%) was quite concerned about their professional future (m = 2.7, sd = 1.02), mostly due to the uncertainty about the end of the emergency situation. the level of concern about the future was positively correlated to the reported level of negative impact (pearson's correlation index: r = 0.17, p < 0.001). dentists reported being quite concerned of contracting covid-19 during their clinical activity (m = 2.52, sd = 1.02). more precisely, 20.2% were extremely concerned, 29.2% were very concerned and 35.7% quite concerned. only 12.6% were little concerned while 2.2% were not concerned at all. 38.2% of them believed patients' concern of contracting the infection during a dental visit was quite high (m = 1.73, sd = 1.06), even though they overall considered the patient's likelihood of infection as low (m = 1.25, sd = 1.11) ( table 4 ). table 4 . dentists' concern of contracting covid-19, perception of the infection likelihood for patients and level of concern attributed to patients. when thinking about covid-19, only 4.2% of the respondents reported to experience fear intensely, while the majority reported to feel lightly (41%) or moderately (23.9%) scared. only 6.2% reported to experience anxiety intensely, while the majority reported to feel lightly (37.4%) or moderately anxious (23.6%). only 16% reported to experience concern intensely, while the majority reported levels of concern ranging from light (26.4%) to moderate (29.8). only 12.6% of respondents felt intensely sad, while 25.3% did not experience sadness at all. anger was experienced in an intense way by only 9.3% of respondents, while 44.1% of respondents did not experience anger at all. overall, these results indicate that thinking about covid-19 mostly caused concern (m = 2.23, sd = 1.11) ( table 5 ). the mean gad-7 score was 6.56 (sd = 4.48) indicating an overall mild level of general anxiety. more precisely, 42.7% of the respondents showed minimal anxiety (score 0-4), 33.3% showed mild anxiety (score 5-10), 15.2% showed moderate anxiety (score 10-14), while 8.7% showed a score indicative of a severe level of anxiety (score [15] [16] [17] [18] [19] [20] [21] . the gad-7 score was positively correlated to the level of concern about the professional future (r (356) = 0.32, p < 0.001), the level of concern of contracting the covid-19 shown by the dentists (r (356) = 0.26, p < 0.001), the perceived patient's likelihood of contracting the infection (r(356) = 0.23, p < 0.001), and to the level of concern attributed to patients (r(356) = 0.28, p < 0.001). the one-way anova showed a main effect of age group for perceived patient's likelihood of contracting the infection (f 2,353 -statistic = 1157, p < 0.001), and reported levels of concern about the professional future ( to the question "during clinical activity, which measures do you use to prevent covid-19 infection?", dentists replied highlighting a good knowledge of what is reported in the most recent indications from the literature. this question could be answered by placing multiple preferences: the highest frequency of answers concerned "reduction of number of patients in the waiting room" (87.1%) and "telephone screening/anamnesis to exclude covid-19 related symptoms" (86.5%). less frequently, "environment aeration" (77.5%), "use of ppe" (73.3%) or "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (68.8%) were indicated. other indications, provided by medical organizations and media-"environment sanitation" and "telephone screening/anamnesis to identify possible critical cases"-received 65.5% and 43.5%, respectively. the answer "body temperature measurement" received the lowest frequency of preferences (21.3%). the same question, repeated at the end of the questionnaire with reference to future behaviors, highlighted percentage variations: "reduction of number of patients in the waiting room" (84.8%), "use of ppe" (82.6%), "telephone screening/anamnesis to identify possible critical cases" (78.4%), "environment aeration" (75.3%), "environment sanitation" (74.7%), "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (66%) and "body temperature measurement" (35.7%). to the question "which aids do you think could help dental professionals during covid-19 pandemic?", for which two preferences could be expressed, the dentists replied indicating "economic relieves from italian government" (65.7%), "social security institutions support and subsidy" (44.1%)," economic relieves from dental associations" (32.1%) and "improvement of communication with patients" (8.1%). the answers to the successive question, which analyzes the category aid measures to be adopted after the emergency, maintained almost the same order of frequency in the answers. there was a decrease in the percentage for "social security institutions support and subsidy" and 9.6% for "bank account support", which was not represented in the answers to the previous question. in descending order, the percentages were: "economic relieves from italian government" (73.9%), "economic relieves from dental associations" (31.2%), "social security institutions support and subsidy" (26.1%), "improvement of communication with patients" (16%) and "bank account support" (9.6%). greater importance was given to communication campaigns with patients. the last question asked "which improvements do you think can result from the covid-19 emergency?" and multiple answers could be indicated. most of the interviewees considered "prevention procedures standardization" very important (66.9%) and a high percentage answered that there will be a "professional rhythm slow down" (36.8%) and "improvement of communication with patients" (23%). lower preferences resulted for "no improvements" (19.9%) and "stabilization of relationship with dental associations" (16.9%). dentists considered the "reduction of dental practices competition" irrelevant, which received the smallest number of indicated preferences (5.1%). since the sars-cov-2 pandemic, other surveys have been proposed by other international institutions, aimed at measuring the impact of this turmoil on dental professionals. one inquiry was performed in israel [14] , a nation where the impact of the covid-19 has been much more contained than in italy. another survey, form saudi arabia [15] , had a more global reach: 650 dentists spread out in many countries, mostly in pakistan, india and malaysia, where the dental setting might differ from western standards and where the majority of the colleagues are employed in public settings. our survey is exclusively focused on a specific geographical area, the province of modena and reggio emilia (the pertinent area of our academic institution) in northern italy, one of the most involved areas in the covid-19 outbreak in italy and, perhaps, in europe. it reached out to 874 dentists, through the lists of the local dental associations (andi, cao), and 40% of them responded. the questions on the survey were developed after reviewing pertinent literature and international guidelines [10, [14] [15] [16] . the questionnaire was designed in the italian language and comprised of questions pertaining to socio-demographic characteristics, dentists' attitudes and perceptions toward covid-19 and infection control in dental clinics. moreover, the investigation was also focused on the psychological impact and changes on the everyday dental practice. the survey was a structured multiple-choice questionnaire divided into four sections. section 1 section centered on practice and owner socio-demographical characterization: age, gender, years of service, number of operative units, number of dental assistants and collaborators. among respondents, the majority were male (60.4%) and private practice owners (64.3%), working on average in 2-3-unit offices, whilst the other part were private or public structures employees. almost half of the sample was aged between 35 and 55. young dentists, aged 35 years old or less, accounted for 16.6%. section 2 is focused on the actual and real impact of the covid-19 outbreak on dental practice nowadays: the totality (100%) of owners closed their dental offices (38.2% before the dm-10m20 and 61.8% after), assuring telephone availability in 96.1% of cases. it was not only the colleagues that were afraid of the situation, but also patients were probably aware of the risks in the dental office, since 92.7% reported cancellation directly from patients, just before the dm-10m20. as a matter of fact, three-fourths of the interviewees reported that there has been an extremely negative impact on their practices. section 3 is about the adaptive behavior to the pandemic outbreak and risk perception. this has been evaluated through the need for ppe implementation, the need for informative sessions about their correct utilization and through a generalized anxiety disorder-7 test (gad-7). sars-cov-2 has been demonstrated to remain aerosolized for 3 h after contamination and on plastics and stainless steel for up to 72 h [17] . this makes the dental community a relatively high-risk population [1] . there are practical guidelines recommended for dentists and dental staff by the centers for disease control and prevention (cdc), the american dental association (ada) and the world health organization to control the spread of covid-19 [18] [19] [20] . like with other contagious infections, these recommendations include personal protective equipment, hand washing, detailed patient evaluation, rubber dam isolation, anti-retraction handpiece, mouth rinsing before dental procedures, and disinfection of the clinic. in our survey, the vast majority performed a telephonic triage the day before the appointment, along with a full-body protection during the operative procedure. the necessity to reduce the number of incoming patients in the waiting room was held important by 87.1% of the colleagues. the way patients are received in the dental office has been modified as well, since 68.8% is providing patients with surgical mask and hand sanitizer upon arrival. surprisingly, only a small minority is considering the body temperature check upon entrance as a valid method for critical case detection notwithstanding the low cost and the good reliability of this procedure. it must be remembered that the current approach to covid-19 is to control the source of infection; use infection prevention and control measures to lower the risk of transmission and provide early diagnosis, isolation, and supportive care for affected patients. based on relevant guidelines and research, dentists should take strict personal protection measures and avoid or minimize operations that may produce droplets or aerosols [21] . only 1.1% of the practitioners referred positivity to covid-19, whereas 68.6% has at least one patient/collaborator/friend that tested positive, so this pandemic is definitely a reality in our settings. it is of interest to note that the majority of practitioners fear infection, but only a minority group is concerned about the possibility that their patients might acquire the infection. the fear of contracting covid-19 from a patient is strongly associated with elevated psychological distress. similar results are reported in a survey conducted in israel: dentists' responses to prevention measures seem better for personal protective equipment, disinfection and sanitation procedures than for measures applied to patients [14] . this could mean that the majority of the interviewees are more concerned about protecting themselves than their patients. measuring anxiety by the means of self-report questionnaires is useful [22] and has been already performed among dental practitioners and patients [23] . in this survey, fear, anxiety, concern, sadness and anger are commonly reported, but fortunately only a minority group reported intense feelings of anger (9.3%) and, as resulting from the gad-7 scale, inability to manage anger and anxiety (10.3%). overall, only 8.7% of the respondents showed a score to the gad-7 scale indicative of a severe level of anxiety. the overall level of general anxiety can be considered as mild (mean gad-7 score was 6.56, sd = 4.48). these data are consistent with those reported by another survey in israel in which elevated psychological distress was found in 11.5% of the sample [14] . what is most expected is the receipt of prompt support from both the national government and the physicians' social security institution (enpam-ente nazionale di previdenza ed assistenza). informative communication for patients is believed to be important to let them know how problems in dental offices are being ameliorated. section 4 of the essay is about the perception of our professional future. a pandemic often brings economic recession, and this is what happened during the first quarter of 2020. this pandemic will have an impact on every aspect of our global economy. some analysts have predicted that-owing to the measures enacted to stop the spread of this pandemic, such as large-scale quarantines, travel restrictions, and social-distancing measures-there will be a sharp decrease in consumer and business spending capacity until the end of 2020 and part of 2021 [24] . this will ultimately lead to a global recession. as health-care professionals, dentists have responsibilities and should explore long-term measures to avoid recrudescence and future outbreaks. this situation will be challenging for medicine and dentistry, and the financial impact on dental practices will be experienced in both the shortand long-term. it is important to note that the vast majority of the respondents reported apprehension about the professional future. what is alarming the most is the inability to prevent the end of the pandemic, followed by the impaired economy that might affect future patient turnover and the capability to pay for the dental practice expenses. moreover, one third of the interviewees expressed concern about the need to buy further devices and to adequate to new clinical protocols to counteract the spreading of sars-cov-2. this will probably result in some physicians and dentists going out of business, especially the oldest (and more experienced) ones, and might also prevent new generation dental practitioners to get into business. dentists aged between 35 and 55 years were the most concerned about their professional future. what colleagues expect as a support to adequately face their professional future is the receipt of benefits from the italian government and social security institutions, as well as from italian dental associations (cao, andi). the government will pay laid off staff for a period; however, this is only a portion of most doctors' overall costs. the dental private sector is already facing a financial crisis and this is expected to worsen, primarily due to the need of providing a better and safer working environment to our patients, staff, and ourselves. this will potentially increase business overheads and reduce profit margins even further. alternatively, professionals could start to conceptualize new paradigms and a new vision about their profession. telehealth has become an essential tool for providing care to patients [10] . it is already allowing physicians to connect with patients sparing costs and time. its use will definitely exponentially increase over time and it might become an interesting tool for dental care providers as well. dentists and oral surgeons could integrate it into their clinical practice. potential uses include preoperative and postoperative visits as well as follow-up controls, thus reducing patient coming and going in our offices. this innovation has actually received good acceptance from patients, government and health-care providers in the u.s. and can represent a new business opportunity for our colleagues [25] . the general feeling among our respondents is such that their profession will change for a long time: harsh preventive measures are felt to be necessary in the near future, such as access limitation to the waiting room, more adequate protection devices, decontamination of the working environment, but still, the body temperature check, upon patient arrival, is considered necessary only by a minority of colleagues. the answers collected by our survey are quite consistent with general recommendations provided to dentists and to other health-care providers world-wide [10, 16, [18] [19] [20] [21] . patients should be asked about their health status and any history of recent contact or travel; patients and their accompanying persons should be provided with medical masks upon entry to the clinic. patients with body temperature >37 • should be registered and referred to designated family doctors. if a patient has been to any epidemic regions within the past 14 days, quarantining for at least 14 days is recommended. at last, our survey is focused on the perception of the professional improvement: what could positively change as a consequence of the pandemic. only less than 20% believe that no improvements will occur. the majority believes that some ameliorations will arise: new standardized preventive procedures, a slow-down in the working-schedule, improvements in communicating with patients and even a diminished competition between dental practices. it is possible to foresee a better awareness about new and strict preventive protocols among dentists as a positive achievement for the category. the aids pandemic resulted in acceptance of solutions that revolutionized the standard of care throughout medicine. prior to hiv/aids, dentists did not commonly wear gloves, masks or eye protection [26, 27] . in the late 1980s and early 1990s, in an attempt to protect health care workers, cdc proposed guidelines to reduce exposure to blood-borne pathogens such as hiv and hepatitis b [28] . dentistry curbed this change at every step but these standards of protections are widely accepted and used nowadays. what will come of this pandemic? commercial air purifiers and air exchange devices are also being explored for dental settings [29] . creating negative pressure operatories may seem a drastic and expensive approach now, but it may become a normal standard a few years from now. despite the findings discussed above, it is important to stress that this survey had a major limitation, due to the fact that our investigation regarded a relatively small area in north italy-the province of modena and reggio emilia-and this prevents us being able to generalize our results. the covid-19-related emergency condition is having a highly negative impact on dental practices in the area of modena and reggio emilia-the area of our academic institution. all of the dentists that completed the survey reported practice closure or reduction, a high level of concern about the professional future and the hope of economic funding for all dental practitioners. concerns related to professional activity were accompanied by severe anxiety levels for a small percentage of respondents. this essay must be contextualized with the geographical area, northern italy-one of the most involved in terms of pandemic-and was delivered during the most critical period of the pandemic. this might have brought a sort of bias in the psychological profiling: probably more pessimistic answers could be anticipated. importantly, some improvements are expected to be derived from the actual emergency situation, such as the adoption of standardized preventive procedures, a slow-down in working-schedule, and even diminished competition between dental practices. transmission routes of 2019-ncov and controls in dental practice epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study anosmia and ageusia are emerging as symptoms in patients with covid-19: what does the current evidence say? classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice clinical features of patients infected with 2019 novel coronavirus in being a front-line dentist during the covid-19 pandemic: a literature review covid-19 transmission in dental practice: brief review of preventive measures in italy coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents a brief measure for assessing generalized anxiety disorder covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in king abdulaziz university hospital aerosol and surface stability of sars-cov-2 as sompared with sars-cov-1 clinical management of severe acute respiratory infection when covid-19 is suspected centers for disease control and prevention. cdc recommendation: postpone non-urgent dental procedures, surgeries, and visits the american dental association. coronavirus frequently asked questions the american dental association. ada recommending dentists postpone elective procedures dental phobia in dentistry patients self-assessed bruxism and phobic symptomatology the socio-economic implications of the coronavirus and covid-19 pandemic: a review the future of our specialty: is oral and maxillofacial surgery in jeopardy? gloves: some unknowns evaluation of the permeability of latex gloves for use in dental practice occupational exposure to bloodborne pathogens: osha-final rule respiratory protection against bioaerosols: literature review and research needs funding: this research received no external funding. the authors declare no conflict of interest. key: cord-335372-tncjfdtp authors: hackney, raymond w.; crawford, james j.; tulis, jerry j. title: using a biological indicator to detect potential sources of cross-contamination in the dental operatory date: 1998-11-30 journal: the journal of the american dental association doi: 10.14219/jada.archive.1998.0103 sha: doc_id: 335372 cord_uid: tncjfdtp abstract the authors conducted a study using surveillance monitoring methodology to identify operatory contamination and to evaluate the effectiveness of infection control procedures. viridans streptococci were evaluated as biological indicators of oral contamination. viridans streptococci, abundant in human saliva, were detected on operatory surfaces after dental treatments were finished and surfaces were disinfected. the findings validate current concepts of infection control as demonstrated in barrier methods. a gallup poll indicated that two-thirds of the adult u.s. population is treated in dental offices each year. 1 protecting a major portion of the populace from infections transmitted by saliva-and blood-contaminated operatory surfaces and equipment is an unending challenge for practicing dentists. the task of protecting patients and dental workers during the past decade has prompted dramatic change in what is required of dental practice. in addition to the bloodborne pathogens standard of the occupational safety and health administration, infection control guidelines published by the centers for disease control and prevention to protect patients have been mandated in all states, according to federal law. [2] [3] [4] in recent years, instrument cleaning, disinfection and sterilization have received detailed attention and definition. [5] [6] [7] [8] [9] patients can be protected from cross-infections only if each patient's oral tissues are not handled alternately with operatory equipment and surfaces contaminated with saliva and blood during the care of previous patients. 5 preventing cross-contamination requires identification of the sources of contamination, as well as the careful implementation of well-designed barriers and aseptic techniques. this article addresses the difficult task of infection control assessment and monitoring for oral contamination on dental operatory surfaces handled during dental treatment. the concepts and findings we describe in this article affirm the design of current infection control methodologies. 6, [9] [10] [11] in addition, this study also supports the importance of monitoring the potential for cross-infection in practice, research and the assessment of new dental equipment and methods. without adequate control procedures, agents of both respiratory and bloodborne diseases left on dental equipment can be transmitted to successive dental patients. intact or injured oral tissues are vulnerable to agents of hepatitis b and c, hiv, and herpes simplex 1 and 2 viruses. infection of oral and respiratory passages can result from transfer of pathogenic bacterial strains of streptococci, staphylococci and pneumococci; influenza, measles and mumps viruses; or varicella-zoster, cytomegalovirus, respiratory syncytial virus, rhinovirus, adenovirus, coronavirus, coxsackievirus or transmission of pathogenic yeasts and bacterial respiratory pathogens from patients' mouths to the mouths of successive patients after radiographic examinations. thus, contaminated operatory surfaces can act as fomites when infection control procedures are not followed. sampling and dye studies have shown that surfaces of operatory equipment handled during oral treatments become heavily contaminated. [29] [30] [31] [32] as saliva contamination is not visible, contaminated sites are easily overlooked. in a busy practice, time allowed between patients for thorough cleaning and disinfecting is often inadequate. these factors make rendering operatory equipment and surfaces free of contamination a difficult challenge. these observations have contributed to the development of guidelines for operatory asepsis. 6, 13, 26, 27, [29] [30] [31] [32] [33] [34] [35] [36] we found nothing in the literature that provided detailed documentation and evaluation of a method of assessing contamination of contact surfaces in the dental operatory, how much contamination is encountered in private operatories or an evaluation of efforts made by private office personnel in preparing operatories for safe reuse. thus, we designed this study to establish a basis for evaluating infection control procedures and equipment, and to propose an initial standard for assessing oral contamination of operatory surfaces. although pathogens can be found in bodily fluids of infected people, shedding of those pathogens is intermittent and epstein-barr virus. [12] [13] [14] [15] [16] [17] [18] [19] hiv from human sources dried on contaminated surfaces becomes inactivated quite rapidly (90 to 99 percent reduction within several hours). 20 however, hepatitis b can survive at 42 percent humidity for seven days. 21 staphylococcus aureus can survive on dried surfaces for a mean of five days. 22 one group of investigators found that when dried on patients' paper charts, herpes viruses survived approximately three hours when mixed with saliva and more than four hours when mixed with blood. 23 rhinovirus survived up to 14 hours in saliva mixed with saline; streptococcus pyogenes survived more than two days, and s. aureus survived more than five days (viable salivary bacteria could be detected for up to five days). 23 when plasticcone x-ray machines were inoculated with bacterial cultures, s. aureus was cultivated from the dry surface after 72 hours, and streptococcus pneumoniae and s. pyogenes after 48 hours. 24 mycobacterium tuberculosis can survive for six to eight months in dried sputum protected from direct sunlight. 25 lamp handles, bracket table handles, air-water syringes, suction hose handles, handpieces, switches, drawer handles, chair controls, clinicians' chairs and charts are frequently handled by oral health care workers whose hands are contaminated with blood and saliva. 26, 27 these workers may then touch their own eyes, nose, mouth or skin lesions. 15 a significant study by autio and colleagues 28 demonstrated the unpredictable. thus, testing for such pathogens can be counterproductive. this problem was handled in the science of water sanitation by designing tests to detect coliform bacteria, indigenous to the healthy human intestine, in an effort to protect drinking water from all fecal waste contamination. like the intestinal tract, the oral cavity hosts specialized indigenous microbes, which can serve as indicators of oral contamination in the testing of dental office equipment and surfaces. for an oral microbe to be an indicator organism, it must meet the following criteria: dit must be common to the human mouth; dit must survive for a useful period of time outside the mouth on surfaces and equipment; dit must be present in low numbers in nondental environments in which there is low potential for oral contamination; dit must be relatively easy to recover and distinguish from other bacteria recovered from dental operatory surfaces; dit must be recoverable from operatory surfaces and equipment known to be contaminated. viridans streptococci are common to the human mouth, are easy to detect when cultured on blood agar, and would be logical indicators of oral contamination if they meet the aforementioned criteria. 10, [37] [38] we found no reports in which such oral streptococci were evaluated as indicators of oral contamination of dental equipment surfaces. we also found few data on the survival of oral streptococci with regard to environmental temperature and humidity. investigators have documented heavy contamina-tion of clinicians' smocks, cuffs and equipment used during treatments, but they did not differentiate oral bacteria from ordinary skin bacteria. 39 seven common oral streptococcus species compose a group called viridans streptococci. they produce α-hemolysis, a zone of partial hemolysis-a greenish discoloration around each colony grown on blood agar. 40 this characteristic makes these microorganisms easy to distinguish from other bacteria found in dust and on skin that might also contaminate clinical surfaces, suggesting the usefulness of α-hemolytic streptococci, or ahs, as standard indicators for detecting oral contamination and for evaluating operatory asepsis. in this study, we assessed the validity of oral ahs as an indicator of oral contamination in the following manner: dassessing the consistency and abundance of ahs in mouths of a sample of patients; ddetermining the distribution of ahs in nondental environments, both clinical and nonclinical; devaluating environmental survival of ahs on operatory materials; dusing ahs as an indicator of contamination after cleaning and disinfection in private dental offices. survey of dental patients' saliva for ahs. the number of ahs commonly found in saliva was determined from saliva samples of 47 randomly selected general dentistry patients at dental school clinics at the university of north carolina at chapel hill. the mean age of the patients in the survey was 39.7 years; ages ranged from 20 to 71 years. of the 47 patients, 24 were male and 23 were female. each saliva sample was diluted 10 -5 and 0.1 milliliter was plated on sheep blood agar. the number of both ahs and nonhemolytic colony-forming units, or cfus, on each plate was counted. overall surface sampling methodology. we chose the swab-rinse method for all sampling because most of the surfaces encountered either were irregular in shape and unsuitable for replicate organism detection and counting sampling or were too large for the rinse method. [41] [42] [43] the swab-rinse method consisted of using a sterile cotton swab moistened in a sterile recovery medium to sample equipment and other surfaces potentially touched by contaminated hands. the entire digital contact area of a surface was sampled. the sampled surface was rubbed several times with back-and-forth strokes (about 3 to 6 centimeters long); then the swab was rotated, and the surface was rubbed with strokes perpendicular to the original strokes. the swab was broken off in a tube containing 2.0 ml of the recovery medium and transported to the laboratory for inoculation of culture plates. to prevent growth of the bacteria in the recovery medium, the samples were kept on ice until they were processed. within one hour of their collection, the samples were taken to the laboratory and processed. spread plates were prepared for each sample. each tube was vortexed for 1.0 minute to release the bacteria from the cotton swabs. the spread plates were prepared by placing 0.2 ml of the sample in 100-millimeter petri dishes containing columbia colistin naladixic acid, or cna, sheep blood agar, an enriched medium selective for gram-positive organisms. the sample was spread evenly over the agar surface with a sterile glass spreader. the plates were incubated in candle jars at 37 c for 48 hours. after incubation, ahs colonies were counted. isolates were identified according to the framework described by facklam 40 and facklam and carey. 44 three recovery media were used: trypticase soy broth, or tsb; letheen broth; and dey/engley, or d/e, neutralizing broth. after disinfectants dry on a surface, the residual disinfectant can be reactivated when moistened by the recovery media from the cotton swab. letheen broth and d/e neutralizing broth contain ingredients that neutralize disinfectants. however, it is known that these neutralizing ingredients also can have bacteriostatic effects on, and some degree of toxicity for, the recovered bacteria. 45 before the sampling in the private offices and in the general environment, we performed tests to determine which of the recovery media was most sensitive for recovery of ahs. letheen broth effectively neutralized residual phenolic disinfectants and was less toxic to the recovered ahs than was the d/e neutralizing broth. d/e broth was approximately six times less sensitive than letheen broth. 10 iodophors, chlorine and hypochlorites are sufficiently neutralized by the organic material in letheen broth, or other nutrient media, such as tsb. 45 tsb was even more sensitive than letheen broth when there were no residual disinfectants recovered in the sample. we chose tsb for sampling surfaces where disinfectants were not used, or where use was limited, because it is not toxic to the bacteria. recovery of ahs from surfaces in the general environment. we evaluated the occurrence of ahs in the general-nondental-environment by sampling surfaces commonly handled or touched in a general medical clinic, an ophthalmology clinic and a barber shop. we sampled surfaces and the entire digital contact area of each equipment handle using swabs moistened with tsb. samples were taken in the afternoon after the last of the patients or customers had been seen. the staff at the medical clinic used a phenolic disinfectant to clean the examination table between patients. other surfaces were cleaned daily with detergent and water. surfaces sam-pled in the general medical clinic included faucet handles, light handles, countertops and examination tables. in the ophthalmology clinic, a 1 percent solution of household bleach (5.25 percent sodium hypochlorite) was sprayed and wiped on all surfaces in the examination room after patients with eye infections were seen. the frequency of visits by patients with eye infections varied from daily to weekly. otherwise, surfaces were cleaned with detergent and water. the ophthalmology clinic surfaces we sampled included the head adjustment handle, countertops, the scope adjustment handle, the lens adjustment handle, patient chair armrests and the patient chair headrest. disinfectants were not used on a routine basis in the barber shop. surfaces sampled in the barber shop included armrests, countertops, clippers, drawer handles, faucet handles, the vacuum/air blower handle and scissors. microbial sampling in the dental operatory. surfaces in the dental operatory were sampled before and after dental procedures were performed in a dental school clinic at the school of dentistry at the university of north carolina at chapel hill, where licensed general dentists treated patients. surfaces of equipment handles were sampled, including the entire digital contact area of each piece. swabs used to sample surfaces that had been disinfected were moistened with d/e neutralizing broth. surfaces sampled before the procedure were the handpiece base and holder, the air-water syringe handle and holder, the syringe water, suction handles and holder, the bracket tray handle and eyeglasses worn by the dentist. a total of 45 samples were taken, before dental treatments began, from surfaces that had been cleaned. we observed the entire dental procedure, noting and counting the number of times each surface was touched by the potentially contaminated hands of the dentist, the dental assistant or both. we also noted handwashing and glove changes. after the dental treatment and before cleanup, the same sur-1570 jada, vol. 129, november 1998 the tubes of recovery medium also were incubated and growth subcultured on columbia colistin naladixic acid sheep blood agar. † no α-hemolytic streptococci, or ahs, detected. ‡ counts of 1 to 9 cfus were estimated when no growth occurred on the plates and growth was detected in the recovery medium alone. faces were resampled, as were dental instruments and other surfaces that were touched with potentially contaminated hands. a total of 91 samples were taken after dental treatments from surfaces that were touched or were potentially contaminated with saliva. after sampling, spread plates were prepared in the laboratory, as previously described. microbial survival in private dental offices after cleaning and disinfection. environmental surfaces in 10 private dental practices were sampled for ahs in the morning before dental procedures began and at the end of the day after cleanup. both sets of samples were from operatories that were "clean" and ready for the next patient. surfaces sampled included items such as handpieces, air-water syringe handles and tips, suction handles, lamp handles, door handles, telephone receivers, bracket tray handles, patient seat buttons, dentist's seat controls, x-ray units and water from the air-water syringe. the surfaces were sampled with a sterile cotton swab moistened with letheen broth (broth containing lecithin and tween 80 detergent (difco laboratories) to neutralize resid-ual disinfectants still remaining on the surfaces). we scrubbed each item or surface vigorously with the swab, using back-andforth and perpendicular strokes and rotating the swab several times. the swab was remoistened in the recovery medium two or three times for each sample; each time, the swab was pressed against the side of the tube to remove excess moisture. all items of a given type in an operatory (handpieces, for example) were sampled with a single swab. as we sampled each item, we wore gloves and used aseptic techniques. the samples were kept on ice and processed in the laboratory as previously described. the tubes with recovery medium were also incubated at 37 c for 48 hours. growth from the tubes was streaked on columbia cna blood agar plates. after incubation, the plates were examined for the growth of ahs colonies. survey of dental patients' saliva for ahs. the average number of ahs cfus counted in the survey was 6 × 107 per ml of saliva, ranging from 4 × 106 to 4 × 108. there was an average of 3 × 107 nonhemolytic cfus per ml of saliva, ranging from 1 × 106 to 1 × 108. recovery of ahs from surfaces in the general environment. ahs were detected in two of the three areas sampled; these results are summarized in (20) 1/10 (10) 4/14 (29) 8/17 (47) * samples were taken after cleanup/disinfection of operatory surfaces. 10 samples yielded low counts of ahs colonies. ten cfus were detected in three positive samples, and 20 cfus were detected in a fourth. dfrom the ophthalmology clinic, fewer than nine cfus were detected in one of 10 samples. the streptococci were detected only in the tube of sampling broth, which was incubated to detect streptococci in the sample that did not grow on the 0.2 ml of plated sample. dfrom the general medical clinic, none of the 12 samples yielded growth of ahs. didentification of the ahs detected in nondental environments showed five to be streptococcus mitis and one to be s. sanguis i. microbial sampling in the dental operatory. of 45 samples taken before dental treatments from surfaces that had been cleaned (in clinic a), three (7 percent) were positive for ahs. two of these samples were from bracket tray handles and one was from the air-water syringe handle and holder. a total of 91 samples were taken after dental treatments from surfaces that were touched or were potentially contaminated with saliva. forty-nine (54 percent) of these were positive for ahs. the four operatory surfaces most frequently touched during the 10 dental procedures observed were the air-water syringe handle (touched 12 times per treatment), the handpiece (touched nine times per treatment), the suction handles (touched eight times per treatment) and the lamp handle (touched seven times per treatment). the average time per treatment was 1.8 hours. ahs were detected on the handpiece and air-water syringe handle on 70 percent of the samples. the suction handles were positive for ahs in 50 percent of the samples. the lamp handle was not sampled because it had been covered with a plastic barrier that is removed and discarded after dental treatment. other items touched by dental personnel with potentially contaminated hands included dental instruments such as pliers, syringes, explorers, scalpels, tweezers, probes, mirror, amalgamator, camera, rubber cement container, spatula, drawer handles, lamp switch, refrigerant spray, floss holder, pencil, ruler, scissors, x-ray units, bur wrenches and cavity varnish containers. items that were positive for ahs were dental instruments, hand mirror, amalgamator, ultrasonic scaler and eyeglasses. microbial survival in private dental offices. ahs were detected on 31 percent (35 of 113) of the surfaces sampled in the morning and 45 percent (60 of 132) of the surfaces sampled in the afternoon, for a combined total of 39 percent (95 of 245) of the surfaces sampled. the fisher exact test was used to investigate the significance of the morning sampling with the afternoon sampling results. the difference was significant (p = .014). the fisher exact test was also used to compare the afternoon sampling results in the private dental offices with the sampling results in the nondental areas ( , as the samples in the nondental areas were also taken in the afternoon. this difference was significant (p = .00129). ahs were detected in all of the dental offices. in one of the offices, no ahs were detected in the morning samples, but four of 14 samples were positive in the evening. the operatory with the highest number of contaminated surfaces had a combined total of 14 positive samples of a total of 22 (64 percent). sampling results of the 10 private offices are summarized in table 2 , which also lists the type of disinfectant used in each office. the most frequently contaminated surface was the x-ray unit (eight of 14, 57 percent), followed by the handpiece (12 of 22, 55 percent) and the patient chair buttons (10 of 19, 53 percent). these results are presented in table 3 . six of the samples had high numbers of ahs: 3,001 to > 5,000 cfus. the numbers of cfus recovered in samples from the private dental operatories are summarized in table 4 . a major goal of this investigation was to determine whether certain oral bacteria found in human saliva could serve as biological indicators of the contamination of operatory equipment. a bacterial indicator of oral contamination would have to be easy to cultivate and recognize, abundant in the mouth, present in low numbers in general environmental areas where there is a low potential for oral contamination, able to survive on environmental surfaces, and detectable on dental operatory surfaces where there is known contamination. in accordance with these criteria, literature data and the results obtained in this study, the best indicator of oral contamination appears to be ahs. the following observations support this conclusion. physiological appearance. ahs have an unusual physiological appearance that makes them easy to recognize on blood agar plates. their α-hemolysis is a result of the bacterial production of hemolysin, which causes a breakdown of red blood cells around a colony on blood agar. the zone of hemolysis is a mixture of lysed and incompletely lysed cells that results in a green or brownish color. 46, 47 the term "viridans" comes from the latin term "viridis," meaning "green." 48 ß-hemolysis, exhibited by other streptococci, appears as a clear zone of completely lysed red blood cells. all seven of the common species found in saliva have α-hemolytic strains, although the strains of streptococcus salivarius are predominantly nonhemolytic (90 percent). 40 α-hemolysis gives oral streptococci a distinguishing characteristic among the other flora growing on the cul-ture plate. ease of culturing and identification. ahs were relatively easy to culture and identify; they grew well on sheep blood agar at 37 c. because growth conditions that provide increased carbon dioxide are favorable for streptococci, studies were conducted using candle jars in which colonies were visible after 18 to 48 hours. typical colonies were transparent to opaque, 1 to 2 mm in diameter, with an α-hemolytic zone of 2 to 3 mm after 48 hours' incubation. positive samples, those with colonies exhibiting α-hemolysis, should be confirmed for the presence of streptococci with gram's stain and catalase test. presence in saliva. ahs were found in high numbers in saliva. the survey of saliva from patients who visited the dental school clinics showed that ahs averaged about 6 × 107 organisms per ml of saliva, ranging from 4 × 106 to 4 × 108. the nonhemolytic colonies of the various species of the viridans streptococci averaged about half the number of the ahs colonies, although there were some patients with more nonhemolytic jada, vol. 129, november 1998 1573 * numbers of colony-forming units, or cfus, are based on colony counts grown from 0.2 milliliters of the 2-ml recovery medium used to suspend each sample. the tubes of recovery medium also were incubated and growth subcultured on columbia cna sheep blood agar. † counts of 1 to 9 cfus were estimated when no growth occurred on the plates and growth was detected in the recovery medium alone. than ahs colonies. presence in general environment. ahs were detected in low numbers and frequency in the general environment. although the ahs were detected in samples from nondental environments, they were present in low numbers. one or two α-hemolytic colonies were observed on spread plates of four of the samples taken in the barber shop. none of the other spread plates for the nondental samples grew ahs colonies, although one sample from the ophthalmology clinic grew the indicator organisms in the recovery medium. the fisher exact test was used to compare the afternoon sampling results in the private dental offices with the sampling results in the nondental areas (16 percent, five of 32), since the samples in the nondental areas were also taken in the afternoon. this difference was significant (p = .00129). the difference is attributed to the activity of saliva-contaminated hands' touching surfaces in a dental operatory despite the efforts of dental personnel to clean and disinfect those surfaces. although this activity does not take place in barber shops or medical clinics, ahs were detectable there nevertheless. ahs also are dispersed into the environment through sneezing, coughing and talking. detection of low numbers of ahs in the general environment is acceptable; however, a higher standard should be applied to an environment in which instruments and fingers of clinic personnel touch or penetrate the mucous membranes of patients. 6 survival on dental operatory surfaces. ahs survived on environmental surfaces for several days. 10 however, relative humidity has a pronounced ef-fect on the survival of ahs in saliva dried on surfaces. there is accelerated die-off at high relative humidities, or rh. at 75 percent rh, the die, or d, value-the time for 90 percent to die, or one logarithm reduction-was demonstrated to be only two hours, whereas at lower rh of 53 percent and 33 percent, the d value was 12 hours and 60 hours, respectively. 10 we used the fisher exact test to compare the private dental office sampling results from the morning (31 percent [35 of 113] of the samples were positive for ahs) with those from the afternoon (45 percent [60 of 132] positive for ahs). the difference was significant (p = .014). this difference is attributed to the die-off of the indicator organisms during the approximately 15 hours after the last patients were seen the day before. the rh in the private dental offices ranged from 30 to 40 percent when the samples were taken. presence on operatory surfaces. ahs were detectable on contaminated operatory surfaces. the indicator organisms were isolated from surfaces immediately after dental procedures and before cleanup. in private office operatories, the indicator organisms were found on surfaces that had been cleaned and were ready for the next patient. thirty-nine percent (95 of 245) of samples taken from "clean" operatories in private practices were positive for the indicator organisms, clearly showing the potential for cross-contamination between patients. we compared the findings of 95 positive samples among 245 total samples with the goal of zero positive samples among 245 total sam-ples. the probability that a proportion that large would happen by chance is far less than one in 10,000. although the primary criterion for interpretation of the monitoring results is whether or not ahs are detected, actual colony counts recovered might assist in evaluating the potential for cross-contamination. surfaces with higher counts of ahs would indicate a higher risk of cross-contamination between patients. ten (4 percent) of the samples had high counts (> 100), estimated to be > 1,000 cfus recovered in sampling. six of these had very high counts, ranging from 300 to more than 500, a total considered too numerous to count but estimated to be from 3,001 to more than 5,000 cfus recovered. it should be understood, however, that the swab-rinse sampling methodology is not a precise measurement of the amount of contamination on a surface. colony counts would depend on variables such as the swabbing technique used and the condition of the surface sampled. colony counts also vary depending on the amount of saliva contamination on a dental care worker's gloves before he or she uses an item and the amount of digital contact he or she makes with the item. for these reasons, any indication of residual contamination should be considered significant in efforts to provide a safe treatment environment. implications of the findings. the environment presented to patients should be free of oral bacteria from previous patients; thus, the goal is that ahs should not be detected on any of the operatory surfaces. since each of the 10 offices was sam-pled twice, a total of 20 sets of samples were taken. as shown on table 2 , only one of the 20 sets was negative for all samples. this finding indicates that the time necessary for thorough cleaning and disinfection is not available in a busy dental practice. disinfection practices should include initial surface cleaning to physically remove debris and much of the contamination. well-cleaned surfaces then should be thoroughly wetted again with fresh disinfectant, allowing as much contact time as possible, according to the manufacturer's instructions. 9, 49 all of the offices surveyed stated that operatory surfaces were disinfected between patients. the types of disinfectants used in each office are listed in table 2 . however, a number of surfaces were left contaminated despite the use of various disinfectants. our finding indicates the difficulty of completely disinfecting all irregular operatory equipment surfaces with consistency. this observation supports the concept that cleaning and disinfection of equipment surfaces is not the most effective or reliable approach to infection control in the busy dental practice. asepsis implications and recommendations. alternatives to complete reliance on disinfection procedures can and should be implemented to control cross-contamination. 6,13,26,27,29-36,50,51 a more effective control method is the use of inexpensive, single-use, disposable plastic bags over surfaces that must be touched during treatments, such as the airwater syringe, the lamp handle, the suction handle, the dental control unit and even the chair. 8 covers can be replaced rapidly between patients, eliminating the need for disinfection unless the bag comes off or its integrity is broken. 11, 30 another effective approach is to prevent direct contact of contaminated gloved hands with occasionally contacted surfaces. this can be achieved in several ways. foot controls rather than chair buttons should be used to adjust seats and to operate water faucets for handwashing. dentists and dental assistants should use a paper towel or remove gloves to hold phones or to touch other surfaces that must not be contaminated during treatments. handpieces and other intraoral dental equipment should be designed to be removed and sterilized between appointments. sampling methodology. the swab-rinse method is preferred for microbial surface sampling in the dental operatory, because it is a simple method suitable for the irregular surfaces encountered in the operatory. the recovery medium should have disinfectant neutralizers if the surface has been treated with a disinfectant that leaves a residual that is reactivated when the surface is moistened. letheen broth effectively neutralizes phenolic disinfectants, quaternary ammonium compounds and iodophor disinfectants, and is more sensitive (not as toxic) for recovering the indicator organisms than d/e neutralizing broth. 10, 45 incubating the recovery broth and then streaking the resultant culture on blood agar increases the sensitivity of the sampling method. sampling consistency is critical. it is recommended that the moistened swab be pressed firmly against the surface, using vigorous scrubbing, reversing directions, with perpendicular strokes, while rotating the swab frequently. all areas of a given surface should be sampled (unless it is too large to be practical), with the swab being remoistened two or three times during the sampling. during moistening and remoistening, the swab should be pressed and rotated against the side of the tube to remove excess moisture. more than one instrument can be sampled with a single swab. 43 the goal in dental asepsis is to break the chain of transfer of blood and blood-contaminated saliva from each patient's mouth to surfaces in the dental operatory and to other patients via contaminated equipment or the hands of dental personnel. in this study (performed before the use of disposable plastic covers became widely recommended), the extensive detection of ahs on unprotected, inadequately disinfected surfaces should be interpreted as a potential for cross-contamination. our detection of ahs in the operatory on unprotected disinfected surfaces indicated the inadequacy of surface disinfection practices. these findings validate and reinforce current concepts of infection control advocated and used widely in dentistry 6,11 : duse of single-use plastic covers over surfaces handled with contaminated gloved hands during treatment, as barriers to contamination; davoidance of unnecessary touching of unprotected items and surfaces directly with contaminated gloves without using an additional clean barrier such as a paper towel or forceps; dsterilization of all other items or equipment that must be handled in the treatment field and cannot be protected in another fashion. this study indicates the usefulness-possibly for a number of applications-of an infection control surveillance monitoring methodology in dental practice environments using biological indicators. these surveillance methods can aid in evaluating equipment and techniques developed for infection control. sampling for indicator organisms also can be used epidemiologically to help determine the routes of infection transmission when investigating outbreaks in a dental clinic or practice. outside consultants or public health organizations required to evaluate asepsis in dental practices can use this technique for indicator organisms as part of an overall monitoring program. dental schools can use the technique as a teaching tool to show students the potential for crosscontamination and to teach or evaluate aseptic techniques and infection control practices. more imminently, sampling for indicator organisms can serve as a process control by dental practitioners. this can help identify hazards in dental practice before the public is harmed, and can be used to raise dental personnel's level of awareness of the potential for disease transmission. heightened awareness can encourage continued adherence to infection control procedures. such self-evaluation by the dental profession could eliminate any potential sources of crosscontamination that might have thus far escaped scrutiny by the profession or the public, ideally preventing any eventual need for greater outside controls of dental care asepsis. i d o you have comments or questions about this article? jada now offers an online resource called ask the author, which can put you in touch with the author of one featured article per issue. check out ask the author in the ada publishing co. portion of ada online at "http://www.ada.org". 21:1. 2. occupational safety and health administration. standard, occupational exposure to bloodborne pathogens. 1030 federal register recommendations for preventing transmission of human immunodeficiency virus and hepatitis b virus to patients during exposureprone invasive procedures the public health and welfare act centers for disease control. recommended infection-control practices for dentistry infection control and management of hazardous materials for the dental team how to choose and use environmental surface disinfectants oral bacteria as biological indicators for dental asepsis (dissertation) university of north carolina at chapel hill the art and science of operative dentistry wilford hall usaf medical center and office of the assistant secretary of defense; 1985. 14. crawford jj. new light on the transmissibility of viral hepatitis in dental practice and its control transmission of rhinovirus colds by self-inoculation low occupational risk of human immunodeficiency virus infection among dental professionals herpetic whitlow: report of a case with multiple recurrences getchell-white si, donowitz lg, groschel dhm. the inanimate environment of an intensive care unit as a potential source of nosocomial bacteria: evidence for long survival of acinetobacter calcoaceticus survival of herpes simplex virus and other selected microorganisms on patient charts: potential source of infection interpatient microbiological cross-contamination after dental radiographic examination miller ch, palenik cj. infection control and management of hazardous materials for the dental team barriers can minimize occupational exposure risks to contagions clinical asepsis in dentistry evaluation of spatter and aerosol contamination during dental procedures council on dental materials and devices and council on dental therapeutics. infection control in the dental office baltimore: williams & wilkins; 1996. 35. crawford jj. sterilization, disinfection, and asepsis in dentistry cross infection control in dentistry: a practical illustrated guide oral microbiology a bacteriologic census of human saliva indications of the sanitation level in a dental clinic physiological differentiation of viridans streptococci biosafety committee. biosafety reference manual a comparative evaluation of methods for determining the bacterial contamination of surfaces comparative evaluation of the cotton swab and rodac methods for the recovery of bacillus subtilis spore contamination from stainless steel surfaces manual of clinical microbiology the use of inactivators in the evaluation of disinfectants ecologic studies of rheumatic fever and rheumatic heart disease taranta a, moody md. diagnosis of streptococcal pharyngitis and rheumatic fever oral streptococci with emphasis on streptococcus mutans council on dental materials and devices and council on dental therapeutics. current status of sterilization instruments, devices, and methods for dental office dental asepsis key: cord-031178-6gnjpmfy authors: khan, ifrah title: being mindful of the environment: why does it matter to dental students? date: 2020-09-01 journal: bdj student doi: 10.1038/s41406-020-0149-3 sha: doc_id: 31178 cord_uid: 6gnjpmfy nan the regulation of amalgam (2018) 5 prohibited use of amalgam in deciduous teeth or children under 15 prohibited use of amalgam in pregnant or breastfeeding women, unless it necessitates the need to meet specific health requirements of the patient. it is compulsory to use amalgam separators amalgam waste must be disposed of correctly, in line with authorised waste collectors adapted from british dental association. dental amalgam. 2020. online information available at https://bda.org/ amalgam (accessed february 2020) ' it is essential that dental schools across the uk teach students to adopt a holistic approach to dental care' 'd entists use a lot a plastic' a year 5 pupil told me, matter-of-factly, at a dental community engagement project at a local primary school in plymouth. up until that moment, it had never occurred to me that the carbon footprint of the dental profession was an area of concern. it got me thinking, how can we as dental students, the leading dentists of tomorrow, consider being more sustainable practitioners? concern among our generation for the future is growing -as we know, the long term prognosis of the world we live in isn't great. dentistry has an important opportunity to address the sustainability of services and set an example for the rest of the nhs and for the wider profession. for students and dentists alike, covid-19 has changed much of that. with patient priorities changing, potentially meaning that routine check-ups are out the window for the time being, chances to create ways to reduce, reuse and recycle are slim. the climate change act 2008, has set a target for the uk net carbon account in the year 2050, to be at least 100% lower than the 1990 baseline of greenhouse gas emissions. 1 in 2018, the uk carbon emissions was 44% below the 1990 levels 2, but targets to meet the next carbon budget do not appear to be on track for the uk. is the main issue of dental carbon footprint is commuting? between 2013 and 2014, 64.5% of greenhouse gas emissions came from travelling to and from dental care practices. this was the highest percentage of the total carbon emissions in nhs primary dental care, in england. 8 in 2018 phe wrote the report carbon modelling within dentistry, towards a sustainable future. comparing the 2013/14 data with now, new academic studies have shown that global carbon dioxide emissions dropped roughly 17% during the forced confinement (not dental specific). aside from greenhouse gas emissions, some other causes for concern include decontamination and waste disposal along with the use of single-use plastics. 3 as practices across the uk gradually re-open their doors, clinicians up and down the country are dressed head to toe in full ppe, much of which is single use and much of which is made of plastic. guidance across the uk on public health and ppe is country specific but the primary focus is protecting human health and stopping the spread of covid-19. at this point in time even the most environmentally concerned among you will need to follow the public health guidance specific to your country. this will sadly mean a lot of plastic. at the moment, that is what you must do until the restrictions ease or the guidance changes. it's not a comfortable place to be but while there are so many unknowns about the virus the guidance must be followed. two of the most commonly used dental restorative materials include amalgam and resin-based composites. there has already been a call to phase down the use of amalgam as a restorative material in dentistry, not just within the uk but also on an international scale. under the minamata convention, dental professionals are responsible for protecting human health and the environment from anthropogenic emissions of mercury compound. 4 this means limiting or prohibiting the use of amalgam on specific patients (summarised in table 1 ) 5 and adhering to the mandatory guidelines of mercury waste disposal. with the growing use of composites as an alternative to amalgam fillings, it is necessary to consider the possibility of leaching waste products from resin-based composites and monomers into our environment. chemicals including eluates and micro-particulates are carried out via the dental chair water systems exiting the surgery, commonly after removing resin-based composites or while polishing them once placed. these have had negative effects on some sea life. while bpa and methacrylate, two of the chemicals associated with resin-based composites, have been shown to have an effect on human development. the challenge remains to identify to what extent these chemicals affect humans and the environment, but it is evident that they are environmental pollutants. 6 what can dental students do? greenhouse gas emissions released as a result of travelling to and from dental clinics could be reduced in a number of ways. for example, opting to walk, cycle, or take shared modes of transport such as buses, trains or car-pooling. likewise, time management and effective treatment planning will enable https://doi.org/10.1038/s41406-020-0149-3 patients to attend an appropriate number of appointments, reducing their overall travel and surgery time. 8 in the current climate, using public transport is a more uncomfortable thought for many. car sharing has always been suggested as an appropriate means of reducing a carbon footprint -but that now is fraught with uncertainty -single car occupancy feels much safer. the toolkit for a greener dental practice written in the heady days of pre-covid-19 suggested encouraging staff/ colleagues that live close to the practice to cycle or walk. dental teams can join the bda good practice programme, which encourages dental professionals to work towards achieving sustainable goals for better practice. 7 conserving the natural tooth structure is one of the key approaches to reducing the need for restorations. all dental professionals can limit the use of dental materials by adopting an evidence-based approach to caries removal and cavity preparation. an international team of researchers at the university of plymouth have recently completed a study, which focused on the use of stem cells to aid tooth wound healing. experiments on laboratory-based models have shown promising results in the development of a novel solution in the science of tooth repair. although further studies are required for use on humans, it could potentially be a method for managing dental caries in the future. 9 areas of research to consider ¾ conservative and regenerative dentistry ¾ dental materials and sustainability ¾ sustainable practice management. as ever, it is incumbent that dental students deliver an impactful message on prevention to their patients. it is essential that dental schools across the uk teach students to adopt a holistic approach to dental care, by promoting healthy lifestyle choices in addition to effective oral hygiene. 7 dental students should be mindful of their contribution to the carbon footprint. although more research is required on the impact of dentistry on the environment, there is evidence that some dental materials have undesirable consequences on humans and the environment. it is essential that dental professionals remain familiar with the legislation surrounding the use of materials not only so that an improved service of care is delivered to patients, but also as a part of a greater responsibility towards global sustainability. there are many resources designed to aid our knowledge of sustainability in dental practice. here are a few to broaden horizons and your understanding: ¾ centre for sustainable healthcare -https://sustainablehealthcare. org.uk/dental-guide ¾ bdj collection on sustainable dentistry: -https://www.nature. com/collections/ djidaaddgi ¾ bda -what they are doing to improve sustainability in practice: -https://bda.org/ news-centre/blog/whatcan-we-do-to-makedentistry-more-sustainable ' as ever, it is incumbent that dental students deliver an impactful message on prevention to their patients' climate change act online information available at https:// www.theccc.org.uk/tackling-climate-change/ reducing-carbon-emissions/carbon-budgets-andtargets online information available at https:// bda.org/about-the-bda/campaigns/sustainable/ pages/sustainability-in-dentistry minimata convention the environmental impact of dental amalgam and resin-based composite materials bda good practice an estimated carbon footprint of nhs primary dental care within england. how can dentistry be more environmentally sustainable? a new method of tooth repair? scientists uncover mechanism to inform future treatment key: cord-302863-9e5ajbgq authors: alhabdan, yazeed abdullah; albeshr, abdulhameed ghassan; yenugadhati, nagarajkumar; jradi, hoda title: prevalence of dental caries and associated factors among primary school children: a population-based cross-sectional study in riyadh, saudi arabia date: 2018-11-30 journal: environ health prev med doi: 10.1186/s12199-018-0750-z sha: doc_id: 302863 cord_uid: 9e5ajbgq background: dental caries is a preventable childhood disease, but public health efforts are hampered due to limited information on associated factors in vulnerable populations. our study was aimed at estimating the prevalence of dental caries and identifying key associated factors in four major risk domains, including socioeconomic factors, child oral health behavior and practices, child feeding practices, and dietary habits among primary school children in saudi arabia. methods: a cross-sectional study design was used to recruit 578 male saudi primary school children, aged 6–8 years, from 12 primary schools in five different regions of riyadh. children were clinically screened to detect carious lesions in primary teeth according to world health organization’s criteria. structured self-administered questionnaire was used to collect information on social and individual factors from the parents. the odds ratios and 95% confidence intervals of associated factors for dental caries were computed using logistic regression models; key factors were identified by systematic selection process that accounted for multicollinearity and bias correction. results: dental caries was prevalent among children (83%, 95% confidence interval 79.7–86.0%). individual factors, including irregular brushing, late adoption of brushing habit, consulting dentist for symptomatic treatment, lack of breast feeding, sleeping with a bottle in mouth, habit of snacking between meals, low consumption of fruits, and frequent consumption of soft drinks and flavored milk, were predominantly associated with dental caries in children, instead of socioeconomic factors (p < 0.05, adjusted r-square 80%). conclusion: dental caries were prevalent in school children, and individual factors were predominantly associated with the disease. electronic supplementary material: the online version of this article (10.1186/s12199-018-0750-z) contains supplementary material, which is available to authorized users. dental caries is a major oral health problem affecting 2.43 billion people (35. 3% of the population) worldwide in the year 2010 [1] . a high burden of dental caries was evident among children in saudi arabia with an estimated prevalence of approximately 80% [2] ; other high-risk areas include latin america, middle east, and south asia [3] . the world health organization (who) emphasizes the need to reduce global burden of dental caries in attaining optimal health. consequently, in the year 2003, who and fédération dentaire internationale (fdi) world dental federation set global goals for oral health in 2020 to guide planners and policy makers to improve the status of oral health in their populations [4] . unfortunately, knowledge gaps with respect to the availability of baseline data on oral health and population-specific key modifiable factors of dental caries restrict the ability of many developing nations and semi-developed countries, including saudi arabia to attain the goals set by who. in addition, competing interests in health care funding warrant prioritizing the associated factors to better direct public health mitigation efforts. although factors, such as occupational status, family income, and level of education of parents [5] [6] [7] [8] [9] that affect the socioeconomic status of populace, have been associated with dental caries, their relative impact on dental caries compared to individual factors is unclear. moreover, modification of socioeconomic factors requires time-consuming macro level changes. in contrast, individual factors, such as child oral health behaviors, child feeding practices, and dietary habits that play a role in cariogenesis, could be targeted for modification by directing the limited resources to primary school children. prior evidence illustrates the importance of adopting good oral health behaviors such as regular brushing of teeth, using mouthwash, and flossing teeth in reducing the disease burden and attaining optimal oral health [10] . similarly, the role of sugary foods (e.g., candies) in cariogenesis was also well established [11] . however, the relative significance of aforementioned oral behavioral factors on cariogenesis compared to other host factors could vary significantly in different populations owing to cultural and behavioral practices. in our globalized world, constant migration of individuals and transfer of certain behaviors or practices (e.g., favoring flavored milk over plain milk among children) [12] is the prevailing norm. therefore, the knowledge of associated factors for dental caries in saudi children not only benefit saudi populace but also international organizations such as who and health authorities in directing the mitigation efforts at vulnerable populations (e.g., children). this study aimed at estimating the prevalence of dental caries in primary teeth and identifying key associated factors in 6-8-year-old school children in riyadh city of saudi arabia would contribute towards the knowledge of dental caries by enriching the baseline data and determining population-specific risk factors of such a highly prevalent and preventable condition. our analysis is the first in saudi arabia to comprehensively evaluate and prioritize factors encompassing all four major risk domains for dental caries, including parental socioeconomic status, children oral health behavior and practices, child feeding practices, and dietary habits. in addition, the relative importance of individual factors (over socioeconomic factors) as determinants of dental caries was assessed using extensive modelling techniques. a population-based cross-sectional study design was employed to determine the burden of dental caries in primary teeth and key associated factors among 6-8-year-old male primary school children recruited from 12 government primary schools for boys located in 5 geographical regions (southern, northern, eastern, western and central) in riyadh city, saudi arabia. the study included only saudi nationals, whose parents were able to fill the self-administered questionnaire and provide informed consent for their child's dental examination at school. non-saudi children or children with non-saudi care givers or parents were excluded. this study was conducted in the year 2015 between september 1 and november 30. sample size was calculated using single proportion formula based on 95% confidence level, expected prevalence of 80% [2] , precision of 0.05, and design effect of 2. the recommended sample size was 492 children with one of their parents as a single unit. we anticipated low response rate owing to the outbreak of middle east respiratory syndrome-corona virus (mers-cov) in riyadh city during the study period. therefore, a total of 1130 questionnaires were distributed to parents and we received 578 completed questionnaires at a response rate of 51% from 12 out of 15 schools considered for recruitment among 513 government primary schools for boys in riyadh region. our study sample was obtained by a multistage random sampling technique. briefly, up to three primary schools in riyadh were randomly selected from each of the five geographical locations in riyadh city based on the list of primary schools obtained from the ministry of education. a maximum of 80 students were randomly selected from each of these schools. each of the five regions in riyadh city contributed a fifth of the total study sample. children underwent a simple dental examination based on the world health organization diagnostic criteria for oral health surveys [13] . the basic oral assessment of every child was performed by a single, well-trained professional dentist by seating each subject on a chair in a good day light using mouth mirror and dental probes. this simple oral examination poses no harm to children. the intra-examiner reliability was good based on re-examination of 30 children prior to the study (kappa value = 0.98). caries status in the crown of primary teeth was assessed using decayed (d), missing (m), and filled (f) teeth (dmft) index [2, 13] ; teeth missing (m) or filled (f) contributed to the overall dmft score only if they were missing or filled because of caries. a dmft score above null indicates the presence of caries, whereas a null score indicates the absence of caries [13] . a structured self-administered parental questionnaire was developed by relying on previous studies [13] [14] [15] [16] [17] [18] [19] [20] and accounting for cultural sensitivities of the study population. the questionnaire was translated into arabic and then back to english to ensure accuracy. face validity, feasibility, and construct validity of the questionnaire was established prior to study. the questionnaire responses provided data on age of the child, demographic and socioeconomic factors such as father's education level, mother's education level, parental occupation as health care provider, monthly income of the family, region of residence, type of residence, and availability of medical insurance with dental coverage. parents also provided information on oral health behavior and practices of children, such as frequency of brushing teeth with toothpaste in a day; age at which children started brushing; use of dental floss; use of mouthwash; frequency of fluoride application; recent visit to the dentist; habit of eating after brushing teeth in night; and child feeding practices, such as type of milk feeding practice (breast-fed only/children mixed-fed with both breast milk and powdered milk/powdered milk only), age of child when breast feeding was stopped, age of child when bottle feeding was stopped, child sleeping with bottle in mouth, number of meals per day, number of snack items consumed between meals, and snack time corresponding to main meals (ate snacks with main meals only/ate snacks in between main meals or with main meals). dietary information included use of multivitamin supplementation (no/yes) and consumption of fresh fruits, fresh vegetables or salads, fast food, candy, potato chips, sweetened chewing gum, fresh juice, flavored juices, soft drinks, fresh milk, and flavored milk at least twice a week (no/yes). some of the original variable categories were combined to create meaningful new groups, and facilitate appropriate analyses. in particular, the 'frequency of brushing teeth' variable was classified in to 3 categories (children brushing less than once daily/once daily/two times or more daily. all analyses of study data were performed using sas software version 9.4 (sas institute inc., cary, nc, usa). categorical variables were described as counts and percentages, whereas means and standard deviations (sd) were computed for continuous variables. the 95% confidence intervals for proportions were constructed using clopper-pearson exact tests. the independence of characteristics of study sample by caries status (presence or absence) was assessed using pearson's chi-squared test (or fisher's exact tests for smaller samples) and p values. missing data were analyzed as a separate category (unknown or other) in corresponding variables. the main associated factors for dental caries in our study were determined in three steps. in the first step, the association between each characteristic of study sample and the presence of dental caries was evaluated using univariate logistic regression analyses; all the variables that were significant at p value less than or equal to 0.05 were selected for second step of analyses. in the second step, the associated factors for dental caries among each of the four broader determinants of health, including socioeconomic factors, child oral health behavior and practices, child feeding practices, and dietary factors, were identified based on four separate stepwise logistic regression analyses. subsequently, the covariates that were significant (p ≤ 0.05) in each of the four analyses were selected for further analysis. in the final step, a stepwise multivariate logistic regression analysis was performed on covariates selected from step two and variable age group of the child (6 or 7 or 8 years) to determine key associated factors for dental caries. in addition, multicollinearity was assessed using collinearity indices, eigenvalues, and variable decomposition proportions for all the multivariate models. one of the highly collinear variables was removed giving precedence to children oral health behavior and practice covariates. in addition, firth's bias correction was applied to the final multivariate model to address potential issues due to small sample size, and complete or quasi-complete separation. the measures of association were reported as unadjusted odds ratios (uor) and adjusted odds ratios (aor) along with their corresponding 95% confidence intervals (95% ci). the discrimination, calibration and overall performance of the final multivariate model was assessed using concordance statistic, hosmer and lemeshow goodness-of-fit test, and adjusted cox and snell r-square, respectively. the performance of final model with and without socioeconomic factors was compared based on adjusted cox and snell r-square, which indicates the proportion of variation explained by the covariates in the model. statistical analyses that yielded a p value less than or equal to 0.05 were considered significant. a total of 578 primary school boys aged 6 to 8 years in riyadh, saudi arabia, were analyzed in this study. the prevalence of dental caries in our sample was 83% (95% ci 79.7-86.0%). about 17% (95% ci 14.0-20.3%) of children had no carious lesions. the age-specific prevalence of dental caries among children aged 6, 7, and 8 years was 87.6% (95% ci 82.4-91.6%), 72.9% (95% ci 65.9-79.1%), and 88.4% (95% ci 82.7-92.8%), respectively. the mean age and dmft score in our sample was 6.92 (sd ± 0.82) and 4.20 (sd ± 2.96), respectively. table 1 provides the frequencies, percentages, and differences (by caries status) for various characteristics of study population. a significant number of fathers (65.7%, 95% ci 61.7-69.6%) and mothers (73.9%, 95% ci 70.1-77.4%) did not attend a college or university, and their children experienced high prevalence of dental caries. majority of the children came from low-income families (59.7%, 95% ci 55.6-63.7%), and approximately 99% of them experienced dental caries. most of the study subjects lived in rental homes, and 77% had no dental coverage in medical insurance. in general, the children had poor oral health behavior and practices as most of them started brushing at a late age (5 or more years) and brushed less than once daily (55%) in any given week. the use of dental floss and mouthwash was negligible, and most of the children visited a dentist for symptomatic treatment. although the practice of breast feeding is common, most of the children were weaned by the first year. the practice of mixed feeding was common in our sample; approximately 81% of mixed-fed children experienced dental caries compared to 93% of children that were exclusively fed with either breast milk or powdered milk. the practice of sleeping with a bottle in mouth and frequent consumption of sugary snacks between meals was also common. the consumption of fresh fruits and fresh juice was less prevalent in our sample. the summary of variables selected during different steps of selection process is illustrated in table 2 . barring few exceptions, almost all the factors were significantly associated with dental caries' experience in univariate analyses (step 1). in the ensuing step 2 multivariate analysis, a limited number of factors were associated with dental caries in each of the four risk domains with more concessions observed among dietary factors. in the final step of model selection, the highly collinear child feeding covariate (i.e., age of the child when breast feeding was stopped) was excluded to address multicollinearity. our model selection process yielded 12 variables that were significant at p < 0.05 for inclusion in the final model. although association measures were not provided in table 2 to avoid confusion, interested readers could find these details in additional file 1. the unadjusted and adjusted odds ratios along with their 95% confidence intervals (based on firth's bias correction) for the variables, representing all four risk domains, in the final model are reported in table 3 . it should be noted that factors representing low socioeconomic status, such as low level of maternal education, low family income, and lack of dental insurance, were associated with a minimum of fourfold increased dental caries experience. child oral health practices, such as failure to brush teeth at least once a day, failure to start brushing on or before a child attained 2 years of age, and visiting dentist for symptomatic treatment, were associated with dental caries experience in children. children habituated to sleeping with bottle in mouth experienced 4.4-fold higher dental caries compared to children not practicing this habit (aor = 4.4, 95% ci 1. 4-13.4 ). in addition, lack of mixed feeding and consuming two or more sugary snack items between meals were predominantly associated with dental caries experience (p < 0.05). dietary habits, such as less consumption of fresh fruits and frequent consumption of soft drinks and flavored milk, were significantly associated with dental caries with an odds ratio of 11.6, 5.3, and 7.7, respectively. the final model was well calibrated (p = 0.7667; hosmer and lemeshow goodness-of-fit test) with very high discriminatory power (c-statistic = 99%) and high overall performance (adjusted r-square of 88%). subsequent exclusion of three variables representing socioeconomic status from the final model also resulted in a well-calibrated model (p = 0.3502; hosmer and lemeshow goodness-of-fit test) with very high discriminatory power (c-statistic = 98%). however, a slight reduction in overall performance from 88 to 80% was noted, signifying the influence of individual or personal factors (represented in the remaining three risk domains) on dental caries experience in children; the overall performance of model with variables representing socioeconomic status was 59%. in addition, the higher magnitude of adjusted odds ratios of individual factors (ranging from 4.4 to 38.4) compared to aors of socioeconomic factors (ranging from 4.2 to 28.2) and the lower confidence limits that were consistently above 1.5 lend further support to the predominant flavored milk x x x *the variables selected in the step were marked with an "x," and variable excluded is marked as "-." the variables selected were significant at p value less than or equal to 0.05 †the variable "age of the child when breast feeding was stopped" was excluded to address the issue of collinearity in the final model influence of individual factors on dental caries' experience in children. dental caries was prevalent among 6-to 8-year-old primary school children in saudi arabia (83%, 95% ci 79.7-86.0). we identified individual factors, encompassing three major risk domains (children oral health behavior and practices, child feeding practices, and dietary habits) that were predominantly associated with dental caries' experience in our study. especially, child oral health behavior and practices, such as brushing teeth at least once daily, starting the practice of brushing earlier than 2 years, and visiting a dentist regularly, were significantly associated with dental caries. in addition, children mixed-fed with both breast milk and powdered milk, children sleeping with bottle in mouth, and the practice of snacking two or more items between meals were linked to dental caries experience in children. dietary habits, such as less frequent consumption of fresh fruits (once a week or less) and more frequent consumption of soft drinks and flavored milk (more than once a week), were significantly associated with dental caries in our study. in our sample, socioeconomic factors (less-educated mothers, low family income, and lack of dental insurance coverage) were less influential than individual factors in determining dental caries' experience in 6-8-year-old male primary school children. the high prevalence of dental caries observed among primary school children in our sample was consistent with previous studies in saudi arabia [14, [21] [22] [23] [24] and uae [25] . a recent meta-analysis of various dental caries studies in different regions of saudi arabia determined the prevalence to be 80% [2] . furthermore, the observed prevalence of dental caries among children in the present study was substantially higher than the target established for the year 2000 (50%) by who/fdi [26] . the collective evidence from our study and previous studies confirm the endemic nature of dental caries in middle eastern population and signify the burden on public health. it is interesting to note that dental caries' experience among primary school children was better explained by individual factors (80%) rather than socioeconomic factors (59%) in our study, which is consistent with weaker role of socioeconomic factors observed in developed nations [6, 15] . this notion was further supported by the relatively stronger associations observed between individual factors and dental caries experience in our study. in contrast, several cross-sectional and longitudinal studies from developing nations demonstrated the dominant role of socioeconomic factors in dental caries' experience [18, [27] [28] [29] . the risk profile of dental caries among children in saudi arabia appears to follow the theme in developed world, where oral health behavioral practices and dietary habits were relatively more important [30] . however, efforts directed at improving socioeconomic status should be continued, owing to evidence from the present study and prior studies that identified maternal education and family income as consistent associated factors for dental caries [16, 17, 27, 28] . in addition, the availability of dental coverage in medical insurance was associated with dental caries. although literary evidence was inconsistent in saudi arabia [16] , the alarming proportion of children (77%) that lacked dental coverage in medical insurance warrant further attention. our results were consistent with previous studies on dental caries that reported an association between dental caries and good oral health behaviors in general [10, 19] , and tooth brushing habits in particular [31, 32] . a recent meta-analysis identified a 1.5-fold higher risk of dental caries among people brushing less than once daily compared to those brushing regularly (odds ratio (or) = 1.56; 95% ci 1.37-1.78) [33] . an overwhelming majority of children started brushing after 2 years (82%, 95% ci 78.6-85.1%) in the present study, consistent with late adoption of brushing observed in previous studies in saudi arabia [20, 34] and in philippines [35] . however, the higher risk of dental caries observed uniquely among children who started brushing late at 3 or 4 years, in our sample, warrant further investigation. particularly, future studies could evaluate the possible table 3 unadjusted odds ratios (uor), adjusted odds ratios (aor), and their respective 95% confidence intervals (95% ci) of the key associated factors for dental caries in primary school children aged 6-8 years (continued) role of cultural habit of using chewing stick (miswak) for cleaning teeth on better outcome observed among children starting brushing at ages 5-6 compared to those starting brushing at 3 or 4 years in saudi arabia. given the importance of brushing teeth regularly and mouthwash use in maintaining good oral hygiene and preventing dental caries [10] , and lower prevalence of these habits observed in our study, detailed investigation of various brushing practices (e.g., use of fluoridated/non fluoridated toothpaste, and use of chewing stick for cleaning teeth), and other oral hygiene practices (e.g., use of fluoride containing mouthwash) among primary school children in saudi arabia is necessary. furthermore, interventions aimed at encouraging good oral health behaviors among children should be undertaken. the negative attitude or apprehension towards visiting a dentist was clearly evident in our study, where only 21.1% (95% ci 17.8-24.7%) of children visited a dentist for regular check-up, while the others visited for symptomatic treatment (e.g., toothache). the problem was even worse among younger children in saudi arabia; a mere 11% of children visited dentist for regular checkup on their first visit [20] . this dangerous trend might have prevented patients from availing sound advice on preventive oral health practices, thereby contributing to high prevalence, delayed recognition, and management of dental caries in saudi arabia. therefore, saudi children would benefit from publicly funded school-based dental screening programs that aid in timely detection and management of dental and other oral health problems. in addition, regular dental screening programs targeted at school children have an added benefit of realizing cost savings due to reduced need for advanced dental care [36] . the present study found a 4.5 (or = 4.5, 95% ci 1.5-13.8)-fold higher risk of dental caries among children falling asleep with the bottle in their mouth, which was consistent with literary evidence [37] [38] [39] . however, the magnitude of risk among australian children sleeping with a bottle in mouth was much lower (or = 1.5, 95% ci = 1.1-2.2) [39] . it was suggested that decreased salivary flow and reduced swallowing reflex as the child gets drowsier would allow carbohydrates to remain in the mouth and pool around the teeth priming the area for bacterial attack [40, 41] . the practice of frequently consuming sugary snacks between meals was associated with dental caries in our study. however, current evidence has been inconsistent with some studies indicating a positive association [42, 43] , while others failed to observe such a relationship [44] . therefore, further evaluation and confirmation of this globally relevant predictor is warranted. although breast feeding is commonly practiced in western countries [45, 46] , the practice of mixed feeding or partial breast feeding (with breast milk and powdered milk) was predominant in saudi arabia [47, 48] . children in our study that were never breast-fed had higher risk of caries, which was consistent with existing literature [49] [50] [51] . breast milk by itself was not cariogenic [52] , but the reported cariogenicity of certain infant formulas [53] and a higher risk associated with practice of breast feeding until late infancy (> 12 months -or = 1.99; 95% ci 1.35-2.95) [54] should not discourage the practice of mixed feeding until the emergence of new evidence. interestingly, children in our study that were exclusively breast-fed also experienced higher risk of caries, rendering support to the practice of mixed feeding. as noted in previously published literature [54] , it is possible that the practice of breast feeding until late infancy could have played a role in excess risk observed in saudi children; however, further research based on a larger sample is warranted to confirm our findings and determine the role of duration of exclusive breast feeding on caries risk among children in saudi arabia. furthermore, our study identified that eating patterns and food choices play an important role in dental caries experience in children. interestingly, the observed association between flavored milk and dental caries in this study could be a result of evolving trends in milk consumption practices in saudi arabia. although prior observational studies [55, 56] contrast our findings, a moderate cariogenic potential of flavored milk observed in a recent animal experiment and the possibility of developing nations adopting this new trend warrant further evaluation [57] . incidentally, our study contributed towards ever increasing evidence for the association between dental caries and sodas (or soft drinks) [58] [59] [60] . the acidic content of these soft drinks combined with sugars were known to reduce oral ph and increase the cariogenic potential of tooth [61] . it is noteworthy that low consumption of fresh fruits (less than twice a week) was associated with increased risk of dental caries among primary school children in this study. in contrast, the literary evidence did not provide a clear benefit of eating fresh fruits in preventing cariogenesis [62, 63] . however, certain fruit extracts (e.g., morinda citrifolia) have been associated with inhibiting the growth of cariogenic bacteria [64] , indicating the need to further evaluate the relevance of fresh fruit consumption to dental caries experience. in general, our findings were consistent with studies that linked intake of foods with high sugar content and dental caries in saudi arabia [19, 65] and other places [58] [59] [60] 66] . the strengths of this study are multi-fold. information from various risk domains was systematically analyzed to aid in prioritizing the modifiable factors associated with dental caries experience in children. unlike several prior studies in this area [10, 14, 16, 19, 34] , this study addressed the issue of multicollinearity and corrected potential bias from small sample in the analysis. the comprehensive nature of information collected encompassing various risk domains enabled us to evaluate the relative importance of individual factors over socioeconomic factors, a component seldom addressed in previous studies. our study provides much needed baseline statistics on several population characteristics to aid not only local authorities, but also international organizations (e.g., who) to evaluate and improve the health programs aimed at mitigating the burden of dental caries in children. however, certain limitations of this study should be considered while interpreting the results. a self-administered questionnaire was used as the main study instrument, which is subjected to recall bias. however, we do not expect our results to be grossly affected by recall, owing to recurrent and current themes tested in the questionnaire. for example, we would expect a more accurate recollection of tooth brushing habits and child feeding practices that were routine activities performed in the recent past; collection of information on flavored milk, a recent trend in saudi arabia, serves as an example for current themes. the study sample was restricted to 6-8-year-old male primary school children in riyadh city of saudi arabia, which warrants caution in generalizing the results to the entire country; however, given the cultural homogeneity and urbanity of the area, we would expect our estimates to be relevant to general population. our study does not support generalizing the results to girl children, as our sample was restricted to boys to comply with school regulations and cultural sensitivities of saudi population. although some of our findings could be relevant to girls owing to shared cultural practices, future research should evaluate and confirm gender-related differences. moreover, the cross-sectional nature of this study warrants against drawing causal inferences. the burden of dental caries is high in saudi arabia with eight out of ten primary school children aged 6-8 years suffering from this preventable condition. several individual factors encompassing three risk domains, including oral health behaviors and practices, child feeding practices, and dietary habits, were found to be more relevant factors associated with dental caries than socioeconomic factors. our results were consistent with findings in developed world where poor brushing habits, lack of dental coverage in health insurance, and high consumption of sodas were predominantly associated with dental caries. future research should focus on confirming some of the unique or globally relevant associated factors for dental caries identified in our study, including late adoption of brushing, frequent consumption of sugary snacks between meals, and consumption of fresh fruits and flavored milk. our results support the development and implementation of public awareness campaigns or health education programs targeted at primary school children to promote good oral health behaviors, feeding practices, and dietary habits. additional file 1: table s1 . unadjusted odds ratios (uor), adjusted odds rations for variables selected within each risk domain (dor), and adjusted odds ratios (aor) for variables selected from all four risk domains at different steps of model selection process*. 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and literature review dietary pattern of finnish children with low high caries experience diet, nutrition and the prevention of dental diseases role of aqueous extract of morinda citrifolia (indian noni) ripe fruits in inhibiting dental caries-causing streptococcus mutans and streptococcus mitis dental caries, sugar consumption and restorative dental care in 12-13-year-old children in riyadh, saudi arabia oral health knowledge, attitudes and behaviour of children and adolescents in china we would like to thank the administration of the schools, parents, children, and dental professionals who participated and provided assistance in our study. we also thank king abdullah international medical research center (kaimrc) for partially funding our research. king abdullah international medical research center (kaimrc) partially funded our research (grant number sp15/081). the funders had no role in the study design; collection, analysis, and interpretation of data; decision to publish; and preparation of the manuscript. please contact the author for data requests.authors' contributions ya and hj conceived the project idea. ya, aa, ny, and hj designed the study and approved the methodology. ya, aa, and hj participated in the data collection. ya, ny, and hj managed the study data and conducted the formal data analysis. all authors contributed extensively towards the preparation of this manuscript and approved the version submitted to the journal. all authors read and approved the final manuscript.ethics approval and consent to participate ethics approval for this study, including oral examination of the children, was provided by the institutional review board (irb) at king abdullah international medical research center (kaimrc) in riyadh under protocol number sp15/081. informed consent was obtained from the parents. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-029374-46okjft6 authors: rashid chawdhary, iqra title: clinical governance for the dental team date: 2020-07-17 journal: bdj team doi: 10.1038/s41407-020-0370-5 sha: doc_id: 29374 cord_uid: 46okjft6 nan risks to patient health and safety. they require effective procedures, policies and systems to be put in place and depend on the performance of the entire dental team in order to secure patient safety and deliver consistent standards of care on which patients can rely. there are seven main 'pillars' or domains which form the basis of clinical governance: 1 1. patient and public involvement 2. information and it 3. risk management 4. audit and peer review 5. training and education 6. effectiveness (clinical) 7. staff management. ppi is about involving and listening to our patients and the public in order to effectively respond to their needs and improve their experiences. this is especially important as practices need to know if the extra measures and precautions they are taking due to covid-19 are helping to reassure patients that the environment is safe to attend and receive treatment in. methods through which this is achieved include: patient feedback questionnaires eg the friends and family test or suggestion boxes having a well publicised complaints procedure in the practice. through reviewing patient feedback, comments and complaints appropriately -for example, through audits and staff meetings -the dental team can update policies and procedures to help improve quality assurance systems, patient experiences and also help find ways of encouraging patients to come back to the dental practice. this is about ensuring data protection and patient privacy/confidentiality in order to effectively store, manage and use patient data eg for audits. it is likely that many more dental practices will start to use computerised systems to store patient data and records instead of paper notes in order to help reduce methods of transmitting the coronavirus to others. methods through which this is achieved include: having regular staff meetings and training to ensure everyone in the dental team understands their responsibility in regards to patient confidentiality and complies with the law ensuring the dental team understand and follow the gdpr guidelines on data access, the data protection act 2018, the fgdp this article has four cpd questions attached to it which will earn you one hour of verifiable cpd. to access the free bda cpd hub, go to https://cpd.bda.org/ login/index.php guidelines on good record keeping 2 and the gdc standards on record keeping and confidentiality 3 performing audits to check compliance with these guidelines eg for gdpr, audits could be done on the data held, where it comes from, why you share it and how long you keep it adhering to the 1997 caldicott principles 4 which state that if we use patient data then we need to justify the purpose, only use it when necessary, use the minimum required and keep access to data on a strict need-toknow basis. practices need to carry out risk management in order to identify and eliminate or mitigate all significant risks to patient and staff safety. it helps to promote a blame-free culture and helps the dental team learn from any mistakes and accidents that have occurred, in order to improve the quality of care patients receive. this is especially important as we are in unprecedented times and it is essential that the dental team work together to find solutions if things do not go to plan. in addition, patients must feel that the dental environment is safe and that the necessary precautions have been taken to minimise the risk of transmission of harmful microorganisms such as the coronavirus. methods through which this is achieved include: adhering to the 2013 department of health htm 01-05 guidelines 5 as well as implementing robust covid-19 infection prevention and control procedures and following radiography, decontamination, waste management and ppe protocols in line with government advice, for example nhs england 6 states: for non-agp care: standard infection control precautions ppe: eye protection, disposable fluid-resistant (type llr) surgical masks, disposable apron and gloves should be worn for all agps: to prevent aerosol transmission: disposable fluid-repellent gown or approved equivalent, gloves, eye/face protection and an ffp3/n95/ ffp2 respirator should be worn by those undertaking or assisting in the procedure. a full-face shield/visor must also be worn if wearing an ffp3 mask that is not fluid-resistant any incidents that do occur should be appropriately reported on and learnt from risk reduction processes should be audited to ensure they meet current standards and policies/systems should be reviewed and updated accordingly. in addition, staff should organised so staff understand "best 'regular team meetings should be with the new practices/protocols.' have received the appropriate training needed to comply with these protocols regular team meetings should be organised so staff understand 'best practice' standards and are up-to-date with the new practice policies/protocols and can reflect on them the dental team should also liaise with the local infection control specialist advisers if needed, in order to support the updating of the infection control policy in regards to covid-19 a dental practice risk assessment should be performed and made available to the entire dental team to review and discuss. risk assessments should also be carried out on all members of staff. a team member should be appointed as the practice covid-19 lead and all members of the dental team should know who this is. auditing helps evaluate existing practice against the gold standards of practice and current policies/procedures. they highlight any shortfalls and help develop methods to improve our outcomes and performance. it is a cqc requirement to have routine audits on accessibility (in line with the equality act 2010), infection control (in line with htm 01-05) 5 and x-rays (in line with fgdp standards) 7 . methods through which this is achieved include: carrying out an audit. the audit cycle involves identifying a problem/concern, setting a standard to compare to eg a local guideline, collecting the data to compare (retrospective/prospective), comparing the data to the standard and identifying any shortcomings, implementing methods of change and then re-auditing after a period of time to close the 'audit loop' and assess the improvements peer review involves a group of 4-8 dental professionals working together to improve the quality of service they provide through sharing their knowledge and experiencesthis is very important in light of covid-19. if not already part of a group, it would be good idea to contact other practices/dental professionals to form a peer review group. in these challenging times you must remember that you are not alone and work together to help one another. policies and procedures are there to protect patients. however, they depend on the performance of the entire dental team. this is achieved through continuing professional development (cpd) to ensure members of the dental team remain up-to-date with the latest research, knowledge and skills. the gdc standards for the dental team 7.1.1 states: 'you must find out about current evidence and best practice which affect your work, premises, equipment and business and follow them at all times' . 3 due to covid-19 there have been many new guidelines produced on what we can or cannot do and also on how we can safely treat patients. it is important that all members of the team are aware of these. methods through which this is achieved include: completing further training and attending courses -due to covid-19 this hasn't been possible, however various webinars and online cpd programmes have been created to help dental professionals continue to further their knowledge and skills from home work appraisals with colleagues to assess competency, identify areas of further training, help develop the dental team and broaden the skill mix to deliver services in a more efficient and resilient way having important policies on raising concerns and safeguarding and making sure the entire dental team are aware of these and adhere to them giving staff the additional training needed so they are up-to-date with the changes that have been made to practice protocols/ policies due to covid-19 fit testing of the n95/ffp2/ffp3 masks should be done on all clinical team members to ensure they are safe to carry out an aerosol generating procedure (agp) on a patient if necessary the donning and doffing of ppe and their designated areas should be demonstrated to the dental team prior to starting work eg via a video tutorial. the dental team should be given the opportunity to practise this too the patient flow should be explained to all members of the dental team prior to reopening, to help them understand the intended flow from triage to patient treatment, discharge and follow-up the dental team should review these requirements frequently to ensure everyone is up-to-date with the changes that are occurring. instead of staff meetings in person, discussions can be done through whatsapp group-chats, phone calls or online 'zoom' meetings it is important to remember that this is a group effort and the dental team should be mindful and help each other in order to effectively work together to meet these standards and requirements. these changes may cause staff concern, stress and anxiety and it is important to ensure all members of the team are adequately supported and can be directed to mental health and wellbeing resources, should they need it. this is about ensuring we adopt an evidencebased approach to provide the best possible outcomes for patients. it is about improving and changing our practice to meet 'best practice' guidelines in order to provide the best care for our patients. methods through which this is achieved include: using evidence-based research to help formulate treatment plans and decision making using standards and guidelines to help inform care eg fgdp radiograph guidelines, 7 nice guidelines on wisdom teeth extractions 8 and dboh guidelines 9 implementing new standards and guidelines as they develop, undertaking cpd that is evidence-based and changing current practice in accordance with the new evidence that is being produced. this ensures each member of staff has the appropriate training and registration for their job. it ensures each member of the dental team knows their role and works together to understand, implement and follow practice policies and procedures. methods through which this is achieved include: understanding the gdc scope of practice 10 and standards for the dental team 3 documents having regular practice meetings, staff training, feedback, appraisals and cpd having an open attitude between employer and staff members in order to provide a good working environment and appropriately manage the team with regards to covid-19, staff need to be aware of the new levels of ppe needed and the new practice protocols. the dental team need to be aware of all the changes being made and should have received the additional training before they return to work. staff should be given adequate notice for the staff training and should be aware of all the precautions that are being put in place to protect them for when they return to work developing a dental practice standard operating procedures (sop) document that works on a local level and allowing all members of the dental team to read it before starting work. this will also give staff the opportunity to ask any questions regarding the document before returning to practice. this document needs to be reviewed regularly so that it keeps up-to-date with the most current guidelines. various new guidelines have been produced by public health england, 11 nhs england 6 and the sdcep 12 to help dental practices adapt to the 'new normal' of care due to covid-19 and help the dental team transition as restrictions continue to lift. i hope this article has provided you with a refresher on why clinical governance is important in dentistry and how the dental team can use these seven pillars to ensure patient and staff safety in order to effectively resume dental services as restrictions ease. primary care dental services -clinical governance framework clinical examination and recordkeeping general dental council. standards for the dental team information governance toolkit: what are the caldicott principles? decontamination in primary care dental practices (htm 01-05) dental practice selection criteria for dental radiography guidance on the extraction of wisdom teeth delivering better oral health: an evidence-based toolkit for prevention general dental council. scope of practice. effective from covid-19: infection prevention and control (ipc) resuming general dental services following covid-19 shutdown this article was submitted through bdj team's online submission portal. just click 'submit' on the homepage. this article has four cpd questions attached to it which will earn you one hour of verifiable cpd. to access the free bda cpd hub, go to https://cpd.bda.org/login/index.php.https://doi.org/10.1038/s41407-020-0370-5: key: cord-014337-nnuvrb6o authors: byrne, s. title: scientific rigour date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2362-4 sha: doc_id: 14337 cord_uid: nnuvrb6o nan for dental education and training, while measures are in place to control the spread of covid-19. version 2. 1 september 2020. available at: https://www. gdc-uk.org/news-blogs/news/detail/2020/09/01/ joint-statement-on-arrangements-for-dental-educationand-training-while-measures-are-in-place-to-control-thespread-of-covid-19-(version-2-dated-1-september-2020) (accessed november 2020). https://doi.org/10.1038/s41415-020-2360-6 oral research sir, i read with interest the paper by sampson et al. 1 regarding a possible link between the severity of sars-cov-2 infections and oral hygiene. their call for excellent oral hygiene as a strategy to potentially aid the prevention of bacterial superinfections in patients with sars-cov-2 infections is not in question here. however, i draw attention to the interpretation of research findings by the authors, and would caution against reporting associations between covid-19 symptoms and oral bacteria without the support of adequate data. postgraduate periodontal training at the university of texas health science center at houston (houston, tx, usa) in response to substantial interruptions in didactic and clinical training. first, we identified our immediate goals: 1. to evaluate the existing curricula and reorganise them by adopting the commission on dental accreditation (coda) compliance protocols on the interruption of education and distance education to allow for a continuation of the pgrs' hands-on and didactic learning 2. to calibrate all full-and part-time periodontal faculty 3. to transition the residents through their respective clinical curricula 4. to provide feedback on the residents' surgical skills. once these goals were met, we aimed to implement the following sessions to allow for the transition of pgrs through the updated curricula: 1. case-based classroom videos from the american academy of periodontology (aap) and webinars allowed residents to enhance their didactic knowledge on clinical techniques 2. clinical case presentations through online sessions allowed continued pgrs' feedback to enhance their presentation and treatment planning skills as well as surgical techniques 3. sessions with invited speakers allowed pgrs to learn clinical management with the experts in the field and receive constructive feedback of greatest concern, sampson et al. 1 report that sequencing data indicate high reads for prevotella, staphylococcus and fusobacterium in patients severely infected with sars-cov-2. the supporting data come from a letter by chakraborty. 2 it is unclear in which publication this letter appears or whether it has been through a peer review process. in the letter, metagenomic sequencing data from five patients are presented. 2 no methods, including no source for the samples is given. this, along with a lack of data from healthy subjects, makes it impossible to draw any conclusions about the number of sequencing reads relating to these genera and any association with sars-cov-2 infection. these data can therefore not be used to associate 4. collaborative seminars in surgical, prosthetic and restorative dentistry with the department of periodontics at the university of illinois at chicago allowed pgrs to get exposed to world-class periodontists and dental implantologists and ask one-on-one questions 5. suturing training modules allowed pgrs to practise suturing at home and learn indications of various techniques 6. virtual sedation cases were utilised to accomplish pgrs' sedation competencies 7. mock periodontal oral board sessions allowed pgrs to prepare for the aap specialty board examination and fulfil temporary coda requirements in certain competencies 8. as laboratory research activities were suspended, pgrs were asked to work towards their master's thesis writing and analysis of the existing data. despite facing changes in a teaching format, especially in clinical training, our approaches, including the use of online portals and modules, maintained and enhanced pgrs' hands-on and didactic experiences. we expect to implement these new teaching approaches in future curricula. the authors also refer to nagaoka et al. 5 as evidence for a relationship between prevotella intermedia and severe pneumonia. this is an in vivo study examining the effect of a bacterial supernatant on experimentally induced pneumonia in mice, and not an observed relationship in human subjects. a global health crisis such as we are experiencing places huge pressure on health professionals and the research community in the rapid search for knowledge. whilst sir, the pandemic has forced dental institutions to change approaches to teaching undergraduate dental students and postgraduate residents (pgr). with great interest we have read recent letters and publications in the bdj 1,2 and elsewhere that outline the approaches our european colleagues have taken. in this letter, we would like to describe our approaches to modify   improving oral hygiene is unlikely to be detrimental, it has never been more important to uphold scientific rigour in the interpretation and reporting of research findings to help build our collective understanding of the aetiology and prevention of disease. s recommendation. this will make handovers concise and easy to follow • make sure to rest properly in your spare time -the job can be demanding so this is vital to stay alert. and lastly, enjoy this time! you will see extremely interesting cases through to the weird and wonderful; you have an amazing opportunity to learn new things in a supported environment so take advantage of it! a. kazmi, liverpool, uk https://doi.org/10.1038/s41415-020-2363-3 sir, i write further to the letter of kalsi et al. 1 in which they described that the product alvogyl (septodont, cedex, france) used in the management of acute fibrinolytic alveolar osteitis had been superseded by a chemically different product alveogyl (septodont) with potentially significant clinical ramifications. these colleagues make a very valuable and important point in that the formulations of not only pharmaceuticals but also dental materials and biomaterials may be changed by manufacturers surreptitiously. this may be necessary due to product development, regulatory demands and ongoing product safety. whilst this is both laudable and proper, the clinician should be mindful of potential changes in product formulation as this may have a significant bearing on how the product is mixed and/or handled clinically. it therefore follows that the failure of the dental team to fastidiously use the material as intended may result in inferior clinical performance. one way of ensuring best practice would be that the directions for use of each new batch of product are read carefully and then stored in a centrally placed file in the clinic, easily accessible to all members of the dental team. a ring binder folder containing punched pockets is ideal and the responsibility of keeping the file contemporaneous should lie with the member of staff responsible for stock management. 2 furthermore, dissemination of any change in handling protocol etc should also be communicated to all appropriate clinical staff. such a measure will ensure that all products intended for clinical use are used correctly to ensure the best outcome for the patient. s. j. bonsor, aberdeen, uk https://doi.org/10.1038/s41415-020-2365-1 emergency dentistry sir, having completed a year as an omfs dct in a major trauma unit, i thought it would be useful for fellow colleagues to have some know-how of how to survive an on call: • if in doubt, ask: senior colleagues will know you haven't done the job before. they have experience of training dcts and will be more than happy to assist you • get to know the paperwork. as laborious as it may be, paperwork is extremely important, and the more you are aware of what needs to be filled in, the smoother the process will be • prioritise your jobs. you will have calls coming from multiple different places at the same time, so you need to know which jobs need to be finished urgently, and which jobs can be completed later • keep a logbook -preferably electronic but if it is in paper form, make sure there is no patient information which will make them identifiable, and make sure to get it verified by your consultant • practise suturing at home. i know it sounds simple, but practising a little can go a long way! you will come across as more confident in front of the patient and will feel less fazed • watch videos on how to cannulate -once again, it will be unlikely you will have sir, thank you for publishing martin kelleher's article (bdj 2020; 229: 225-229). martin has long been highly respected as an excellent teacher and communicator, and a voice of reason in our profession. the first part is a truly appalling account of just one problem at the gdc. the second is an excellent reminder that we must not let lawyers overrule common sense in the way we practise. the profession needs a regulator (note not plural) with an understanding of what comprises good dental practice. in the meantime we look to the bda and its esteemed journal to continue the fight on behalf of our profession. p. s. nayler, brighton, uk https://doi.org/10.1038/s41415-020-2364-2 sir, there is an increasing number of dentists who have started to provide specialist skin care. may i emphasise, i do not mean facial aesthetics courses (botulinum toxin and fillers). this is after they have gone to a alternative teaching aids vr systems in dental education alvogyl or alveogyl a clinical guide to applied dental materials key: cord-033803-79me0615 authors: holland, caroline title: why prevention must be targeted, creative and multi-faceted date: 2020-10-16 journal: bdj team doi: 10.1038/s41407-020-0440-8 sha: doc_id: 33803 cord_uid: 79me0615 nan than fantastic. we have done a lot of learning but our motto was "every problem has a solution". it's about making sure that parents and carers had a voice and doing what we can to make a difference to the children of greater manchester. 'until covid-19, we had 40,000 children toothbrushing on a daily basis. since covid-19, nobody has disengaged. ' with dental practices and many early years settings closed, jo described how everyone involved in the programme did what they could to ensure children still got their toothbrushing packs. using voluntary services, food banks and aid workers, they wanted every child who needed a pack to get one. forty thousand, two hundred and seventeen packs were distributed when the pandemic was at its height. another important aspect of their work is to engage with health visitors and ensure they are training to deliver key oral health messages to new parents. once the pandemic was underway and health visitors could no longer go out to parents' homes or provide clinics, the team worked with midwives. they also distributed -electronically -the videos 8 made by the british society of paediatric dentistry and brush dj with dr ranj in the pandemic. another area of the country where flexible commissioning has been embraced is in north yorkshire and humber. as in manchester, programmes are geared to funding gdps to provide prevention as well as building links between dental practices early years settings and health visitor and social care teams. the beauty of the flexible commissioning approach, according to simon hearnshaw, the chair of the local dental network, is that there is no additional cost. the region's in practice prevention programme 9 uses trained dental nurses to deliver patient-centred evidence-based prevention pathways targeted at children who have dental decay or are being referred for ga extraction. simon said: 'in simple terms, the flexibly commissioned resource pays for the ringfenced time to deliver key messages and interventions and to encourage and support behaviour change. over two and a half years more than 17,000 targeted one-to-one prevention appointments have been delivered to children with disease. ' he has been working with ingrid perry, a practice manager at a mydentist practice in hull and one of the urgent dental care centres during the pandemic. she is helping to devise a toolkit to support the training of oral health educators in mydentist practices who will be part of the fc initiative. devolved health and social care partnership, allowing professional teams to advance their own strategies via managed clinical networks. these professional groups, in which clinicians and commissioners work together to ensure services meet the needs of local populations, are well established, including for paediatric dentistry. in 2017, the dental community in greater manchester announced its ambitious vision for change. gdp mohsan ahmad, chair of the local dental network, wrote the foreword to a document 4 setting out the three-year plan, stressing that dental teams would play an essential part, by engaging communities to value good oral health, driving improvement in outcomes. if all goes according to plan, flexible commissioning across greater manchester should result in a number of practices being accredited as child friendly dental practices. they will be expected to carry out the locally developed baby teeth do matter online training and provide evidence-based treatments, such as placement of preformed metal crowns using hall crowns or silver diamine fluoride (sdf) application in order to arrest caries and reduce the number of children being referred into secondary care for extractions. if this was a good idea a few years ago, it's essential now that secondary care appointments are in such high demand. the dental check by one campaign, 5 recently reinvigorated by the british society of paediatric dentistry, is also central to an accredited child friendly dental practice. in january of last year, the greater manchester health and social care partnership (gmhscp) launched 6 a £1.5 million programme to reduce dental decay. jo dawber is the gmhscp project manager for oral health transformation under the leadership of consultant in dental public health, emma hall-scullin. social challenges are considerable in greater manchester which has four of the 13 national priority areas set out in starting well: a smile4life initiative: 7 bolton, oldham, rochdale and salford. one of jo's first jobs was to ensure that there was a network of trained primary care 'dental champions' who would lead the way in improving dental care in early years settings through supervised toothbrushing schemes. jo provided the training for 20 champions who together brought 150 early years settings into the programme. she also oversaw the purchasing of toothbrushes and toothpastes in bulk quantities which went into dental packs. jo said: 'interest in the programme from early years providers has been nothing less their job is critical, says ingrid, because of the high number of patients who were unable to see a dentist during lockdown: 'prevention is the way forward and we are going to see more of a need for it now. by working collaboratively with multiple stakeholders such as health visiting and school nursing teams flexible commissioning will have a positive impact on not only the dental health but also the general health of our local communities, especially in areas of severe social deprivation where you find the highest disparities in health. ' with many of the most deprived areas of the uk in the north of england, it's no surprise that targeted prevention is being driven hard. positive support for oral health prevention nationally continues to emerge and momentum is building. a key development was the green paper published last year 10 in which the government committed to put prevention at the heart of all its health and social care decisionmaking. in terms of school toothbrushing schemes, the government said it wanted to reach 30% of the most deprived 3-5-yearolds by 2022. the green paper advocated that funding barriers to fluoridating water should be removed and local authorities which pursue water fluoridation should be rewarded by allowing them to benefit from the savings achieved via fewer fillings and extractions. water fluoridation requires no behaviour change and the evidence shows that it is highly effective in reducing dental decay and delivers the most benefit to the most deprived. 11 dental health should now be included in the curriculum in both primary and secondary schools 12 in england while a powerful new announcement this month 13 from the royal college of paediatrics and child health (rcpch) reinforces the importance of all aspects of prevention of dental disease: going to the dentist, ideally starting before the age of one a healthy diet toothbrushing with a fluoride toothpaste fluoride in water working with fluoride in toothpaste to provide an extra layer of protection. another essential weapon in the prevention armamentarium is dietary advice. the mother of all prevention schemes is nhs scotland's child smile 14 which incorporates guidance on nutrition and the frequency of sugar consumption. dental health in scotland is improving and the target of 60% of 11-year-olds having no obvious decay has been met. meanwhile, designed to smile, the programme in wales to reduce dental decay in children, is ten-yearsold and is also bringing down dental decay. 15 in england, dentists look enviously at scotland and wales which both have national prevention programmes. this is deemed impossible in england because since 2012, public health has been the remit of local authorities. 16 to return to health inequalities, earlier this year and ten years on from the marmot review, the health foundation showed, 17 shockingly, that social inequalities are now worse than they were a decade ago, especially for women. intractable problems need a creative response and one is social prescribing, an approach to health which recognises that illness can be caused by environmental or social factors. its role was also recognised in the green paper on prevention. jo ward chairs the north west social prescribing network and has led on the development of a new handbook -the national women and children's creative health handbook: wellbeing by design -which includes a section on oral health. this is yet more welcome evidence that the mouth is now being considered integral to health and wellbeing and that the methodology needs to be targeted and creative. new figures 18 for general anaesthetics to remove teeth in children showed that there has been an 8% decrease in the number of 5-9-year-olds being referred into hospital for extractions between 2017/18 and 2018/19. this is welcome progress -but who knows what the impact of covid-19 will be? is it possible to maintain the progress that's been made? with the country still in crisis from covid-19, we don't have that answer, nor do we know what will happen to the work of public health england now the government is abolishing it, or to the prevention green paper and other government commitments, but we do know that in order to be effective, prevention programmes must be funded, targeted, multi-faceted and creative. and we have an impressive groundswell of people and organisations working to give children a better start to life. fair society healthy lives (the marmot review) children's oral health improvement programme board action plan oral health as a marker for poverty putting the mouth back in the body' for greater manchester welcome to dental check by one stopping the rot: greater manchester under 5s to benefit for programme tackling tooth decay british society of paediatric dentistry. smiles for life! supertooth's healthy teeth guides north yorkshire & humber local dental network in practice prevention web portal advancing-our-healthprevention-in-the-2020s/advancing-ourhealth-prevention-in-the-2020s-consultationdocument area-level deprivation, childhood dental ambulatory sensitive hospitalizations and community water fluoridation: evidence from new zealand why is child oral health so important? royal college of paediatrics and child health ten years of designed to smile in wales public health in local government. the new public health role of local authorities government must take action to level up the health and wellbeing of the population. launch of the marmot review 10 years on: health foundation response series/collection key: cord-030240-c8lank21 authors: mcguckin, bronagh title: dental triaging: past, present and future date: 2020-08-10 journal: bdj in pract doi: 10.1038/s41404-020-0472-y sha: doc_id: 30240 cord_uid: c8lank21 nan according to the economist, the idea of disruptive innovation is one of the most influential business ideas of the 21st century. disruption can be a force for good, accelerating new ways of working; providing new opportunities and driving us to be innovative so that we can improve our services. this current covid-19 pandemic has equipped the dental profession with the opportunity to reflect on professional practices and to learn new more efficient processes which can readily be deployed when practices open again. as a profession, we have sadly had to down our drills in favour of lifting our telephones. regular patient contact has been replaced with advice from afar and referrals to 'hubs' if treatment is required. we have become accustomed to what is referred to as a 'true' dental emergency and what is designated as 'routine' care. in the aftermath of covid-19, i anticipate there will be a major upheaval in how we manage dental emergency appointments in general practice. this article explores the topic of dental triaging; our past, present and the future practices that will be defined by disruption and innovation brought about by covid-19. typically, the first point of contact for emergency patients is the frontline team which may include the practice manager, receptionist and/or dental nurse. their role is critical in controlling access for patients to the dental team and whilst they may carry out a basic form of triaging, this may vary significantly between general practices. at present, there is no requirement for members of the wider dental team to undertake any formal training in triaging. patients may present as an emergency patient for a variety of reasons: pain, a lost filling, a lost crown or trauma, to name but a few. these problems have a range of complexities and therefore the time required for the emergency appointment can vary significantly. every associate can appreciate the stress and strain placed by the addition of emergency appointments to their diary throughout the day. research has shown that time pressure is general professional trainee our perspective of what is deemed a 'true' dental emergency has changed dramatically, under the guidelines of nhs england commissioning standard for urgent dental care. whilst a 'lost' upper anterior crown may have previously constituted a dental emergency requiring an urgent nonscheduled appointment, during this pandemic this does not warrant emergency treatment, despite the emotional distress this may cause the patient. in the era of the dreaded 'd-i-y dentistry' , it is we dentists who are now encouraging patients to visit their local chemist and attempt to place a temporary filling at home. as indicated at the beginning, disruptive innovation allows us to experiment with new regimes and triaging is now at the forefront of the services we can provide during this pandemic. it has been an eye-opening opportunity to gain an insight into the workings of our frontline dental team and has highlighted the role of effective triaging in management of emergency patients across the country. its importance must not be forgotten, and indeed should be a driver for change well into the future. with thorough training and appropriate guidance, experienced dental nurses and reception staff may be able to safely triage by following a decision-support flowchart, such as that provided by scdep in their covid-19 guidance, in order to determine the urgency of a patient's problem and triage accordingly. 5 by following a triage protocol, more information can be gathered from patients to allocate them an appropriate appointment length within an appropriate timeframe for their condition. ' patients may present as an emergency patient for a variety of reasons: pain, a lost filling, a lost crown or trauma, to name but a few. these problems have a range of complexities and therefore the time required for the emergency appointment can vary significantly.' one of the major causes of stress for dentists. 1 emergency appointments can be short and often double-booked, with limited time for the dentist to successfully diagnose and provide treatment for these patients. a study carried out amongst general practitioners' (gp) surgeries showed that the inadequate appointment time is a source of conflict between gps and their reception staff. 2 this highlights the importance of effective appointment booking to ensure good working relationships within the healthcare team. a recent study was conducted amongst dental surgeries in england which aimed to investigate current triage practices. worryingly, some nurses reported they were under strict instructions to ensure all patients were allocated non-scheduled appointments, regardless of how full the diary may appear. 3 this places undue pressure on frontline staff and can impact negatively on their employment and the working relationship between members of the wider dental team. as dentists, we are one of the most-high risk and exposed professions with regards to cross-infection due to the close proximity to patients and bodily fluids from the oral cavity. we routinely use high-speed drills and 3-in-1 handpieces which create vast aerosols. the main transmission path of sars-cov-2 is through droplet infection. recent research has shown this aerosol, due to their small particle size (<50μm), can be carried several metres away and can be detected in the room air for up to 30 minutes after the procedure. 4 this has significant implications for the profession during a pandemic, where the virus (covid-19) is highly contagious and risks putting ourselves, our staff and our patients at risk by continuing to carry out routine care. as a result, all routine dental care has been temporarily suspended throughout the uk and only emergency care can be provided through designated hubs and telephone triaging. an array of guidance has been published by organisations such as bda and scdep, to allow practitioners to triage dental emergencies with ease. this takes the form of advice and flowcharts, allowing most patients to be successfully managed by the ' aaa' approach of advice, analgesia and antibiotics. only patients who have severe dental and facial pain, suspicious oral lesions, dental and soft-tissue infections, progressive or life-threatening swellings or severe trauma, warrant referral to the designated hubs which have sprung up across the country. formal training could be implemented for all members of the dental team which would cover a range of topics including: assessing and interpreting symptoms, assigning urgency to clinical need, management of diary pressures and patient expectations, and providing simple practical telephone advice regarding oral hygiene and analgesia. this type of innovative approach would have a positive impact both on patients and the wider dental team. implementation of such a dental triage system, along with appropriate staff training, could lead to improved patient outcomes and more efficient use of surgery time. primarily, this should be researched more thoroughly by means of a pilot scheme in a select number of practices, with the results disseminated widely and if positive recommended as best practice throughout the sector. while this has been a testing time for the profession, it has provided us with an invaluable opportunity to reflect on current practices allowing us to make significant improvements so that when we return to routine dentistry, both patients and the wider dental team will benefit from streamlined services. our frontline dental team: receptionists, nurses and practices managers, have a vital role to play in the management of the diary, emergency patients and the overall smooth-running of a dental practice. formal training to undertake this role will ensure the safety of patients with acute dental problems whilst also optimising the efficient running of a dental practice. ◆ it's difficult being a dentist': stress and health in the general dental practitioner what do general practice receptionists think and feel about their work? ability of the wider dental team to triage patients with acute conditions: a qualitative study position paper: sonic and ultrasonic scalers in periodontics. research, science and therapy committee of the american academy of periodontology management of acute dental problems during covid-19 pandemic key: cord-270712-v6nnnzhm authors: woodcock, j. a. title: test, test, test! date: 2020-06-26 journal: br dent j doi: 10.1038/s41415-020-1800-7 sha: doc_id: 270712 cord_uid: v6nnnzhm nan patients' general medical practitioners (gmps), funding restraints have resulted in nhs clinical commissioners advising against the routine prescription of high fluoride toothpaste in primary medical settings. 2 we conducted a pilot survey investigating the awareness of orn amongst gmps and gmp trainees in the midlands in 2019, the results demonstrating that this was very limited, but that there was a willingness to engage in teaching and education. the potential role for gmps to support with preventative measures and vulnerable patients struggling to access routine dental care was identified. while dentists can continue support for these patients, future education and collaboration with our medical colleagues in primary care must also be considered in order to improve patient access, and ensure holistic patient care is being provided across all clinical settings. s. lakhani, k. martin, birmingham, uk sir, i was disappointed to read the statement in an otherwise excellent document from the fgdp and college of general dentistry that pre-treatment antiviral mouthwash was not recommended because of 'a lack of evidence of virucidal activity for use of pre-operative mouthwash'. i wonder if a flurry of recent papers, possibly overlooked, might lead to a questioning of that statement. what is now known is that sars-cov-2 replicates in the oral cavity and that extremely high numbers (>10 million) of infectious viral particles per ml saliva can be found at an early stage in sars-cov-2 infection. 1 the virus in saliva is not contamination from elsewhere, but reflects active replication probably in ace2 positive epithelial cells in minor salivary glands. 2 similar high levels are found in the nose. 3 this is clearly an infection risk to any clinician working around the mouth or nose. any virucidal agent applied to those sites may substantially reduce the risk of cross infection. 4 several commonly used antiseptic mouthwashes with anti-bacterial activity also have anti-viral activity against coronaviruses demonstrated in vitro. 5 two (povidone iodine and ethanol) have been shown to have substantial activity against sars-cov-2 and one (pvp-i) sars-cov in the presence of organic matter designed to replicate in vivo conditions. 6 what is not known is how effective any anti-viral mouthwash actually is in vivo, nor how long the antiviral effect lasts. this has been estimated as greater than 20 minutes. 4 thus, does one recommend withholding a potentially effective agent (thus potentially exposing substantial numbers of dental hcws to extra risk), or does one recommend that a simple, cheap, safe and potentially effective agent is used to help safeguard the profession while the extra information is sought? pvp-i has been used in dentistry for over 60 years and its safety profile well sir, each year there are approximately 12,200 new cases of head and neck cancer diagnosed in the uk. 1 for patients undergoing radiotherapy (either alone or in conjunction with resective surgery), the detrimental effects on oral health are well established, including the risk of developing osteoradionecrosis (orn) of the jaws. preventative advice is paramount to reduce the need for future 'high risk' procedures including exodontia, which could initiate orn. clinical guidelines on the oral management of oncology patients recommend that adults are prescribed 5,000 ppm fluoride toothpaste and to rinse at least once daily with an alcohol free fluoride mouthrinse (0.05%). however in reality, this is not always the case. for oncology patients without a regular gdp, or those who may have intermittent treatment in a tertiary dental centre, accessing prescriptions for high fluoride products may be particularly challenging during covid-19. although fluoridated products could be prescribed by sir, there are two reasons why the current guidelines pose an existential risk to dental practice: • the additional costs involved plus the required fallow periods make general practice dentistry unsustainable • the necessity to approach our patients while dressed like darth vader will raise perceived levels of fear and panic among them. many will think that our practices are 'hot beds' of covid-19 infection and they will simply stay away. the policy as it stands (both in terms of national control and the dental protocols) will simply allow us to lurch falteringly to the inevitable second lockdown, due in the autumn or winter. the only way forward is to take charge of our own profession and use our own applied knowledge and skills. there   is a workable alternative approach and it relies on two fundamental factors: • in dental practice the vast majority of dental patients are booked as 'elective' patients. we know who they are, we know when they are coming and we know what we are planning to do for them when they arrive. this means we can plan in advance of treatment and we can choose to delay treatment if necessary. medical personnel in icus at hospitals have to be in close proximity to infectious patients -we do not have to be, nor should we be • the only patients who present any form of risk from dental treatment (agps included) are those patients who are actively infectious at the time of treatment. someone who has not been infected by the virus poses zero risk and someone who has been infected but recovered and seroconverted poses zero risk. only a very small percentage of the population are infectious at any one time and these individuals are infectious only for a limited time. the smart strategy means we need to identify the risk patients by advance swab testing of our patients when they require an appointment. swab testing could be done onsite by a trained practice member in advance of any appointment booking. those who test negative would be allowed normal full access to dental services. these appointments would be undertaken using exactly the same protocols as were used prior to the covid-19 outbreak. those who test positive will need to delay booking until they have a negative test -presumably about four weeks later if they remain well. the main advantage of this approach is that it is proportional, specific and minimally disruptive. furthermore, if the dental profession begins to test all of our patients this will have a significant advantage for the population as a whole, taking a burden away from the government or other healthcare sectors. therefore, we do not need to change dentistry fundamentally forever, we need to be smart and targeted for now. if testing is done by the dental profession there will be spin-off benefits for all. to use the current 'management speak' it is a win/win situation. https://doi.org/10.1038/s41415-020-1800-7 sir, while going through a large pile of past copies of the bdj, a front cover image is shown of a 'face-mask for the protection of the dentist while operating' circa 1920, 100 years ago (fig. 1) . it is important to reflect that we have always been an infection aware profession and have therefore often been at the forefront of infection control in the surgery for both our patients and the whole dental team. 1 along with other dental schools, 2 we stopped student patient contact before lockdown, however, we have continued with online lectures, tutorials, one to ones and imaginative online remote assessment. we are now grappling with the expectation of teaching again in september. naturally, much important education can occur for example, with group work on evidence-based dentistry and with teaching preclinical skills in skills laboratories. indeed, some elements of education, such as case reports, clinical reasoning and team care planning are probably easier to timetable across year groups and inter-professionally in the virtual environment, than face to face. as primarily a school teaching dental nurses to certificate level, separate degree programmes in dental therapy and in dental hygiene, as well as teaching final year students from king's college london integrated team care, our focus on minimal intervention comes to the fore in a post covid-19 era. however, even behind our ffp3 masks and visors, the logistics of teaching clinical skills and caring for patients will remain a significant but critical challenge in our large open clinics with narrow passageways between clinical units. in addition, the need for one to one qualified dental nursing and new equipment that produces less aerosol, will not just need imagination, but like all of high street dentistry, considerable financial investment. we are about to enter a new era of dental education. d. r. radford, c. louca, portsmouth, uk https://doi.org/10.1038/s41415-020-1801-6 sir, we would like to highlight a case of oral squamous cell carcinoma (oscc) brought to our attention via digital and virtual communications methods. a 78-year-old male, in the midst of the recent pandemic lockdown, could not access an in-person consultation at his local gp surgery. his son was able to arrange tele-communications with the gp using a smartphone to take photos at the patient's home and email them to the gp who, after review, forwarded these via email to our oral and maxillofacial surgery department for assistance (fig. 1) . on receiving the photos an immediate video consultation was set up between clinician, patient and family member using nhs attend anywhere to allow an initial history and assessment to be undertaken. it was suspected that the lesion was sinister and further higher quality photographs were requested and received reinforcing concern of an advanced lower lip scc. urgent head and neck scans and biopsy investigations were organised for a one-time hospital visit, to reduce the number of in-person interactions for this shielded patient. by this stage a primary care assessment, secondary care referral, subsequent history and examination and planning of one-day further investigations   fig. 1 the cover image of the bdj volume 227 issue 8, published on 25 october 2019 conditions for which over the counter items should not routinely be prescribed in primary care: guidance for ccgs systematic review of adherence to infection control guidelines in dentistry dentistry and coronavirus (covid-19) -moral decision-making key: cord-310736-b31x746c authors: teichert‐filho, r.; baldasso, c. n.; campos, m. m.; gomes, m. s. title: protective device to reduce aerosol dispersion in dental clinics during the covid‐19 pandemic date: 2020-08-18 journal: int endod j doi: 10.1111/iej.13373 sha: doc_id: 310736 cord_uid: b31x746c aim: to describe the use of a new protective device to reduce aerosol dispersion in dental clinics during the covid‐19 pandemic. methodology: the device consists of a rigid translucent acrylic structure (methyl polymethacrylate), adjusted to the dental chair, involving the patient's head, neck and chest regions. there is also a piping system to generate negative pressure, for aspiration and filtering of the air inside the device chamber. the operator works through small holes in the acrylic structure, to reduce contact with the microparticles arising from aerosols during dental procedures. simulated dental procedures using a fluorescent dye in the water of the dental equipment were carried out, with and without the use of the device. the presence of the dye was analysed at various locations, such as on personal protective equipment (ppe), the dental chair and on the clinic floor. results: in the simulated dental procedure without the device, the dye was obvious on surgical gloves, aprons (waist, chest, legs, fists) and face shields, as well as on the dental chair (backrest, light reflector) and clinic floor. in the simulated dental procedure using the device, the dye was observed only on surgical gloves, apron (fists), inside the pipe system and internal walls of the acrylic chamber. there was a certain limitation of movement and visualization by the dentist whilst using the device. conclusions: the present device is a low‐cost complementary resource for use in conjunction with standard ppe, to reduce the transmission of sars‐cov‐2 in the dental setting. further clinical trials should be carried out to test the efficacy of this device to reduce aerosol dispersion and the consequent vector of contamination, as well as the ergonomic impacts related to its use. . additional infection control measures in dental practice are necessary and have been recommended to prevent the spread of the virus and help control the pandemic (meng et al. 2020) . one of the most concerning characteristics related to the nature of dental procedures during the pandemic is the use of high-speed handpieces and ultrasonic tips, which generate aerosols of saliva particles, blood and other fluids (bentley et al. 1994 , rivera-hidalgo et al. 1999 , toro glu et al. 2001 , kohn et al. 2003 , timmerman et al. 2004 , feres et al. 2010 , nejatidanesh et al. 2013 , gupta et al. 2014 , veena et al. 2015 . special attention should be paid to the role of saliva as a significant source of sars-cov-2 transmission, since the angiotensin-converting enzyme 2 (ace2) is present in the epithelial cells of the ducts of salivary glands. ace2 is the main host cell receptor of sars-cov-2 and plays a central function in the entry of viruses into the cell to cause infection (wang et al. 2020 , xu et al. 2020a . due to the unique characteristics of dental practices, standard protective measures in daily clinical work may not be effective enough to prevent the spread of sars-cov-2, especially when patients are in the incubation period and may ignore or even deny they are infected (meng et al. 2020) . current protocols recommend preventive measures to limit sars-cov-2 contagion in dentistry, such as patient triage, prescription of mouth rinses before dental treatment, hand hygiene, the use of personal protective equipment (ppe) (including gloves, n95 or ffp2 masks, protective outerwear, protective surgical glasses and face shields) for dental practitioners and the oral health team, use of rubber dam isolation, limitation of aerosol-producing procedures and cleaning of potentially contaminated surfaces (izzetti et al. 2020 , meng et al. 2020 , peng et al. 2020 , prati et al. 2020 , umer et al. 2020 . significantly, none of the present oral healthcare protocols suggest a specific device to reduce aerosol dispersion, even though the current gold standard to manage covid-19 is to enhance ppe and airborne isolation in negative pressure rooms (cubillos et al. 2020) . recent studies from medical fields suggested using devices to reduce aerosol dispersion (canelli et al. 2020 , cubillos et al. 2020 , francom et al. 2020 ), but those did not consider the peculiarities of dentistry, such as the need for constant suction and good visualization of the operative field, since dental procedures require gentle and precise movements. thus, this study aimed to describe the use of a new protective device to reduce aerosol dispersion in dental clinics during the covid-19 pandemic, to be used as a low-cost complementary resource in conjunction with standard ppe. the device with the aspiration and filtering system the main purpose of the device is to reduce aerosol dispersion in dental clinics, isolating the patient in an 'internal environment' through which the operator (in the 'external environment') can have access to perform the dental procedures whilst protected by a physical barrier. the prototype of the device consists of a rigid translucent acrylic structure (methyl polymethacrylate) designed to fit on the dental chair, covering the patient's head, neck and chest. the shape and dimensions of the acrylic structure are shown in figures 1, 2a ,b. the device is propped up on the dental chair, positioned simultaneously when the patient sits ( fig. 2b) . access for the operator's hands is provided through three oval-shaped holes in the acrylic chamber, which allow dental procedures be performed whilst seated in the 9 to 3 o'clock ergonomic positions. these orifices are covered by translucent flexible polyvinyl chloride (pvc) films, in which small incisions are made, allowing the hands and arms of the operator to reach inside the device, whilst keeping the operator as close as possible to the patient. the back of the device is open (no rigid acrylic structure) and should be sealed with flexible pvc films, so the patients can comfortably support themselves in the chair, whilst the pvc film protects the chair from contamination. the working position with the device is shown in figure 3 . within the acrylic structure, there is a piping system ( fig. 2c) for the aspiration and filtering of air, which provides a negative pressure inside the chamber. the aspiration system is composed of two hoses strategically positioned in the chamber (fig. 2c) and a suction unit. the aspiration system forces the air to pass through an external box containing an antiseptic solution (2% naocl), aimed at neutralizing circulating microorganisms and toxic particles before the air returns to the external environment (fig. 4) . standardized simulated dental procedures were carried out, with and without the use of the device. for illustration purposes, a dye (fluorescent reflective solution-color fluor; bio technology, city of amparo, são paulo, brazil) was added to the water system of the dental unit. according to the manufacturer, the composition of the dye was glycerine, methylparaben, aqua, magnesium silicate, calcium carbonate, peg-7 glyceryl cocoate, hydroxyethylcellulose, parfum, butylphenyl methylpropional, hexyl cinnamal and linalool. figure 1 schematic representation of the protective device to reduce aerosol dispersion in dental clinics during the covid-19 pandemic. the equipment consists of a rigid translucent acrylic structure designed to fit on the dental chair, covering the patient's head, neck and chest regions. within the acrylic structure, there is a piping system for the aspiration and filtering of air, which provides a negative pressure inside the chamber. dimensions are expressed in centimetres (cm). for both simulations, a human mannequin was positioned in the dental chair (fig. 2b ). the dentist worked in the 11 o'clock position (fig. 3a) . a highspeed handpiece was activated towards the maxillary incisors for a period of 60 s. due to the use of the fluorescent dye, the simulations were carried out using an ultraviolet flashlight illumination in the working field ( fig. 3b) . images of the simulations were registered through photographs and videos. the presence and spreading of the dye were analysed in different locations, such as personal protective equipment (ppe), dental chair and floor of the operatory room. descriptive results were reported. in the simulated dental procedure without the device, the dye was observed on the face of the mannequin, surgical gloves, apron (chest, legs, fists) and face shield, as well as on the dental chair (backrest, light reflector) and floor. the dye was found on the operator's clothes under the apron, revealing the possibility of contamination. the presence of dye on the operator's cap and mask was not observed. figure 5 illustrates the results of the simulation without the device. in contrast, in the simulated dental procedure using the device, the dye was observed only on the surgical gloves, apron (fists), inside the pipe system and internal walls of the acrylic chamber. figure 6 illustrates the results of the simulation with the device. additional details of the device and the simulation results can be observed in the video s1. a certain limitation of movements and visualization by the dentist during the operative procedures with the use of the device was observed. the figure s1 shows a series of images of a clinical case illustrating an emergency dental procedure using the device, in a patient presenting with symptomatic apical periodontitis in a maxillary left second molar. this report describes a novel low-cost device that can be integrated into dental practice, in conjunction with standard ppe, during the covid-19 pandemic. although previous studies suggested strategies to reduce aerosol dispersion in various medical areas (canelli et al. 2020 , cubillos et al. 2020 , francom et al. 2020 , the present device seems to be the first aerosol box designed for the dental setting. of note, considering the remarkably high risks of infection by sars-cov-2 during dental practice, the use of this device may contribute to preventing the spread of the virus and help to control the pandemic. the role of saliva as a significant source of sars-cov-2 transmission has been studied. ace2 is a protein widely distributed in the upper respiratory tract and epithelial cells of the ducts of salivary glands in monkeys and humans (liu et al. 2011) , and it has been demonstrated that sars-cov-2 protein s has a significant binding affinity for human ace2 (xu et al. 2020a, b) . thus, ace2 is the main host cell receptor of sars-cov-2 and plays a pivotal role in host cell infection (wang et al. 2020 , xu et al. 2020a . ace2 is present in several organs of the human body, such as small intestine, testicles, adipose tissue, thyroid gland, kidneys, heart muscle, colon, ovaries and salivary glands. the expression of the ace2 protein varies in each organ, and as the salivary glands are in the tenth position in the expression level (https://gtexportal.org), there is robust evidence for the establishment of careful preventive sars-cov-2 infection control protocols in dental clinics (xu et al. 2020a, b) . the world health organization recommends the use of a particulate respirator at least as protective as a us national institute for occupational safety and health (niosh)certified n95, european union (eu) standard ffp2 or equivalent, when performing aerosol-generating procedures such as tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy (world health organization 2020c). surprisingly, aerosol-generating dental procedures are not mentioned in that recommendation, but the use of n95 or ffp2 respirators are highly recommended (meng et al. 2020) . the simulated dental procedure carried out in the present study followed a standardized protocol, aiming to illustrate the dispersion of aerosol particles using a fluorescent dye. the time of activation of the high-speed handpiece was standardized and limited to 60 s, which is usually much shorter in relation to the activation time in a regular dental visit. moreover, no ultrasonic tips were used in the simulations. thus, it is possible to infer that the results of aerosol-spreading in this simulation study are underestimated, and this raises the alert for risks of aerolization in clinical practice. the results from the simulation using the device revealed a number of dye particles inside the aspiration system piping. the negative pressure inside the apparatus seems to be of great value, preventing the dispersion of the aerosol. in the simulation using the device, the dye was observed in considerably fewer areas of the ppe (only in the surgical gloves and fists of the apron), compared to the simulation without the device, where gloves, apron (chest, legs, fists) and face shields were marked. thus, it is possible to infer that the use of the device may help to reduce the infection of health professionals during unbundling (disrobing) procedures, where the risk is significantly increased (driggin et al. 2020) . in addition, without the device, the dye was observed in distant areas of the dental surgery, such as the light reflector and floor. these findings reinforce that standard protective measures in daily clinical work may not be effective enough to prevent the spread of sars-cov-2 and suggest that the use of the device may contribute in reducing the dissemination of infection during and after the dental visit, contributing to control cross-infection between patient professional and between patients. the device may also help to reduce the viral load exposure of the dental team, a relevant factor which may influence the evolution and prognosis of covid-19 (coulthard 2020) . various aerosol boxes have been proposed in the medical field (canelli et al. 2020 , cubillos et al. 2020 , francom et al. 2020 . previous extra-oral dental suction systems have been proposed and commercialized, but none using an aerosol box. some devices include a large clear cup-shaped acrylic plate to capture the aerosols under high negative pressure, but with no physical barriers to limit the dispersion of aerosol particles. thus, pre-existing devices may likely reduce but not prevent the aerosol dispersion in the air room and consequently may not completely prevent the contact of aerosol particles with the dentists and their staff. the device described in the present study has a filtering system of the air inside the chamber, before it returns to the environment. the filtering system presented in this prototype used a 2% naocl solution, which aimed to neutralize circulating microorganisms, mainly sars-cov-2. however, the antimicrobial action of naocl is highly dependent on the duration of contact of the air with the solution, and at this time, there is no scientific evidence of the antimicrobial efficacy of the present method. device to reduce aerosol dispersion teichert-filho et al. figure 6 series of detailed images resulting from the simulation with the device. the fluorescent dye can be observed on the mannequin's face (a, b, c, d, f, g) , internal walls of the acrylic chamber (a, b, d, f, g, j, k), internal walls the piping system (i), operator's gloves (c, d, f, g). the dye was not observed in the operator's waist, chest and head regions (e), nor in the light reflector (h) or operating room floor (l). previous extra-oral dental suction devices included several filtering systems using high efficiency particulate arrestance (hepa) filters or ultraviolet light. future prototypes of the present device may include the addition of hepa filters along with ultraviolet light, which may present a greater antimicrobial efficiency. nevertheless, all these variances should be tested under clinical use. the circulation of microorganisms in the ambient air may reach the respiratory tract of the health team and patients or even be deposited in the clothes or object surfaces inside the room. thus, a highly efficient aspiration and filtering system seems to be important to reduce the risks of transmission to the health team, patients and society. using the device, the dye was observed on all the internal walls of the apparatus, which emphasizes the importance of a physical barrier to prevent aerosol dissemination. on the other hand, it highlights the need for a complementary system to frequently clean and dry the acrylic walls during the dental procedure, to allow the proper visualization of the operative field. for that purpose, the prototype described in the present study used an aquarium cleaner with a magnet, but this system should be improved for future versions of the device. the costs to build the device prototype were relatively low, and if produced on large scale, the costs may be further reduced. economically viable alternatives are particularly important, to allow the broad dissemination of this protective option which may help dental professionals to safely return to their activities. moreover, the device was built to be reused several times, considering the actual scarcity and consequent increased costs of standard ppe in face of the current pandemic. several limitations of the present device were observed. the disinfection of the internal walls of the apparatus between patients may be time-consuming, and the disinfection of the aspiration system piping is challenging. currently, a 0.2% quaternary ammonium compound solution has been used in the service where the device is being tested, for disinfection of the acrylic surfaces of the device. in addition, the internal walls of the piping system are being disinfected by aspiration of a 2% naocl solution. alternative disinfection techniques of the device should be proposed and tested in the near future. additionally, with the device there is a restriction of movement for the patients, who cannot spit, and some may experience anxiety and a claustrophobic sensation which may hinder the use of the device. limitations regarding the communication between dentist and patient may occur as well. moreover, there was a certain limitation of movements and visualization of the operative field by the dentist using the device, compared to the standard clinical protocol. nevertheless, at this point, the device is being tested under clinical conditions in a public dental service, and it is being accepted by most patients and operators, and it does not preclude real dental procedures. for illustration purposes, the report of a clinical case using the device in a dental emergency visit is included ( figure s1 ), in which a symptomatic apical periodontitis in a maxillary left second molar was treated, and all necessary procedures were performed such as rubber dam isolation, coronal access, root canal access, irrigation and root canal debridement, intracanal dressing and temporary coronary sealing. furthermore, the device described in this study has three oval-shaped holes which allow four-hand procedures, so the dentist can work with an assistant. the ergonomic impact of the use of the device should be tested in future clinical investigations. the present study was restricted to the detailed description of the device, illustrating its usage with a simulation using a fluorescent solution. importantly, further clinical trials are recommended and should be carried out to test the efficacy of this device to reduce microbial aerosol dispersion and the consequent vector of contamination. a clinical trial is underway in brazil, aiming to evaluate both the microbial efficacy and ergonomic implications of the present device. in the meantime, considering the unprecedented pandemic scenario, this low-cost device may be improved and used in different dental settings, possibly reducing the risks of contamination and helping dental professionals to act decisively to prevent the transmission of sars-cov-2 and other infectious diseases. finally, the present device may be adapted to other health services, and not just used for dental purposes. it may be used at both ambulatory or hospital levels, for medical procedures that involve aerolization, aiming to reduce the spread of particles, thus contributing to control the cross-infection during the covid-19 pandemic and also in the prevention of future epidemics. the present device represents a low-cost complementary resource to be used in conjunction with standard device to reduce aerosol dispersion teichert-filho et al. ppe, to contribute to the prevention of transmission of sars-cov-2 in the dental settings. further clinical trials should be carried out to test the efficacy of this device to reduce aerosol dispersion and the consequent vector of contamination, as well as the ergonomic impacts related to the use of the device. evaluating spatter and aerosol contamination during dental procedures barrier enclosure during endotracheal intubation dentistry and coronavirus (covid-19) -moral decision-making a multipurpose portable negative air flow isolation chamber for aerosol generating medical procedures during the covid-19 pandemic cardiovascular considerations for patients, health care workers, and health systems during the covid-19 pandemic the effectiveness of a preprocedural mouthrinse containing cetylpyridiniuir chloride in reducing bacteria in the dental office pediatric laryngoscopy and bronchoscopy during the covid-19 pandemic: a four-center collaborative protocol to improve safety with perioperative management strategies and creation of a surgical tent with disposable drapes efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study national uk programme of community health workers for covid-19 response covid-19 transmission in dental practice: brief review of preventive measures in italy guidelines for infection control in dental health-care settings epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine risk of contamination of different areas of dentist's face during dental practices transmission routes of 2019-ncov and controls in dental practice covid-19: its impact on dental schools in italy, clinical problems in endodontic therapy and general considerations aerosol and splatter production by focused spray and standard ultrasonic inserts atmospheric contamination during ultrasonic scaling evaluation of aerosol contamination during debonding procedures role of respirators in controlling the spread of novel coronavirus (covid-19) among dental health care providers: a review dissemination of aerosol and splatter during ultrasonic scaling: a pilot study does infection of 2019 novel coronavirus cause acute and/or chronic sialadenitis? medical hypotheses 140, 109789. world health organization (2020c) advice on the use of masks in the context of covid-19: interim guidance world health organization (2020b) country & technical guidance -coronavirus disease (covid-19), environmental protection world health organization (2020a) who director-general's opening remarks at the media briefing on covid-19. https:// www.who.int/dg/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-covid salivary glands: potential reservoirs for covid-19 asymptomatic infection evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission this study was financed in part by the coordenac ßão de aperfeic ßoamento de pessoal de n ıvel superior -brazil ( teichert-filho r owns a pending patent of the device described in the study. the other authors have stated explicitly that there are no conflicts of interest in connection with this article. additional supporting information may be found in the online version of this article:video s1. video illustrating details of the device and a summary of the main findings of the simulated dental procedures with and without the device. figure s1 . series of images of a clinical case illustrating an emergency dental procedure using the device: (a) initial digital periapical radiography of a symptomatic apical periodontitis in a maxillary left second molar; (b) initial intraoral aspect, showing the maxillary left second molar with a deep caries lesion and a fractured restoration; (c) rubber dam isolation with the patient inside the device; (d) use of the high-speed handpiece for caries removal and coronal access; (e) professional at the work position and protected by the device; (f) root canal irrigation and aspiration, a four-hands procedure; (g) open view of a four-hands procedure, revealing the possibility to work with a dental assistant; (h) mechanical debridement of the root canals with a hand #10 kfile; (i) details of four root canal orifices into the pulp chamber (mesiobuccal, mesiopalatal, distobuccal and palatal root canals); (j) application of the intracanal dressing and a cotton pellet; (k) temporary coronary sealing with light-curing glass ionomer cement; (l) photopolymerization carried out by the dental assistant; (m) open view of the finishing procedure of the temporary restoration using a high-speed handpiece; (n) removal of the rubber dam isolation; (o) detail of the droplets from aerolization produced during the finishing of the restoration; (p) detail of the clinical aspect of the final temporary coronary sealing; (q,r) details of the lateral lower support of the device, which can be fixed by passing outside (q) or inside (r) the arm of the chair; (s) detail of the upper support of the device, which can be propped up on the head support of the dental chair, and detail of the four-hands work inside the device; (t) open view of the course of care with professional, dental assistant and patient positioned; (u,v) sequence of the removal process of the device, starting by removing the suction tubes (u) and the acrylic box (v) of the device; (w) detail of the back part of the device after use, showing the flexible pvc film which is removed and discarded, so the rigid part of the acrylic can be disinfected; (x) detail of the interior of the device after use, showing the aggregation of humid particles (droplets) as a result of the aerolization processwithout the device, these droplets could reach the legs, waist and chest of the professional and assistant, or could be deposited in the dental chair surfaces and in the room floor.device to reduce aerosol dispersion teichert-filho et al. key: cord-026765-cw4rh1on authors: dingle, m.; irshad, h.; mckernon, s.; taylor, k. title: altered exodontia techniques date: 2020-06-12 journal: br dent j doi: 10.1038/s41415-020-1726-0 sha: doc_id: 26765 cord_uid: cw4rh1on nan excipients apart from water. this has reduced the product expiration to 28 days, however this will be extended in due course as the solution is self-preserving. we have followed the s. j. challacombe et al. dosing protocols as accurately as possible (to standardise the dosing), and we anticipate the that the product will be available mid-may, initially in a 5l presentation, primarily for dentists, while a nasal and throat spray will follow in late may primarily for pre-procedural use in the hospital setting. while it cannot now be claimed that my position is unbiased, i can claim my intention from the start of this project was to find a low cost intervention to potentially break the link of patient to healthcare worker transmission. it has been very pleasing to have one's research intention and findings validated by s. j. challacombe et al., amongst others, and it is these validations that have motivated and enabled the speedy provision of ready to use povidone iodine for dentists and for preprocedural applications in the hospital setting. j following an intensive exploration regarding the use of videne as a potential product, we came to the conclusion that it is preferential to completely avoid phenol, a component of videne, as this represents an unnecessary risk. we have therefore produced a product in partnership with a pharmacy specials nhs manufacturer, which contains no sir, we write to inform your readers about techniques for non-surgical exodontia we have adapted to at liverpool university dental hospital during the covid-19 pandemic. as part of the avoidance of aerosol generating sir, i am the chief of dentistry at a tertiary care hospital in the biggest metropolis of pakistan. the first documented case of covid-19 in our country was reported in late february at our very own hospital. as cases in our population grew the dental clinic went on an emergency only protocol and to date we have provided dental care to almost 500 patients and performed approximately over 100 dental emergency procedures. during this period we also had 11 patients who subsequently underwent covid-19 testing for various non-dental reasons; later, two patient visits were verified as confirmed covid-19 cases. whilst the average infection rate for our surgery colleagues at the hospital was 20%, the dental clinic has had zero infections amongst 60 dental staff members including faculty and residents. 1 this fortuitousness can be attributed to strict administrative and engineering controls, and provision of adequate personal protective equipment (ppe) immediately after consulting recommendations which came out from national health services and the american dental association. sir, social distancing measures are predicted to last for some time but networking and faceto-face contact have always been important in the world of dentistry. for example, picking up and trying on a pair of loupes at a trade show cannot be emulated over the internet. ideally, the exhibition industry will return to its pre-covid-19 status. yet, social distancing may well become a way of life, and in that case it will be interesting to see the effect on the future of dental events. n. axiotis, l. benson, manchester, uk https://doi.org/10.1038/s41415-020-1749-6 special attention towards ppe and initiating a respiratory programme including fit testing for all our dental staff were key elements of our success. 2 furthermore, donning and doffing measures for ppe were reinforced to all staff members; adequate training via online meetings and hands-on exercises were provided; and each staff member was asked to observe one another and provide constructive feedback to improve these procedures every day. i would also like to acknowledge the unwavering support from our leadership and department of infection control during this pandemic; the provision of an adequate supply of ppe was dynamically managed and stocked up, which went a long way towards uplifting staff morale. as there is still limited understanding of the covid-19 disease, it is important to share the learnings from our experiences to help build the evidence-base. once any new guidelines come into place we can recalibrate our responses and adjust our priorities. f. umer sir, i would like to share my thoughts and experiences on how covid-19 has affected me as a year 13 student, applying to university to study dentistry this september. unfortunately our a-level examinations have been cancelled this summer. this means that instead of receiving our final grades, determining meeting our offers for university, our results will be based on grades predicted by our teachers based on past exams and schoolwork. if we are not satisfied with our predicted grades on a-level results day, we have the option to appeal and sit alternative exams during the autumn or next year. therefore, we were advised by our schools to continue revising to complete the specification of our subjects in case the appeal process is necessary. this circumstance of a retake will probably void our current university offers. i am majorly concerned about being successfully admitted to dental school this september, having already battled through the incredibly competitive personal statement, interview process and securing my offer. my fellow students and i are experiencing a number of difficulties. we are also troubled about our early dental school career possibly being spent in lockdown instead of in university, as i understand the importance of being orientated with the introduction of the course and the onsite facilities available. this is particularly essential for first year students. sir, now that roche's sars-cov-2 antibody test has been approved by public health england, might it be reasonable for dental practice generally and sdcep in particular to take this into consideration? a patient who has tested positive could be viewed as reasonably safe for agps, with normal ppe. i do understand that we have a lot still to learn, but we need some decent working hypotheses. in the larger picture, we might be able to help roll out broader testing, take the load off our medical colleagues and help the public and especially the nhs and carers get back to work safely. this is in line with scottish government policy. 1 dental patients could also be tested on their examination appointment by the dentist; results are rapid and follow up could be quickly organised to book positive patients in for agps. dentists will need some phlebotomy training. many of us have experience in this but may need updating and being taught the specific requirements of the elecsys anti-sars-cov-2 serology test; others do not have such experience and will need a somewhat more extended course. perhaps the practicalities of such training could be investigated by nes. in scotland a mechanism for reimbursement already exists within the sdr; 3601 -taking of material for pathological examination: per course of treatment £14.00 (£11.20). this would be a good mechanism for reporting results via practitioners' services, to the wider nhs and sir, the region of madrid (population 6.6 million) is one of europe's regions most affected by covid-19 with around 60,000 cases officially reported (beginning of may). on 14 march 2020 the spanish government decreed a state of alarm under which the whole population was subjected to compulsory home confinement. a few days later, the general dental council of spain advised that due to a general shortage of ppe, practices which do not have this equipment available would immediately cease to operate, including cases involving dental emergencies. consequently, only 5% of the dental clinics remained open for urgent dental care. we present a preliminary analysis of some aspects of urgent dental care performed by a dentist in this region (17 march-3 may) who was on call 24 hours a day, six days a week, with the support of an assistant. before an appointment patients underwent a telephone interview by the dentist; none reported covid-19 symptoms nor contact with infected persons. following this protocol, patients were then seen at the practice within one hour. some 25% were treated between midnight and 6 am. the time span between the presentation of symptoms and the request for urgent consultation was usually over ten days. the majority of patients (75%) had received treatment involving only the usual medication. at all times, the dentist used appropriate ppe, minimising the use of aerosol generating procedures. total patients seen were 187 (98 women; 89 men; aged 20 months-87 years). seven were children under the age of 12 and 12 were over 75. the most common diagnosis (50%) was acute periapical periodontitis, with associated abscess (19% of cases), irreversible pulpitis (13%), complications of third molar pericoronitis (7%), periodontal abscesses procedures (agps) we have been avoiding the use of a surgical handpiece where possible, removing bone with rongeurs, bone chisel/ osteotome (with a mallet) and bone files and using chisels to divide teeth (with a mallet). 1 the importance of a good pre-operative clinical and radiographic assessment as well as fully informing the patient of potential treatment and risks involved is essential. these older techniques are useful to avoid additional ppe issues and environmental issues associated with agps. m. dingle, h. irshad, s. mckernon, k. taylor, liverpool, uk change in surgical practice amidst covid 19; example from a tertiary care centre in pakistan role of respirators in controlling the spread of novel coronavirus (covid-19) among dental health care providers: a review coronavirus covid-19 impacts to dentistry and potential salivary diagnosis key: cord-272354-pu9l36j9 authors: bennardo, francesco; buffone, caterina; fortunato, leonzio; giudice, amerigo title: covid‐19 is a challenge for dental education—a commentary date: 2020-06-28 journal: eur j dent educ doi: 10.1111/eje.12555 sha: doc_id: 272354 cord_uid: pu9l36j9 the covid‐19, which appeared to originate in china in december 2019, has spread worldwide pandemically. in this commentary, authors described this new challenge for dental education using the recent literature and experience gained in the italian university of catanzaro. at this stage, our dental clinic remained available only for the treatment of dental emergencies, all appointments were rescheduled. it will probably still be some time before education activities on patients can start again. the italian university education system provides that the course of study leading to the graduation in dentistry is divided into 6 years (the first 5 with teaching and clinical rotations, the sixth year with only clinical rotations). the students of the last year have always been engaged in the spring semester in the preparation of the graduate thesis. the other students will have to recover the clinical rotation activities during the next semester, but before restarting they must be able to correctly use the personal protective equipment (ppe) in order to protect themselves and avoid a new spread of the infection. after a month of distance education, we can draw a first balance of our experience: • online examinations are probably not the ideal way to evaluate students in health education, as it was possible to verify the students' skills only theoretically; • e-learning has been appreciated by students and professors, also in terms of teacher-student interaction; • clinical training cannot be totally replaced by remote activities, and therefore, these assets will have to be recovered in the next semester; • distance learning has proven effective in limiting covid-19 infections in our university. at the end of this semester, it will be possible to assess the impact of covid-19 on dental educations through questionnaires to students and teachers and comparing educational results with those of previous years. over the past years, numerous studies have analysed the effectiveness and acceptability of e-learning in dental education with good results. 13, 14 whilst for post-graduate students blended learning is universally adopted in dental schools almost over the world, face-to-face learning was the main method for undergraduate students of dental schools. 15, 16 development in innovative pedagogical approaches with new technologies helped to create an active and interactive learning environment that was welcomed by dental students. 17 it is reported in the literature that dental students have generally positive attitudes towards e-learning. 18 smart devices allow students to follow lessons anytime and anywhere. furthermore, students should be encouraged to learn independently from the scientific literature and to access the resources made available online by dental scientific societies (clinical videos, webinars, etc). 19 universities with limited resources can take advantage of free software for education, such as g suite for education (google llc) and microsoft office 365 education (microsoft corporation), which allow interaction with students through numerous applications for meetings, file sharing, etc. however, the use of sars-cov-2 diagnostic tests for patients, healthcare professionals and dental students could allow the sustainable resumption of clinical activities in the next weeks. 21 the covid-19 pandemic is likely to change dentistry and our training approach for the following years, with the need to reduce all situations potentially associated with risk of infection. blended learning will probably be a cornerstone of future dental education. clinical rotations will need to be reorganised according to guidelines for dental treatments and safety of dental team. the availability of ppe could also affect the way in which a clinical internship occurs. it will be interesting to evaluate in the future the pedagogical effects of the sudden change in educational method caused by the covid-19 pandemic. we wish to shortly go back to routine dental education, but we cannot exclude that the entire profession might change significantly in the next years. our hope is to be able to adequately train the dentists of the future. the authors declare that they have no competing interests related to this study. no financial support was received for this study. data sharing is not applicable to this article as no new data were created or analysed in this study. https://orcid.org/0000-0002-6528-2681 pathological findings of covid-19 associated with acute respiratory distress syndrome severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and corona virus disease-2019 (covid-19): the epidemic and the challenges world health organization clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study new therapeutic opportunities for covid-19 patients with tocilizumab: possible correlation of interleukin-6 receptor inhibitors with osteonecrosis of the jaws the impact of the covid-19 epidemic on the utilization of emergency dental services transmission routes of 2019-ncov and controls in dental practice coronavirus covid-19 impacts to dentistry and potential salivary diagnosis covid-19 transmission in dental practice: brief review of preventive measures in italy coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine sars and its effect on medical education in hong kong +12+del+9+april e+2020+-+forma to+acces sibile effectiveness and acceptability of face-to-face, blended and e-learning: a randomised trial of orthodontic undergraduates a comparison of two forms of teaching instruction: video vs. live lecture for education in clinical periodontology blended learning in situated contexts: 3-year evaluation of an online peer review project comparing two methods of education (virtual versus traditional) on learning of iranian dental students: a post-test only design study faculty professional development in emergent pedagogies for instructional innovation in dental education attitudes towards e-learning amongst dental students at the universities in croatia learning clinical procedures through internet visual resources: a qualitative study amongst undergraduate students psychological responses to the sars outbreak in healthcare students in hong kong to test or not to test? an opportunity to restart dentistry sustainably in "covid-19 era covid-19 is a challenge for dental education-a commentary key: cord-013311-r10f5yb0 authors: javed, m.; bhatti, y. title: frugal solutions date: 2020-10-23 journal: br dent j doi: 10.1038/s41415-020-2294-z sha: doc_id: 13311 cord_uid: r10f5yb0 nan sir, as a past president of the bda i am dismayed and bemused to read frequent reports in national newspapers decrying the number of children awaiting many months for tooth extractions in hospitals. indeed, the daily telegraph claims that this is the most frequent referral cause for children to hospital, numbering equating to 177 cases per day nationally at an estimated cost of £41 million. a further report of this problem appears in the recent bdj (potential surge in post-covid child tooth extractions; bdj 2020; 229: 278). is this because dentists, both in practices and community dental services, are either unwilling or unable to perform this treatment? furthermore, it seems that frequent courses of antibiotics are prescribed to keep infection from carious teeth at bay pending hospital extraction. as we are all too aware, this repeat prescribing is undesirable, building up unnecessary resistances. i presume dental schools still educate undergraduates in the expert technique of extractions, therefore one must conclude that the problem is due to an unwillingness of clinicians in primary care to undertake these treatments. we must remember that for every child suffering from painful teeth, there are parents having to cope with stressful situations. many years ago, i was a member of the then termed 'poswillo' working party, reporting to the department of health on the safety of administering general anaesthetics (ga) in practices, but additionally our role included reviewing other means of anaesthesia. whilst not advocating a return to providing gas in outpatient clinics, in a primary care setting it is perfectly possible and permissible to extract offending teeth using either sedation or local anaesthesia or a combination of both. as healthcare professionals, dentists have a duty to relieve pain and to prevent the risk of complications arising from long-term infections rather than referring patients to a seemingly endless waiting list, especially during these difficult covid-19 times, which is exacerbating this dire state of affairs. j. stuart robson, york, uk https://doi.org/10.1038/s41415-020-2282-3 used a purpose built protection box during aerosol generating procedures (https://www. facebook.com/dentistsatwork). these solutions may not be perfect but they can provide necessary protection in the best and quickest way possible in the face of exponential spread of the pandemic and economic limitations. m. javed, qassim, saudi arabia, y. bhatti, london, uk sir, in the current pandemic, the lack of equitable oral healthcare facilities, shortfall of dental healthcare providers, shortages of equipment/materials, and inadequate management of existing services is well known in developing countries. 1 it may not be possible for such countries to upgrade the dental surgeries in their tertiary care facilities to the suggested level of ventilation, filtration, and negative pressure, due to financial limitations. the alternative solution for resource constrained environments is to explore frugal innovation approaches to make the most of existing assets and skills. 2, 3 for instance, for creating a temporary negative pressure in dental surgeries strong exhaust fans have been connected to the simple duct system to deliver the air from the surgery at the minimum three metres above the roof. 4 to prevent the transmission of infection through aerosol in the dental setting the 'protection box' is an innovative and economical solution for performing aerosol generating procedures. 5 the protection box has excellent visibility and can be reused after disinfection. recently, in pakistan a dental surgeon has designed and sir, i would like to thank all my colleagues who have worked so diligently to up-skill and kindly help guide others through the current covid-19 pandemic. until six months ago, like many colleagues, i had little knowledge of this new respiratory virus and its impact on the dental profession. thanks to this new novel virus, we now have a growing number of colleagues within dentistry who understand much more about respiratory viruses than i ever seem to remember learning at dental school or during my postgraduate studies. if we add to this the long list of acronyms with sops, agps, non-agps, ffps, written and re-written sops, the latest technology to help oral health care systems in developing and developed countries fast and frugal innovations in response to the covid19 pandemic frugal and reverse innovation in surgery frugal solutions for the operating room during the covid-19 pandemic patients' case scenario as well as approaches and strategies adopted to manage covid-19 pandemic at aligarh muslim university letters to the editor send your letters to the editor, british dental journal, 64 wimpole street, london, w1g 8ys. email bdj@bda.org. priority will be given to letters less than 500 words long. authors must sign the letter, which may be edited for reasons of space. key: cord-293784-nrumr61g authors: deery, chris title: the covid-19 pandemic: implications for dental education date: 2020-06-26 journal: evid based dent doi: 10.1038/s41432-020-0089-3 sha: doc_id: 293784 cord_uid: nrumr61g aim this narrative review aims to report on the impacts of covid-19 on the provision of dental education in the 67 dental schools in the united states (us). having set the scene and current challenges, it aims to suggest some strategies to overcome the issues facing dental schools going forward. background in the us the occupational safety and health administration classified dentists in the very high risk category because of the potential for exposure to the virus as a result of aerosol generating procedures (agp). in the last 20 years there have been two previous outbreaks of coronaviruses (severe acute respiratory syndrome and middle east respiratory syndrome) which resulted in no long-term changes in the provision of dental education. the recent paper from wuhan, china described action in the height of the infection but no sustainable actions to deliver dental education going forward. challenges the challenges identified include: protecting the health of students, faculty and staff; ensuring the continuity and quality of dental education; ensuring confidence in health and safety measures; and keeping up with guidance. there is some variation across the us but most schools have suspended clinical teaching and implemented stay at home policies. others have implemented social distancing in laboratories including clinical skills. the final challenge is ensuring that students have the teaching, experience and are assessed to ensure the competency of the graduating student. solutions technology in teaching and learning offers many opportunities. for didactic teaching distance learning has been implemented. there are 'off the shelf' programmes for teaching and assessment. the development of bespoke content is time consuming and one solution is for schools to share material. although still requiring social distancing, manikins and haptics offer some opportunities for skills training. the need for excellent information sharing with faculty and students is emphasised. conclusion schools should re-evaluate their policies and curricula and incorporate appropriate methods of distance learning permanently into their teaching. students should have outreach and multi-professional support in order to allow them to assist in the community during public health crises. finally, gaps have been identified in us dental schools preparedness for pandemics. although this review is us focused the impacts on dental education in the immediate and longer term because of the covid-19 pandemic are shared across the world. 1 the introduction and background sets the scene well and the current understanding of risks associated with aerosols. 2 the point that is not emphasised is that dental schools are different to primary care dental practices and non-teaching secondary care institutions, because they have large open clinics and a need for supervising dentists to move between patients. both this review and the paper from wuhan, china discuss strategies to deliver emergency care during the pandemic, such as patient screening, remote consultations and appropriate use of personal protective equipment (ppe). 3 however, there is no discussion of how to deliver clinical dental education in the future, particularly on open clinics, assuming there continues to be an infection risk for the foreseeable future. fortunately infection levels among dental personnel appear the covid-19 pandemic: implications for dental education practice points • dental schools should embrace technology to support clinical and theoretical teaching • there is an urgent need for further research into the risks of dental aerosols, and mitigation of these risks • schools should make staff and student wellbeing a key priority a commentary on dentistry and coronavirus (covid-19) -moral decision-making occupational safety and health administration. guidance on preparing workplaces for covid-19. osha 3,990 coronavirus disease 2019 (covid19): emerging and future challenges for dental and oral medicine a scoping review on bio-aerosols in healthcare and the dental environment evaluation of minimum required safe distance between two consecutive dental chairs for optimal asepsis key: cord-319297-h6ulh3y7 authors: eliades, theodore; koletsi, despina title: minimizing the aerosol-generating procedures in orthodontics in the era of a pandemic: current evidence on the reduction of hazardous effects for the treatment team and patients date: 2020-07-16 journal: am j orthod dentofacial orthop doi: 10.1016/j.ajodo.2020.06.002 sha: doc_id: 319297 cord_uid: h6ulh3y7 the purpose of this critical review is to list the sources of aerosol production during orthodontic standard procedure, analyze the constituent components of aerosol and their dependency on modes of grinding, the presence of water and type of bur, and suggest a method to minimize the quantity and detrimental characteristics of the particles comprising the solid matter of aerosol. minimization of water-spray syringe utilization for rinsing is suggested on bonding related procedures, while temporal conditions as represented by seasonal epidemics should be considered for the decision of intervention scheme provided as a preprocedural mouth rinse, in an attempt to reduce the load of aerosolized pathogens. in normal conditions, chlorhexidine 0.2%, preferably under elevated temperature state should be prioritized for reducing bacterial counts. in the presence of oxidation vulnerable viruses within the community, substitute strategies might be represented by the use of povidone iodine 0.2%-1%, or hydrogen peroxide 1%. after debonding, extensive material grinding, as well as aligner related attachment clean-up, should involve the use of carbide tungsten burs under water cooling conditions for cutting efficiency enhancement, duration restriction of the procedure, as well as reduction of aerosolized nanoparticles. in this respect, selection strategies of malocclusions eligible for aligner treatment should be reconsidered and future perspectives may entail careful and more restricted utilization of attachment grips. for more limited clean-up procedures, such as grinding of minimal amounts of adhesive remnants, or individualized bracket debonding in the course of treatment, hand-instruments for remnant removal might well represent an effective strategy. efforts to minimize the use of rotary instrumentation in orthodontic settings might also lead the way for future solutions. measures of self-protection for the treatment team should never be neglected. dressing gowns and facemasks with filter protection layers, appropriate ventilation and fresh air flow within the operating room comprise significant links to the overall picture of practice management. risk management considerations should be constant, but also updated as new material applications come into play, while being grounded on the best available evidence. minimizing the aerosol-generating procedures in orthodontics in the era of a pandemic: current evidence on the reduction of hazardous effects for the treatment team and patients the purpose of this critical review is to list the sources of aerosol production during orthodontic standard procedure, analyze the constituent components of aerosol and their dependency on modes of grinding, the presence of water and type of bur, and suggest a method to minimize the quantity and detrimental characteristics of the particles comprising the solid matter of aerosol. minimization of water-spray syringe utilization for rinsing is suggested on bonding related procedures, while temporal conditions as represented by seasonal epidemics should be considered for the decision of intervention scheme provided as a preprocedural mouth rinse, in an attempt to reduce the load of aerosolized pathogens. in normal conditions, chlorhexidine 0.2%, preferably under elevated temperature state should be prioritized for reducing bacterial counts. in the presence of oxidation vulnerable viruses within the community, substitute strategies might be represented by the use of povidone iodine 0.2%-1%, or hydrogen peroxide 1%. after debonding, extensive material grinding, as well as aligner related attachment clean-up, should involve the use of carbide tungsten burs under water cooling conditions for cutting efficiency enhancement, duration restriction of the procedure, as well as reduction of aerosolized nanoparticles. in this respect, selection strategies of malocclusions eligible for aligner treatment should be reconsidered and future perspectives may entail careful and more restricted utilization of attachment grips. for more limited clean-up procedures, such as grinding of minimal amounts of adhesive remnants, or individualized bracket debonding in the course of treatment, handinstruments for remnant removal might well represent an effective strategy. efforts to minimize the use of rotary instrumentation in orthodontic settings might also lead the way for future solutions. measures of self-protection for the treatment team should never be neglected. dressing gowns and facemasks with filter protection layers, appropriate ventilation and fresh air flow within the operating room comprise significant links to the overall picture of practice management. risk management considerations should be constant, but also updated as new material applications come into play, while being grounded on the best available evidence. (am j orthod dentofacial orthop 2020;-:---) t he pandemic outbreak of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has had a large impact on the frontline of health care workers, and among those, on dentists and orthodontists. 1 besides the public health and economic burdens of the coronavirus disease 2019, it is now evident that its massive spread around the world has imposed great occupational challenges, with the implementation of routine dental services being at stake. 2 the nature of the virus' infectious route, with direct implication of airborne droplets in the form of aerosol, has revealed certain potential hazards underlying conventional and standard oral health care procedures. 3 orthodontic practices are not to be left aside. an aerosol is defined as a suspension system of solid or liquid particles in a gas. 4 the term was introduced by frederick g. donnan to describe an aero-solution-clouds of microscopic particles in air. the various types of aerosol, classified according to physical form and how they were generated, include dust, fume, mist, smoke, and fog. aerosol should be differentiated from solid particles staying airborne for some time in the air and the splatter of relatively large sized droplets of water generated by splashes in a dental setting, such as those produced by using the water syringe. aerosol-producing dental procedures, along with upcoming concerns, are not new to the dental discipline and at most, these concerns should not be selectively twisted, hampered, or emphasized under the light of the present pandemic or potential future endemics. they are effectively there since more than 20 years, and protective measures for dentists and clinic personnel should be prioritized in practice, irrespective of the presence of a pandemic, epidemic, normalized conditions, or otherwise. 5 furthermore, these concerns and protective measures should effectively be carried forward through advancements in technologies as well as evidence directed by new knowledge over the years. the current pandemic situation has boosted our thinking and endorsements on how to efficiently manage and minimize aerosol production in contemporary practice. evidently, common categories and burdens of orthodontics-related applications producing aerosol and/or airborne particulates are focusing on bonding and debonding strategies. the former involve application of water-spray practices in connection to enamel etching, before conditioning with bonding agents and bracket bonding; the latter pertain to enamel clean-up practices after removal of fixed appliances on completion of orthodontic treatment. of late, in the line of debonding strategies, an additional procedure liable to aerosol generation has emerged in the clinical field; composite attachment removal after aligner therapy or possible attachment replacement and/or removal cycles during treatment with aligners should not be neglected. 6, 7 this is particularly striking if one considers that most orthodontists and/or other clinicians utilizing aligner methods to straighten teeth and treat malocclusions have adopted wide application of these adjuncts in everyday practice. 8, 9 with regard to bonding strategies, the conventional acid-etching stage may be employed with the use of a gel etchant of very thick consistency, a gel of lower viscosity, or a liquid etchant (fig 1) . implications for the first alternative are rather straightforward, as it might require a considerably higher pressure of water flow to be rinsed off, as well as a longer rinsing period; but practically, there is more. very thick consistencies of gel essentially negate the action of acid for the amount of material not in contact with the enamel surface owing to limited wetting. thus, the 2 other alternatives are often selected. however, high water pressure used generates splatter, which does not belong to the aerosol classification, but may too contribute to the contamination of the operatory. water pressure is normally set at 40 psi in the dental units, with existing air pressure at 80 psi. the american dental association (ada) has suggested testing of water squirt of more than 1.3 m (4 ft), as a practical measure of raised water pressure. 10 regarding debonding strategies of fixed appliances, implication of rotary instruments used to remove remnants of composite compounds after fixed appliance removal, as well as utilization of water as cooling agent during handpiece usage form priority factors that should be considered. cutting efficiency and aerosolized dust formation are also discussed. this narrative article aims to discuss the hazards arising from routine orthodontic practices implicated to aerosol generation, sometimes on par with and following examples from standard dental procedures, and also to elucidate potential interventions or alterations of conventional orthodontic applications as an attempt to minimize substantial hazards or adverse effects. the narrative is built on 2 basic pillars regarding aerosol generation; the microbiologic on one side, and particulate production and toxicity related implications on the other. etching agents with variable viscosity. note the considerably lower viscosity of the green-colored agent, resembling a liquid etchant state. the green, blue (right side) and red agents should be preferred over the first 2, because they would require less water pressure to be rinsed away. the pathogenic pervasiveness of dental aerosol rests in its dependence on the concentration of bacterium or virus load in compressed air, or water-spray spatter mixed-up with tooth material, plaque, blood, calculus, and saliva debris that are theoretically and practically produced during routine dental practice, which makes use of an intraoral service handpiece. as such, orthodontic practices fall within the range of these procedures, seemingly within a more limited extent, but it is important that they are not neglected. the presence of dental unit waterlines (duwls) microbiota has also been considered an additional intriguing factor, especially because pathogens get carried forward through the water supply system directly to the handpiece in use. 11 when coolants are used during service, the interaction of the cooling agent with fluids and debris produced within the oral environment as a result of composite or tooth grinding practices or use of ultrasonic scaling is present, and inductively, it may be detected in air-suspended particles and aerosol. 11 the centers for disease control and prevention 12 has established a safety maximum level of colony forming units (cfus) emitted and detected in the air at the threshold of 500 cfus per ml as a result of dental handpiece and water and/or air supply instrumentation usage, excluding coliform bacteria for nonsurgical procedures. these levels are liable to reduction when immunocompromised patients are in chair, and are lowered to 200 cfus per ml. evaluation of pathogen levels may be done through simple commercially available test strips or kits. in addition, air and/or water related dental instrumentation (handpiece, spray syringe, and/or ultrasonic scaler) in direct usage to patients' oral cavity should be flushed and pseudotested for 2 minutes at the start of each day, as well as for 30 seconds between patients. 13 a recent systematic review on bioaerosols in dental environment has pinpointed the presence of 38 types of micro-organisms, including 19 bacteria and 23 fungal genera, indicating a high variety of a range of species, whereas it was interesting that none of the included articles reported on the presence of viruses or parasites; seemingly, this is not linked to their absence from airsuspended droplets, but rather to the line of focus of the primary studies, partially in favor of the abundance and commonness of the former pathogens and their easier and nonspecific detection through wide air sampling techniques. 14 a mean bacterial load range of 1 to 3.9 cfus in logarithmic scale has been reported after procedural produced aerosol, while the most eminent load has been reported in the range of 1.5 meters from the oral cavity, even higher compared with closer distance measures such as that of 1 meter from the patient. 15 fusobacterium family pathogens have been identified in aerosols produced after ultrasonic scaling in practice through checkerboard dna-dna hybridization techniques. 16, 17 of the family, fusobacterium nucleatum has been identified as a bacterium related to pathologic, ophthalmic, and respiratory implications, while also inductive of cellular apoptosis in vivo. 18, 19 in addition, it has been reported as related to the launch and progression of periodontitis, or as attenuating attribute of gingival fibroblast mesenchymal cell proliferation. 20 however, the results of checkerboard hybridization techniques should be interpreted with caution as per the exact bacteria species eligible for identification, because such practices are close ended, checked in preselected dna-probe panels and other pathogens not prespecified might be present within droplet spatters as well. nonetheless, studies assessing mostly periodontal pathogens have identified an increased prevalence of species belonging to the socalled orange complex in aerosols generated during usage of ultrasonic scaler. 16, 17 these mostly pertained to campylobacter rectus, prevotella intermedia, and others, including f. periodonticum in addition to f. nucleatum. apart from directly exposed aerosolized bacteria, another potential contamination source within dental offices or in hospital based dental units has been identified and special attention has been placed to the presence of legionella pneumophilla as well as pseudomonas spp in duwls. 11, 21 these might well serve as routes of infection for patients and/or dental personnel indirectly and via droplet suspension after aerosol-generating handpiece or water and/or spray syringe usage. other sources of l. pneumophilla constitute air-conditioning systems or cooling towers within dental settings. 14, 22 interestingly, the novel sars-cov-2 has also been lately reported to demonstrate capacity of emanation via the airflow of air-conditioning units in business environments. 23 an array of clinical studies, since more than 25 years and until recently, have attempted to identify effective methods of reducing pathogen load stemming from aerosol forming procedures in dental settings (fig 2) . the vast majority have studied in-service utilization of ultrasonic scaling, whereas some have reported on orthodontic related strategies of debonding procedures, or other dental prophylaxis or restorative procedures. 17, [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] largescale efforts have been lately endorsed to collectively appraise all available evidence and provide justifiable ranking of the efficiency of these methods. 35, 36 the most prevalent recorded approaches were preprocedural mouth rinse using a wide variety of potentially antimicrobial agents, such as, chlorhexidine (chx) 0.12%, chx 0.2% or tempered chx 0.2%, cetylpiridinium chloride 0.05%, povidone iodine (pi) 1%, chlorine dioxide, herbal-based agents, or others pertaining to ozone irrigation, use of high volume evacuators and/or dental isolation systems, or agents added to duwls to reduce the load. 27, 28, 37, 38 evidence from a study on bacterial load during orthodontic procedures comparing bracket debonding followed by enamel clean-up with high-speed handpiece and water cooling versus standard orthodontic care involving archwire and/or ligature change, and replacing procedures, highlighted the increased pathogenic state of aerosols produced by the former, with a mean difference of 49.2 (95% ci, 19.4-79.0) in total cfus. 31 this highlights the exposure hazards of orthodontists related to certain orthodontic procedures in practice and draws attention to additional prophylactic measures to be selectively taken within the dental operating office. effectively, bacterial load in aerosol in the dental and/or orthodontic cabinet has shown to be significantly raised immediately within 5 min of service for an aerosolgenerating procedure, including enamel clean-up. further evidence on microbiologic assessment of aerosol produced after debonding of fixed orthodontic appliances and during composite clean-up has elucidated the increased potential of aerosolized particles, particularly those with aerodynamic diameters of 50 mm or less, to surpass the respiratory barriers and invade deep into the lungs, along with pathogen contaminants. 32, 39 bioaerosol infiltration has been detected in simulation studies all the way to the respiratory tree from the pharynx to the bronchial alveoli of the lungs. although decreased particulate size seems to exhibit increased potential to penetrate deep into the lungs, the viability of pathogens has been shown to simultaneously decrease, also impacting biodiversity at the deep respiratory levels. 32, 40 use of preprocedural mouthrinse with chx of either 0.12% or 0.2% concentration has been identified by individual studies as an important decontaminating agent contributing to identification of decreased bacterial amounts of infected aerosol; latest data coming from an endorsement to compare all direct and indirect evidence from examined interventions (mouth rinses, evacuators, decontamination of duwls, and others) across studies and within dental settings, has revealed this supremacy of preprocedural chlorhexidine mouthrinse over other measures for 30 s to 1 min, but also with documented prevailing of tempered (47 c) chx 0.2%. 27, 29, 30, 35, 36, 41, 42 tempered chx solution at 47 c, has been reported to offer increased anti-microbiologic action against bacteria of the human dental plaque, while also preserving adverse effects on tooth and pulp vitality to the minimum. 43 the increase in bacterial kill rate has been determined to reach as high as 25% surplus, while to avoid storage contamination with toxic compounds such as p-chloroaniline, freshly made chx solutions should undergo heating. 43 as this measure might be potentially considered impractical for the routine management of clinical practice, it might still be the treatment of choice for highly prone to aerosol induction procedures, with water cooling involvement; other solutions could also be considered for more conservative procedures. among the priority treatments of choice and apart from chx solutions (either tempered or nontempered), pi 1% has also been considered a viable alternative. 35, 36 aforementioned documented evidence originates, as discussed, primarily from ultrasonic scaling clinical studies, randomized in most cases, while total bacterial count in generated aerosol has been the outcome of interest, leaving virus load aside. extrapolation to other potentially producing aerosolized compounds procedures, however, seems reasonable within a dental cabinet setting and certain orthodontic procedures, such as fixed appliance debonding, may benefit from such measures. at present and in the middle of sars-cov-2 pandemic mid-2020, there is no evidence from clinical trials on the effectiveness of interventions taken preprocedurally in dental offices against viral load in airsuspended droplets or aerosols. however, it would be reasonable to assume that mouth rinses or irrigates with proven capacity to interact with viral molecules and its cellular membranes might prove beneficial. on the basis of the oxidative action of such agents against the lipid membrane of coronaviruses, latest reports as well as primary guidelines of the national health commission by the people's republic of china on measures against sars-cov-2, have indicated a decreased effectiveness of chlorhexidine as a measure of choice, mostly because of the lack of oxidative action, while use of hydrogen peroxide 1%, or pi 0.2% to 1% appear more realistic as effective alternatives. [44] [45] [46] oxidative agents act directly on the lipid shell membrane of the virus and destroy cellular components. in particular, pi action is enhanced by the slow and gradual release of iodine as carried by the povidone vehicle, while any adverse effects of iodine are reduced, allowing for a toxicity-free simultaneous interaction. 47 based on the absence of clinical trials in the field of virus load of aerosols, latest calls have emerged and suggest the use of flavonoids or cyclodextrine agents to fight or attenuate sars-cov-2 infection through saliva expectorations or spatters secretions. 48 however, their effectiveness remains to be tested. composite grinding and particulate production during handpiece instrumentation usage in routine dental practice has been considered an additional source of potentially hazardous concern for dentists and orthodontists in general, but also in particular in the middle of a pandemic of a novel sars-cov-2, with unprecedented impact worldwide. 1 an initial notion before any consideration of produced aerosolized dust is cutting efficiency and types of dental rotary instruments that might effectively reduce grinding duration. knowledge on the topic may largely be attributed to the extensive research and work on this field by a.j. von fraunhofer et al. [49] [50] [51] [52] [53] type of cutting bur and mode of action first, discrimination between commonly used burs in terms of cutting mechanism is discussed, roughly between 2 of the most prevalent cutting instruments in use, tungsten carbide and diamond burs. the tungsten carbide burs differ from diamond burs, as they are considered to achieve material removal through a flow-dependent fracture process (plastic flow), occurring as a result of elevated shear forces between the carbide blades and the material surface; this makes them rotary instruments of choice for cutting ductile substrates including composites, dentin, or metals. dissimilarly, diamond cutting burs induce brittle fracture of substrates, functioning by creating grooves and making use of dislocation motion and subsequent radial flow of the material, ultimately leading to propagation of cracks by the generated tensile stresses produced and chip formation. evidently, diamond burs are mostly efficient for ceramics or enamel surface. 49 latest innovations for adhesive removal after completion of orthodontic treatment, entail the use of fiber-glass or fiber-reinforced composite burs, which have been reported to exhibit a potential for reduced enamel surface roughness on enamel clean-up, compared with standard carbides. 54, 55 however, no data is currently available with respect to the effect of these cutting burs on particulate composite dust dynamic. moreover, water supplementation and spray patterns of the handpiece during tooth or material grinding, apart from the straightforward effect on preservation of temperature within tooth and pulpal tolerable standards, have also been implicated as a medium for achieving efficiency during the cutting procedure. 56 water spray during tooth preparation within a proximal value of 40 ml/min room temperature has been considered reasonable for avoiding pulp interactions. 56 in reality, water or other lubrication medium has been considered to play a significant role in cutting efficiency following reynold's hydrodynamic lubrication theory. in particular, across dental setting environments where standard and known length and material cutting instruments are used for commonly used 400,000 rpm bur rotation speed, it appears unlikely that effects of dynamic viscosity of coolant media may be significant. testing across water coolant, alcohol (1%) as well as glycerol (2%) solution has revealed comparable effects. 49 further, water application as coolant usage during material grinding in practice, including enamel cleanup from bonding remnants after orthodontic treatment, offer a thin line layer of interproximal matter between the carbide and material interface. this is considered to induce surface adsorption alterations in the substrate material after reduction of the surface-free energy, produced by changes in the strength of association of the interatomic bounds between interactive entities, thus resulting to surface hardness changes. 49 to this respect, and as discussed above, cutting with carbide burs in ductile substrates such as resin remnants after debonding of fixed appliances or bonded attachment removal after or during aligner therapy, shall be advantaged, in terms of cutting efficiency, by water supplementation targeted directly to the carbide-composite interface, in the following manner: initial groove formation after bur application is generated, followed by lateral displacement of the substrate, pilling-up material dislocation, and crack propagation, resulting in chip formation. 49 the described procedure broadly follows the original work of rehbinder et al 57 back in 1940s, who suggested that chemically-induced surface hardness changes bear the potential to increase drilling efficiency of the cutting tool in mining settings with aqueous surfactant solutions, within a range of 30%-50%. gain is 2fold, with subsequent extrapolation to orthodontic and dental practice: faster advancement of the bur into the substrate and decreased demand for heavy load application in practice, thus reduction in operating time and total amount of aerosol production. resin composites are known to possess a wide range of applications in dentistry, with orthodontics usage in bonding procedures of both fixed appliances as well as treatment with aligners and attachment adjuncts being in the spotlight. 58 normal composite composition comprises of the resin matrix (usually represented by bisphenol-a [bpa] diglycidyl dimethacrylate, triethylene glycol dimethacrylate, and ethoxylated bpa glycol dimethacrylate), the inorganic filler compounds as well as a coupling agent to guarantee bonding between the two. 59-63 filler compounds usually fall below 0.4 mm and may serve in a wide range of particulate sizes and even fall within the nano-range. 62, 63 orthodontic adhesives have also been considered to acquire quartz-type filler particles as well. 64 heavy metal oxides are preferred, namely barium, strontium, zinc, aluminum, or zirconium, while their primary service remains to offer enhanced physical and mechanical properties to the material, including polymerization shrinkage water sorption and solubility, radiopacity, and reduction of biodegradation in-service. [65] [66] [67] [68] during debonding strategies, but also lately increasingly during attachment removal in the course of and/or after the end of aligner treatment with thermoplastictype devices, breakdown of the bulk of composites takes place, with material micro-and/or nano-fragments being aerosolized. 6 these particulates bear the aerodynamic potential to surpass the respiratory fraction barriers and natural defense mechanisms of the clinician, patient and office personnel and find their way deep into the lungs. 69, 70 a foremost effort to provide evidence in the field of aerosolized composite compounds in dental settings, has been mainly initiated and driven by 2 separately working groups in leuven, belgium, and bristol in the united kingdom, in essence after simulation in clinical conditions. 32, 64, [69] [70] [71] [72] [73] [74] [75] evidently, aerosols comprising of particles lower than 10 mm or 2.5 mm (pm 10 or pm 2.5 , particulate matter) are gaining attention due to their potential to enter the respiratory tract; interestingly, even smaller particulates within the range of dozens of nanometers (\100 nm) have been associated with an increased dynamic to surpass the primary boundaries of the respiratory system and reach deepest levels of the terminal epithelial bronchioles of the lungs because of their increased surface to volume ratio, offering an amplified reactive potential when in interaction with cellular interfaces. [76] [77] [78] [79] [80] [81] [82] several studies have investigated the content compounds of composite dust produced in aerosols in dental and orthodontic setting, and it has been claimed that percentage and concentration of nano-sized identified filler particles in the aerosols might be related to the original filler content of the composites. however, this is far from the case, because all types of composites, irrespective of filler size, have been reported to exhibit significant amounts of nanoparticles within the range of 38-70 nm during grinding and clean-up. 64, 70, 71, 73 in particular, surface friction and heating shock during composite grinding results to matrix decomposition of the substrate, aging, c5c conversion of bonds on surface, and ultimately production of respirable composite dust. [83] [84] [85] wet or dry conditions apart from water supplementation contribution to the cutting efficiency of grinding tools on the composite substrate during debonding, thus offering minimization of (bio)-aerosol production duration, the effect of water as per emanation, and generation of airborne dust has been disputed, however, with scarce evidence from few research efforts, across variable settings. in essence, a recent study inspected the effect of water cooling in slow-handpiece usage on bulk composite sticks containing an array of filler sizes under simulated conditions of dry and wet grinding. 74 their work suggested consistent findings for all types of composites, which demonstrated a significant reduction in the number of detected nanoparticles being released when water spray was in-service (5.6 3 10 5 -13.7 3 10 5 numbers per cubic centimeter), denoting a half-pace reduction, compared with dry settings. interestingly though, both dry and wet grinding alternatives produced high numbers of nano-sized particulates being aerosolized overall. the highest amounts have been detected during the last minute of grinding, reaching levels of approximately 33 3 10 5 numbers per cubic centimeter. particulate agglomeration has been considered to occur across time, thus contributing in increasing average particulate diameter, overall. to this respect, under water usage conditions, airborne generated nanoparticles have been considered particularly prone to being trapped within water droplets, resulting in increased matter sizes, which are less likely to achieve penetration of the epithelial bronchial barriers and find their way to the lungs. the aforementioned conditions and settings could be considered as vastly resembling to the bulk attachment material removal during orthodontic treatment with aligners. 6 as previously discussed, aligner usage for treatment of malocclusions currently involves increasingly frequent adoption of composite grips bonded to tooth enamel, sometimes more than 1 per tooth, as attachments of various sizes and shapes, with nonnegligible dimensions, varying within the range of 2-5 mm and also width or thickness that may exceed 1 mm. 6, 8 these adjuncts target to the achievement of modes of tooth movement, either rotational or translational, within all 3 planes of space, which would otherwise be non-manageable with the early phase plain thermoplastic aligner usage, that do not necessitate enamel involvement. 86 this compares to the thin layer of composites used as a layer of "sandwich-type" pattern between the bracket base and the enamel surface in a conventional case fixed appliance treatment, with an average estimated thickness of 150 to 250 mm; one may evidently cognize that the bulk and thickness of the attachment grips in aligner therapy is implicated in 2 conditions: first, the occurrence of an excessive amount of composite polymerized material within the oral cavity, allowing for the potential risk of bpa release or monomer leaching, depending on the number and shape or size; second, grinding procedures for attachment removal may prove extremely exhaustive and timely, bearing an increasing risk of excessive production of aerosolized composite dust. 6, 59, 87, 88 handpiece role furthermore, an earlier report on human extracted teeth and subsequent simulated bracket removal and enamel clean-up, has examined the effect of handpiece, water coolant, and high volume evacuator as well as surgical facemask, on the amount of particulate production and particle concentration during composite grinding after debonding; however, the baseline effect of handpiece was variable, because slow-speed handpiece was used in absence of water coolant, whereas high-speed handpiece only under water-spray emission. 75 findings structured on nonparametric data revealed a significantly higher concentration of airborne particulates under wet conditions and the use of high-speed instrumentation. in addition, use of facemask appeared considerably effective, contributing to the reduction of the detected concentration, while high volume evacuator was not identified as a critical parameter in this respect. to date, there is no further evidence on the direct crude effect of handpiece variation and rotary instrumentation speed with regard to airborne particulate generation, under otherwise comparable conditions. following research about cytotoxicity and xenoestrogenic effects of bpa and/or monomer release of adhesive compounds within the oral cavity, airborne particulates produced during grinding of composites after fixed appliance removal or aligner's attachment elimination, are seemingly a potential source of similar concerns. 88,89 a mild but gradual reduction of human bronchial epithelial cell viability in laboratory conditions has been documented, giving rise to speculations on the reactive dynamic of such particulates. [62] [63] [64] 72 composite filler particles and matrix composition of restorative adhesives did not appear to play a role. interestingly, the latest report encompassing orthodontic adhesive material evaluation at grinding stages after simulated conventional orthodontic treatment, pinpointed the aptitude of aerosolized particles of adhesives comprising of quartz-type fillers to demonstrate disrupting effects on interacting cell membrane integrity and cellular viability, while also to intervene with cellular growth potential of epithelial bronchial populations at an early stage. 64 these effects are probably related to the size and shape of such fillers' configuration, following the increased surface to volume ratio they present. related evidence on orthodontic adhesives comes also from the assessment of in vitro estrogenicity of orthodontic composited ground under simulated bonding-debonding settings. estrogenic effects appear as a result of residual monomer release (bpa), which follows action as an endocrine disruptor because of the very similar structure with beta-estradiol. 59, 90 under the use of highspeed handpiece without water-spray, eluents containing airborne particulates, after grinding different types of adhesives (ie, chemically or light-cured), have shown an increased proliferating capacity on mcf-7 breast cancer cells in vitro. 84 such findings are of particular interest and raise considerable awareness when it comes to the largescale removal of attachment grips implicated in aligner therapy. the bulkiness and volume of these adjuncts evidently requires a great amount of grinding efforts and intraoral cutting instrumentation service. it is therefore likely that a significant amount of heat influx occurs first at the surface of the composite substrate if not substantially cooled, resulting in heat shock of the matrix. 84 resultant effects on chemical decomposition of the produced aerosolized dust with further implications on monomer release and bpa diglycidyl dimethacrylate compounds might be alarming. 91, 92 thus, broad and time-consuming composite removal, as required in extensive removal of attachments, with no water cooling in-service, should largely be avoided, while further research in the field is critical to detect specific effects of water supplementation to the emanation of monomer and other potentially estrogenic compounds. direction of measures taken to minimize effects of aerosol production in orthodontic practice should target in 2 basic routes: bonding and debonding procedures, in essence those are interconnected (table) . the former basically comprises procedures that take place before bracket placement on tooth surface and involve rinsing actions for enamel preparation agents and use of certain types of bonding materials. as previously stated, very thick consistencies and substantial amounts of etchant acid gels applied on tooth surface, apart from presenting compromised action per se, evidently require higher water and/or spray pressure to be rinsed off, thus increasing the likelihood for spatter emanation and droplet formation, but also resulting in prolonged working times. conventional acid-etching agents entailing low viscosity or even liquid gels should be prioritized. self-etching primer alternatives have also been proposed, although these may require careful pumicing to ensure a precipitations-free enamel substrate. 93, 94 in the same line and to avoid rinsing application and aerosol production, glass-ionomer cements as compared with conventional light-cured counterparts may be preferred. 95 these material alternatives present a chemical interaction and adherence with enamel surface, do not involve prior conventional enamel conditioning, or involve a thin layer of polyacrylic acid agent in contact with enamel, with an induced shallow depth of penetration of approximately 5 to 7 mm. 96 they are also less susceptible to moisturized oral cavity conditions, thus offering a viable alternative to classic adhesives bringing the aforementioned advantages, but also bearing a reduced risk for iatrogenic damage to the enamel surface. 97, 98 however, all currently and widely adopted bonding alternatives do not target on the desirable minimization of adhesive remnants covering the enamel surface after debonding. starting from the necessity of an enamel-friendly bonding agent, there has been an endorsement and inspiration, following nature and wildlife environment, to design new material structures on par with living creatures' observations. these form the so-called biomimetic materials. for example, gekkonidae lizards (geckos) acquire a unique adhesion ability attributed to their foot pad, the "contact splitting." 99 in particular, geckos' foot pad contains densely packed ultrafine hair, split in the endings, thus offering increased number of contact points per unit area, contributing to greater adhesion forces generated. as such, geckos are capable of sustaining their weight upside-down, with a gravity defying ability, without mediation of any chemical agent, relying only to physical forces, otherwise being impossible to achieve. this type of strong gecko-feet grip has inspired the design of medical adhesives and might attain applicability in orthodontic bonding agents for dry environments. 100 moreover, to overcome failures of geckos' inspired materials, in wet conditions, scientists have studied the use of mussel adhesion as a combination approach, with a resulting new material named "geckel," which might exhibit enhanced adhesion potential both in dry and wet conditions. mussel biomimetic polymers are based on l-3,4-dihydroxyphenylalanine (dopa), offering "sticky" and "glue" resembling properties in the materials. 101 in essence, biomimetic based bonding primers such as l-dopa might offer clinicians a significant tool against oral environment conditions. in combination with geckos' related properties and applicability to bracket bases, sufficient bond strength to enamel surface might be achieved, without necessitation for prior enamel conditioning, also making debonding practices and enamel clean-up at the end of treatment, effortless. pertaining to debonding procedures, calls and endorsements for aerosol containment, in general, should be focused first on preventive measures to minimize composite remnants after bracket removal in conventional orthodontics, and second on effective grinding patterns to reduce dust, particulate generation, and operating time, with further speculations on bio-aerosol formation and microbiologic perspectives, as well as xenoestrogenic action of the produced particulate matter. the compositebracket base interface may play a significant role in achieving a desirable limited amount of adhesive remnant for grinding. alterations in the adhesive-base interlocking characteristics may take place by induced modifications in the resin filler content and also in the adhesive retention patterns within the bracket base. 96 targeting an efficient combination of bracket base mesh, size, and shape with adhesive composition that may result in a cohesive composite fracture on debonding, would allow for minimal enamel clean-up (fig 3) . in this respect, applications from high technology and automotive industries might offer reformative solutions in orthodontic procedures in the near future. lately, adhesives that debond on command have been used in interlocking joint positions in technology adjuncts to allow for a temperature-controlled initiation of the debonding process. 96, 102 this is achieved mostly through the embedding of thermally expandable particles (tems) into the adhesive matrix. 103 the idea about tems dates many decades back and resides in the transformation of the particles through heat shock, occurring by softening of the cell particulate matter jointly with gasification of the inner liquid phase hydrocarbon. 103, 104 in the same line, ferrous microparticles within the micron range, have been introduced as fillers and act by being preferentially distributed after external magnet polarity reversal, thus inducing destabilization of the polymer structure and initiating crack states within the resin matrix that may easily be diffused. other initiatives might also entail application of irradiation to reverse polymerization and produce a highly viscous adhesive state easily to be removed. 96 wide adoption of bpa-free adhesives has been suggested for a range of dentistry applications including orthodontic bracket or fixed retainer bonding. 105 to this line, advantages of such alternatives which miss bpa monomer derivatives, have been directed towards the elimination of the reactive oxygen species produced after bpa leaching in the oral cavity, after incomplete polymerization of the adhesives and being able to incite an estrogenic potential. the majority of such alternatives make use of aliphatic co-monomers based on triethyleneglycol dimethacrylate, urethane dimethacrylate, and cycloaliphatic dimethacrylates or are effectively represented by a single aromatic dimethacrylate derivative. these efforts might prove beneficial also with regard to elimination of bpa release in aerosolized dust at the debonding stage. 96, 105 conclusion in all, wide and consistent adoption of occupational measures to control generation of aerosol in orthodontic practice should be universal, with microbiologic considerations, particulate matter production as well as toxicity related perspectives being on the spot, even more within the course of a pandemic. realistic management in practice, should focus on bonding and debonding strategies, while careful selection of procedures and application of safety measures depending on individualized patient needs is fundamental. in particular, minimization of water-spray syringe utilization for rinsing is anticipated on bonding related procedures, while temporal conditions as represented by seasonal epidemics should be considered for the decision of intervention scheme provided as a procedural mouthrinse, in an attempt to reduce the load of aerosolized pathogens. in normal conditions, chx 0.2%, preferably under elevated temperature state should be selected for minimization of bacterial load. in the presence and spread of oxidation vulnerable viruses within the community, substitute strategies should be opted, effectively represented by the use of pi 0.2%-1%, or hydrogen peroxide 1%. after debonding, largescale enamel clean-up strategies should entail the use of carbide tungsten burs under water cooling conditions, to augment cutting efficiency, timely fulfillment of the procedure, as well as reduction of aerosolized nanoparticles. attachment clean-up at the end of aligner therapy falls into this category; however, selection strategies of malocclusions eligible for aligner treatment should be reconsidered, and a more confined use of attachment grips might also be a viable future perspective. for more limited clean-up procedures, with traces of adhesive remnants left on enamel substrate or individual "re-bracketings" or grinding after bracket breakage in the course of treatment, water cooling rotary instrumentation might not be the treatment of choice, whereas hand-instruments for remnant removal might represent better an effective strategy. furthermore, in-office measures of self-protection should never be neglected. dressing gowns and facemasks with filter protection layers and face shields for all clinic personnel, appropriate ventilation, and fresh air flow within the operating room are of paramount importance. risk management considerations should be constant but also updated as new material applications come into practice and/or epidemiologic equilibrium of the community is disrupted. coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine the hallmarks of covid-19 disease aerosol technology: properties, behavior, and measurement of airborne particles infection control in dentistry the use of attachments in aligner treatment: analyzing the "innovation" of expanding the use of acid etching-mediated bonding of composites to enamel and its consequences safety considerations for thermoplastic-type appliances used as orthodontic aligners or retainers. a systematic review and meta-analysis of clinical and in-vitro research influence of attachment bonding protocol on precision of the attachment in aligner treatments comparison of achieved and predicted tooth movement of maxillary first molars and central incisors: first premolar extraction treatment with invisalign infection control recommendations for the dental office and the dental laboratory. ada council on scientific affairs and ada council on dental practice prevention and control of legionella and pseudomonas spp. colonization in dental units summary of infection prevention practices in dental settings: basic expectations for safe care ada's guidelines for infection control a scoping review on bio-aerosols in healthcare and the dental environment bacterial aerosols in dental practice -a potential hospital infection problem? the effectiveness of a preprocedural mouthrinse containing cetylpyridinium chloride in reducing bacteria in the dental office effectiveness of a pre-procedural mouthwash in reducing bacteria in dental aerosols: randomized clinical trial fusobacteriosis presenting as community acquired pneumonia fusobacterium nucleatum facilitates apoptosis, ros generation, and inflammatory cytokine production by activating akt/mapk and nf-k b signaling pathways in human gingival fibroblasts persistent exposure to fusobacterium nucleatum triggers chemokine/cytokine release and inhibits the proliferation and osteogenic differentiation capabilities of human gingiva-derived mesenchymal stem cells european oral microbiology workshop (eomw) 2011. healthcare-associated viral and bacterial infections in dentistry palusi nska-szysz m, cendrowska-pinkosz m. pathogenicity of the family legionellaceae covid-19 outbreak associated with air conditioning in restaurant efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling comparative evaluation of two different ultrasonic liquid coolants on dental aerosols efficacy of two pre-procedural rinses at two different temperatures in reducing aerosol contamination produced during ultrasonic scaling in a dental set-up -a microbiological study effect of aloe vera as a preprocedural rinse in reducing aerosol contamination during ultrasonic scaling comparative evaluation of colony forming unit count on aerobic culture of aerosol collected following pre-procedural rinses of either 0.2% chlorhexidine gluconate or 1% stabilized chlorine dioxide during ultrasonic scaling: a clinical and microbiological study the efficacy of preprocedural mouth rinse of 0.2% chlorhexidine and commercially available herbal mouth containing salvadora persica in reducing the bacterial load in saliva and aerosol produced during scaling evaluation of aerosol contamination during debonding procedures microbiological assessment of aerosol generated during debond of fixed orthodontic appliances reducing bacterial aerosol contamination with a chlorhexidine gluconate pre-rinse efficacy of preprocedural rinsing in reducing aerosol contamination during dental procedures interventions to reduce aerosolized pathogens in dental practice. a protocol for a systematic review and meta-analysis interventions to reduce aerosolized pathogens in dental practice. a systematic review with network meta-analysis of randomized controlled trials periodontal disease and rheumatoid arthritis: a systematic review comparative evaluation of chlorhexidine and cinnamon extract used in dental unit waterlines to reduce bacterial load in aerosols during ultrasonic scaling studies on dental aerobiology. i. bacterial aerosols generated during dental procedures size relationship between airborne viable bacteria and particles in a controlled indoor environment study compare the effcacy of two commercially available mouthrinses in reducing viable bacterial count in dental aerosol produced during ultrasonic scaling when used as a preprocedural rinse efficacy of 0.2% tempered chlorhexidine as a pre-procedural mouth rinse: a clinical study antiplaque effect of tempered 0.2% chlorhexidine rinse: an in vivo study transmission routes of 2019-ncov and controls in dental practice national health commission prc. guidance for corona virus disease 2019. prevention, control, diagnosis and management review of disinfection and sterilization -back to the basics covid-19: a recommendation to examine the effect of mouthrinses with b-cyclodextrin combined with citrox in preventing infection and progression enhanced dental cutting through chemomechanical effects handpiece coolant flow rates and dental cutting the effect of handpiece spray patterns on cutting efficiency comparison of sectioning rates among carbide and diamond burs using three casting alloys dental burs-what bur for which application? a survey of dental schools comparative evaluation of enamel surface roughness after debonding using four finishing and polishing systems for residual resin removalan in vitro study enamel surface roughness after debonding: a comparative study using three different burs in vitro comparison of the cutting efficiency and temperature production of 10 different rotary cutting instruments. part i: turbine the effect of medium and adsorption layers on plastic flow of metals materials science for dentistry bisphenol a and orthodontics: an update of evidencebased measures to minimize exposure for the orthodontic team and patients update on dental nanocomposites direct esthetic restorations based on translucency and opacity of composite resins particulate production and composite dust during routine dental procedures. a systematic review particulate production and composite dust during routine dental procedures. a systematic review with meta-analyses cytotoxic and genotoxic potential of respirable fraction of composite dust on human bronchial cells investigations on mechanical behaviour of dental composites determination of polymerization stress of conventional and new "clustered" microfill-composites in comparison with hybrid composites phillips' science of dental materials dental materials in orthodontics airborne particles produced during enamel cleanup after removal of orthodontic appliances should we be concerned about composite (nano-)dust? nanoparticle release from dental composites cytotoxic effects of composite dust on human bronchial epithelial cells release of monomers from composite dust the effect of water spray on the release of composite nano-dust quantitative and qualitative analysis of particulate production during simulated clinical orthodontic debonds the health effects of pm2.5 (including ultrafine particles) mucociliary and long-term particle clearance in the airways of healthy nonsmoker subjects pulmonary effects of inhaled ultrafine particles the potential risks of nanomaterials: a review carried out for ecetoc the nanosilica hazard: another variable entity casarett and doull's toxicology: the basic science of poisons scientific update on nanoparticles in dentistry unreacted methacrylate groups on the surfaces of composite resins characterization and in vitro estrogenicity of orthodontic adhesive particulates produced by simulated debonding detection of nanoparticles released at finishing of dental composite materials effects of variable attachment shapes and aligner material on aligner retention the effect of orthodontic adhesive and bracket-base design in adhesive remnant index on enamel release of bisphenol-a from a light-cured adhesive bonded to lingual fixed retainers bpa qualtitative and quantitative assessment associated with orthodontic bonding in vivo assessment of bisphenol-a release from orthodontic adhesives biodegradation of acrylic based resins: a review the effect of temperature on bisphenol: an elution from dental resins failure rate of selfligating and edgewise brackets bonded with conventional acid etching and a self-etching primer: a prospective in vivo study self-etch primers and conventional acid-etch technique for orthodontic bonding: a systematic review and meta-analysis effect of intraoral aging on the setting status of resin composite and glass ionomer orthodontic adhesives future of bonding advances in glass-ionomer cements. carol stream. quintessence publishing orthodontic materials research and applications: part 1. current status and projected future developments in bonding and adhesives structural properties of a scaled gecko foot-hair gecko lizard toe hairs inspired the design of medical adhesives a reversible wet/dry adhesive inspired by mussels and geckos debonding on command of adhesive joints for the automotive industry an overview of the technologies for adhesive debonding on command. the annals of expansible thermoplastic polymer particles containing volatile fluid foaming agent and method of foaming the same development and testing of novel bisphenol a-free adhesives for lingual fixed retainer bonding key: cord-262998-cugd2t1l authors: singh, vishwendra; lehl, gurvanit k; talwar, manjit; luthra, ankur title: the novel coronavirus and challenges for general and paediatric dentists date: 2020-05-02 journal: occup med (lond) doi: 10.1093/occmed/kqaa055 sha: doc_id: 262998 cord_uid: cugd2t1l nan the novel coronavirus pandemic is spreading at an alarming rate. as of 4 april 2020, it has affected 1 034 163 people globally and 2567 individuals in the indian subcontinent [1] . the causative agent is a positive-stranded rna virus which gains entry into the host cell by attaching itself to the angiotensin-converting enzyme 2 (ace 2) receptors and has been named the 'severe acute respiratory syndrome coronavirus-2 (sars-cov-2)'. the disease it causes is the 'coronavirus disease 2019 (covid-19)' [2] . three main transmission routes are known; droplet, contact and aerosol. however, affected patients also present with abdominal discomfort and diarrhoea and the gastrointestinal system has also been identified as a potential route of transmission [3] . it usually affects individuals between 25 and 89 years of age with a slight predilection for males; however, no generalizations can be made [3] . a lower incidence has been reported in children and this might be due to the fact that children are generally well cared for and thus at lower risk for exposure to infected people. other possible reasons are immature ace 2 receptors, presence of antibodies to different viruses especially in the winter months when they get multiple upper respiratory tract infections and a developing immune system which reacts differently to the virus [4] . a general observation is that older age and existence of underlying co-morbidities (e.g. respiratory disease, hypertension and cardiovascular disease) are associated with poorer outcomes [5] . diagnosis is based on a combination of epidemiological factors (e.g. history of travel to or residence in affected region), clinical symptoms, computed tomography (ct) findings and laboratory tests according to who standards [6] . currently, no definite treatment is available for covid-19 and so it is recommended that preventive steps be taken to lower risk of transmission. frequent hand washing lasting at least 20 s with soap and water, use of hand sanitizers with at least 60% alcohol, avoiding touching mucosal surfaces (mouth, nose, eyes) with unwashed hands, practicing proper cough etiquette, wearing a face mask (if symptomatic), limiting exposure to affected people and maintaining a distance of at least 2 m from others are the suggested preventive steps [1] . there is a high risk of cross infection between patients and dental practitioners. dental procedures involve face-to-face contact between the practitioner and patient, aerosolization of body fluids, exposure to saliva, blood and handling of sharp instruments. ace 2 receptors to which the virus binds are ubiquitous throughout the respiratory tract and salivary gland duct epithelium in the human mouth, and transmission is possible from there [7] . dental patients may cough or sneeze during treatment and their salivary (and possibly blood) secretions can become aerosolized during use of ultrasonic instruments or high-speed handpieces. dental instruments may become contaminated or be exposed and these infected instruments can cause infections through puncture of or direct contact with mucous membranes and hands [7] . an article in the new york times placed dentists at the highest risk for sars-cov-2 infection [8] . it is therefore imperative that guidelines and protocols are made for effectively and efficiently handling patients with covid-19 in the dental clinic and minimizing risk of nosocomial transmissions. the american dental association (ada) [9] has categorized dental treatments into emergency and non-emergency procedures. only dental emergencies like uncontrolled bleeding, cellulitis or a diffuse bacterial infection with intra-oral or extra-oral swelling that can compromise patient's airway and trauma involving facial bones, potentially compromising the patient's airway, and urgent dental care including treatment for dental pain, pericoronitis, surgical post-operative osteitis, dry socket dressing changes, abscesses, tooth fracture, avulsion/luxation, dental treatment required prior to critical medical procedures, final crown/bridge cementation should currently be undertaken. all other treatments should be postponed. the ada encourages dentists to use their professional judgement in determining a patient's need for urgent or emergency care as guidelines may change as the pandemic progresses. in india both the dental council of india (dci) and indian dental association (ida) also currently advise against elective dental procedures [10, 11] . they advise obtaining proper health and travel history and contact details of all patients. patients with respiratory infections (current or in the last 48 h) and those with travel histories to covid-19-affected regions should be reported to the health department and should be rescheduled. physical barriers in reception areas and proper personal protective equipment (ppe) should be used to limit close contact with infectious patients. use of rubber dams, high-volume evacuation and proper sterilization protocols after each patient have also been highlighted. a 1% hydrogen peroxide (or a 0.2% povidone) solution should be used as a pre-procedural mouth rinse. patients should be educated about hand and respiratory hygiene and cough etiquette, and proper disposal of contaminated items. hand sanitizers (with 60-95% alcohol), tissues and no-touch receptacles for disposal should also be provided in public areas of the clinic. waste generated through treating covid-19 patients should be properly disposed of using a 'gooseneck' ligation [7] . government agencies are producing regular updates on coronavirus and management of patients. paediatric dentistry is in a unique position in the coronavirus pandemic. children may act as asymptomatic carriers of the virus. various dental organizations state that only emergency dental procedures be performed [9-11] and paediatric dentistry is no different. the american association of paediatric dentistry (aapd) [12] has been posting regular updates about treatment. the aapd advises paediatric dentists to postpone all elective procedures for at least 3 weeks but to continue emergency or urgent care. they also suggest that elective general anaesthesia cases be postponed so that operating room resources are not stressed. the international association of paediatric dentistry [13] has also made recommendations for parents to maintain optimal oral health of children and avoiding dental clinic visits: • brushing at least twice daily with fluoridated toothpaste. • taking only water between meals. milk and juices should be taken at mealtimes only. • limiting snacking-not to eat more than five times during the day (breakfast, snack, lunch, snack and dinner). • sugar-containing foods should be consumed in moderation. chewy sweets which stick in the mouth for extended periods should be avoided. • healthy eating habits should be adopted as they not only prevent cavities but improve weight and a healthier childhood. • parents should remain in touch with their paediatric dentist in case they have any queries about oral health or require assistance. though these suggestions may seem redundant, they are of prime importance when social distancing and home confinement are crucial. the novel coronavirus presents unprecedented challenges to the healthcare industry with its rapid transmission and unknown characteristics. no specific treatment modalities are available, so social distancing and proper respiratory and hand hygiene are key to avoiding transmission. dental professionals are at high risk as almost all dental procedures generate aerosols, and droplet and contact transmission may also occur. stringent protocols, precautions and triaging of patients should be adopted in dental care during the pandemic. covid-19 coronavirus pandemic coronavirus disease: a review of a new threat to public health epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in china coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine clinical management of severe acute respiratory infection when novel coronavirus (2019-ncov) infection is suspected: interim guidance transmission routes of 2019-ncov and controls in dental practice the workers who face the greatest risk dental council of india. precautionary and preventive measures to prevent spreading of novel coronavirus (covid-19) american academy of pediatric dentistry. covid-19/ covonavirus update international association of paediatric dentistry the authors report no conflict of interest. key: cord-292173-95t89yee authors: villani, federico alcide; aiuto, riccardo; paglia, luigi; re, dino title: covid-19 and dentistry: prevention in dental practice, a literature review date: 2020-06-26 journal: int j environ res public health doi: 10.3390/ijerph17124609 sha: doc_id: 292173 cord_uid: 95t89yee sars-cov-2 is a member of the family of coronaviruses. the first cases were recorded in wuhan, china, between december 2019 and january 2020. italy is one of the most affected countries in europe. covid-19 is a new challenge in modern dentistry. new guidelines are required in dental clinics to avoid contagion caused by cross-infections. a narrative review was performed using both primary sources, such as scientific articles and secondary ones, such as bibliographic indexes, web pages, and databases. the main search engines were pubmed, scielo, and google scholar. twelve articles were selected to develop the bibliographic review by applying pre-established inclusion and exclusion criteria. precautionary measures should be applied to control covid-19 in clinical practice. several authors have highlighted the importance of telephone triage and/or clinic questionnaires, body temperature measurement, usage of personal protective equipment, surface disinfection with ethanol between 62% and 71%, high-speed instruments equipped with an anti-retraction system, four-handed work, and large-volume cannulas for aspiration. clinically, the use of a rubber dam is essential. ffp2 (or n95) and ffp3 respirators, if compared to surgical masks, provide greater protection for health workers against viral respiratory infections. further accurate studies are needed to confirm this. this article is a narrative review. zoonotic diseases constitute a large group of infections that can be transmitted from animals to humans, regardless of the presence of vectors [1] . approximately 80% of viruses, 50% of bacteria, and 40% of fungi are capable of generating a zoonotic infection [2] . bats are considered important reservoirs and vectors for the exponential spread of zoonotic infectious diseases; they are associated with sars and ebola, the latter of which was responsible for an epidemic with its epicenter in sub-saharan africa in 2014 [3] . sars coronavirus in 2003 and 2019, and h1n1 flu in 2009 have demonstrated how a zoonotic infection can spread rapidly among humans, causing potentially irreversible global repercussions, from an economic, social, and health-related standpoint [2] . compared to previous eras, globalization and the intensification of international movements have greatly facilitated the spread of viruses [1] [2] [3] [4] . coronaviruses are a subfamily of viruses [5] . all viruses contain nucleic acids, either dna or rna, and a protein coat which encases the nucleic acid. some viruses are also enclosed by an envelope of fat and protein molecules [5, 6] . towards the last week of december 2019, cases of abnormal pneumonia with unknown etiology were recorded in wuhan, the capital of the hubei province, in the geographical heart of the people's republic of china [11] . in the second half of january, the chinese competent authorities confirmed 6000 cases of patients infected with sars-cov-2, although 80,000 cases were estimated at that time [21] . however, unlike sars-cov-1, sars-cov-2 has shown a greater tendency for rapid human-to-human transmission, with an r0 varying between 1.4 and 6.5, and an incubation period ranging from 2 to 14 days, with an average of 7 days [10] . on 31 january 2020, 213 deaths had been confirmed globally in 19 different countries [11] . according to the data of 14 march 2020, italy was the most affected european country, followed by spain [22] . on 3 may 2020, the number of people currently positive in italy was 100,179, with 28,884 deaths [23] . the average age of people who died of covid-19 was 78.5 years, while, the average age of diagnosis was 65 [22] . the age group with the highest mortality rate was 80 to 89 years, with a male predominance (67%). the mortality rate in the male population increased by 10% (77%) in the 70-79 age group [22] . forty-eight percent of patients deceased from sars-cov-2 exhibited three or more comorbidities, two comorbidities (26%), one comorbidity (23%) and no comorbidity (1.2%). hypertension, diabetes, and ischemic heart diseases are among the main preexisting pathologies. only 1% of deaths from covid-19 occurred in patients under the age of 50 years. lombardy was the most affected region, accounting for 68% of the national cases, followed by emilia romagna (16.4%) and veneto (4.3%) [24] . these data prompted authors to investigate the existence of a possible link between the exponential transmission of covid-19 in certain italian regions and the pollution of atmospheric particulate matter, the latter acting as a vector of the virus [25] . however, this is a spurious association because there are systematic errors that determine the lack of correlation between these two factors. according to that reported by the new york times [26] , dentistry is one of the most exposed professions to the covid-19 contagion. it is necessary to establish a clinical protocol to be applied in the working environment to avoid new infections and progressive virus spread. in daily clinical practice, the patient's oral fluids, material contamination, and dental unit surfaces can act as sources of contagion both for the dentist and the assistant, and for the patient himself or herself. saliva and blood droplets that are deposited on the surfaces or aerosol inhalation generated by rotating instruments and ultrasound handpieces constitute a risk for those who occupy or will occupy those environments. therefore, the use of disinfectants and personal protective equipment (ppe) remain essential for the proper development of the dental profession [27] . the sudden spread of sars-cov-2 has determined the need to modify both preventive and therapeutic protocols in dental practice. consequently, the need to analyze the available sources in the literature to update clinical practice is crucial. the aim of this narrative review is to investigate preventive measures in dental practice by assessing the operator and patient health protection during the new covid-19 emergency by considering past experiences in terms of prevention, as the virus was only recently discovered. special attention is devoted to personal protection equipment, such as respirators and surgical masks, due to the major exposition of dental workers to the coronavirus. the authors carried out a narrative review and not a systematic review, as the topic is based on a recent event, and there are still several aspects pending to be analyzed. the process of selecting scientifically valid sources took place over five weeks, between 1 april and 4 may 2020. the search engines used were pubmed, scielo, and google scholar. the boolean operators used "and" and "or". the mesh terms for the research were: "dental care", "dentistry", "dental offices", "masks", "coronavirus", "dental equipment", and "disinfectants". non-mesh words were "sars-cov-2" and "ppe" the following terms were used with boolean operators to combine searches: "covid-19" or "sars-cov-2" or "coronavirus" and "dental care" or "dental office" or "dentistry" with no limitation to the year of publication. in addition, a second search was made: "masks" or "disinfectants" or "ppe" or "dental equipment" and "covid-19" or "coronavirus" or "sars-cov-2". included in the study were bibliographic reviews, systematic reviews, meta-analyses, randomized controlled trials, cohort studies, case reports, and studies in english, italian, spanish, and portuguese. the exclusion criteria were as follows: articles not related to the topic, animal studies, full-text not available, and articles in other languages. no time limits were applied during the screening phase of the scientific articles ( figure 1 ). given the heterogeneous results, the selected articles were divided into two main groups according to the treated topic: sars-cov-2 guidelines in dentistry ( table 1 ) and analysis of preventive masks used for protection against sars-cov-2 (table 2) . a third group, on disinfectants, was analyzed. the results obtained demonstrate compliance and homogeneity between the authors. in studies done by rabenau et al. [37] and kampf et al. [38] , ethanol proved to be one of the first-choice disinfectants in percentages ranging from 80 to 95% (used as a hand rub gel) [37] or 62 to 71% (used as a surface disinfectant) [38] . the coronavirus is reduced to below recording levels in a variable lapse of time between 30 and 60 s. in the study by rabenau et al., similar results were observed with disinfectant based on 45% iso-propanol, 30% n-propanol, and 0.2% mecetronium ethyl sulfate. furthermore, the use of surface disinfectants such as mikrobac forte (containing benzalkonium chloride and laurylamine), khorsolin ff (containing benzalkonium chloride, glutaraldehyde, and didecyldimonium chloride), and dismozon (containing magnesium monoperphthalate) can be valid options, even if the desired effect is obtained after 30-60 min [37] . with all tested preparations, sars-cov-2 was inactivated to below the limit of detection, regardless of the type of organic load (0.3% albumin, 10% fetal calf serum, and 0.3% albumin with 0.3% sheep erythrocytes). kampf et al. in carrier tests demonstrated the disinfectant action of ethanol at 62-71% against the sars coronavirus in 60 s, of sodium hypochlorite between 0.1-0.5% in one min, and glutaraldehyde at 2%. in contrast, 0.04% benzalkonium chloride, 0.06% sodium hypochlorite, and 0.55% ortho-phtalaldehyde were less effective [38] . the percentages varied in the suspension tests, where ethanol (between 78 and 95%), 2-propanol (70-100%), the combination of 45% 2-propanol with 30% 1-propanol, glutardialdehyde (0.5-2.5%), formaldehyde (0.7-1%) and povidone iodine readily inactivate the coronavirus; hypochlorite is effective at a concentration greater than 0.21% [38] . fundamentally, the authors agree ( table 1 ) that it is essential to perform an accurate telephone triage, a subsequent triage in dental clinics, and a complementary questionnaire to collect as much information as possible about the patient and his or her family members, specifically regarding symptoms and movements in the previous 14 days [27] [28] [29] [30] [31] . temperature measurement is recommended when the patient enters the dental office; if the body temperature exceeds 37.3 • c, it is suggested the treatment be postponed [30] . in patients with a cured covid-19 infection, the american dental association (ada) guidelines propose to reschedule dental treatment at least 72 h after the resolution of the symptoms, or 7 days after the appearance of initial symptoms, such as fever controlled without antipyretics and spontaneous improvement of breathing [39] . meng et al., in a precautionary way, set the necessary recovery period to 30 days before performing non-deferrable dental care in patients who have been infected [28] . for medical-legal issues, a patient's self-certification is also required with regard to what he/she claims during the telephone and clinical triage phase. the ada and the centers for disease prevention and control (cdc) recommend keeping the waiting room empty, without magazines, and avoiding the overlap of two or more appointments. if this is not possible, the minimum distance between one patient and the other must be 2 m (6 feet) in each direction. in extreme situations, for health protection, it is reasonable to ask patients to wait in their vehicle, if possible, or nearby to the dental clinic, and advise them by telephone call or message when it is their turn [40] . as far as pediatric dentistry is concerned, persons accompanying minor age patients are asked to come to the appointment in the smallest possible number, wear a protective mask, wait in the waiting room, and not attend the patient's treatment to avoid the risk of aerosol inhalation [27] . further accurate studies have been carried out to demonstrate the importance of oral rinses just before dental treatment; costa et al., in a study in 2019, highlighted how the use of chlorhexidine at 0.12% and 0.20% alters the amount of bacteria, viruses, and fungi present in the oral biofilm, reducing the risk of cross-contamination due to aerosol [29] . since covid-19 is sensitive to oxidation, peng et al. proposed rinsing with 1% hydrogen peroxide or, alternatively, with 0.2% povidone-iodine [30] . this must be interpreted with caution: saliva is constantly and cyclically renewed by the salivary glands, making the virus available again. regardless of the type of treatment planned, healthcare professionals, especially dentists, hygienists, and dental assistants, must follow rigid protocols related to dressing and personal protective equipment. hair caps, protective goggles, surgical masks or n95, disposable surgical gowns, special footwears, and protective visors are essential [27] [28] [29] [30] [31] . according to the "en iso 374-5.2016" regulation, for medical protection gloves to be considered functional against microorganisms, such as bacteria and fungi, must pass the penetration test, which analyzes air and water transition through material pores, seams, holes, and other structural imperfections [41] . "iso 16604: 2004 method b" is an additional test that is necessary to certify the specific protection of the gloves against viruses [42] . the ppe should be used as asserted in the instructions in the user manual and must be disposed of as special waste. it is always recommended to check the integrity of the ppe, and if any negative findings, eliminate the ppe immediately [43] . there are several articles in the scientific literature on the effectiveness of surgical masks in comparison to respirators ( table 2 ). the distance and length of time in which particles remain suspended in the air are determined by particle size, settling velocity, relative humidity, and air flow [36] . the european standard classifies filtering facepiece respirators (ffp) into three categories: ffp1, ffp2, and ffp3 with minimum filtration efficiencies of 80%, 94%, and 99%. consequently, ffp2 respirators are approximately equivalent to n95, and therefore recommended for use in the prevention of airborne infectious diseases in the us and other countries [44, 45] . both long et al. [32] and radonovich et al. [34] , in their respective analyses did not find significant differences between the n95 and surgical masks in terms of protection from the influenza virus. similar results were also observed in the study by offeddu et al., which was performed two years before the current covid-19 health emergency. on one hand, there is an equal effectiveness between the two types of masks on the influenza virus. however, compared to nonspecific respiratory tract infections, the n95 masks give slightly better results [33] . macintyre et al. instead obtained diametrically opposing results; they showed, through a randomized controlled clinical study on 3591 subjects, that health workers who used n95 masks continuously during the shift or in situations considered to be at high risk, presented an 85% chance of not contracting a viral infection transmitted via droplets [36] . in addition, the n95 mask group compared to the control group was associated with a significantly lower risk of contracting influenza, as confirmed by the laboratory. the authors suggest updating the classification of infectious transmissions; they consider that focusing only on aerosols and droplets is an oversimplification. in a recent study, ma et al. analyzed the degree of protection of surgical masks, n95, and home masks (four layers of paper and polyester) against the virus; n95 masks showed greater reliability [35] . lee et al., focused on particles between 0.093 and 1.61 µm, and demonstrated that the ffp respirators provided better protection than the surgical masks, suggesting that such surgical masks are not a good substitute for ffp respirators in the case of airborne transmission of bacterial and viral pathogens [44] . the principal limitation of surgical masks is due to the poor face fit and the consequential possibility of aerosol aspiration [43] . in spain, the dentists council (consejo de dentistas) reports a maximum of 4 h of use, and if kept in good condition, ffp2 or n95 masks can be sterilized through various techniques: hydrogen peroxide vapor, dry heat at 70 • c for 30 min, or in humid heat at 121 • c; however, not for more than 2-3 times [45] . the who protocol recommendations suggest the use of ffp3 masks according to the european nomenclature or n100, according to the united states nomenclature [46] . hand hygiene is considered the first step in limiting the spread of the virus; who guidelines impose scrupulous hand-washing before and after any contact with the patient [46] . being previously considered an essential tool for correct operating practice, the rubber dam has become even more so after the viral epidemic of 2020. various authors underline the utility of the rubber dam on containment and protection from oral fluids; it reduces the particles present in the aerosol by 70% [30] and also drastically reduces the risk of cross-infection [27, 28, 30 ]. if it is not possible to position it, peng et al. recommend the use of the carisolv and an excavator for conservative treatments [30] . high-speed rotating instruments, such as the turbine and the contra-angle, must be equipped with an anti-retraction system, which prevents the release of debris and fluids that can accidentally be inhaled by healthcare professionals during clinical procedures [29, 30] . meng et al. suggests minimizing the use of these tools; if this is not possible, the last appointment of the day should be intended for those patients who need dental treatments requiring the use of high-speed rotating instruments [28] . they also recommend not to use intraoral radiographs; therefore, they propose the use of orthopantomography or ct if strictly necessary. the authors agreed on the need for four-handed work to reduce the risk of spreading the virus in the dental care unit, to manipulate the water-air syringe with extreme caution, and to use large-volume aspirators [27, 28, 30] . concerning potentially deferred dental emergencies, luzzi et al. recommend remote telephone or assistance support from the dentist. in the case of pulp pain, therapy with non-steroidal anti-inflammatory drugs, such as ibuprofen, and antibiotics, such as beta-lactams, are recommended, if the patient does not have allergies [27] . alharbi et al. classified therapeutic dental procedures into five groups: emergencies, emergencies manageable through invasive or non-invasive procedures (minimum aerosol), non-emergencies, and elective treatments, depending on the dentist. among the emergencies, the authors highlight maxillofacial fractures that compromise the respiratory tract, uncontrolled post-operative bleeding, and bacterial oral soft tissues infections with intra-or extra-oral swelling that negatively affect the patient's respiratory capacity [47] . orthodontists are suggested to stop activating the rapid palate expander; parents are instructed to reposition the ni-ti arch if it should go off-axis and cause a contact ulcer on the oral mucosa. any non-urgent treatment must be postponed; if this is not possible, the dentist must follow strict protocols to avoid contagions. peng et al., advise the elimination of waste using special yellow double-layer bags for special waste and mark them to facilitate their elimination [30] . various disinfectants available on the market, can effectively inactivate the sars-cov-2. the italian dentists association recommends covering all surfaces, where possible, with polyethylene wrap [48] . the results obtained demonstrate compliance and homogeneity between the authors. rabenau et al. [37] and kampf et al. [38] illustrated that various groups of disinfectants, such as propanol, sodium hypochlorite, and ethanol, in percentages ranging from 80 to 95% (as a hand rub) [37] or 62 to 71% (as a surface disinfectant) [38] , can reduce sars-cov-2 load to below recording levels in a variable lapse of time. pertinent papers on this topic are limited. the who guidelines recommend the use of 5% sodium hypochlorite, with a 1:100 dilution, to be applied on surfaces for an average action time of 10 min; constant ventilation of the dental surgery room is also recommended [46] . studies have shown that other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate probably have lower efficiency [49] . the spanish dentists council suggests the use of 1% sodium hypochlorite for the disinfection of the impressions. the action time of the disinfectant varies depending on the material used: 10 min for alginate, and 15-20 min for elastomers [45] . as reported by kyun-ki et al., it is necessary to establish preventive policies in clinical and hospital settings to avoid the high risk of nosocomial infections, as with mers [50] . sabino-silva et al., starting with the assumption that covid-19 may be present in saliva through major salivary gland infection or through the crevicular fluid, suggest more accurate studies in order to evaluate the possibility of early and non-invasive virus diagnosis using saliva samples [51] . the possibility of the role of salivary gland cells in the initial progress of the infection and as a source of the virus should be considered and validated [8] . dentistry remains one of the most exposed professions to sars-cov-2; each individual clinical situation must be adequately controlled and pondered by the healthcare professional; defaults in protocols cannot be tolerated. however, there are indications in the literature on how to deal with emergencies. currently, the swab represents the only system of diagnosis, and it requires a laboratory procedure that cannot be implemented in the dental clinic. however, rapid immunoglobulin tests, which are not considered for diagnosis, can report whether a healthcare professional has had the disease and been immunized. the development of new diagnostic tools will provide a reasonable hope for greater protection from the virus in the future. two types of rapid tests are currently being developed for covid-19: the first one directly detects sars-cov-2 antigens by nasopharyngeal secretions, while the second indirectly records the antibodies present in the serum as part of the autoimmune response against the virus [52] . ahmed et al. conducted a cross-sectional study on 699 dental practitioners from 30 different countries using an online survey between the second and the third weeks of march 2020; 87% of participants were afraid of becoming infected with covid-19 from either a patient or a co-worker. a considerable number of dentists (66%) wanted to close their dental cabinets until the number of covid-19 cases declined [53] . the fear that dentists have regarding becoming infected by covid-19 could be less if dentists and dental healthcare workers conscientiously follow the relevant recommendations [53] . looking ahead, it is necessary to increase research efforts in aerosol control during dental treatments, including improving engineering control in dental office design. the covid-19 pandemic has exposed important gaps in the collective response of global healthcare systems to a public health emergency [54] . dentistry as an integral part of the health care system should be prepared to play an active role in the fight against future emerging life-threatening diseases. preventive measures against covid-19 in dental practice include telephone and clinical triage supported by a questionnaire on recent symptoms and movements, body temperature measurement, oral rinses with 1% hydrogen peroxide, and the use of specific ppes. pragmatic and technical recommendations for correct clinical practice are the implementation of anti-retraction dental handpieces, four-handed work, the use of a rubber dam, and large-volume cannulas for aspiration. ffp2 (or n95) and ffp3 respirators, if compared to surgical masks, provide greater protection to health workers against viral respiratory infections. ethanol between 62% and 71% and sodium hypochlorite between 0.1% and 0.5% are considered to be the best among the surface disinfectants. this narrative review has some limitations. as there is a current emergency, in the literature there is a limited and heterogenous number of primary sources directly related to the repercussion of sars-cov-2 on the dental discipline. further studies are needed in the future. author contributions: authors equally contributed to conceptualization, methodology, validation, investigation, writing-original draft preparation, writing-review and editing, supervision. all authors have read and agreed to the published 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pandemic-prone acute respiratory infections in health care guidelines for dental care provision during the covid-19 pandemic. saudi dent linee guida covid19 restart being a front-line dentist during the covid19 pandemic: a literature review risk of transmission via medical employees and importance of routine infection-prevention policy in a nosocomial outbreak of middle east respiratory syndrome (mers): a descriptive analysis from a tertiary care hospital in south korea coronavirus covid-19 impacts to dentistry and potential salivary diagnosis european centre for disease prevention and control. an overview of the rapid test situation for covid-19 diagnosis in the eu/eea fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak dental care and oral health under the clouds of covid-19 this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-302527-n53d5en0 authors: dadlani, shashi title: sars-cov-2 transmission in a dental practice in spain: after the outbreak date: 2020-06-29 journal: int j dent doi: 10.1155/2020/8828616 sha: doc_id: 302527 cord_uid: n53d5en0 the world health organization declared a pandemic on march 11, 2020, due to a virus named sars-cov-2 discovered in wuhan, china, in december 2019. many countries have been hit hard including spain, with the highest number of healthcare workers being infected (>50,000). a lack of personal protective equipment and protocols at the time of the outbreak led to many fatalities. although few of these healthcare workers are dental professionals, this community required protective measures as well. fortunately, there are no reported cases of sars-cov-2 transmission in dental practices. dental professionals were advised only to treat dental emergencies, and such cases were screened via telephone to maintain social distancing. nevertheless, new protocols and measures are needed as dental professionals return to normal practice after weeks of confinement in many countries. relatively, few articles have discussed the management of dental practice during the sars-cov-2 with no known articles on postpandemic outbreak guidelines. though some protocols and measures are the same, there are also many differences. here, we describe protocols and measures for dental practice in spain in accordance with the spanish health ministry. a new coronavirus of unknown origin was discovered in wuhan, china, in december 2019 [1] . it caused an emergent pneumonia outbreak and since then has rapidly spread around the globe. on january 30, 2020, the world health organization declared it as a public health emergency of international concern [2] , and on 11 february 2020, the virus was given the name sars-cov-2 [3] . sars-cov-2 is a human-to-human viral infection [4, 5] transmitted through airborne droplets from talking, coughing, or sneezing [6] or by touching or coming into contact with contaminated surfaces that are then transmitted to oral, nasal, and mucosal membranes [7] . is pandemic has severely affected many countries worldwide, causing many deaths in countries such as the usa, uk, italy, brazil, france, and spain [8] . spain has seen the death of 27,134 people [9] . it has the second highest death rate per 100,000 people in the world after belgium according to john hopkins university. most importantly, more than 50,000 healthcare workers have been infected and are in quarantine; some have tragically died [10] . is high number can be due to the lack of professional protection equipment and protocols in the initial phases of the outbreak. in contrast, chinese studies showed that only 3.8% of infected people were healthcare workers [11] . dentists are a low percentage of those affected, and there are no reported cases of sars-cov-2 transmission in a dental practice including dental offices; nevertheless, special care is needed in dental facilities. during the coronavirus outbreak, dentists in spain and other countries were recommended to only attend dental emergencies under strict measures wearing specific professional protection equipment to minimize the risk and maintain social distancing [12] . routine dental care was also suspended during the outbreak in china [11] . treatments that could emit aerosol or droplets were postponed or treated without handpieces. dental healthcare professionals work in close proximity to patients and therefore have a high risk of being infected [13] . sars-cov-2 has been identified in the saliva of infected patients [14] , suggesting that the aerosols generated during dental procedures from an infected person can be extremely contagious. ese droplets can remain in the area even after the patient has left the clinic, leading to infection of dental professionals via contaminated surfaces [15] . furthermore, universal precautions must be considered for all patients because asymptomatic patients can also transmit the virus [16] . sars-cov-2 is highly transmissible, and there are three ways of viral transmission. direct transmission is between an infected person and a susceptible individual-this requires contacts such as a handshake. indirect transmission is via a fomite [14] -an object that has been in contact with an infected person and can thus transmit infection to someone else. recent studies have shown that sars-cov-2 can remain on certain surfaces for up to 9 days [17] . e third mode of transmission is airborne transmission, i.e., via droplets from sneezing or coughing, which can be inhaled by other susceptible individuals [18] . ese droplets can be large (>5 µm in diameter) or small (<5 µm in diameter). large droplets fall to the ground at a faster pace due to gravitational forces, but small ones can stay suspended in the air for a much longer period of time and be inhaled by a susceptible person [19] . e media has focused more on direct and indirect transmission of the virus. ey emphasize handwashing and not shaking hands with other individuals, especially after touching possible contaminated surfaces; less focus has been given to aerosol transmission. e airborne spread of sars-cov-2 through aerosols in medical procedures has been well documented [14] . moreover, dental procedures also produce aerosols and droplets that can be contaminated with the virus [18] . e fact that asymptomatic patients can transmit the virus has led us to implement universal protection measures due to cross infection for all patients whether symptomatic or not [16] . it is still unclear exactly how presymptomatic or asymptomatic patients can transmit the virus, but recent literature has confirmed that it is possible [16] . e inhalation of airborne particles and aerosol particles during dental treatments on patients with sars-cov-2 is a very high-risk procedure where dentists can be exposed to the virus. erefore, dental professionals should improve preventive measures to avoid exposure. guidelines on dental care during the sars-cov-2 outbreak suggest limiting practice to dental emergencies [11] , but it is unclear which protocols should be followed after the outbreak. many things will be similar to practice during the outbreak. first, the dental staff should be studied and confirmed to be free of disease with no contact with infected people; ideally, they should be screened daily even after the confirmation of testing negative for sars-cov-2. positive people should be quarantined for 14 days before re-taking the test [20, 21] . before the patient is given an appointment, telephone screening will be done similar to that done during the pandemic outbreak. questions will include medical history and symptom characteristics of the virus such as fever, dry cough, sore throat, breathing difficulties, headache, or muscle pain. if any of these symptoms are identified, then treatment should be deferred and sent to a physician [11] . a travel history should also be collected during the last 14 days including any positive contacts. e objective of this screening is to identify a clear rationale for the visit (emergency or just a routine treatment) and to screen the health history. patients should come alone to the appointment unless they are a minor, disabled, or elderly people who need help. ey should be informed not to wear any jewelry or metal devices to avoid contaminating articles in the dental practice. punctuality is also very important to minimize waiting room congregation. patients are also recommended to pay with the credit card to avoid the risk of contaminated bank notes. patients should maintain a 2-meter distance with the receptionist. a methacrylate protective screen is recommended to create a barrier between dental staff and the patient. subjects should not wander around the dental practice unless it is to use the restroom. all magazines should be removed from the waiting room. studies have demonstrated that coronavirus can survive 24-30 hours on cardboard and paper [17] . decoration should also be removed, and patients should ideally be given appointments one at a time to respect social distancing. if this is not possible, then patients should sit 2 meters apart. shared areas should be ventilated every 5-10 minutes, and centralized air conditioners should be switched off if they share air from the clinic areas and the shared areas. negative pressure treatment rooms are recommended for airborne infection isolation rooms including for patients suspected of having sars-cov-2 who could be asymptomatic. sars-cov can remain infectious on inanimate surfaces for up to 9 days with greater preference for humid conditions; hence, frequent disinfection of shared areas (door handles, chairs, and washrooms) is mandatory. surface disinfection with 0.1% sodium hypochlorite or 62-71% ethanol significantly reduces coronavirus infectivity on surfaces within 1 min exposure time. we expect a similar effect against sars-cov-2 [17] . surface disinfection in the dental cabinet should be performed after every patient; the environment must be kept dry. before entering the dental cabinet, patients should wash their hands with soap for 20 seconds and use hand sanitizers (preferably with 60% alcohol). ey should be given disposable surgical shims to cover their shoes. plastic coverings 2 international journal of dentistry for dental equipment are needed including the dental chair. e four-handed technique is much more efficient in avoiding cross infection during treatments. patients should be given povidone as a mouth rinse because it is highly effective against sars-cov and mers-cov (related to sars-cov-2) [22] . patients will be advised to rinse their mouth with 0.2% povidone-iodine prior to dental treatment to reduce the viral load in saliva [23] . other alternatives such as 0.5-1% hydrogen peroxide can also be used but have not yet been shown to have specific viral activity against coronaviruses. studies with chlorhexidine have not yet been proven to be effective against coronaviruses [15] . during the dental treatment, patients are protected with eye protection, and rubber dam isolation is recommended whenever possible to minimize the production of saliva and blood that could be contaminated. aerosol emission from handpieces and ultrasonic scalers is restricted during the outbreak. extraoral radiographs are advisable because intraoral radiographs could cause a cough reflex. if intraoral radiographs are required, then sensors should be carefully protected to create a barrier and prevent perforation or cross infection [24] . treatments such as tartrectomies, endodontic access, cavity cleaning, osteotomy surgeries, tooth filing, or implant placement are high-risk procedures due to the aerosols generated. if possible, work at low speed with manual cooling. other treatments such as manual cleaning, manual scaling, root planning, and dental explorations that do not generate aerosols have a lower risk of infection [25] . highpower aspiration is critical to reduce aerosol production, and the aspirating nozzle should be very near the area that is being treated to avoid aerosol diffusion. disposable syringes and/or mouth mirrors are recommended to avoid cross contamination. e dental professionals should try to perform the treatment in as few visits as possible [26] . ppe minimizes airborne transmission and should be used including impermeable gowns and double gloves [26] . removing the external glove is recommended after treatment; the internal glove can thus be used to transport material to the sterilization area or to remove any contaminated waste. icker gloves are recommended for cleaning. ffp2 masks are mandatory; they should not have an exhalation valve to avoid diffusion of the virus through exhalation (spanish ministry of health) [27] . ffp2 masks have a 92% particle filtration efficacy and are recommended by the spanish health ministry. no evidence has yet been published proving that ffp3 masks offer better protection from the coronavirus. ese masks can only be used once although van straaten et al. suggest that they can be sterilized using hydrogen peroxide vapor in dry heat at 70°c for 30 minutes or humid heat for 15 minutes while retaining function [28] . eye protection is also critical, and there is strong evidence that the virus can penetrate through the eyes to infect a susceptible individual [29] . either goggles or protective shields can be used or in some cases both. finally, impermeable gowns and caps that avoid virus penetration and avoid splatter are recommended [30] . dental professionals who are in close proximity to patients are at a high risk of exposure to infection. more data are needed on aerosol transmission in dental practice. dental professionals have always been prepared to avoid cross infection and have navigated diseases such as hiv and hepatitis; however, sars-cov-2 is an airborne disease that is much more contagious. ere is still no scientific evidence to accurately conclude when patients are positive but asymptomatic. is makes disease tracing more difficult and transmission more likely. after the sars-cov-2 outbreak has flattened, dental colleges and institutions will need new protocols and measures. e author declares that there are no conflicts of interest regarding the publication of this paper. a novel coronavirus from patients with pneumonia in china world health organization europe, 2019-ncov outbreak is an emergency of international concern, world health organization europe e species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster gisaid: global initiative on sharing all influenza data-from vision to reality 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preventive measures in italy key: cord-326961-ti6mrzxf authors: aly, mariam mohsen; elchaghaby, marwa aly title: impact of novel coronavirus disease (covid-19) on egyptian dentists’ fear and dental practice (a cross-sectional survey) date: 2020-10-12 journal: bdj open doi: 10.1038/s41405-020-00047-0 sha: doc_id: 326961 cord_uid: ti6mrzxf objectives: this study aimed to evaluate the fear of infection among egyptian dentists practicing during the current coronavirus disease 2019 (covid-19) pandemic and to explore the dentist’s knowledge about guidelines to fight the virus and to assess various modifications in dental practice. methods: an online survey was submitted to dental professionals. data were collected through a validated questionnaire consisting of 23 closed-ended questions. the gathered data were statistically analyzed. results: an overall 216 dentists completed the survey. a total of 200 (92.6%) dental professionals were afraid of becoming infected with covid-19 while 196 (90.7%) became anxious to treat patients showing suspicious symptoms. the majority of the participants were aware of the mode of transmission of covid-19 and a lot of them were updated with the current disease control and prevention (cdc) or world health organization (who) guidelines for cross-infection control. conclusions: covid-19 pandemic has a significant impact on dental professionals. in december 2019, patients with pneumonia of unknown cause were detected in the city of wuhan and within a couple of weeks, it reached other parts of the world, which generated a major public health crisis worldwide and imposed a challenge to healthcare systems across the six continents. 1, 2 the world health organization (who) named the chinese outbreak covid-19 and declared it to be a public health emergency of international concern posing a high risk to countries with vulnerable health systems. 3, 4 the spread of coronavirus (covid-19) has posed significant challenges for dentistry and medicine, and dental and medical schools, in all affected countries. 5 the reaction speed and response type to this disease have been very variable around the world according to different healthcare systems, economies, and political views. 6 due to the nature of dental settings, the risk of cross-infection may be huge between dental practitioners and patients through direct transmission by a sneeze, cough, or droplet inhalation, or contact transmission such as ocular contact or through mucous membranes of the eyes and nose and saliva. 3 for dental clinics and hospitals in regions and countries that are potentially influenced by covid-19, firm, and effective infection control protocols are crucially required. this is a result of the unique attributes of dental procedures where an enormous number of droplets and aerosols could be generated, the usual protective measures in daily clinical practice are not effective enough to counter the spread of covid-19, especially when patients are in the incubation period and are unaware that they are infected or prefer to conceal their infection. 7 different practical guidelines were recommended for dental professionals by the centers for disease control and prevention (cdc), the american dental association (ada), and the who to control the spread of covid-19 and like other contagious infections, these recommendations include personal protective equipment, hand washing, detailed patient evaluation, rubber dam isolation, anti-retraction handpiece, mouth rinsing before dental procedures, and disinfection of the clinic. 8 in a pandemic, fear raises anxiety and stress levels in healthy persons and escalates the symptoms. the number of persons whose mental health is affected tends to be greater than the number of persons affected by infection. 9 fear and anxiety are powerful emotions that may be associated with the overwhelming reports on the pandemic by social, electronic, and print media, the absence of wellstructured scientific evidence and knowledge about covid-19, time-consuming screening and diagnostic methods, insufficient personal protection equipment, unclear treatment, and immunization. 5 mild anxiety is natural and fosters preventive and safeguarding behavior. although the ada has published preventive guidelines, the majority of dentists are still reluctant and fearful of treating patients in such a situation. 10 before effective approaches to reinforce dental professionals can be developed, it is crucial to recognize their specific sources of anxiety and fear. focusing on addressing those concerns, rather than teaching general approaches to reduce stresses, should be the main focus of support efforts. 11 this study aimed to evaluate the fear of infection among egyptian dentists practicing during the current covid-19 pandemic and to explore the dentist's knowledge about guidelines to fight the virus and to assess various modifications in dental practice. the present study was a cross-sectional study of a random sample of egyptian dental professionals. the strobe guidelines were used to ensure the reporting of this observational study. data were collected via an online survey link and received a response through an online survey submission. any egyptian dentist having a bachelor of dentistry or equivalent degree was invited to participate while dental students were not included in this survey. trial registration this study has been registered with clinicaltrials.gov under the title: fear and practice modification among dentists during covid-19 pandemic with an identifier: nct04383626. to assess the prevalence of fear of becoming infected, the sample size was calculated (http://www. nss. gov. au/ nss/ home.nsf/ pages/ sample+ size+ calculator) using the following assumptions: confidence level = 95% ci = 5%, the total number of dentists with an estimated percentage of fear of becoming infected = 87% according to ahmed et al. 10 the number was increased by 25% to allow for nonresponse. the required sample size was 216. this online survey tried to evaluate: data sources and measurement data were gathered using an english language self-administrated questionnaire, which developed based on a similar study by ahmed et al. 10 after taking their permission. on the first page of the questionnaire, the participants were briefed about the purpose of the study and the voluntary and confidential nature of their participation. informed consent was obtained from each participant in the form of answering a question (yes/ no) before proceeding with answering the questionnaire. the questionnaire design consisted of 23 close-ended, multiplechoice questions (yes/no/unaware or yes/no/don't know) in three different sections. the first section of the questionnaire with four questions was related to the demographic data of the participants. the second section with 7 questions focused on the dentists' fear of becoming infected with covid-19 and the third section with 12 questions was designed to gather information regarding their knowledge about guidelines to fight the virus and to assess various modifications in dental practice. to limit selection bias, all dental professionals who participated in this study were randomly selected and invited to respond to a self-administered anonymous questionnaire. to limit information bias, all participants were offered the same explanation regarding the nature and the aim of the study. statistical methods collected data were analyzed by ibm-spss (version 22.0) software package for microsoft windows. descriptive statistics were calculated as frequencies and percentages. a total of 216 dental professionals completed the questionnaire. most of them were general dental practitioners 113 (52.3%), below the age of 40 years with no sex predilection. approximately about 146 (67.6%) of dentists enrolled were working in private clinics as illustrated in table 1 . fear of dental personnel during the covid-19 outbreak was assessed using the questionnaire as shown in table 2 information regarding the knowledge of dental personnel about guidelines to fight the virus and various modifications in dental practice were also obtained using the questionnaire as illustrated in table 3 . most of the respondents 203 (94.0%) were aware of the mode of transmission of covid-19 but only 156 (72.2%) were updated with the current cdc or who guidelines for cross-infection control. unfortunately, only 55 (25.5%) of dental personnel took the patient's body temperature, 103 (47.7%) requested a patient's travel history before performing any dental treatment, and only 154 (71.3%) deferred dental treatment of patients showing suspicious symptoms. regarding the use of personal protection, 180 (83.3%) of dentists believed that the surgical mask wasn't enough to prevent cross-infection of covid-19, and 175 (81.0%) believed that n-95 mask should be routinely worn. although the majority of dentists 183 (84.7%) followed the universal precautions of infection control routinely, only 53 (24.5%) of the respondents reported the use of rubber dam isolation and 104 (48.1%) reported the use of high-volume suction. one hundred and ninety-nine (92.1%) of participants practiced washing hands with soap and water or sanitizer before and after treatment of patients, while 134 (62.0%) of participants were aware of the proper authority to contact if they came across a patient with a suspected covid-19 infection. this cross-sectional study assessed the fear of infection between egyptian dentists practicing during the present covid-19 pandemic and to explore their knowledge about guidelines to fight the virus and various modifications in dental practice through an online survey. data were gathered using a questionnaire based on the previous study of ahmed et al. 10 that was validated through intra-class correlation with a strong relation of 0.74. the online survey method is considered a useful tool for collecting data quickly with many benefits including saving time and money, ease of use, the capability to prohibit errors when entering and editing data, and rapid transmission of survey results. 12 in a pandemic, fear, anxiety, and stress levels increase. correspondingly, the rate of distress among healthcare staff is higher compared with the general population, because they are more at risk for infection. 9, 13 this is a result of the unique attributes of dental procedures including the proximity to the patients, the enormous number of droplets and aerosols generated during dental procedures, 1 as the main route for transmission of coronavirus is through droplets and aerosols, the likelihood of dental professionals becoming infected and further spreading the virus is elevated. 10 as a considerable viral load was consistently detected in the saliva of patients diagnosed with the infection by up to 91.7%, 1 a high percentage of dentists reported their fear of becoming infected with covid-19 from a patient or a co-worker in this study. as usual protective measures in daily clinical practice are not effective enough to counter the spread of covid-19, especially when patients are in the incubation period and are unaware that they are infected or prefer to conceal their infection, 7 the majority of dentists stated being anxious when providing treatment to a patient who is coughing or showing suspicious symptoms. these findings triggered a large number of participated dentists to close their dental practice until the number of covid-19 cases starts declining. while dental professionals often accept the elevated risk of infection, as part of their chosen profession, they usually show concern about transmitting the infection to their families, especially if family members are elderly, immunocompromised, or possess a chronic medical condition. almost all participants in the study feared for their families as they battle covid-19, which can be linked to the fact that about 3000 healthcare providers in china became infected and transmitted the infection to family members. despite the admission that transmission occurs mostly via symptomatic individuals, there are reports of asymptomatic individuals who transmitted the disease to multiple family members. 14, 15 these results were in accordance with the finding of ahmed et al., 10 who reported that a large number of dentists fear becoming infected by their patients or co-workers and are also fearful of providing treatment to any patient reporting suspicious symptoms. the majority of the respondents were aware of the mode of transmission of covid-19 and many of them were updated with the current cdc or who guidelines for cross-infection control. however, a great number of participants reported not using rubber dam isolation or high-volume suction for every patient in their practice. concerning the mode of transmission of covid-19, the utilization of rubber dams can dramatically diminish the production of saliva-and blood-contaminated aerosol or spatter, especially when dental ultrasonic devices and high-speed handpieces are used. also, it could significantly decrease airborne particles in the~3-foot diameter of the operational area by 70%. the use of high-volume suction is also considered a crucial means to limit aerosols evacuation during dental treatment and should be used for most of the patients. considering the benefits, there is no excuse for not using a rubber dam during dental procedures, especially while using rotary instruments. 16, 17 many of the participants considered that the surgical mask wasn't enough to counter the cross-infection of covid-19 and that the n-95 mask should be routinely worn in dental practice during the current outbreak. it can be explained as surgical masks protect the oral and the nasal mucous membranes from droplet spatter, but they do not provide complete protection against the inhalation of airborne infectious agents unlike n-95 masks. 5, 16 hand hygiene was performed by most of the dentists. current evidence indicates that the covid-19 virus is transmitted through respiratory droplets or contact. contact transmission appeared directly when a contaminated hand contacted the mouth, the nose, or the eye; the virus can also be transmitted indirectly from one surface to another by contaminated hands. therefore, hand hygiene is very important to prevent the spread of the covid-19 virus. 18, 19 conversations with front-line caregivers may help reduce anxiety. the focus should be on supportive communication, clear guidance when recommendations exist attempts to minimize misinformation, and efforts to reduce anxiety. transparent and thoughtful communication could contribute to trust and a sense of control. ensuring that workers feel they get adequate rest, can tend to critical personal needs and are supported both as healthcare professionals and as individuals will help maintain individual and team performance over the long run. 14, 18 limitation of the study this research was subjected to some limitations: • time constraints: the rapid and extensive nature of the new coronavirus may intensify the respondent's responses and feelings. also, a change in their behavior might occur. • internet access: this study was conducted online so it was limited to participants who had internet access. conclusions covid-19 pandemic has a significant impact on dental professionals. this is reflected in the high percentage of dental professionals experiencing fear and anxiety of getting infected while providing dental care. some dental professionals often accepted the elevated risk of infection as part of their chosen profession and introduced several modifications in their dental practices in compliance with the recommended guidelines. while others want to close down their dental practice for a period of time until the number of covid-19 cases starts declining. the majority of dental professionals were knowledgeable about the mode of transmission of covid-19 and many of them were updated with the current cdc or who guidelines for cross-infection control. covid-19 pandemic and role of human saliva as a testing biofluid in point-of-care technology an epidemiological study on covid-19: a rapidly spreading disease human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) common misconceptions regarding covid-19 among health care professionals: an online global cross-sectional survey dentistry and coronavirus (covid-19) -moral decision-making coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine dentists' awareness, perception, and attitude regarding covid-19 and infection control: cross-sectional study among jordanian dentists pandemic fear" and covid-19: mental health burden and strategies fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic online survey software as a data collection tool for medical education: a case study on lesson plan assessment covid-19 and anxiety: a review of psychological impacts of infectious disease outbreaks supporting the health care workforce during the covid-19 global epidemic presumed asymptomatic carrier transmission of covid-19 interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (covid-19) pandemic possible aerosol transmission of covid-19 and special precautions in dentistry knowledge and attitude of dental practitioners related to disinfection during the covid-19 pandemic world health organization. recommendations to member states to improve hand hygiene practices to help prevent the transmission of the covid-19 virus: interim guidance which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder this study was self-funded. competing interests: the authors declare no competing interests.ethics approval: approval for conducting this study was obtained from the ethics committee of the scientific research, faculty of dentistry, cairo university. dentists were briefed about the general objectives of the study, along with the voluntary nature of participation and informed consent was attained from each participant. the questionnaires were completed anonymously to ensure the confidentiality of the information provided.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-253162-lebgynsz authors: chang, tsai-yu; hong, guang; paganelli, corrado; phantumvanit, prathip; chang, wei-jen; shieh, yi-shing; hsu, ming-lun title: innovation of dental education during covid-19 pandemic date: 2020-08-19 journal: j dent sci doi: 10.1016/j.jds.2020.07.011 sha: doc_id: 253162 cord_uid: lebgynsz background/purpose: the impact of the pandemic of covid-19 has a certain influence on various walks of life around the world. because of the pandemic of this novel coronavirus in terms of covid-19, the social life global wide has been changed a lot. to keep the social distance between human being to prevent from being infected is the most important strategy for all the countries. many dental schools have been locked down to minimize the spread out of this coronavirus infection. close contact between human being are required for all those learning process in traditional dental education. learning methods should be innovated to keep on the learning process but away from being infected for dental education during pandemic. the purpose of this manuscript is to exchange the information and experience of those dental educators from different countries to prepare for the future demand for dental education during pandemic. materials and methods: by means of three online symposiums, dental educators from different countries were invited to give presentation and discussion regarding to the information and experience in the innovation of dental education during the pandemic. results: the results showed that the impact of the pandemic of covid-19 affects the dental education a lot. intelligent technology has certain benefit for the learning process of dental education during the pandemic. conclusion: the impact of the pandemic of covid-19 affects dental education a lot. the model of dental education should be innovated to suit different situations and novelty intelligent technology should be applied for future dental education. 60 61 the impact of the pandemic of covid-19 has a certain influence on various walks of life around the world. 1e3 from west to east, from living style to business model, all have suffered from this coronavirus situation. 4 because of the pandemic of the covid-19, the social lifestyle global wide has been changed a lot. even though the geographic distance among different countries becomes smaller due to the spread out of this coronavirus, the social distance between human beings should be increased to prevent from being infected. 5e7 many dental schools have been locked down because of the pandemic. 8 most of the lectures are switched to the online mode to keep on the learning progress for their dental students. dental education is mainly composed of three parts: the first is a lectures/problem based learning (pbl) part. this part is easy to switch to online mode. there are different systems available in the internet like: zoom meeting, google classroom, google meet, skype, and so on for the online learning. it is not difficult to keep the social distance for this kind of study. the second part is a simulation laboratory courses. for this course, traditionally, after a demonstration by the teachers, the student will make practice in the simulation models. in such a pandemic environment, this part may be done using modern digital or virtual reality (vr) techniques. however, current facilities are not good enough, and also the procedure as well as the final work needs to be checked step by step by the teachers. thus, the simulation laboratory courses need close contact between teacher and student. the third part is a clinical skill training in terms of internship training which is the most important infrastructure of dental education. there will be close contact between the intern doctor and the patient as well as the teacher. this part is also the most difficult part of dental education to deal with in a pandemic environment. in other hand, most of dental school have a research duty for faculty and student (undergraduate and postgraduate). for research, both in vitro and in vivo, students need close contact between human beings or with animals. how to achieve the balance between keep on learning progress for dental students but not inducing spread out of infected cases is an important issue for dental education. 9 after the pandemic has been ebbing then lifting the shut down may induce another pandemic crisis because of the inevitable social contact in dental education. this will be an important issue in the ongoing dental education. many lifestyles have been changed during the pandemic, to fit the future demand or another pandemic, dental education should be preparing in advance to face the future challenge and another possible pandemic. through trial and error, many dental schools around the world are working extremely hard to continue dental education in such kind of covid-19 pandemic environment. the purpose of this manuscript is to exchange the information and experience of those dental educators from different countries, to prepare for the future demand for dental education. the association of dental education, asia pacific (adeap), co-organized three online symposiums with chinese taipei association for dental sciences regarding to the innovation of dental education during covid-19 pandemic. dental educators from different countries were invited to attend online symposiums with zoom software (zoom video communications inc., san jose, california, usa) and give presentations regarding their information and experience in the innovation of dental education during the covid-19 pandemic from their own countries. these three online symposiums were held on 30th march, 2020, 15th april, 2020, and 10th june, 2020, separately. the topic of 1st symposium was "influence of covid-19 in dentistry". eight scholars from the university of sydney, australia; the university of hong kong, hong kong; loma linda university, usa; international medical university, malaysia; national yang-ming university, taiwan; tohoku university, japan; chulalongkorn university, thailand; and columbia university, usa were invited to present the current situation of dental education during the pandemic in each own country. the topic of the second meeting was "how to proceed the clinical skill training courses under the pandemic of covid-19?" seven scholars from seven countries were invited to present how to proceed the clinical skill training under the pandemic of covid-19, which includes: king's college of london, england; university of geneva, switzerland; tohoku university, japan; harvard school of dental medicine, usa; university of health science, cambodia; manila central university, philippines; and taipei medicine university, taiwan. the topic for the third online symposium was "post covid-19 challenges in dental education, research and clinical activities". five scholars from university of brescia, italy; university of british columbia, canada; hokkaido university, japan; national university of singapore, singapore; and our lady of fatima university, philippines, were invited to present and discuss the innovation of dental education to fit the future demands for the lifting post-covid-19 pandemic lockdown. finally, we have compiled information and experience that collected from these online symposiums. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 we summarized the information and experience obtained from different countries in table 1 . the results showed that lectures and pbl courses are processed in online mode except in taiwan. simulation laboratory courses are desisted in most countries except in cambodia (with video demonstration). simulation laboratory courses remain proceeded in taiwan only. all the clinical training courses are desisted in most countries except in taiwan. in japan, the students are divided into small groups and case conferences and assessments were held online. most of the research work is desisted in most countries except in taiwan. in japan, all the animal studies were suspended, only limited studies in vitro can still proceed. the private dental clinic is almost closed in most of the countries, except in taiwan. emergency dental treatment can be performed in the teaching hospital or local public dental clinic in all countries. while emergency dental treatment can also be performed in the private dental clinic in taiwan. the pandemic of novel coronavirus has a great impact on all the aspects of human life in global wide. 1e3 to prevent spread out of those infected cases by maintaining the social distance becomes the most important rule for all the countries. 3,10 stay home to keep away from gathering can minimize the possibility of infection transmission in one way. but in another way, it limits the human contact and many social activities which downgrade the economic condition in many countries. lockdown the border of neighboring countries by suspending the transportation from one country to another has an advantage to keep away from coronavirus infection, but it also ceases the communication between different countries. the business will be terminated due to the lockdown, if the trade model has not been changed. dental education is a profession with the demand for close contact between human beings. after more than four months of lockdown because of the pandemic of covid-19, we are facing another challenge in terms of "unblock" which may induce another crisis of being infected. thus it is worthwhile to study the information and exchange the experience of those dental educators from different countries, to prepare for the future demand for dental education. the results showed that almost all the lectures (or pbl courses) are switched to online courses to keep the social distance from gathering (table 1 ). many meetings have also been proceeded using online meetings. different apps have been utilized during the pandemic, i.e.: zoom, google meet, skype, microsoft teams, panopto, canvas. the lockdown browser is used for the students' examination in some of the dental schools in the usa. by means of the lockdown browser, students cannot search on the internet (like google and so on) to find an answer during the internet examination. this is one of the example to use modern information technology (it) to prevent from cheating during the examination. in other hand, a dedicated online examination platform for dental education will also need to be developed. different it products have been used. microsoft teams has been used for real time online teaching for undergraduate students, while zoom is used for postgraduate students because it is convenient for the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 students to call a meeting. not only students but also the teachers should be familiar with those advanced it productions. professor keiichi sasaki from tohoku university, japan said that the change of learning modes from the auditorium to online, students can adapt it more quickly than senior teachers since students are more familiar with those it productions. but the change may be difficult for those senior staff to adapt. this generation gap may become minimized after the pandemic, because of the current and future demand for the inevitable necessity of it products for all generations. simulation laboratory courses are suspended in most countries, because of the movement control in many countries to keep the social distance and from gathering ( table 1 ). video demonstration of simulation was used in cambodia. however, since hand-on training is essential for the simulation laboratory course of dental education, a simple and easy-to-use virtual reality (vr) haptic device must also be developed. otherwise, it is impossible to bring the simulation laboratory course online. since the new semester in taiwan was postponed for two weeks to begin, thus all the simulation laboratory courses were delayed for two weeks to start in february, 2020. but it was carried on through the whole semester until the middle of june, 2020 in taiwan. all the clinical training courses in each country are suspended because most of the dental hospitals and clinics are closed during the pandemic, except in taiwan (table 1 ). in japan, students are divided into different groups to decrease the number of students to minimize the risk of socalled 3c: closed indoor venue, crowded place, and close contact, and only prepare the online case presentation and assessment. all the research work are suspended in most countries. animal studies were suspended in japan, but limited in vitro studies, which can be proceeded with computer at home were remain conducted. but all those research activities were ongoing in taiwan. however, many researchers and scientists should be facing shift work during this pandemic situation. even post-covid-19 pandemic, the situation would be no any different. since most of the dental hospitals and dental clinics are closed, only emergency treatment like uncontrolled bleeding, cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient's airway, or trauma involving facial bones will be treated in the emergency unit of teaching hospital or public dental clinic in most countries. video visits and telephone visits were used in australia and usa. but emergency cases can be treated both in teaching hospitals as well as private dental clinic in taiwan. the hospital should develop the guideline to protect patient and doctor from covid-19 infection. the guideline for emergency dental services are: 1. to wear personal protective equipment (ppe) which includes surgical hat, surgical gown including foot cover, surgical mask, and face shield. 2. to take the patient's temperature and ask the medical history (symptoms of covid-19), traveling and contact history. 3. high power suction and rubber dam isolation for aerosol generation procedures are mandatory during treatment procedures. 13e17 this is similar in other countries. emergency treatment should also be part of dental education during the pandemic of covid-19, only attending doctors and residents practiced in the emergency room but not intern doctors in most of the teaching hospitals of most countries, this may be due to movement control and lack of ppe. 10 the dental emergencies and urgent care have the risk of nosocomial infection to either student or staff state of washington's governor ordered subject to major penalties if performing non-emergency procedures. dental students can be involved in this kind of emergency treatment only if ppe and other anti-infected equipment is sufficient to support this special learning course. 10 australia government announced level 3 restrictions which declared that all of the dental clinics should be closed, because of the shortage of surgical masks and n95 respirators for a protracted period. ppe should be prepared in stock not only for dental practice but also for dental education purpose in advance for the challenge of the next pandemic to keep the right to education for those dental students. taiwan demonstrated an exception in dental education during the pandemic. it may be due to some early actions taken in taiwan. the central epidemic commanding center (cecc) has been activated since 20th january, 2020. strategies suggested and controlled by cecc in the field of medication included: triage and screening for patients with fever, limited visitors to all hospitals, and management of outsourcing manpower. surgical masks and gowns as well as 75% alcohol for sterilization have been rationed by the cecc. all hospital medical professionals were required by the cecc to refrain from going abroad. dental services have been classified as one of the high risk health services, ppe were suggested to use and provided by cecc accordingly, non-emergency dental services, especially those generating aerosols, are suggested to be delayed to a later time. tocc (travel, occupation, contact, cluster) history have been used to screen for the high risk group. the it of taiwan's public health insurance system has been very useful in providing traveling history, occupation history and rationing surgical masks for all citizens. to wear a surgical mask is mandatory for everyone during taking public transportation. all schools and universities delayed their new semester for two weeks to decrease social/community interactions. cecc calls press briefing at 2 pm every day to provide the public with correct information both domestically and internationally. more than 50,000 people has been quarantined by the cecc, and a fine up to 30,000 usd for incompliance. because of these strategies, the dental education can be proceeded as usual only all the staff and students have to wear a surgical mask all the time and take the temperature before entering dental school. internship clinical skill training course is proceeded in the teaching hospitals as usual only the number of patients treated are decreased because of delayed treatment asked by some patients. the severity of the pandemic of covid-19 was depended upon the social contact among people. 3, 5 the number of confirmed cases and the number of death because of the pandemic of covid-19 seem to be higher in those countries whose strategy to lockdown were later than those countries with an earlier decision to lock down. the number of death may also due to the pandemic are higher in those countries with super aged society. 18, 19 it may be due to those elderly are general health compromised. 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 general health into dental education becomes more and more important. 21 dental patients are also becoming more and more elderly. therefore, we must pay attention to this point when we are providing dental education. online lectures or demonstration becomes an inevitable technique for future dental education. to learn sufficient knowledge and technology regarding to it will be mandatory in dental education both for educators and students. how to make assessment online will be an important issue for future demand. the epidemiology experts say that second and third wave of covid-19 pandemic is certain to come. humans have fought various epidemics and viral outbreaks throughout history. even after this covid-19 pandemic, there will be another pandemic sometime in the future. we, as dental educators and dental professionals, must create a system to address this situation. there is a lot of work to be done, such as build online lectures, develop vr devices for online simulated training, develop an online exam system, and create guidelines for dental education under the pandemic situation. crisis can also produce opportunities. since many lectures are switched to online courses during the pandemic. by means of the internet, those courses can be disseminated to as many students as possible only if the internet is equipped. many dental schools are shortening of teaching staff ie; man powers and teachers. 22, 23 in this case, if online courses can be shared among different dental schools in different countries, we can not only solve the problem of shortage of teaching staff but also can determine the main courses for the core competency of the dental students in different countries to reach a consensus of core competency world-wide. the impact of the pandemic of covid-19 affects dental education a lot. to face the future challenge the dental educators should be cautious but not panic, being flexible, and willing to face the changes. the novel coronavirus may force dental educators to revolutionize the education system. intelligent technology can help for dental education in many ways during the pandemic. the model of dental education should be innovated to suit different situations and new technological tools should be applied for dental education. uncited reference 11, 12 q3 . the authors have no conflicts of interest relevant to this article. dental education during covid-19 pandemic 5 + model 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 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tensions and ethical quandaries rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages american dental association. ada interim guidance for minimizing risk of covid-19 transmission guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine covid-19 outbreak: guidance for oral health professionals recommendations to member states to improve hand hygiene practices to help prevent the transmission of the covid-19 virus australian dental association. managing covid-19 guidelines the impact of the covid-19 epidemic on the utilization of emergency dental services long-term care policy after covid-19 d solving the nursing home crisis the coming acceleration of global population ageing systemic diseases in association with microbial species in oral biofilm from elderly requiring care covid-19: the immediate response of european academic dental institutions and future implications for dental education the graduating european dentist: a new undergraduate curriculum framework basic and clinical research: issues of cost, manpower needs, and infrastructure the q1 authors wish to thank all of those speakers from different dental schools of different countries, i.e., prof. key: cord-298641-3munq51l authors: ionescu, andrei c.; cagetti, maria g.; ferracane, jack l.; garcia-godoy, franklin; brambilla, eugenio title: topographical aspects of airborne contamination caused by the use of dental handpieces in the operative environment. date: 2020-07-01 journal: j am dent assoc doi: 10.1016/j.adaj.2020.06.002 sha: doc_id: 298641 cord_uid: 3munq51l abstract background the use of dental handpieces produces aerosols containing microbial agents, bacteria and viruses representing a high-risk situation for airborne cross-infections. this study aimed to map and quantify the biological contamination of a dental operatory environment using a biological tracer. methods streptococcus mutans suspension was infused into the mouth of a phantom, and an operator performed standardized dental procedures using an air turbine, a contra-angle handpiece or an ultrasonic scaler. the presence of the tracer was measured at 90 sites on the dental unit and the surrounding surfaces of the operatory environment. results all tested instruments spread the tracer over the entire dental unit and the surrounding environment, including the walls and ceiling. the pattern and degree of contamination were related to the distance from the infection source. the maximum distance of tracer detection was 360 cm for air turbine, 300 cm for contra-angle and 240 cm for scaler (11.8, 9.8 and 7.9 ft, respectively). no surface of the operative environment was free from the tracer after the use of the air turbine. conclusions attention should be paid to minimize or avoid the use of rotary and ultrasonic instruments when concerns for the airborne spreading of pandemic disease agents are present. practical implications. the present study supports the recommendations of dental associations to avoid treatments generating aerosols, especially during pandemic periods. guidelines for the management of dental procedures involving aerosols are urgently needed, as well as methods for the aerosols modification aimed to inactivate the infective agent. the risk of airborne contamination in dentistry is considered high 1 due to the unique characteristics of the dental equipment. the cooling spray of dental handpieces is one of the primary sources of splatter and aerosol in surgery. [2] [3] [4] splatters are air suspensions of liquid or solid particles having a particle size of approximately 100 µm or more, while aerosol particles have a smaller diameter (<50 µm). 5 splatters are too large to be inhaled but can contaminate skin, eyes, hair, and clothing, in addition to the dental working area. on the contrary, aerosol particles can remain suspended for a relatively long time (up to 30 min) after the end of an operative procedure and are easily spread throughout the operative environment by air currents. [6] [7] [8] there is evidence that dental aerosol can reach a distance of 1 through 3 meters from its source. 9, 10 from this point of view, they are vectors of infective agents that show potential for contamination not only of the dental personnel and patients but also of all exposed surfaces of the dental unit and the operatory environment. 5 in addition to microbial species from non-pathogenic oral flora, aerosols may contain pathogenic bacteria (such as mycobacterium tuberculosis, legionella pneumophila, and staphylococcus spp) and viruses (such as hiv, hbv, hcv, hsv, influenza virus, and rhinovirus). [11] [12] [13] [14] the problem of airborne contamination in the dental operatory environment recently returned to the spotlight due to the outbreak of coronavirus disease 2019 (sars-cov-2). this infective agent owes its virulence to high contagiousness related to airborne transmission and to the fact that it can survive on surfaces for up to 72 h. 15 the spreading of sars-cov-2 places tremendous stress on health systems worldwide. 16 for this reason, additional preventive measures are introduced and continuously updated in all health care settings, including dentistry, to reduce further dispersion of this disease. 4, [17] [18] [19] [20] [21] [22] in the last 50 years, attempts have been made to determine the topographical distribution of the airborne contamination caused by the different rotary and vibrating-oscillating dental instruments. 3, 19, 20 the relevance of these data is profound in terms of trying to rationally direct the disinfection procedures on areas of higher contamination, and to control the spreading of diseases. different approaches have been used to map the contaminants, from dye tracers to microbiological evaluation of air and surface contamination. 2, 10, 14, 23 the literature shows that dental treatments significantly increase biological contamination of dental operatories to a higher level than public areas. 14, 24 nevertheless, to our knowledge, no study has determined the topographical distribution of surface contamination in the dental operatory, though this information is essential to implement protocols for disinfection procedures in areas with critical levels of contaminants. in the present study, we aimed to evaluate the contamination resulting from the use of rotary and vibrating oscillating instruments in a dental operatory, using a biological tracer. the null hypotheses were that the presence of the tracer would be uniformly detected on the dental unit and the operatory environment surfaces, and the spread of the tracer would not be different when using different handpieces. a 598 x 376 x 270 cm (length x width x height, corresponding to 19.6 x 12.3 x 8.9 ft) operative environment located in the dental clinic, san paolo hospital, university of milan, was used for the study. both raised floor and false ceiling were made of 60 x 60 cm-sized pvc panels (2 x 2 ft). the air-conditioning system of the room was isolated by sealing the inlet. the room was equipped with a dental unit (skema 4, castellini, bologna, italy), two dental stools and a four-door cabinet located behind the dental chair. the presence of a biological tracer was measured in 22 sites of the dental unit and 68 sites of the operatory room, as follows. a total of 14 sites were located on the dental chair, one on the assistant pad, one on the instrument tray, one on the cuspidor cup, one on the water glass tray, three on the overhead dental unit light and one on the foot pedal. in the operative room, we located 48 sites on the floor, 4 on the wall in front of the dental unit, 1 on the lateral column, 5 on the back wall, 6 on the ceiling and 4 on the cabinet (fig. 1, 2) . the same sites were used throughout all the experiments. bacteria. all reagents and culture media were obtained from becton-dickinson (bd diagnostics-difco, franklin lakes, nj, usa). a wild strain of streptococcus mutans was isolated on mitis salivarius bacitracin (msb) agar from the dental operator who performed all dental procedures. biochemical identification of the isolated strain was performed using an automatic device (vitek 2, biomerieux, marcy-l'etoile, france). then, a pure suspension of s. mutans in trypticase-soy broth was obtained from a single colony grown on the selective medium after a 12h incubation at 37 °c in a 5%-supplemented co 2 environment. cells were harvested by centrifugation (1.500 x g, 19°c, 5 min), washed twice with sterile phosphate-buffered saline (pbs), and resuspended in the same buffer. the cell suspension was subjected to sonication (sonifier experimental setup. a phantom head was adapted to the chair headrest in a standard working position (fig. 1a) . the jaws inside the phantom were equipped with resin teeth (columbia dentoform corp., long island city, nyc, usa). the drainpipe of the phantom was connected to a high-speed suction. after that, the operator performed a total of three standardized dental procedures on the lower right first molar, as follows. for the first procedure, the operator prepared a class i cavity using an air turbine handpiece (bora led, bien-air dental sa, bienne, switzerland) equipped with a cylindrical diamond bur (835kr.314.016, komet italia srl, milan, italy). the air pressure was 3.3 atm, and the speed was 320.000 r.p.m. for the second procedure, a contraangle handpiece (1:1) (ca 1:1, bien-air) was used with a round tungsten carbide bur (h1sm.204.020, komet) inside the already prepared cavity at a speed of 50.000 r.p.m, to mimick removal of deep carious tissue and cavity refining. in the third procedure, an ultrasonic scaler (suprasson, satelec -acteon, merignac, france, operating at 28 khz oscillation frequency) equipped with an a2 insert, reached below the gumline of the labial, lingual and interproximal surfaces of the same tooth. each procedure lasted 240 s, and the resin tooth was replaced after performing the three procedures. a continuous flow of s.mutans suspension (30 ml/min) was infused in the mouth of the phantom on the lingual surface of the lower right second molar throughout all procedures using a drip device. the operator wore biohazard protective full suit, including cover shoes, gloves, ffp2/n95 mask without valve, and face shield to protect himself against possible infections by the tracer agent. operatory and microbiological procedures. before the beginning of each procedure, 90 msb agar plates were coated and placed one in each of the corresponding sites, keeping the lid closed. the operator took their position and then a coworker, equipped with the same biohazard protections as the operator, opened the lids of every plate. after that, the operator opened the suspension drip and performed a 4-min procedure. the plates were closed by the coworker 26 min after the end of the procedure to allow aerosols to settle. then, he immediately transferred the plates to the microbiological laboratory. the plates were incubated at 37 •c for 48h in a 5% supplemented co 2 environment. at the end of the incubation, colonies were counted, and results were expressed as colony-forming units (cfu)/cm 2 . the procedure was repeated 15 times for each handpiece. between procedures, the environment was disinfected overnight using an ambient decontamination device (phileas 75, devea, granchamp-des-fontaines, france). the operator repeated the same procedures once without using the bacterial suspension, considering the results for the tested dental unit and the operative environment as the tracer's blank. statistical analysis. the statistical software (jmp 10.0, sas institute, cary, nc, usa) was used to analyze microbiological data belonging to the tracer presence on the dental unit and the operatory room. shapiro-wilk's test was applied to check the normality of the data distribution, and bartlett's test was used to check homogeneity of variances preliminarily. since the data distribution was not normal, data were log-transformed to approach a normal distribution. a two-way anova was used considering the handpiece and the topography as fixed factors, and tukey's hsd posthoc test was used to highlight significant differences between groups, at a level of significance (α) of 0.05. tracer presence on dental chair unit. anova results showed a highly significant difference in tracer levels between the tested handpieces (p<0.01). the mean levels of tracer were as follows: air turbine (0.51±0.17) > scaler (0.47±0.14) > contra-angle handpiece (0.41±0.14). no significant difference was found between different sites on the dental unit when considering the distance from the infection source (p>0.05). also, an interaction between the considered factors was not found (p=0.08). when considering the two sides of the dental chair, the left -side showed higher tracer levels than the right side when the air turbine was used (p=0.01). no significant differences in tracer presence were noticed when using contra-angle or scaler (p=0.98 and p= 0.48, respectively). the danger of cross-infection through splatters and aerosols has long been considered one of the main concerns in the dental practice. 2, 3, 14, 20, 24 air-spray cooled handpieces, such as air turbines, contra-angles, and scalers, produce splatters and aerosols that can reach a considerable distance, carrying potentially infective agents. 6, 14, 19, 22 despite being necessary, the use of air-spray cooling is recognized as one of the primary sources of contamination in the dental setting. 23 in fact, even before the outbreak of sars-cov-2, the potential airborne spreading of life-threatening infections was well recognized. 13, 14, 25 nevertheless, there is very little data available on the topographical distribution of contamination induced by aerosol-generating devices. the sars-cov-2 outbreak highly increased the need for such experimental data, 22, 26, 27 in order to rationally address the operative and disinfection procedures yielding the lowest possible contamination levels. the contamination usually produced directly by the patient themself (talking, breathing, sneezing or coughing) or during high-risk medical procedures (tracheal intubation, manipulation of the oxygen mask, bronchoscopy, non-invasive ventilation, insertion of a nasogastric tube) shows a high variability due to interindividual differences. 14, 28 furthermore, aerosols produced by the patient show different behavior depending on the particle size. indeed, it was observed that the size of a pathogen dictates the size of the particle that is carrying that pathogen. for instance, aerosol particles that carry viral particles are much smaller than particles carrying larger pathogens such as bacteria. 12 this may not be the case in the dental setting since aerosols and splatters are mechanically produced and thus have a particle size that depends on the functioning parameters of each handpiece. the current study showed that dental handpieces generate a contamination pattern with relatively low variability. the reason for this phenomenon is due to the direct production of the aerosol by handpieces in a standardized way following defined operating parameters. studies demonstrated that aerosols and splatters produced by dental handpieces are able to carry and diffuse any pathogen that is present in the oral environment and in saliva. these pathogens include bacteria and viruses from the nose, throat, and respiratory tract. 6 is an infective pathogen that is mainly harbored in these locations, and therefore it is prone to be carried by aerosol-generating dental procedures. the present findings allowed to reject both null hypotheses, implying that the presence of the tracer was not uniformly detected on the dental unit and the operatory environment surfaces, and the spread of the tracer was significantly different when the tested handpieces were used. in fact, the present results revealed the existence of heavy contamination involving the whole dental unit as well as the surrounding surfaces of the operative room. values higher than 0.10 cfu/cm 2 exceeded the guideline value for good hygiene, indicating moderate contamination 29 . values higher than 0.20 cfu/cm 2 were arbitrarily considered as a high contamination level. furthermore, the area contaminated by the biological tracer via splatters and aerosols was surprisingly wide, reaching a maximum distance of 360 cm from the infection source when we operated the air turbine. subsequently, no surface of the operative environment was left free from the biological tracer after the tested dental procedures involving air turbine. when looking at the contamination in the dental operatory, the contra-angle yielded lower tracer levels than the air turbine, and the scaler showed the lowest tracer levels overall. the same sequence was evidenced when considering the maximum distance at which the tracer was detected. high variability in colonies distribution of the sites within 150 cm from the infection source after using the handpieces likely suggests that splatters were the primary vector of the tracer. this result may suggest that the primary source of contamination for both dental operators and dental unit surfaces may be splatters rather than aerosols. on the contrary, relatively regular distribution of the bacterial colonies at a higher distance suggests aerosols as the primary vector of the tracer, and this finding was not dependent on the type of handpiece. walls and ceiling showed a relatively regular distribution of the colonies, being seemingly reached by aerosols. this result is relevant since no study in the literature demonstrated the possibility for aerosols to reach such surfaces. these findings suggest the need for disinfection protocols to include such surfaces. regarding the topographical distribution of the tracer on the dental chair, the distance from the infection source did not influence tracer levels, except for air turbine, that caused a higher degree of tracer presence on the left side of the chair, likely due to the fact that the operator was righthanded. also, lower tracer presence on the floor behind the operator was probably due to the barrier effect caused by the operator's position. considering airborne transmission, bacterial and viral infectious agents may be carried by aerosols which can remain suspended for a significant amount of time and travel relatively long distances 5, 6, 14, 18, 27, 30 . however, there is no evidence in the literature that bacteria behave differently from viruses when spread by an aerosol. in the present study, a biological tracer was used to simulate clinical conditions as closely as possible and to allow both quantitative and topographical evaluation of aerosol diffusion. the bacterial tracer (s. mutans) was selected to simulate the diffusion of any infective agent by aerosol. the choice of a relatively low pathogenic microorganism as a tracer and of a passive method of sampling was motivated by health risk concerns and ethical reasons. due to the peculiar characteristics of the analysis techniques that were used in the present study, relatively large variability of the data was seen, as expected. a high number of replications (15) of the experiments were made to control such effects. we have to distinguish between studies using an active sampling method and the studies using a passive one. an active sampling method is based on suction systems coupled with filters or agar plates that collect the infective agents in specific sampling locations. this technique has been extensively used to characterize the different types of infective agents of an aerosol 30, 31 . however, it does not allow to map the surface spreading of the contamination. passive methods are mainly based on detection of surface contamination by aerosols, most often by agar plates or sampling filters, that collect the droplets coming into contact with the surface after a specified amount of time. the latter method, therefore, allows for precise mapping and evaluation of the variability of the contamination at a specific site. very few studies mapped the operatory room surfaces reached by aerosols produced by dental handpieces, and, to our knowledge, none are based on the use of a biological tracer under standardized conditions. miller and coworkers. 3 used a setup similar to that of the present study, and they demonstrated the presence of a high degree of bacterial contamination at about 240 cm (the measured maximum distance) using an air turbine. hackney and coworkers used viridans streptococci as biological indicators of oral contamination of the operatory since they are known to be abundant in human saliva 32 . these bacteria were detected on operatory surfaces after dental treatments were finished, and surfaces were disinfected, confirming the validity of using a biological tracer, though. the approach is quite similar to the one used in the current study, yet it was performed without a true standardization of the infection source. contrarily to the setup of that study, the experimental conditions applied in this study allowed us to define the topographical distribution of the contamination and to measure this parameter reliably. a comparison between the contaminating effect of the different tested handpieces was therefore possible. rautemaa and coworkers collected fallout samples on blood agar plates (measured maximum distance: 200 cm) in the operatory after using air turbine. 20 the results showed significant contamination at all sampled distances. these findings are in agreement with those of the present investigation on air turbine contamination. using a similar experimental setup as in the present study, purohit and coworkers evaluated the effect of rinses with an antibacterial mouthwash on the reduction of airborne contamination measured at a maximum distance of 60 cm. 33 contrarily to our results, the ultrasonic scaler produced significantly higher contamination than the air turbine. higher variability in contamination data at the recorded distance may explain the differences between the findings. the results of chuang and coworkers showed that bacterial aerosols could reach a 100 cm horizontal and a 50 cm vertical distance (measured maximum distances) from a patient's oral cavity, remaining suspended for 20 minutes. 34 the findings of the present study show that the distances reached by dental aerosols are severely underestimated. possible limitations of the present investigation are related to the operatory that provided space constraints to the source of infection, and the absence of data regarding the operator contamination. when looking at the topographical distribution of the tracer, it is reasonable that the operator was exposed to highest tracer levels. also, the air-conditioning intake was blocked in the present setup; therefore, the effect of air currents on aerosols are not known. further research is needed to find alternative approaches to the threat represented by aerosol generation in dentistry. a possible solution could be represented by modifying the composition of the aerosols produced by handpieces. this could be achieved by the addition of water spray with a disinfectant agent able to inactivate the pathogen while avoiding deterioration of dental unit waterlines and having very low toxicity, such as for instance 0.5% hydrogen peroxide for coronaviruses. in this way, the disinfectant agent could be active both on the aerosol spreading phase and once deposited on surrounding surfaces within one minute 35 . another topic for future research should be to study the influence of additional protection procedures, such as the use of high-volume suction systems and rubber dams on the spread of contamination. dental procedures involving rotary and oscillating handpieces spread the biological tracer throughout the dental operatory. therefore, attention should be paid to minimize their use, especially during a pandemic by an airborne spreading agent. the results of the present study highlight the need to disinfect all surfaces of the dental operatory within 360 cm of the infection source (patient's oral cavity). furthermore, since the maximum contamination was found in the dental unit area, the highest attention must be paid to the use of personal protection equipment and decontamination procedures of the operators. cross-transmission in the dental office: does this make you ill? aerosol and splatter contamination from the operative site during ultrasonic scaling studies on dental aerobiology. ii. microbial splatter discharged from the oral cavity of dental patients dental bioaerosol as an occupational hazard in a dentist's workplace bacterial aerosols in the dental clinic: a review aerosols and splatter in dentistry: a brief review of the literature and infection control implications effect of an ultrasonic scaler on bacterial counts in air high-speed dental handpieces and spread of airborne infections reducing bacterial aerosol contamination with a chlorhexidine gluconate pre-rinse dissemination of aerosol and splatter during ultrasonic scaling: a pilot study aerosol transmission is an important mode of influenza a virus spread the role of particle size in aerosolised pathogen transmission: a review efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review a scoping review on bio-aerosols in healthcare and the dental environment aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 the covid-19 epidemic cross-contamination in dentistry: a comprehensive overview dental aerosols: a silent hazard in dentistry! microbial aerosol contamination of dental healthcare workers' faces and other surfaces in dental practice bacterial aerosols in dental practice-a potential hospital infection problem? coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice cross-contamination potential with dental equipment airborne microbes in different dental environments in comparison to a public area production of extracellular traps against aspergillus fumigatus in vitro and in infected lung tissue is dependent on invading neutrophils and influenced by hydrophobin roda salivary glands: potential reservoirs for covid-19 asymptomatic infection possible aerosol transmission of covid-19 and special precautions in dentistry influenza aerosols in uk hospitals during the h1n1 (2009) pandemic--the risk of aerosol generation during medical procedures a guide book to monitoring surface hygiene microbial aerosols in general dental practice airborne microbial contamination in dental practices in iasi using a biological indicator to detect potential sources of cross-contamination in the dental operatory efficacy of pre-procedural rinsing in reducing aerosol contamination during dental procedures investigation of the spreading characteristics of bacterial aerosol contamination during dental scaling treatment persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents , p<0.05 ). an apparent decrease in tracer presence with an increasing distance from the infection source can be seen in the operating environment, independently from the tested handpiece. however, air turbine spread the tracer at a significantly higher distance than contra-angle, which in turn spread the tracer farther than the scaler. all sites of the dental unit generally obtained very high tracer presence; the highest one was found on the cuspidor cup when we used the air turbine, while the lowest one was found on the same site when we operated the contra-angle handpiece.disclosure. none of the authors reported any disclosures. key: cord-277539-xt2nt11e authors: kochhar, anuraj singh; bhasin, ritasha; kochhar, gulsheen kaur; dadlani, himanshu; thakkar, balvinder; singh, gurkeerat title: dentistry during and after covid-19 pandemic: pediatric considerations date: 2020 journal: int j clin pediatr dent doi: 10.5005/jp-journals-10005-1782 sha: doc_id: 277539 cord_uid: xt2nt11e this article is a rumination on the outbreak of the dreaded coronavirus disease-2019 (covid-19) pandemic which has engulfed both the developed and the developing countries, thereby causing widespread global public health concerns and threats to human lives. although countries have made varied efforts, the pestilence is escalating due to the high infectivity. it is highly likely that dental professionals in upcoming days will come across covid-19 patients and sars-cov-2 carriers, and hence must ensure a tactful handling of such patients to prevent its nosocomial spread. despite the avalanche of information that has exploded in relation to this rapidly spreading disease, there is a lack of consolidated information to guide dentists regarding clinical management including precautions to take materials to use and postprocedure care, during and after the covid-19 pandemic. available sources of information have been analyzed, while relying on peer-reviewed reports followed by information available from the most respected authoritative sources, such as who, centers for disease control and prevention (cdc), and ada. this review aims to provide a comprehensive summary from the available literature on covid-19, its insinuation in dentistry, recommendations that have been published, and the actual in-practice implications, so a plan can be formulated and adapted to the circumstances of each dental practice during the pandemic and the times to follow. how to cite this article: kochhar as, bhasin r, kochhar gk, et al. dentistry during and after covid-19 pandemic: pediatric considerations. int j clin pediatr dent 2020;13(4):399–406. coronavirus disease-2019 (covid-19) pandemic presented as a black swan event, later spreading its tentacles into almost all spheres of life. the carcinogenic consequences have made it the need of the hour that dental healthcare professionals understand the mortiferous effects of this dreaded disease in order to prevent its malignant spread. the sars outbreak was the first readily communicable infectious disease that the world faced in the 21st century. it was presumed not to be the last such contagion. 1 the covid-19 outbreak that was the first reported in the area of wuhan, china, drastically developed into a public health quandary. 2 who has declared a global emergency with millions of people presently in quarantine, self-isolation, or lockdown. 3 constant diligent efforts to curb the effects of the pandemic are being carried out but the situation is still escalating owing to the high transmissibility of the virus leading to a community spread. it is speculated that dental professionals will come across covid-19 patients and sars-cov-2 carriers, and hence must ensure a careful handling of such patients to prevent its nosocomial spread. despite the avalanche of data that is available in relation to this disease, there is confusion due to a lack of consolidated information to guide dentists. the purpose of this review is to provide a comprehensive summary from the available literature on covid-19, its insinuation in dentistry, recommendations that have been published, and the actual in-practice implications, so a plan of measures can be formulated and adapted according to the circumstances of each dental practice during the pandemic and the times to follow. initially, covid-19 started as a zoonotic infection, but soon human transmission started through nosocomial routes and later viruses were found in respiratory droplets as well. 4 this causes an alarming concern to dentists as they deal with the orofacial region. also, of concern is the presymptomatic transmissibility for covid-19, during the incubation period up to 14 days, with the mean of 5-6 days which has been documented by aggressive reconnaissance of clusters of confirmed patients. [5] [6] [7] this is buttressed by information, via contact-tracing efforts that few individuals can test positive for the disease 1-3 days before the development of symptoms. 8 it is noteworthy that infectious droplets or aerosols are still a prerequisite for transmission. asymptomatic transmission has also been reported similar to presymptomatic, by measures of contact tracing, wherein an individual test positive for covid-19, however, presents without any symptoms. 3, 6, 7, 9 owing to the transmission by presymptomatic and asymptomatic patients, the high r 0 (basic reproductive number/ infectious agent's epidemic potential) for sars-cov-2 which ranges between 1.4 and 6.5, with an average of 3.28, might be justified. 10, 11 even in those who are symptomatic, several people with covid-19 express only faint clinical presentation, such as cough, 12 however, this is a cause of concern in dentistry, because, there is an increased exposure risk if performing or being present for an aerosol-generating medical procedure (agmp). aerosolgenerating medical procedure comprises tracheal intubation, extubation, cardiopulmonary resuscitation, nebulizer treatment, sputum induction, noninvasive ventilation, tracheostomy, manual ventilation prior to intubation, and bronchoscopy. 12 however, surprisingly, there is no mention of dental procedures. 13 fomites and feco-oral are other possible transmission routes that require attention. recent updates suggest the possible routes of entry to be via the exposure of mucous membranes of nose, mouth, and eyes, 10, 14 and raise the concern for hand hygiene by the dental team as well as patients. another matter of concern is air conditioner airflow direction, which was implicated as a means of transmission in guangzhou, china and was published by centers for disease control and prevention (cdc). 15 knowledge of signs and symptoms of covid-19 is important for the dental practitioners. an elaborate history must be taken and should include questions regarding any flu-like symptoms, ranging from cough, shortness of breath, fever, and diarrhea, trouble breathing persistent pain or pressure in the chest. mildly symptomatic patients also report alterations in smell or taste in sars-cov-2 infections which often were the first apparent symptoms. questions regarding the same by the dentist can also prove to be beneficial in the initial diagnosis by the dentist, but results must be interpreted with caution. 16 detailed medical history is imperative as presence of comorbidities (obesity, diabetes, hypertension, cardiovascular disease, pulmonary disease, and renal disease) have been found to be risk factors for the disease. 17, 18 diagnostic tests sars-cov-2 tests may either detect the virus itself [viral ribonucleic acid (rna)]/antigens or detect the serological antibodies produced in response. 19 real-time pcr test which mainly makes use of a nasopharyngeal swab is still the confirmatory test. 20, 21 rapid testing and monitoring which is hot off the fire, detects igm, iga, igg, or total antibodies, 19 and can be used by the dental practitioners for in-clinic screening of patients, with the results being available within a short span of time. 22 of the many rapid test kits that have been developed recently, as on april 24, 2020, 45 have been approved by fda 23 (fig. 1) . however, dentists should be cautioned, as early in the disease a single nasopharyngeal swab for pcr test is only 70% sensitive. 24 on the contrary, although the rapid test infers expedited diagnosis of covid-19, false-negatives are a bigger problem which cannot be overlooked. hoffman et al., stated that the precision of the test was 94.1% for igm and 98% for igg, considering rt-pcr positive cases as true positives. further they outlined that although a sensitivity of 69 and 93.1% for igm and igg was observed, the assay showed an overall specificity of 100 and 99.2% for igm and igg, respectively. 25 similar results were obtained by the researchers at cleveland clinic who in an unpublished report stated a false-negative rate of 14.8%. 26 hence, one must be forewarned that a negative test alone should not be used as the sole basis for ruling out covid-19 infections and making patient management decisions, instead should be supplemented with history, clinical signs and symptoms, radiological findings, and epidemiological information. 27 to et al., found the presence of the novel coronavirus in selfcollected saliva specimens of 91.7% patients which might be a viable source for diagnosis. 28 also, a study by wyllie et al. showed that the collection of saliva can be self-administered, more sensitive, and viable as compared to nasopharyngeal swabs and could make accurate sars-cov-2 testing a possibility, be it at home or in a dental setting with lower risk to healthcare workers. 29 another valuable tool that can be used as an adjunct in the dental clinics is pulse oximeter, which is fast, easy, noninvasive, and harmless, to detect silent hypoxia, in covid-19 patients. this has become a recent topic for consideration but requires further studies to be validated. 30 prophylactic hydroxychloroquine or chloroquine for asymptomatic healthcare professionals while treating covid-19 patients has been advocated by the indian council of medical research (icmr). the advised prophylaxis with hydroxychloroquine (400 mg twice on day 1, followed by 400 mg once a week) is a matter of concern as it can cause an undue optimistic perception of a drug whose efficacy is not verified for the particular use, the advantages unseen, and the undesirable consequences, including potentially lethal cardiac arrhythmia in certain individuals, overlooked. [31] [32] [33] also, prophylaxis could last for the entire duration of the pandemic, and in countries where malaria is highly prevalent, appropriate resistance monitoring of plasmodium species is needed. 34 a chemoprophylaxis advice without reliable evidence might be questionable. 30 hence, risks vs benefits should be evaluated, a thorough medical assessment and physicians' approval for the same must be taken. sound knowledge of the spread of sars-cov-2 is required to prevent its transmission in the dental practice. though numerous routes of infections exist in the dental scenario, aerosols are one of the predominant routes for transmission of pathogens including sars-cov-2, therefore stringent infection control measures are imperative. [35] [36] [37] [38] thus, for patient screening and infection control, specific proposals and strategies for dental healthcare practice are critical. dentists must abide by the most recent recommendations from international, federal and local public health authorities. before a patient comes to the clinic, a telephonic appointment must be made with the dentist. aggressive screening of patients, attendants, dental practitioners, and the staff should be performed for covid-19. patients must be enquired about any close contact with a known covid-19 patient or symptoms including fever, dry cough, and shortness of breath over the phone and where possible, video call. it can help screen suspected covid-19 patients and also identify whether the patient requires in-office treatment. 2 another recommended method by the cdc is an online bot nicknamed clara which can act as a screening aid 39 (fig. 2) . *positive pcr confirms infection. antibody test not required **patient should be treated with caution in accordance with most updated cdc guidelines, as no information still available about infectivity during convalescence 3 ***treatment to be carried out after cdc guidelines fulfilled 3 proposed clinic contingency plan *this is a contingency plan outline, and can be used as a skeleton to formulate a customised plan for a dental practice while following the most updated national and international guidelines **sensitivity and accuracy of the test must be checked prior to use and interpretation though teledentistry has now become an integral part of care, some patients may not be comfortable with it. studies have reported that telehealth presented an impediment to traditional healthcare and many patients were discontented with the same, 40,41 when their primary anticipations were not met. 42 also, while minor signs and symptoms may seem unimportant to the patient, these assumptions of aggressive telescreening are relying heavily on patients' information or lack thereof. dentists should make the patient comfortable, gain their confidence, and encourage them to report even the mildest of symptoms, which they might usually ignore. dental treatment of any suspected or confirmed covid-19 patient ideally must be deferred for 2 weeks from the time of exposure. 35 analgesics and/or antibiotics can be considered as therapeutic agents in certain cases. during the peak of the pandemic dental treatments should be categorized according to the severity as well as, the extent of invasiveness and risk of the procedure, especially when the federal and local public health authorities have deferred elective treatment. treatment should be considered after risk vs benefit evaluation 43 keeping in mind the possibility of disease progression, as reversible pulpitis might progress to irreversible, irreversible to apical periodontitis, and further on. there might be consequent tooth loss as well. 44 dentistry might see a splurge of patients once life resumes its "normalcy" with patients presenting with dental problems of much more severity and poor prognosis. if a patient requires in-person visit, temperature needs to be checked at the point of entry itself, preferably with a noncontact thermometer, 3 followed by a questionnaire and rapid test if available. to avoid transmission, magazines, toys, and other unnecessary items must be removed from the clinic and appointments should be staggered. 3 in pediatric dental setup, only one parent should accompany the child. alcohol-based hand rub (abhr) should be available at appropriate locations in the waiting area to help improve hand hygiene by children, parents, and staff. if treatment needs to be performed, informed consent 2 must be obtained and the operatory must be prepared for the same. treatment of any suspected covid-19 patient if required, must preferably utilize a negative pressure/airborne infection isolation room (aiir). 2 furthermore, a portable high-efficiency particulate air (hepa) filter with negative ion generator may be considered, 45 which are available mostly in hospital based settings only. 46 in a recent study, after sars-cov-2 application on copper and only cardboard, no live viable sars-cov-2 was observed after 4 and 24 hours, respectively. however, viable virus was more stable and discerned up to 72 hours on stainless steel and plastic. 47 this recent ground-breaking research about the aerosol and surface viability of the virus might provide a beneficial implication for dentistry as well. cardboard use as barriers and the use of coppercoated instruments instead of stainless steel may be considered as a substitute and further research is recommended for the same. 47 who recommended abhr formulations with 80% ethanol or 75% 2-propanol, have been assessed against sars-cov and mers-cov, and were found to be effective. benzalkonium chloride, however, has less efficiency than either of the alcohols, against coronaviruses. 35, 38 due to the current situation, healthcare organizations that grapple with paucity of abhr can consider local production of formulations as described by the fda policy for compounding of certain alcohol-based hand sanitizer products. 3 few studies illustrate that poor compliance with hand hygiene practices remains a challenge for infection prevention and control (ipac) among practitioners all over the world who mistake gloving as a substitute for hand washing. 48, 49 alcohol-based hand rub use should be encouraged between all patients, they should be provided in appropriate areas close to the health workers, and additionally hand-washing promoted when hands are visibly soiled. use of custom-fit n95 respirator, eye protection, face shield, and overgown during agmp on confirmed or suspected covid-19 patients have been propounded. 35, 37, 38 long-sleeved gloves with double-gloving technique, eyewear including side shields or fullface shields, and hair covers/hoods are recommended. 35 the use of powered air-purifying respirator (papr) in invasive treatments is suggested by few. 13, 50 donning a surgical mask or n95 is predicated on the size and dispersion of the respiratory secretions, and the dimension of droplets known to be contagious for a specific pathogen, rather than the size of the virus itself. 51 although wearing double gloves, overgown, and face/eye protection that have been overemphasized during agmp along with papr in invasive treatments, 13,50 but the reduced dexterity owing to the double layers of gloves, diminished visibility by flexible face shields, and back ache due to paprs may result in poor compliance. 52 thus, rather than donning everything, the most appropriate personal protective equipment (ppe) to be used in covid-19 patients is contingent on the clinical procedure being performed. association for the advancement of medical instrumentation (aami)-level 2 gown, surgical mask with face shield, and single gloves are advisable for caretakers who are not involved in high-risk agmp. 53 for healthcare personnel present in the operatory during an agmp, aami level-2 gown, n95 mask, eyeshield, head cover, and single gloves are advised; and practitioners performing agmp, should deploy aami level-3 gown, neck cover, and two pairs of gloves. 53 the coated fabric that has to be used must pass iso 16603 and iso 22612 testing for the usage of ppe kit. 54 another concern is contamination during doffing but abiding by doffing recommendations by cdc may lead to reduced crosscontamination, in comparison with a lack of guidance. 55 though this has not been paid heed to, nitrile gloves show better penetration resistance to viral load, when compared to latex. 56 when comparing latex and nitrile gloves in terms of barrier performance, both were superior to vinyl gloves. 57 sars-cov-2 has been found to be susceptible to oxidation, hence, pre-procedural rinse incorporating oxidative agents like 1% hydrogen peroxide or 0.2% povidone iodine is advocated to reduce viral load, though substantial evidence is not available. 38 spraying local anesthetics must be avoided due to the propensity to disseminate the virus in aerosols. 35, 38 however, if treatment is to be performed under ga, lidocaine should be used before endotracheal intubation as coughing can produce aerosols. 58 furthermore, ultrasonic scalers, three-way syringes, and high-speed handpieces must be obviated. 2 if indispensable, antiretraction handpieces 35 or electric friction grip handpieces 59 must be used to prevent aspiration and expulsion of debris and fluids. 35 suction, low or high volume can reduce aerosol production. 41, 42 if restorative or endodontic treatment is necessary, chemomechanical caries removal, such as carisolv and papain gel, is a viable alternative. 35, 60 also, silver diamine fluoride and gic can be used to restore teeth to prevent disease progression 61, 62 (table 1) . the reduction in bacteria-laden aerosols with rubber dam has been recommended for aerosol-generating procedures by peng et al. 35 studies by samaranayake et al. have suggested 78% reduction by and 70-88% reported by cochran et al. 63 hence, caution needs to be observed despite its use. extraoral radiography must be preferred over intraoral to reduce saliva production. 2, 35, 38 in case intraoral digital films are needed, supplemental barrier protection with finger 64 aerosols are the foremost reason for panic, owing to cross infection through it. during this pandemic, high-volume evacuators (hves) may offer a promising solution by controlling aerosol particles before they leave the mouth and can reduce 90-98% of aerosols, regardless of source. 35, 37, 65 air-cleaning systems also used for the same purpose significantly reduce the potentially hazardous aerosols created as shown by early studies; but still there is a dearth of published evidence for the same. 66 following every dental procedure, rigorous disinfection of all the surrounding surfaces should be carried out. therefore, there should be a time lapse of at least an hour between subsequent appointments to perform thorough decontamination. this has also been advocated by ti and colleagues. 52 moreover, there may be a backflow of pathogens with the use of handpieces in the water tubes of the dental chair. owing to this, purging should be appropriately done. all sterilizable instruments must be timely cleaned, disinfected, and sterilized. all disposables should be considered highly infected medical waste and discarded appropriately. 27, 58 the potency of human coronaviruses on inanimate objects is up to 9 days at room temperature. although data on the transmissibility of sars-cov-2 from contaminated surfaces to hands were not found, 5-second contact time has been documented to transmit 31.6% of influenza a virus to hands. 67, 68 ethanol at concentrations between 62% and 71%, 0.1-0.5% sodium hypochlorite, and 2% glutaraldehyde reduced coronavirus infectivity within 1 minute exposure time. a comparable effect is expected against the sars-cov-2 and these agents should be used for appropriate surface disinfection. 67 hydrogen peroxide vaporizer can also be used to decontaminate the operatory. 3, 52 various advisories and specifications have been put forward by the governing authorities. despite these recommendations, absolute infection control measures sometimes require constant reiteration. 49 therefore, the administration of the dental healthcare practice must make sure and evolve infection prevention and occupational health programs. written infection prevention policies and procedures including standard operating protocols for the services provided by the facility should be formulated and maintained. provision of supplies necessary for hand hygiene products in easily accessible areas should be ensured. definitive infection prevention education and training must be made available. the complete team must be provided with appropriate ppe for the procedure to be performed and their role in the same, to prevent droplet and contact infections. dental healthcare settings must institute procedural protocols for donning and doffing ppe. prior to the treatment, the dental team must identify and review • extra-oral • if intra-oral with double barrier and finger cots *above the age of 5 years **thorough evaluation and clinical signs and symptoms to be noted, risk vs benefit evaluation and individualistic approach required. this table has been created using information from suri et al., 3 alharbi et al., 43 peng et al., 35 and meng et al. 37 the in-procedural protocols, and plan ahead for triage, pre-procedure operatory preparation, minimizing aerosols during procedure and postprocedure disinfection. routine evaluation and reevaluation of the infection prevention program, including adherence to infection prevention practices should be established. • in these unforeseen times, events are unfolding rapidly. hence, all dental practitioners should be abreast with the latest news and guidelines in accordance with state, federal, national, and international bodies. • especially in pediatric dentistry, children should be made to feel comfortable with the new ppe and protocols in the dental practice setting in order to reduce fear and increase cooperation. • a customized approach should be taken by practices to safeguard patients, patients' families, and dental healthcare personnel during and after this pandemic. • although currently catastrophic, even after the critical peak of the outbreak has been contained, stringent ipac protocols need to be updated, followed, and reviewed. severe acute respiratory syndrome and dentistry: a retrospective view coronavirus disease 19 (covid-19): implications for clinical dental care clinical orthodontic management during the covid-19 pandemic can we contain the covid-19 outbreak with the same measures as for sars? pattern of early human-to-human transmission of wuhan anesthetic management of patients with covid 19 infections during emergency procedures a familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period a family cluster of sars-cov-2 infection involving 11 patients in nanjing, china asymptomatic cases in a family cluster with sars-cov-2 infection presymptomatic transmission of sars-cov-2 -singapore coronavirus disease, 2019 (covid-19) situation report -73 summary of assumptions updated dentistry and coronavirus (covid-19) -moral decisionmaking ocular tropism of respiratory viruses covid-19 outbreak associated with air conditioning in restaurant alterations in smell or taste in mildly symptomatic outpatients with sars-cov-2 infection are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? prevalence of comorbidities and its effects in coronavirus disease 2019 patients: a systematic review and meta-analysis testing recommendation for covid-19 (sars-cov-2) in patients planned for surgery -continuing the service and 'suppressing' the pandemic the sars-cov-2 outbreak: diagnosis, infection prevention, and public perception the promise and peril of antibody testing for covid-19 report from the american society for microbiology covid-19 international summit coronavirus covid-19 diagnostic tests and shortages in emergency use authorizations coronavirus disease 2019 (covid-19): protecting hospitals from the invisible evaluation of a covid-19 igm and igg rapid test; an efficient tool for assessment of past exposure to sars-cov-2 false negatives in quick covid-19 test near 15 percent: study https:// www.the-scientist.com/news-opinion/false-negatives-in-quickcovid-19-test-near-15-percent-study-67451 maxillofacial surgery and covid-19, the pandemic!! consistent detection of 2019 novel coronavirus in saliva saliva is more sensitive for sars-cov-2 detection in covid-19 patients than nasopharyngeal swabs. medrxiv 2020.04.16 covid-19 patients with respiratory failure: what can we learn from aviation medicine? hydroxychloroquine prophylaxis for covid-19 contacts in india chronic hydroxychloroquine use associated with qt prolongation and refractory ventricular arrhythmia caution needed on the use of chloroquine and hydroxychloroquine for coronavirus disease 2019 chloroquine or hydroxychloroquine for prophylaxis of covid-19 transmission routes of 2019-ncov and controls in dental practice the impact of the covid-19 epidemic on the utilization of emergency dental services coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine covid-19 transmission in dental practice: brief review of preventive measures in italy centers for disease control and prevention cochrane effective practice and organisation of care. effective practice and organisation of care (epoc) resources for review authors the quality, safety and governance of telephone triage and advice services -an overview of evidence from systematic reviews a systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and gp satisfaction guidelines for dental care provision during the covid-19 pandemic characteristics of endodontic emergencies during covid-19 outbreak in wuhan could air filtration reduce covid-19 severity and spread? implementing a negativepressure isolation ward for a surge in airborne infectious patients aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 hand hygiene: from research to action cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in king abdulaziz university hospital practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients personal protective equipment (ppe) for both anesthesiologists and other airway managers: principles and practice during the covid-19 pandemic what we do when a covid-19 patient needs an operation: operating room preparation and guidance simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (covid-19) pandemic clothing for protection against infectious agents -test method for resistance to dry microbial penetration personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff testing for viral penetration of non-latex surgical and examination gloves: a comparison of three methods in-use barrier integrity of gloves: latex and nitrile superior to vinyl recommendations for anesthesia in patients suspected of coronavirus 2019-ncov infection high speed handpieces an evaluation of different caries removal techniques in primary teeth: a comparitive clinical study topical silver diamine fluoride for managing dental caries in children and adults oral health management of children during the epidemic period of coronavirus disease 2019 the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment assessing the effectiveness of direct digital radiography barrier sheaths and finger cots contaminated dental aerosols a pilot study of bioaerosol reduction using an air cleaning system during dental procedures persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents survival of influenza viruses on environmental surfaces key: cord-257680-ds1y3ks9 authors: schiller, marcus; pilette, marijatta; rahlf, björn; von see, constantin; gellrich, n.-c. title: management of pandemic or large-scale emergencies in germany with a focus on the current and potential role of university schools of dentistry: can it help in covid-19 time? date: 2020-10-02 journal: bull natl res cent doi: 10.1186/s42269-020-00427-4 sha: doc_id: 257680 cord_uid: ds1y3ks9 background: the study presented here systematically examines the potential involvement of dental, oral and maxillofacial centres (zmk) in the management of pandemia or in large-scale emergencies. it looks at available material and infrastructural resources and how they can be brought to bear in such incidents or situations. the aim was to gain an initial scientific overview of how zmk can potentially contribute to the handling of a pandemia or mass casualty (mascal) situation in terms of available resources as well as their location within the hospital as a whole and their integration into the existing infrastructure. the study was conducted on the basis of a questionnaire consisting of 70 individual questions, which was sent to all universities in germany that offer a course of study in dental medicine. the responses were then statistically evaluated. results: the study outlines the current status of zmk and discusses what could be an important component of emergency medical care in the overall hospital context. conclusion: the involvement of zmk—with their own resources and existing infrastructural links to the hospital as a whole—could lead to faster and more effective patient treatment in the event of a pandemic or mascal situation. the increasing threat of international terrorism has shifted public focus in germany onto the question of how large-scale emergencies can be managed. after the 9/11 terrorist attacks in new york, the standing conference of federal and state ministers and senators of the interior decided to critically review civil protection and disaster control policies (simon and tepermann 2001; cook 2001) . 1 as a result, hospitals were also forced to take a closer look at this issue and to reevaluate existing emergency response plans, especially after the recent terrorist attack on a christmas market in berlin. one question that needs to be answered is how to sensibly involve dental medical centres in existing emergency concepts. so far, there have been widely differing views on this subject at the various hospitals, although there already page 2 of 8 schiller et al. bull natl res cent (2020) 44:174 are several german and international studies available on the potential integration of such centres (pahor 1992; sakr 2000; mitchell 2008) . that is because in general, each dental treatment unit (i.e. dentist's chair) could be considered a small operating table in its own right. after all, it provides an opportunity for surgical hand disinfection, a small surgical light, a suction device, monopolar electrocoagulation and, above all, various ways to position the patient, including the shock position. examinations and surgical treatments such as wound care, splinting or other emergency treatments are possible. taking into account previous studies, the aim of this study was thus to systematically investigate the current rate and potential increase in integration of dental medical centres at university hospitals in the emergency response plan of the hospital as a whole. for this purpose, a specifically developed questionnaire was used to survey the structures and resources of the dental medical centres at german university hospitals. their potential involvement in providing emergency medical treatment in case of large-scale emergencies is illustrated using hannover medical school (mhh) as an example. previous contingency plans for a mass casualty scenario had foreseen the fire service, germany's federal disaster relief agency (thw) and the red cross setting up and operating treatment stations at the outpatient clinic of the mhh to support the hospital. the option of falling back on the dental treatment stations of the dental medical centre is currently not included. emergency medicine as we know it today is a relatively new medical discipline. its history can be traced back to lessons learned in military campaigns that were translated into principles for the rescue and evacuation of casualties. it was not until after world war ii that civilian emergency medicine became truly established (ambulances, triage, etc.). 2 härtel stated in 1920 that physicians who worked in other specialties during times of peace had to get used to thinking and acting as surgeons in times of war (robertis et al. (2017)). the way ambulance services in germany are organised today is a result of the adaptation of military principles, the further development of medical knowledge and increasing regulation (skandalakis et al. 2006) . during world war i, emergency rescue was the responsibility of the red cross and the fire services. after world war ii, the emergency rescue services were shaped by the occupying powers and the different occupation zones. rutherford suggested that the order of evacuation should depend on the pattern of injury in the different triage categories. 3 on the federal level, civil disaster control tasks fall into the remit of the federal ministry of the interior and are allocated to the federal office of civil protection and disaster assistance. this office is a higher federal authority and supports the supreme federal authorities in uniform civil defence planning. in case of a hazard or emergency situation, crisis staffs at the federal ministry of the interior assume coordination tasks (niska and shimizu 2011) . in germany, 95% of medical assistance delivered in an emergency situation is provided by nongovernmental organisations. 4,5 a system of fast response units has been established, which are mainly employed for preclinical tasks (sakr 2000) . 6, 7 the länder (german federal states) disaster control in germany reflects the german federal system as federal law assigns certain tasks to the länder [article 73 (1) of the basic law]. however, the federation also makes recommendations and cooperates with the länder [article18 (1) of the civil protection and disaster management law]. this is especially the case in largescale emergency situations or emergency situations of national significance (niska and shimizu 2011) . in order to improve joint coordination and practice, the federal minister of the interior and the ministers of the interior of the länder decided in 2002 to conduct a national crisis management exercise. over 180 hospitals in lower saxony provide medical care for the state's population. in the event of an emergency, the number of patients they will treat will exceed normal capacity. in this context, a contingency plan may be important to facilitate an appropriate response. according to sefrin et al., a working emergency response plan is a prerequisite for extending the treatment capacities of every hospital in an emergency (schenk 2008) . page 3 of 8 schiller et al. bull natl res cent (2020) 44:174 allocating patients in successive waves may counter clinical overload (adams and tecklenburg 2007) . this plan of admitting patients in "waves" makes it possible to maintain the hospitals' ability to act, even though requests for treatment capacity can no longer be accommodated. the tool used by the länder for adapting to actual needs is the so-called hospital plan. this plan provides the basis for ensuring requirement-oriented support of the population with respect to the hospitals needed according to their location, specialties, number of beds and functional units (niska and shimizu 2011; mistovich et al. 2013) . the state of lower saxony has such an emergency response plan in place. the hannover medical school (mhh) is a well-established university hospital and a supramaximal care hospital. with a capacity of about 1500 beds (as of 2013), the mhh is one of the largest hospitals in lower saxony. together with the university medical centre göttingen, the mhh is one of two hospitals in lower saxony to feature a university dental medical centre and offer a course of study in dental medicine. the 2015 hospital plan of lower saxony states that the number of beds assigned to oral and maxillofacial surgery is equivalent to 0.3 inpatient beds per 10,000 inhabitants (adams and tecklenburg 2007) . a credo of emergency medicine is that each patient should be provided with individual care as quickly as possible, but not past the point where, in the case of a large number of casualties, the treatment of that individual patient would have a disproportionate negative effect on the prognosis of others. forecasts about the type of patients admitted to hospital as well as their patterns of injury and time of arrival are mostly based on the nominal analysis of patient numbers. the population of the study consisted of 28 hospitals. questionnaires were sent out to the following university hospitals with dental medical centres and/or dental student training (fig. 1 in the run-up to the study, ethics commission at the hanover medical school was asked. this study does not require an ethics vote, as the study is purely anonymous. of the 28 university hospitals-based dental medical centres that were invited to participate in the study, 71.4% returned the questionnaire. most dental medical centres feature instruction rooms (88.0%). in 14 (60.9%) of these centres, such rooms have separate entrances with direct access to the outside. only 30.4% of them lack access to the outside area. sterile processing is carried out in three different places: at the central sterile processing department of the entire hospital, at the central sterile processing unit of the dental medical centre or locally, i.e. at the individual departments of the dental medical centre. if only the central sterile processing department (n = 4) or a combination of that department and the central sterile processing unit at the dental medical centre (n = 4) is used, transportation/supply of sterile items is possible 24 h a day. if the hospital provides transportation services for patients on a 24-h basis all year round, sterile material will also always be transported/supplied 24 h a day (n = 18). of the hospitals that do not provide 24-h transportation/supply of sterile items, 50% did not provide a patient transportation service either. on average, the dental medical centres feature a total of 82.5 dental treatment units and 4.9 surgical rooms, which fall into the categories of minor surgery rooms, emergency operating theatres and operating theatres. in dental treatment centres equipped with dental treatment units, the numbers are: (fig. 2) . the number of minor surgery rooms, operating theatres and emergency operating theatres was also determined. the graph illustrates the results (fig. 3) . four dental medical centres are equipped with intensive care capacities. a maximum of three intensive care beds are available in 4.5% of all dental medical centres. two such beds are available in 13.0% of the centres. this results in an average capacity of 0.4 intensive care beds at dental medical centres. the ratio of surgical room capacities to bed capacities is 1:7 (one operating theatre per seven ward beds). the ratio between operating theatre capacity (4.9) and recovery room places (2.35) is approximately 1:2. schiller et al. bull natl res cent (2020) 44:174 digital networking upon investigating the dependency on information technology (it), we found that a digital record exists in 36.0% of all hospitals, including dental medical centres. the number of patients to be treated in a mass casualty event is always difficult to estimate (mistovich et al. 2013; rutherford 1989) . it depends not only on the total number of people affected by the event but particularly on the number of people with injuries that see them classified as triage categories i-iii. a comparison of the german eschede train disaster with the terrorist attacks in madrid in terms of victims shows that the number of injured who reach a hospital does not have a linear correlation with the overall number of people affected. in eschede, only 50% of casualties were alive upon arriving at a hospital for treatment, compared with 90% of victims in madrid (turégano-fuentes et al. 2008) . insufflation anaesthesia is required for almost all patients of triage categories i and ii. of the total number of patients to be expected, 60% will fall into these two categories. at least 20% of trauma patients classified as "category red" are in need of life-saving emergency surgery. for critically injured patients, surgical capacity is one of the decisive bottlenecks. analyses of the surgeries performed after the madrid bombings have shown that out of the 124 operations carried out within the first 24 h, 17 were maxillofacial surgeries. about 10% of these injuries were pure fractures of the jaw and facial bones, while around 66% affected the face, head and neck area. of all seriously injured category i patients, approximately 26% require surgical interventions in the region of the head and neck. patients with minor injuries can be expected to make up a proportion of 40%. adams has in different publications already suggested having these patients treated at a dental, oral and maxillofacial clinic by staff of the dental medical centre. triage category iii patients can usually be treated under local anaesthetic. treatment under local anaesthetic is part of the standard treatments routinely performed by dentists (pahor 1992; daubländer 2012) . they have the required facilities and equipment at their disposal, and treating their patients in a dentist's chair is common practice for them. this resource, which is available in relatively large numbers, should thus be considered for use in major emergency situations. in that case, such facilities and the dental treatment units would mainly be used for the treatment of triage category iii patients. this would involve the organisational integration of the staff and in some cases the students at dental medical centres, who would cooperate with doctors and assistant personnel in a multidisciplinary approach. a dentist's chair can fig. 2 numbers of available minor surgery rooms, operating theatres, emergency operating theatres page 6 of 8 schiller et al. bull natl res cent (2020) 44:174 generally also be used for the treatment of regions other than the head and neck area. an average of 86 dental treatment units are available, which means that 86 treatment stations are available for triage category iii patients. these units are spread all over germany according to the distribution of universities for dental, oral and maxillofacial medicine. in addition, dental medical centres lend themselves to providing rooms for crisis staffs or families as well as for pastoral care, etc. this workload sharing within hospitals equipped with a dental medical centre would make it possible to more efficiently use the resources for triage categories i and ii at the main hospital. if the condition of a triage category iii patient deteriorates during treatment and a more severe triage category needs to be assigned, the traditional surgical and monitoring facilities within the dental medical centres can be incorporated across the specialties. the objective of this study was to investigate the existing and future potential integration of dental, oral and maxillofacial clinics into the emergency concepts of hospitals as a whole. the data obtained were statistically evaluated and analysed. the majority of dental medical centres in the area surveyed were found to not be included in the emergency concepts of university hospitals. of the 18 dental medical centres that are in fact included in emergency concepts, only two-thirds were able to provide details on the exact nature and extent of this involvement. we thus conclude that resources for patient examination, treatment and admission are generally available but not used to their full extent. in terms of these resources, we were able to establish the numbers of dental treatment units (average 82.5), minor surgery rooms (average 2.8), operating theatres (average 3.0) and ward beds (average 25.1). we further conclude that dental medical capabilities in germany are insufficiently used as a potential resource in case of an emergency. there are doubts about the integration of dental (assistant) personnel. however, the geographical distribution of existing dental medical centres is an additional positive aspect in terms of their potential involvement in case of large-scale emergencies. in the current situation, hospitals are flooded with a large number of patients. the focus of the hospitals is on the treatment of emergencies and especially on the treatment of covid-19 patients. additional places are being created for triage, either by setting up additional treatment places or by putting up tents. the use of the resources of dental medical centres to relieve the main clinics should be included in the considerations. dental medical centres offer a large number of possibilities for the initial treatment and/or treatment of patients with mild to severe diseases. the integration of dental medical centres, with their own resources and existing infrastructure connections to the hospital compound, could facilitate quicker and more efficient treatment in a mass casualty event. in such emergency situations, physicians and other non-dental medical personnel could take up work at the dental medical centres, and their dentist colleagues who work in hospitals and in outpatients setting could also be involved. the necessary statutory provisions would first have to be established, however. the usa sets a positive example in this regard. constant further development of the task spectrum of dentists as part of mass casualty planning and the creation of a clear statutory framework ensure that all capabilities are exploited to their full potential. through extended training in the field of emergency medicine as students, dentists are thoroughly prepared for their future tasks and thus able to provide a real contribution to casualty care in large-scale emergencies. der notfallplan des krankenhauses the world trade center attack. the paramedic response: an insider's view neue notfallfolge trainieren für den tag x. zahnärztl mitteil the monopolisation of emergency medicine in europe: the flipside of the medal prehospital emergency care a brief history of triage hospital preparedness for emergency response: united states historical article: ear, nose and throat in ancient egypt triage for simple compensated disasters casualty, accident and emergency, or emergency medicine, the evolution krankenhaus-alarm-und -einsatzplan (kaep) -niedersächsisches muster the world trade center attack. lessons for disaster management to afford the wounded speedy assistance": dominique jean larrey and napoleon injury patterns from major urban terrorist bombings in trains : the madrid experience publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. authors' contributions mp, ms, br, cs and ncg conceived the study and participated in its design and coordination. mp and ms made substantial contributions to data acquisition and conception of manuscript. ms, br and cs drafted and designed the manuscript and contributed equally to this work. ms and ncg were involved in revising the manuscript. all authors read and approved the final manuscript. not applicable. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. not applicable. yes. the authors declare that they have no competing interests. key: cord-281099-l2i7r1bp authors: izzetti, rossana; gennai, stefano; nisi, marco; barone, antonio; giuca, maria rita; gabriele, mario; graziani, filippo title: a perspective on dental activity during covid‐19: the italian survey. date: 2020-08-13 journal: oral dis doi: 10.1111/odi.13606 sha: doc_id: 281099 cord_uid: l2i7r1bp objectives: during the months of march and april 2020, italy saw an exponential outbreak of covid‐19 epidemic. dental practitioners were particularly limited in their routine activity, and the sole performance of urgent treatments was strongly encouraged during the peak of the epidemic. a survey among dental professionals was performed between 6(th)‐13(th) of april, in order to evaluate the status of dental practice during covid‐19 in italy. materials and methods: an online anonymous questionnaire was administered to retrieve data on the dental procedures performed, the preventive measures adopted, and the predictions on the future changes in dentistry following the pandemic. results: the survey was completed by 3,254 respondents and, according to the results obtained, dental activity was reduced by the 95% and limited to urgent treatments. the majority of the surveyed dentists employed additional personal protective equipment compared to normal routine, although in a non‐negligible number of cases difficulty in retrieving the necessary equipment was reported. conclusions: the survey provided a snapshot of dental activity during the sars‐cov‐2 outbreak. overall, following the peak of the epidemic, it is probable that dental activities will undergo some relevant changes prior to fully restart. covid-19 has seen in the last few months a worldwide diffusion, with more than 9 million cases confirmed (https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd 40299423467b48e9ecf6). italy was the country with the earliest diffusion in europe. lockdown was disposed at the end of february in some northern regions, lombardy and veneto, to limit the exponential increase in the number of infected subjects, and was followed on the 9 th of march by the rest of the country due to the rapid escalation in the numbers of contagion. the highest number of active cases (108, 237) was registered on the 20 th of april, and was followed by a slow, progressive decrease, which led to the complete end of the lockdown on the 3 rd june 2020. during the peak of the epidemic, dental care was considered an essential service. however, italian regulations imposed to limit as much as possible routine activity during the lockdown, as only urgent procedures which could not be postponed could be performed. as a matter of fact, the straightforward transmission route of sars-cov-2, the relatively close contact with the patient, and aerosol generation during the majority of dental procedures concur to exposing dental practitioners to a higher risk of contagion, (izzetti et al. 2020 , peng et al. 2020 . indeed, sars-cov-2 is transmitted through aerosol and droplets, and has a relatively long resistance in aerosol for up to 3 hours (van doremalen et al. 2020) . numerous guidelines and recommendations on resuming dental activities are released these days (cochrane oral health 2020) . standard procedures appear insufficient in protecting from sars-cov-2, and thus specific measures to prevent virus transmission should be adopted to safeguard the health of both patients and oral care providers (izzetti et al. 2020 , peng et al. 2020 . in particular, several steps have been added for the correct management of dental patients in order to identify subjects at higher risk of being infected. phone and in-office triage, along with temperature recording, have become routine procedures to investigate the presence of symptoms suggestive for covid-19 and behaviours which may have caused contagion (izzetti et al. 2020 . moreover, covid-19 has led to a re-design of the dental office, from the waiting room to the clinical setting, and has made necessary the adoption of personal protective equipment (ppe) also for non-clinical staff (izzetti et al. 2020 ). during the lockdown, a survey on the current status of dental profession was performed, with the aim to give insight into how dentistry was changing and what were the expectations for the future. in the accepted article present work, the acute impact of the covid-19 pandemic on the dental profession in italy and the predictions on the impact on dentistry are reported. this article is protected by copyright. all rights reserved after a protocol preparation and approval from the committee on bioethics of the university of pisa (review no. 11/2020), a questionnaire for dental practitioners, aimed at investigating various aspects of dental activity during the early stages of the covid-19 pandemic, was specifically developed for the study. initially, the preliminary questionnaire was pre-tested on 20 subjects prior to administration on a national scale. for all the items of the questionnaire, an intraclass correlation coefficient (icc) >0.80 was considered satisfactory. in cases of items with icc values <0.80, the questionnaire was edited in order to increase icc. an online platform was directly emailed by the national federation of medical doctors and dentists (federazione nazionale ordine dei medici chirurghi e odontoiatri, commissione albo odontoiatri -fnomceo) to all the provincial coordinators with the request for distribution among colleagues. an open invitation was posted on social media and promoted via professional networks. the survey was administered between the 6 th april and the 13 th april 2020. the questionnaire (appendix 1) addressed the following dimensions: -demographic and professional status -professional activity during the epidemic -adherence to preventive measures -questions on the future perspectives of dental practice the demographic and professional status section aimed at collecting data on age, gender, practice location, professional background, and practice organization (number of dental chairs, collaborators, dental assistants). the status of dental activity was investigated in terms of types of treatments performed and number of procedures per week. the adherence to the preventive measures suggested by the italian dental institutions and associations was investigated according to four domains previously identified (izzetti et al. 2020) . in particular, these domains were: in-office triage and dental office preparation (phase ii) -post-dental treatment management of the dental office (phase iv) a focus on highly epidemic areas, registering the higher number of cases, was also performed in order to evaluate the potential presence of differences between the regions in northern italy and the rest of the country. this article is protected by copyright. all rights reserved finally, the subjective predictions on the potential changes occurring in dental practice following the pandemic were investigated, in order to give an overview of the professionals' point of view. sample size estimation for representativeness was set at 1,491 responses, considering a ci of 95%, an error of 2% and maximum heterogeneity in a population of 50,000 subjects. overall, the total number of dental professionals in italy is reported to be around 62,000, although unofficially it would appear that the active dentists are approximately 45,000 (according to the national federation of medical doctors and dentists -fnomceo; https://portale.fnomceo.it/). data analysis was conducted using spss version 26 (ibm). descriptive and inferential statistics were provided. chi-square and fisher-yates tests were used to compare categorical parameters and frequencies. non-parametric correlation analyses were performed with spearman rank analyses. data were graphically tested for normality, and logarithmic or square root transformations were made as needed before applying the adequate non-parametric tests. statistical significance was set with a p-value of 0.05. a total of 3,254 respondents completed the survey, representing about the 5.25% of italian dental professionals. the study sample's geographic distribution reflected the distribution of general dental population. the sample was representative of the general dental population in italy per gender and age. the characteristics of the respondents are illustrated in table 1 . in the results, only significant data are presented. at the time of the survey (6 th -13 th april, 2020), 99.7% of participants reduced the activity to urgent treatments or totally stopped working. as per the procedures performed, the treatment of pulpitis, prosthesis de-cementation, and abscess were the most common urgent procedures provided (table 1) . the mean number of procedures performed per week was 5.27/dentist. overall, it is estimated that the surveyed professionals have guaranteed 11,778 urgent dental treatments from the start of the lockdown (9 th march 2020) to the date of the survey. phone triage this article is protected by copyright. all rights reserved phone triage was performed by the 95% of the sample, and 98.8% assessed the presence of symptoms suggestive for covid-19. moreover, the potential risk of contact with infected subjects was also investigated by the majority of surveyed dentists (table 2) . in-office triage and dental office preparation unlike phone triage, the in-office triage questionnaire was performed by 49.5% of dentists. only the 25.2% performed temperature recording, using in the majority of cases a contactless thermometer. the set-up of the waiting room (non-clinical area) was adapted to the new situation by almost the totality of the sample, by providing a hydro-alcoholic solution for hand disinfection, removing objects at risk of contamination, and reorganizing the schedule in order to guarantee social distancing. environment disinfection of the dental setting (clinical area) was mostly provided using isopropyl alcohol and sodium hypochlorite. in 99.1%, clinical staff performed hand washing for 20-40 seconds, while the 55.7% also performed hand disinfection with a hydro-alcoholic solution prior to wearing gloves. ppe involved the use of gown, cap, masks, and eye protections. in the 50.3% of cases, two pairs of gloves were used (table 2) . in almost 90% of cases, patients were asked to perform a mouth rinse prior to dental treatment, in the majority of cases using hydrogen peroxide. in 88.5% of cases, measures were adopted to limit aerosol production, while the four-hands technique was used only in 37.8% (table 2) . post-dental treatment management of the dental office room ventilation was provided after dental treatment in 98.1% of cases. almost the totality of the sample repeated hand washing and disinfection after removing the gloves at the end of the procedure (table 2) . in table 3 , a comparison between lombardy and veneto and the rest of the italian regions is provided. overall, in highly epidemic areas, compliance with preventive measures was higher. the 57.2% of dental professionals reported being able to retrieve ppe in northern italy, a slightly lower percentage compared to the 59.9% reported on average in other regions. in northern regions, more than 90% of dental professionals endorsed being informed on the preventive measures to be adopted during covid-19. moreover, in highly epidemic areas a slower re-start of routine activity was expected ( figure 1 ). this article is protected by copyright. all rights reserved questions on future perspectives of dental practice the majority of the sample expected some changes in the dental profession following the epidemic, in particular regarding ppe and dental office set-up in terms of schedule and preparation for treatment. while an increasing use of ppe was reported by the 60% of the surveyed professionals, 90.4% reported difficulty in accessing ppe supply and an increase in ppe costs. the 80.6% feared a reduction in dental activity after the pandemic. the mean expected time of return to routine dental activity was thought to be around 4.9 months whilst the majority of the surveyed dentists reported a maximum period of 3 months as the threshold of economical sustainability. a positive correlation (p<0.05) was found between the decrease in dental activity and the expected time of return to regular activity. in particular, the higher was the percentage decrease in dental activity, the longer was the time expected for the return to regular activity ( figure 2 ). the mean time estimated for managing treatment suspension without affecting patient's health was thought to be up to 2 months by the 78.3% of the surveyed dentists. in 82.7% of cases, it was believed that standard procedures could be adopted again but increasing protection against aerosol should be needed. after the beginning of the lockdown, dental activity was reduced by 95%. in particular, almost the totality of the surveyed sample (99.7%) performed only urgent treatments, consistently with the italian government recommendations (circolare del ministero della salute n. 7422 del 16 marzo 2020). all the dental professionals showed a high level of adherence to the preventive measures suggested (izzetti et al. 2020 ). phone triage was performed by 95% of the sample. triage, both at the telephone or in-hospital, has been widely employed in several medical fields, in particular emergency care, where it is adopted to assess the need for hospitalization (boggan et al. 2020 almost all the sample provided re-organization of the waiting room in order to limit the number of surfaces which could transmit infection (izzetti et al. 2020) . although thorough disinfection with alcoholbased solutions or chloro-derivatives may inactivate the virus on the surfaces, it is reported that sars-cov-2 can persist on surfaces up to 9 days (kampf et al. 2020) , and has an estimated median half-life of approximately 5.6 hours on stainless steel and 6.8 hours on plastic (van doremalen 2020). the presence of infectious sars-cov-2 was investigated also on surgical masks, where the virus was found to persist for up to 7 days, although being susceptible to standard disinfection methods . therefore, removing all the unnecessary objects from the waiting room is an effective measure to limit the risks of infection (ada 2020). correct hand washing is effective in controlling the diffusion of various diseases (goldberg 2017) . performing hand washing for at least 60 seconds is an effective measure in removing potential infectious microorganisms, especially if associated with the use of hydro-alcoholic solutions which contribute to the inactivation of enveloped viruses, including coronaviruses (lotfinejad et al. 2020). the combination of hand washing and disinfection is, therefore, the best practice in providing virus elimination. ppe use is crucial to protect health care workers from sars-cov-2 due to the relatively easy way of transmission. in particular, adequate provision of ppe is the first measure to ensure the safety of health care workers (lancet 2020). several protocols have been suggested to correctly protect from covid-19, providing the protection of eyes, nasal and oral mucosa. in our survey, we found that the majority of this article is protected by copyright. all rights reserved dental professionals employed the correct set of ppe, therefore suggesting a high sensitivity towards personal protection. however, it is essential to highlight the reported difficulty in obtaining ppe, which could have limited a wider use. considering dental treatment, almost all dentists prescribed a mouth rinse prior to the beginning of the procedure. while the majority employed hydrogen peroxide, a non-negligible number of professionals employed chlorhexidine. such a result is consistent with the findings of cagetti and co-workers (2020) in their survey on the dental professionals of northern italy, where in the 50% of cases the use of chlorhexidine-based mouth rinse was reported. in this sense, it would be advisable to evaluate the effects of chlorhexidine on sars-cov-2. however, it is not to be forgotten that saliva is a viral reservoir, thus posing the problem of the actual effectiveness of mouth rinsing prior to treatment. finally, as much as the oral cavity might be virus free, the mere breathing activity of the patient would contribute to the diffusion of the virus in the dental setting. the awareness of the risks related to aerosol generation was demonstrated by the large number of dentists that reported minimization of aerosol-generating procedures, and the adoption of dedicated strategies. the risks related to dental aerosols were previously highlighted during the spread of the severe acute respiratory syndrome (sars) between 2002 and 2004, when the control of aerosols was claimed as a necessary part of dental infection control procedures (harrel 2004 , harrel & molinari 2004 . moreover, the tropism of sars-cov-2 for ace2 cell receptors and the viral presence in saliva represent a non-negligible risk factor xu et al. 2020) . limiting aerosol by working manually is important. however, this is not always possible, thus several measures may be useful to limit aerosol production (izzetti et al. 2020; meng et al. 2020; peng et al. 2020) , with the use of surgical aspiration, the limitation in the use of handpieces, and four-hands technique appearing the most effective. however, in our survey, the four-hands technique was not widely employed. finally, post-treatment management was correctly carried out in most cases, providing room ventilation and surface disinfection, due to the reported viral persistence both in aerosol and on surfaces (van doremalen et al. 2020). the most critical aspect of this survey is the fact that data are self-reported, particularly for items such as those asking respondents to recall granular behaviours carried out by themselves and their staff. this article is protected by copyright. all rights reserved moreover, given their profession, respondents may have been likely to be uniquely focused on their patients' oral health (and possibly focused on maintaining their practice from a financial standpoint), which may have influenced their opinions about the speed at which regular dental practice should be allowed to resume. finally, respondents were not explicitly asked to weigh all the aspects against noteworthy risks that characterize this unprecedented situation. following the peak of the epidemic, numerous doubts arose as per the dental activities to be fully restarted, mostly regarding the use of adequate ppe and the management of aerosols produced by the use of handpieces. moreover, it was overall observed an attitude towards a modification of dental practice, a relatively slow return to regular activity, and a concern towards treatment management after suspension. italian dental professionals massively embraced novel and numerous precautions to minimize the professional contagion risk as indicated by the adoption in more than 90% of cases of the majority of the key suggestions provided. it is also likely that these changes might be perpetual as the 70.9% of the sample reports uncertainty on the virus eradication in influencing medium-long term disinfection and clinical protocols. however, the adoption of ppe was strongly influenced by its accessibility (40.3% reported complicated retrieval). thus, the availability of ppe impacts the overall scenario. accordingly, the vast majority (97.3%) showed uncertainties in the professional sentiment about the future. lastly, it is important to highlight that the abrupt stop of dental activity during the epidemic has left uncompleted an extremely high number of treatments. this is worrying and of concern, as it is believed by the 78.3% that even 2 months more without completing actual treatments would be prejudicial to the oral health of patients. in conclusion, with the present survey, we aimed to take a photograph of the situation of italian dentistry during the pandemic. it is remarkable that, despite numerous uncertainties and difficulties, dental health care professionals kept ensuring urgent treatments to the population in these dire times, providing the best standard of care possible while adhering to the preventive measures suggested by national institutions and associations. this article is protected by copyright. all rights reserved tables table 1. summary of sample characteristics. global this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved figure 2. scattered plot of the correlation between the dental activity decrease during the epidemic and the expected time of return to regular activity. the dental professionals who experienced higher decrease ada interim guidance for minimizing risk of covid-19 transmission incubation period of 2019 novel coronavirus (2019-ncov) infections among travellers from wuhan, china effectiveness of acute care remote triage systems: a systematic review covid-19 outbreak in north italy: an overview on dentistry. a questionnaire survey a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study recommendations for the re-opening of dental services: a rapid review of international sources 2019 novel coronavirus-important information for clinicians guideline implementation: hand hygiene clinical characteristics of coronavirus disease 2019 in china airborne spread of disease--the implications for dentistry aerosols and splatter in dentistry: a brief review of the literature and infection control implications state 2019-ncov case investigation team (2020). first case of 2019 novel coronavirus in the united states clinical features of patients infected with 2019 novel coronavirus in wuhan covid-19 transmission in dental practice: brief review of preventive measures in italy rapid design and implementation of an integrated patient self-triage and self-scheduling tool for covid-19 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents covid-19: protecting health-care workers prevention and control of new coronavirus infection in department of stomatology accepted article this article is protected by copyright. all rights reserved coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine transmission routes of 2019-ncov and controls in dental practice stability and infectivity of coronaviruses in inanimate environments transmission of 2019-ncov infection from an asymptomatic contact in germany effectiveness of remote triage: a systematic review consistent detection of 2019 novel coronavirus in saliva accepted article key: cord-257940-12nf27j4 authors: schwendicke, falk; krasowski, aleksander; gomez rossi, jesus; paris, sebastian; kuhlmey, adelheid; meyer-lückel, hendrik; krois, joachim title: dental service utilization in the very old: an insurance database analysis from northeast germany date: 2020-09-30 journal: clin oral investig doi: 10.1007/s00784-020-03591-z sha: doc_id: 257940 cord_uid: 12nf27j4 objectives: we assessed dental service utilization in very old germans. methods: a comprehensive sample of 404,610 very old (≥ 75 years), insured at a large statutory insurer (allgemeine ortskrankenkasse nordost, active in the federal states berlin, brandenburg, mecklenburg-western pomerania), was followed over 6 years (2012–2017). our outcome was the utilization of dental services, in total (any utilization) and in five subgroups: (1) examinations and associated assessment or advice, (2) restorations, (3) surgery, (4) prevention, (5) outreach care. association of utilization with (1) sex, (2) age, (3) region, (4) social hardship status, (5) icd-10 diagnoses, and (6) german modified diagnosis-related groups (gm-drgs) was explored. results: the mean (sd) age of the sample was 81.9 (5.4) years. the utilization of any dental service was 73%; utilization was highest for examinations (68%), followed by prevention (44%), surgery (33%), restorations (32%), and outreach care (13%). utilization decreased with age for nearly all services except outreach care. service utilization was significantly higher in berlin and most cities compared with rural municipalities, and in individuals with common, less severe, and short-term conditions compared with life-threatening and long-term conditions. in multi-variable analysis, social hardship status (or: 1.14; 95% ci: 1.12-1.16), federal state (brandenburg 0.85; 0.84–0.87; mecklenburg-western pomerania: 0.80; 0.78–0.82), and age significantly affected utilization (0.95; 0.95–0.95/year), together with a range of co-morbidities according to icd-10 and drg. conclusions: social, demographic, regional, and general health aspects were associated with the utilization of dental services in very old germans. policies to maintain access to services up to high age are needed. clinical significance: the utilization of dental services in the very old in northeast germany showed significant disparities within populations. policies to allow service utilization for sick, economically disadvantaged, rural and very old populations are required. these may include incentives for outreach servicing, treatment-fee increases for specific populations, or referral schemes between general medical practitioners and dentists. electronic supplementary material: the online version of this article (10.1007/s00784-020-03591-z) contains supplementary material, which is available to authorized users. for decades, interventions to improve dental health have been focused on children and adolescents, with widely acknowledged success in many high-income countries. while adults and older individuals also benefitted from a general improvement in oral health, showing a reduced number of restored or missing teeth [1, 2] , data on the resulting treatment needs in these populations are scarce. especially for the very old, defined as those aged 75 years or older, there is very limited knowledge on their needs for and utilization of dental service. this group of very old, notably, is the only growing one in many high-income countries, with remarkably complex oral health dynamics: retaining an increasing number of teeth up to such high age, this group is, oftentimes suddenly, affected by general health deterioration, impacting on the capability for oral self-care as well as the physical abilities to utilize in-office dental care [3] [4] [5] [6] . in a previous study and building on claims data, we found a disparate utilization of prosthetic services in the very old, with those aged 85 years or older, those living rural, and those with severe general health conditions utilizing prosthetic services, by large, to a lower degree than younger, urban living and only limitedly sick seniors [7] . the only service the former group used more often was maintenance of existing prosthetics. notably, claims data come with a range of possible limitations, e.g., selection bias, confounding bias, or misclassification bias. however, employing claims data allows to investigate groups which are otherwise hard to represent, e.g., the very old, the sick, and the rural living ones. claims data also come with robust sample sizes and represent everyday care. they also suffer from limited risks of recollection or reporting bias and have a high generalizability for their respective healthcare setting [8, 9] . in the present study, we used claims data from a large health insurance in northeast germany to assess dental service utilization in the very old. we hypothesized that utilization differed according to age, general health, socioeconomic status, and place of living. for reasons of comparability, the design and conduct of this study largely aligns with that of a previous publication on prosthetic treatment patterns in the same population [7] . the investigated cohort was evaluated based on routinely collected claims data from a statutory (public) health insurance in germany. individuals aged 75 years or older from one large insurer, the aok nordost, were followed over 6 years (2012 to 2017). the aok nordost is a regional branch of the allgemeine ortskrankenkasse (aok), acting mainly in the northeast of germany in the federal states of berlin, brandenburg, and mecklenburg-western pomerania. our reporting follows the record statement [10] . the aok nordost insures around 1.8 million individuals from the described three federal states. insured individuals may, however, also move into other areas of germany, which is why for our geographic analyses only individuals living in these federal states between 2012 and 2017 were included. the area of interest encompasses the german capital, berlin, and two rural states, brandenburg and mecklenburg-western pomerania, with only few larger cities (> 70,000 inhabitants). all three states are considered economically weak in comparison with other parts of germany. data for this study were claims data, including claims from 1 january 2012 to 31 december 2017. data were routinely collected and provided under ethical approval in a pseudonymized form using a data protection cleared platform via the scientific institute of the aok nordost, the gewino. a comprehensive sample of very old, aged 75 years or above, insured with the aok nordost in 2012, was drawn and followed over 6 years. no further eligibility criteria were defined. variable ascertainment was only possible via insurance base data and claims data. the database had been curated for plausibility at gewino and once more by the study team. no formal sample size estimation was performed given this being a comprehensive sample. our outcome was the relative utilization (in % of the population) of dental services. within the statutory german insurance, dental services are provided on a fee-per-item basis using fee items catalogs of the statutory or private german insurance [11, 12] . the vast majority (88%) of patients are statutorily insured. for the statutory insurance, all items are drawn from the fee item catalog bewertungsmaßstab (bema), which contains a large range of granular items comprising (1) examinations, assessment and advice, radiographic evaluations etc. (examinations); (2) restorative dentistry (restorations), note that within german insurance coding, crowns are not subsumed under "restorations" and hence there is no overlap between this service group and our previous analysis on prosthetic dentistry; (3) oral surgery and medicine (surgery); (4) prevention (for adults, the only preventive measure available until 2015 was removal of calculus; in 2015, further fee items (focusing on oral hygiene measurement, and oral hygiene plan, denture cleaning, and fluoride application) were introduced but these were not available for the present analysis); and (5) outreach care. further items include, for example, periodontal treatment, prosthetic therapies, and adjunct measures. we here report on any utilization in bema (min 1 item claimed/year) as well as stratified along the item blocks 1-5. as this is the first detailed analysis on dental service utilization in the very old in northeast germany, we provide largely descriptive analyses. the utilization of dental services was assessed according to following independent variables: (1) sex (male/female); (2) age (in years) in each year of follow-up; (3) region, we used municipalities as regional units, mainly as on a lower (more granular) spatial level only few individuals were retained in some areas. municipalities included the capital berlin (with over 3.5 million inhabitants), medium-sized cities (70,000-200,000 inhabitants), and rural areas. further analyses were performed on federal state level; (4) social hardship status (income < 1246 euro/month per capita in 2019); (5) icd-10 diagnoses, derived from outpatient diagnostic data; (6) inpatient hospital diagnoses and treatments, derived from german modified diagnosis-related groups (gm-drgs). the gm-drgs classify diseases in groups of similar pathogenesis, characteristics, and treatment complexity, and are mainly used for reimbursement reasons. only the 25 most frequently recorded icd-10 and gm-drg codes were used. the data used for this study were provided by the gewino using a data protection approved storage and analysis platform after cleaning and consistency controls. data were pseudonymized and included individuals' age, sex, social hardship status, spatial code of their place of living (allowing classification into municipalities), all bema items claimed per year as well as icd-10 codes and gm-drgs for each year, among further variables. comparability of data between different years and data consistency was given. a comprehensive sample had been used, and neither participants nor providers were aware that the collected claims data will be used for routine data analyses later on. the data collection is not prone to selection and detection bias. however, given this being claims data from only one insurance, the overall population of very old germans differs and data may be affected by biases associated with claims data, as laid out above and in the discussion. no further measures against these biases could be taken. the statistical analysis was performed on a sample (n = 404,610) of the database provided by aok nordost. the only inclusion criterion was that an individual had to be insured in the year 2012 and had to be aged 75 years or above at this point. for the descriptive analysis of utilization of dental services, we considered an individual to have consumed a particular service if at least once during the period 2012 to 2017 the provision of such a service was claimed. descriptive statistics of age groups were computed based on the age distribution in 2012. an individual was assigned to having a social hardship if the individual was assigned to this status at least once during the period 2012 to 2017. for geographical analysis, we excluded all individuals that relocated from one of the federal states (berlin, brandenburg, and mecklenburg-western pomerania) to another federal state, thereby decreasing the sample size to 390,044. however, we did not correct for relocations within the three federal states during the observational period. for each particular outpatient diagnosis (icd-10 codes) and inpatient hospital diagnosis and treatment (gm-drgs), we summed up all claims and ranked them from most to least frequent. we then selected the 25 most frequent diagnoses each (in total 50) and computed for each of them the number of individuals that were assigned to having a diagnosis, respectively, treatment, during 2012 to 2017. we applied logistic regression, a method to model a binary outcome variable as a linear combination of predictor variables. the response variable was the utilization of any type of dental services claimed by an individual at least once in the year 2012. as predictor variables we included age, sex, being deceased, social hardship status, federal state (note that we allowed the category "other" for relocated individuals), and the described outpatient and inpatient hospital diagnosis variables, all of them referring to the year 2012. all analyses, modeling, and visualization were performed using python (version 3.7, available at http://www.python.org) and auxiliary modules from its scientific computing ecosystem. overall, 404,610 very old (75 years or older) individuals were followed over a period of up to 6 years (173,733 of these did not survive follow-up). the mean (sd, median, min, max) age of the sample was 81.9 (5.4, 81, 75, 109) years. the population comprised significantly more females than males and those aged 75-84 years old than those aged 85 years or older. about one-third lived in berlin, and the other two-thirds in the more rural brandenburg and mecklenburg-western pomerania. social hardship status was claimed by nearly half of the population at least once during the follow-up period (table 1 ). our sample was overall more female and much older and claimed far more hardship status than the national average. the utilization of any dental service was 73%; utilization was highest for examinations (68%), followed by prevention (44%), surgery (33%), and restorative (32%) and outreach care (13%). utilization decreased with age for nearly all services except outreach care (fig. 1) . utilization of restorations, surgery, and prevention decreased by 75-80% (in relative terms, e.g., from 36% to 6% for restorations) between age 75 and 95 years; the decrease after age 95 years was limited. a slightly less pronounced, but nevertheless consistent, decrease was found for examinations. in contrast, outreach care increased and was, at age 95 years or above, the main service (together with examinations, which one would assume is the minimum consequence of outreach care). utilization was further different between regions ( table 1 , fig. 2 ). utilization of any dental service was generally higher in cities than rural areas, and highest in berlin and three other urban municipalities (rostock, potsdam, schwerin). utilization further differed geographically according to specific services. utilization of restorations was nearly 50% increased in certain cities and one rural southwestern municipality compared with most other rural areas. surgical services were provided more often in berlin and the south as well as cities in general; a similar pattern was observed for preventive services. for outreach care, no such strict pattern was observed; certain cities as well as a stretch of municipalities along the coastline showed higher utilization. utilization of any dental service was assessed according to icd-10 codes (table 2) . utilization was higher for the majority of codes, e.g., for eye conditions (e.g., presbyopia, cataract, astigmatism), gonarthrosis, cox-arthrosis, benign hypertension, anti-coagulants therapy, varicose, prostate hyperplasia, osteoporosis, hyperlipidemia and hypercholesterinemia and unspecified chronic pain. a similar pattern was found for most specific services. notably, individuals with dementia showed a similar utilization with regard to any services, but mainly received examinations, not restorative or surgical care. the same was found for patients with urinary incontinence. for outreach care, an opposite pattern was observed, with higher utilization by those with dementia and incontinence, and lower utilization by those with eye conditions, for example ( table 2) . we further assessed the utilization of any dental service stratified according to different gm-drgs (table 3) . utilization of any service was higher in participants hospitalized for non-severe gastrointestinal ulcerations, non-severe arrhythmia, bronchitis, non-severe hypertension, syncope, non-severe renal insufficiency, and non-complicated cardial diagnostics or eye operations. utilization was lower in patients with severe gastrointestinal ulcerations as well as severe heart insufficiency. these trends of higher or lower utilization were similar for other services, except outreach care, where a different pattern emerged: utilization was higher in patients with non-severe but also severe ulcerations, paraplegia/tetraplegia, non-severe hypertension, infections, head or skin injuries, joint operations, apoplexy, and geriatric rehabilitation. it was lower in patients with bronchitis (table 3) . in multi-variable analysis, social hardship status (or: 1.14; 95% ci: 1.12-1.16), federal state (brandenburg 0.85; 0.84-0.87; mecklenburg-western pomerania: 0.80; 0.78-0.82) and age significantly affected utilization (0.95; 0.95-0.95/year), together with a range of co-morbidities according to icd-10 and gm-dgrs (table 4, table s1 ). pseudo-r 2 indicated that the model generally had limited explanatory power (r 2 = 0.15). understanding dental service utilization in specific populations and groups may allow to increase access to the right services for every individual, thereby improving health and services' efficiency and equitability [13] . the present study tried to evaluate how factors driving services' needs (age, sex, general health) and access on patient level (income and financial means, place of living) and system level (physical and organizational) impact on utilization [14, 15] . we hypothesized that the utilization of dental services in the very old was associated with an individual's age, general health status, place of living, and social status. moreover, we assumed to find service-specific disparities. we confirm these hypotheses; social, demographic, regional, and general health aspects were associated with the utilization of dental services in very old germans. a number of aspects should be discussed. first, utilization in this specific group was comparably high; in general, dental service utilization in germany is higher than that in most other countries, likely due to the setup of the service provision, with most services being available at no costs at all to the patient [16]. moreover, regular consumption of dental services is incentivized using a bonus scheme, with patients getting a discount on their out-of-pocket expenses for prosthetic services in case they can demonstrate a history of regular yearly checkups. such incentive will be especially efficacious in old individuals, who either have or expect to have prosthetic services with higher likelihood than younger ones. we also found only minimal changes in the age-specific utilization over the 6-year period; that is, seniors of similar age did not show considerably increased utilizations in 2012 compared with 2017, for example. the only detectable increase occurred between 2012 and 2013, most likely associated with a general policy shift in dental healthcare in germany (an entry fee existing until 2012, with patients paying 10 euro to the practice-which passed it on to the insurer-whenever entering the practice for the first time in a quarter of a year had been abolished in 2013). these findings of rather constant utilization over the first half of the last decade as well as the increase in utilization of dental services from 2012 and 2013 are in line with previous research [17, 18] . our findings are in so far relevant, as a number of major policy shifts targeting the very old requiring care assistance have been introduced between 2013 and 2015, the effects of which our analysis did not capture (so far). this might be as we only included individuals aged 75 years or older in 2012 and followed them for 6 years (i.e., those entering this group later on were not included), but also as we did not focus on those requiring care assistance, i.e., probably "diluted" their relevance in our analysis. it would be relevant to re-assess this cohort, expanding it to individuals aged 75 years or older in 2018 and focusing on only those receiving care assistance. we find a drastic and only limitedly service-specific decrease in utilization with age; individuals aged 85 years, for example, consumed only a fraction of services compared with those age 75 years. notably, from age 95 years onwards utilization was fairly stable, indicating a possible "survivor" effect. the only exception from these observations was outreach care, as discussed below. age is associated with an increasing prevalence of chronic and severe diseases or hospitalization [19] . in line with our previous analysis on prosthetic services, such severe general health conditions (e.g., severe gastrointestinal ulcerations as well as severe heart insufficiency) were found to significantly decrease utilization. notably, for most other (especially icd-10 coded) conditions, the overall utilization was unaffected. this might be as icd-10 codes were derived from ambulatory assessments, where individuals need to attend their general practitioners and hence show some kind of mobility and self-capability. moreover, individuals with dementia (and incontinency) showed reduced utilization of therapeutic services (but not examinations). this might be as these individuals do not accept more intense (and time consuming) care for treatment. we further assessed the impact of social hardship status on utilization. such status is a proxy for low income. it has been found associated with increased utilization of prosthetic services, as individuals with this status usually pay very low or no additional fee at all for any prosthetic service; that is, financial utilization barriers for this type of dental treatment are very low or absent [7] . for the present analysis, hardship status was used only as a social marker, as the analyzed dental services (examination, restorations, surgery, prevention, outreach care) are coming at no costs for all statutorily insured individuals, regardless of their age. [29] this is a remarkable difference of the german compared with many other healthcare systems, where retirement oftentimes means loss of professionally supported health insurance [20] [21] [22] and a subsequent collapse of service utilization [23] . it is noteworthy that utilization for those with hardship status was found significantly increased in multivariable analysis (in bivariate analyses this was less clear, indicating possible confounding by age, place of living, or health status, for example). as those with low social status are also likely to show the poorest oral and general health [24], it is highly relevant to find them to consume services more often, too. it is beyond this study to elucidate the reasons underlying this utilization. notably, though, existing public policies to support healthcare utilization in vulnerable groups in germany, e.g., those with chronic diseases [25] , do not capture those with economic constraints and poor oral health, i.e. cannot be at the heart of this association. independently of the found increased utilization, policy makers may want to revisit such policies and to strengthen dental service utilization for the very old, the very sick, and the very poor. we also found an association between utilization and place of living [13] . such association has been assumed to be grounded in rural areas being underserviced due to workforce shortages while urban areas suffer from provider clustering and associated supply-side-induced demand [26, 27] . we confirm such ruralurban disparities for any service utilization in the very old. the two rural federal states in our study, brandenburg and mecklenburg-western pomerania, show much lower dentist densities than berlin [28] , possibly explaining our findings. notably, utilization in the whole population (not only the very old) has been found to follow the opposite pattern, with higher utilization in the two rural states than in berlin [17] . hence, the observed inequalities seem to be moderated by age: older individuals seem to seek care more often, but are not able to physically access it in rural areas, while younger individuals could access it more easily in urban areas, but are not seeking care. we want to highlight that our analyses on smaller spatial level (municipalities) showed a more nuanced picture, with some rural areas showing high utilization of specific (but not all) services. we are so far unable to entangle possible reasons underlying this observation, which may be grounded in local dentist densities (some municipalities show surprisingly high densities) or a locally increased proportion of dentists with specific contractual agreements with care homes (thereby increasing access to care for the very old). more in-depth analyses seem warranted to first confirm and then explain such peculiar patterns, as they may allow to identify local best practices which could be translated to regional or national level. we identified service-specific utilization patterns not only across regions, as described, but also age. our findings of a generally decreasing utilization between age 75 years and 95 years have been identified before, with utilization of dental therapeutic services decreasing by around 50% along this age span in a national sample [17] . in the national sample, restorative care was provided far more often than surgical care, while we found restorative care being consumed to a similar degree like surgical care. this might be as our sample was generally older and also represented a different target population (see below). we assume that these two factors drive a treatment concept where maintaining teeth (using restorative care) is deprioritized while achieving an overall pain free status (by removing teeth, for example) is getting more important (and usually also being the only available option). notably, prevention (which was only calculus removal in the present study) continued to be provided up to high age (albeit to a lower intensity). the only service where utilization was increasing with age was outreach care, while this seemed to allow for only very limited provision of therapies. it is relevant to understand the drivers behind treatment patterns in outreach care, and it may not be sufficient to only incentivize outreach visits, but also support outreach management or referral concepts for those requiring more complex care. in light of the covid-19 pandemic and the near-global shutdown of any dental visits (except for emergencies) to care homes (also in germany), outreach care is likely to be re-evaluated with regard to its benefits and risks. overall, our study calls for a range of possible policy and research initiatives: first, healthcare policy and decision makers should install incentives to provide services to the high needs elderly population. this may come by increasing single treatment fees for this group, or more generally by making outreach services more attractive. the latter may be realized by increasing fees once more or trialing and allowing different kinds of servicing, e.g., involving task delegation to assistance personnel. outreach care should further be provided not only to individuals in long-term care centers (nursing homes) but also to those residing at home (which is the vast majority of elderly). similarly, referral schemes between general medical practitioners and dentists may be helpful to identify high-risk individuals; mandatory follow-ups after such referrals may make sure that sick and remote older individuals (who seldom proactively seek care) are not plainly overlooked by standard dental healthcare. integrated service models (for example oral and dental hygiene enforcement for patients at risk for pneumonia) should further be strengthened. dental research, on the other hand, is called to action to develop applicable concepts fig. 2 regionally specific utilization of dental services, stratified in services blocks, in northeast germany. relative (in %) any utilization and specific service utilization is shown. larger cities with an increased or decreased utilization compared with the surrounding municipalities are further highlighted by arrows table 2 utilization of dental services according to international disease classification (icd-10, german modification) codes by the very old in northeast germany. any and specific service utilization (in %) is shown icd-10-gm *categories z00-z99 are intended for cases in which facts are indicated as "diagnoses" or "problems" which cannot be classified as disease, injury or external cause under categories a00-y89 **this chapter includes (subjective and objective) symptoms, abnormal results of clinical or other investigations, and inaccurately identified conditions for which there is no classifiable diagnosis elsewhere table 3 utilization of dental services according to german modified diagnosis-related groups (gm-drgs encompassing effective management of dental diseases at optimal infection and transmission control measures. right now, servicing is at a minimal level due to fears of infection and it can be expected that infection control will remain a highly relevant topic in this vulnerable population even when covid-19 is finally brought behind us. moreover, dental research should develop and evaluate the described complex care models involving delegation or cooperation. a number of initiatives are currently underway in germany in this direction (e.g., https://innovationsfonds.g-ba.de). further, primary and secondary prevention models in this group should be enhanced; currently prevention concepts in the elderly are by large identical with those in younger individuals. policy makers may want to revisit such age-group-specific prevention concepts when they are available. generally, we see a great need to emphasize prevention in this group (based on our findings, prevention was near-absent for the very old in the northeast). dentists and dental bodies may want to actively participate in such research and also the implementation of possible policies, especially considering that with the very old, there is a growing group with high needs who can truly benefit from dental care. this study has a number of strengths and limitations. first, this is one of few longitudinal studies evaluating dental service utilization in very old individuals. our cohort involved over 400,000 individuals from three federal states spanning an area of similar size as austria or the netherlands and belgium combined. second, we evaluated a range of demographic, social, general health, and regional factors, some of which (drgs, icd-10) have not routinely been employed when evaluating dental healthcare. third, and as a limitation discussed above, claims data suffer from a range of biases. provided and claimed treatment cannot be equated with needs or morbidity. exploring causality is only limitedly possible, and within the present (largely descriptive) analyses, this was also not within our scope (the available longitudinal data may permit some more in-depth analyses in the future). any identified bivariate association may suffer from confounding bias, and even the performed multivariable analysis showed only limited explanatory value, likely as further relevant factors (e.g., medication, care status) were not available and accounted for, or as available factors (e.g., social hardship status, place of living) came with very limited granularity. fourth, individuals insured by aok nordost are not fully representative for other individuals from the same target area or even the whole of germany: more affluent people are often not statutorily insured (there is a minimum income level defined as entry barrier into private insurances in germany). this may affect the individual's health status and his or her utilization behavior (reflecting health literacy, but also specific incentives set by insurers towards seeking or avoiding care) as well as the number and type of services provided by the dentists (as services are remunerated differently). the northeast of germany is overproportionally old and, as mentioned, economically comparably weak (notably, there is a significant economic disparity within the northeast, too, which our data reflect on). the rural parts of the northeast suffered from emigration to other areas of germany especially after the reunification, while berlin experienced an over-proportional immigration in the 1960s from aboard as well as the last 20 years from within germany. these specifics will impact service utilization but may not be found to this degree in other areas of germany. future studies on the present dataset may explore them in detail, if possible, to better understand what impact on utilization they have. in conclusion, and within the limitations of this study, social, demographic, regional, and general health aspects were associated with the utilization of dental services in very old germans. we identified consistent and considerable disparities in utilization between populations. policies to allow service utilization also for the sick, economically disadvantaged, rural, and very old should be developed, tested, and employed. competing interests the authors declare that they have no competing interests. ethical approval and informed consent all experiments were carried out in accordance with relevant guidelines and regulations. data collection was ethically approved by the ethics committee of the aok nordost. no informed consent was required for this study given that data were pseudonymized. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. global burden of severe tooth loss: a systematic review and meta-analysis trends in caries experience in the permanent dentition in germany 1997-2014, and projection to 2030: morbidity shifts in an aging society our current geriatric population: demographic and oral health care utilization ageing, dental caries and periodontal diseases elder's oral health crisis. the journal of evidence-based dental practice zahnverlust und prothetische versorgung prosthetic treatment patterns in the very old: an insurance database analysis from germany the limitations of using insurance data for research misclassification in administrative claims data: quantifying the impact on treatment effect estimates the reporting of studies conducted using observational routinely-collected health data (record) statement befundbezogene festzuschüsse als innovatives steuerungsinstrument in der zahnmedizin defining and targeting health care access barriers societal and individual determinants of medical care utilization in the united states barriers to and enablers of older adults' use of dental services can we predict usage of dental services? an analysis from germany dental visits among older u.s. adults, 1999: the roles of dentition status and cost disparity in dental coverage among older adult populations: a comparative analysis across selected european countries and the usa dental care utilization and retirement oral health conditions of community-dwelling cognitively intact elderly persons with disabilities versorgungsprävalenzen bei älteren senioren mit pflegebedarf bekanntmachung eines beschlusses des gemeinsamen bundesausschusses über eine änderung der chroniker-richtlinie accessibility of general practitioners and selected specialist physicians by car and by public transport in a rural region of germany vertragszahnärztlichen versorgung von pflegebedürftigen und menschen mit behinderungen, kzbv/bzäk zahnarztdichte in deutschland nach bundesländern im jahr der wirtschaft: trend zu festsitzenden versorgungen hält an acknowledgments we thank the gewino for providing access to the data within.author contributions the study was conceived by fs. fs, akr, and jk planned the analyses. fs, akr, and jk performed the analyses. all authors interpreted the data. fs wrote the manuscript. all authors read and approved the manuscript.funding open access funding enabled and organized by projekt deal. this study was funded by the bundesministerium für bildung und forschung (bmbf tailohr, az 01gy1802).data availability data used in this study cannot be made available by the authors given data protection rules, but may be requested at the gewino. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-318944-13zk6cco authors: bizzoca, maria eleonora; campisi, giuseppina; lo muzio, lorenzo title: covid-19 pandemic: what changes for dentists and oral medicine experts? a narrative review and novel approaches to infection containment date: 2020-05-27 journal: int j environ res public health doi: 10.3390/ijerph17113793 sha: doc_id: 318944 cord_uid: 13zk6cco the authors performed a narrative review on severe acute respiratory syndromecoronavirus-2 ( sars-cov-2) and all infectious agents with the primary endpoints to illustrate the most accepted models of safety protocols in dentistry and oral medicine, and to propose an easy view of the problem and a comparison (prevs post-covid19) for the most common dental procedures. the outcome is forecast to help dentists to individuate for a given procedure the differences in terms of safety protocols to avoid infectious contagion (by sars-cov-2 and others dangerous agents). an investigation was performed on the online databases pubmed and scopus using a combination of free words and medical subject headings (mesh) terms: “dentist” or “oral health” and “covid-19” or “sars-cov-2” or “coronavirus-19”. after a brief excursus on all infectious agents transmittable at the dental chair, the authors described all the personal protective equipment (ppe) actually on the market and their indications, and on the basis of the literature, they compared (before and after covid-19 onset) the correct safety procedures for each dental practice studied, underlining the danger of underestimating, in general, dental cross-infections. the authors have highlighted the importance of knowing exactly the risk of infections in the dental practice, and to modulate correctly the use of ppe, in order to invest adequate financial resources and to avoid exposing both the dental team and patients to preventable risks. the era of corona-virus-disease-19 is an important historical period from various points of view, from the world health to the huge cascade of socio-economic implications. everyday habits have been turned upside down, and the way of life of people all over the globe, engaged in all activities, especially in the health sector, will be involved in this necessary change. dentists, being in close contact with the patient's droplets and aerosols generated, have to revise the operating protocols to protect the team and the patients from the risk of infectious diseases. unfortunately, the pandemic covid-19 will not stop immediately and everyone will have to face each other very long working and social recovery times of the population. in this time, a large part of the population will avoid dental treatment other than those imposed by pain or urgency, both due to money issues and, principally, for a psychological reason: it will not be easy to overcome the fear of infection. for many, the dental practice is a source of possible infections, considering that the first person at risk is the dentist himself. the scenario in dental practices is very complex and several problems can arise which are dangerous for the dental practice [1] [2] [3] [4] [5] [6] [7] [8] [9] . for an infection to emerge, it is necessary that an adequate number of specific microorganisms can infect a person or groups. the classic contamination paths clearly incorporate all the dental unit (team and patient): body fluids in direct contact with the wound site during operation, injuries of the skin and the mucosa with sharp objects, body fluids and contaminated material contact with eyes, aerosols arising during the operation with air produced by turbine and ultrasonic devices, contamination via droplet, and surgical smoke formed during electro-cautery or laser applications [10, 11] . the first problem raised with respect to covid-19, is related to the easy spread of viral agents in the air during dental procedures [12] [13] [14] [15] . hence, aerosol is the most aggressive source of covid-19 as well as other viral infections, placing dentists and their collaborators at the first line of the exposure to risk scale within the context of healthy personnel [10, 16] . the second problem is related to the persistence of the biological agent in operating rooms. the aerosol produced by high rotation instruments and ultrasound could remain for several hours in the air and on the surfaces [17, 18] . although it can save the operator, if well protected, during the therapeutic acts, it means that the air will be contaminated, thus presenting a risk for operators after removing the ppe (personal protective equipment) and for the next patients. this covid-19 pandemic has shown that several people can be positive and spread the viral agents around without any symptoms or signs of biological agents. so, the dental team, a part performing the double triage [1] , should consider each patient as sars-cov-2 positive until proven otherwise and use protective equipment in order to preserve their own health and the health of all patients as attending the dental office. for these reasons, it is necessary to use rigid and precise operating protocols capable of classifying dental procedures based on risks for the team as well as for the patients. this study was born from the awareness of a necessary change in decision making processes. it involves a rereading of relevant literature in order to build protocols addressed to dentists, to assess and modulate the risks of contagion in the dental practice. moreover, it proposes, on the basis of information from literature, a classification of dental procedures based on the risk of contagion of infectious agents, showing what will change for the dentist and the oral medicine expert. an investigation was performed on the online databases pubmed and scopus using a combination of free words and mesh terms: "dentist" and "covid-19" or "sars-cov-2" or "coronavirus-19", and "oral health" and "covid-19" or "sars-cov-2" or "coronavirus-19". only studies fulfilling the following inclusion criteria were considered eligible for inclusion in this study: (i) performed on human subjects, (ii) written in the english language, and (iii) published in 2019-2020. the manuscript titles list was highlighted to exclude irrelevant publications and search errors. the final selection was performed by reading the full texts of the papers in order to approve each study's eligibility based on sars-cov-2 and other infective agents involved in dentistry. data selection and revision was performed by two independent reviewers (meb, university of foggia and gc, university of palermo). they singularly analysed the papers, and in agreement, included 142 papers in this narrative review. the authors, in consideration of the importance of the emerging topic, decided to include also guidelines, online documents, reviews, experts' opinions, renouncing the prisma-related design of regular systematic reviews ( figure 1 ). after a brief excursus on all possible infectious agents, the authors described, on the basis of the literature selected, all personal protective equipment (ppe) actually on the market and their indications. then, they compared (before vs after covid-19 era) the correct safety procedures for each dental practice selected, underlining the danger of underestimating, in general, dental cross infections, if focused only on the newest sars-cov-2. results are summarised in tables 1-8. different classes of bacteria, viruses, and fungi can cause human infections. three factors are important for the transmission of these infectious agents: an infectious agent, a receptive subject and a transmission mode. the pathogens involved in infections during health care mainly derive from staff, from patients (and possible careers), but also from inanimate environmental sources ( figure 2 ). these human sources can: 1) have active infections, 2) be asymptomatic or in an incubation period, or 3) be colonized transiently or chronically with pathogen microorganisms. the infection is the consequence of the contact between a contagious agent and a potential host. moreover, the same characteristics of the host can influence the onset and the severity of the infectious disease. however, several other factors can modify the virulence and behavior of infectious disease such as the number of infectious agents, the transmission way and the pathogenicity [19] . predictors of the disease evolution in a specific subject could be: immune status at exposition time, age, comorbidity, and virulence of the agent [20] . there are two main ways of infective transmission, namely vertical (from mother to fetus: transplacental, during vaginal birth or breast feeding) and horizontal (sexual and non-sexual). in a dental setting, infectious agents are transmitted in the horizontal, non-sexual route [21] . in the non-sexual horizontal transmission, direct or indirect contact (e.g., herpes simplex virus, respiratory syncytial virus, s. aureus), droplets (e.g., influenza virus, b. pertussis) or airways (e.g., m. tuberculosis) are possible routes. other viruses can be transmitted by the blood (e.g., hepatitis b and c viruses and hiv) via percutaneous or mucous membrane exposure [3, 4, 14, 22] . in synthesis, the three main routes of the transmission are [23] : contact transmission: contact transmission can be through direct contact and indirect contact. during direct contact transmission, pathogens are transmitted from an infected person to another subject without an intermediate object or person (for example, mucous membrane or breaks contact blood or other blood-containing body fluids infected, or contact hsv lesion without gloves) [3, 4, 14, 15, 18, 22, 24, 25] . during indirect contact transmission, pathogens are transmitted to the host through objects or human body carrying those pathogens [17, 18, 22, [26] [27] [28] [29] [30] . moreover, all the personal protective equipment (ppe), such as uniforms or isolation gowns, can be contaminated by infectious agents during the treatment of a patient colonized or infected. • droplet transmission: some infectious agents can reach the host through the direct and indirect contact routes or through droplets [3, 15, [31] [32] [33] . droplets can carry infectious pathogens travelling for short distances directly from the respiratory tract of the infectious subjects to host reaching susceptible mucosal surfaces [3, 15, [31] [32] [33] . respiratory droplets are produced during coughs, sneezes, or talks [34] or by airway health procedures. the nasal mucosa, conjunctivae, and mouth are good portals for respiratory viruses [35] . to date, the maximum distance that a droplet can reach is not known, even if pathogens transmitted by a droplet do not run across long distances [19] . the size of droplets has traditionally been defined as being >5 µm [19] . several types of droplets, including those with diameters of 30 µm or greater, can remain suspended in the air [36] . the sizes of the droplets can determine the maximum distance reached: largest droplets, between 60 and 100 microns, totally evaporate before spontaneously falling 2 m away [37] . for respiratory exhalation flows, the critical factor is the exhalation air velocity: these droplets are carried more than 6 m away by exhaled air at a velocity of 50 m/s (sneezing), more than 2 m away at a velocity of 10 m/s (coughing), and less than 1 m away at a velocity of 1 m/s (breathing) [37] . airborne transmission: this means of transmission consists of dissemination of airborne droplet or small particles containing infectious pathogens that remain infective over time and distance (e.g., spores of aspergillus spp., and m. tuberculosis) [31, 33, [38] [39] [40] [41] [42] . several infectious agents can involve dentist and his team [10] (table 1) . • sars-cov-2 determines covid-19 (coronavirus disease 2019), an infectious disease characterized by several important systemic problems such as coronavirus associated pneumonia. the principal symptoms are fever, cough, and breathing difficulties; the most patients have mild symptoms, some progress to severe pneumonia [43] . the diagnosis is performed with the identification of the virus in swabs of patient throat and nose. covid-19 can involve the respiratory tract determining a mild or highly acute respiratory syndrome due to the production of pro-inflammatory cytokines, such as interleukin (il)-1beta and il-6 [44] . one mechanism that can make the coronavirus lethal is the induction of interstitial pneumonia linked to an over-production of il-6 [44, 45] . based on this principle, several researchers have started to use an anti-arthritis drug, tocilizumab, for its anti-il-6 action [46] [47] [48] [49] . herpes simplex virus (hsv) can determine a primary infection with minor, ulcerative lymphadenopathy gingivostomatitis [50] and a recurrent infection with cold sores. herpetic whitlow, an hsv infection of the fingers is usually caused by direct contact of the same fingers with infected saliva or a herpetic lesion [51] [52] [53] . skin, mucosal lesions, and secretions such as saliva can determine the transmission [54, 55] . lesions are usually characterized by vesicles and sequent crusting. acyclovir can be used for the treatment of the diseases. it is sufficient to wear gloves in order to avoid the herpetic whitlow when the clinician treats patients with hsv lesions [10, 56] . • varicella zoster virus (vzv) can determine chickenpox (primary disease), usually in children, and shingles, which is very painful (secondary disease), for the reactivation of a virus residing in sensory ganglia during the latency period [57] [58] [59] . chickenpox disease is highly contagious and spreads via-airborne routes [60] [61] [62] . the virus can infect nonimmune dental team via inhalation of aerosols from a patient incubating the disease. masks and gloves can be not sufficient for complete protection of the healthcare workers [10] . [77] . it is present in saliva and could infect susceptible subjects via direct contact or aerosols [78] . human t-lymphotropic virus is involved in adult t cell leukaemia and spastic paraparesis. this virus can be transmitted through blood [79] [80] [81] [82] and, in a dental setting, it can infect via sharp instruments injuries [10] . hepatitis b virus (hbv) causes acute hepatitis and it is an important risk-agent for the health care staff [83, 84] . the possible ways of transmission are sexual intercourse, through blood, contaminated material injuries, and perinatal way [85] [86] [87] [88] . so, all operators of the dental team should be vaccinated [10, 89] . hepatitis c virus (hcv) causes "non-a" and "non-b" hepatitis and it is transmitted like hbv [85] [86] [87] 90] . the primary infection is often asymptomatic and the most of infected subjects become carriers of the virus with risk of development of chronic liver disease that could evolve in hepatocellular carcinoma [10] . human immunodeficiency virus (hiv) infects the immune system of susceptible subjects, t-helper cells particularly. it can be transmitted like hbv (sexual intercourse, blood borne and perinatal ways) [91, 92] . moreover, this infection have oral manifestations that can help in diagnosis: e.g., oral candidiasis, oral hairy leukoplakia, oral necrotising ulcerative gingivitis and oral kaposi's sarcoma [10, [93] [94] [95] [96] . • cytomegalovirus (cmv) is part of the herpes virus family and can cause diseases with several manifestations [97] . mumps virus is part of the paramyxoviridae group. this pathogen often affects the parotid glands, and the consequently characteristic symptom is swelling of these salivary glands [98] . moreover, this virus can cause inflammation of the ovaries, testis, pancreas or meninges with several complications. after the introduction of the vaccine against measles, mumps, and rubella (mmr), mumps incidence has decreased, even if several mumps cases have recently been reported [99] . • mycobacterium tuberculosis causes tuberculosis and is a bacterium transmitted by inhalation, ingestion and inoculation. the main symptoms are cervical lymphadenitis and lung infections. in order to prevent infection, the dental team should be adequately vaccinated and wear ppe [100] [101] [102] [103] [104] [105] . this bacterium is resistant to chemicals and, for this reason, sterilization and disinfection protocols must be rigorously performed [10] . • legionella spp. is a gram-negative bacterium that causes legionellosis and generally it resides in water tanks. legionellosis occurs with pneumonia, sometimes lethal in older people. since this pathogen lives in water, it can be easily transmitted during dental procedures through aerosols from incorrectly disinfected water circuits [106, 107] . in fact, water circuits that remain unused for long periods of time should be checked regularly to prevent legionella bacteria from residing [106, 107] . • treponema pallidum causes syphilis and dental team must wear gloves in order to adequate protect themselves [10, 108] . meningococcal spp. are gram-negative bacteria. they are located on the nasopharyngeal mucosa and their presence is generally asymptomatic. the bacterium is easily transmitted, especially during adolescence, when people get together. as already mentioned, colonization of the nasopharynx is common, and while the resulting disease is rare, at times, it can cause death or permanent disability [109, 110] . staphylococcus aureus is an important agent involved in nosocomial infections. this bacterium causes a wide range of diseases that can be mild or life-threatening (e.g., bacteraemia, pneumonia, and surgical site infection [111] ). in addition, s. aureus can easily have antimicrobial resistance. this bacterium principally resides on the epithelium of the anterior nares in human beings [112] . group a streptococcus (gas) is a gram-positive, beta-haemolytic bacterium. this pathogen is responsible for several diseases in human beings, such as acute pharyngitis, impetigo and cellulitis. it can also cause serious invasive diseases such as necrotizing fasciitis and toxic shock syndrome (tss) [113] [114] [115] . the bacterium mainly resides in human nose, throat and on skin and it is often transmitted without symptoms [116] [117] [118] . obviously, asymptomatic subjects are less contagious than the symptomatic carriers of this bacterium. gas is transmitted through respiratory droplets spread in the air, for example during coughing, sneezing and nasal secretions [117, 118] . in addition, this bacterium can spread through close interpersonal contact during a kiss, using the same dishes and sharing the same cigarette. streptococci mutans mainly colonize dental surfaces after tooth eruption and is associated to the development of caries [119] . this bacterium may be transmitted horizontally between children during the initial phases of the s. mutans colonization in nursery environments [120] . there is scientific evidence of vertical transmission of s. mutans from mother to child [121] . • some periodontal bacteria (e.g., a. actinomycetemcomitans, p. gingivalis) are considered person-to-person transmitted, but it is still unclear if transmission is governed only by domestic pathways, without definitive implications for the dental office. vertical transmission of a. actinomycetemcomitans is between 30% and 60%, while that of p. gingivalis is rarely observed. horizontal transmission ranges from 14% to 60% for a. actinomycetemcomitans and between 30% and 75% for p. gingivalis [122] . certainly, by understanding the spread mechanisms of these bacteria, it would also be possible to prevent a number of systemic diseases [123] . the dental team must adapt several precautions to avoid these infections; an adequate training and information of the personnel is mandatory in order to control infections in the dental office. the individual protection methods include a series of enforcement with the aim to reduce the risks of contamination, unfortunately without being able to eliminate them. the basic principle of infection control is to approach to each patient as if he was an infected patient (by one of the main microbes listed above) and to correctly carry out the protection methods [124] . adequate personal protective equipment (ppe) must be selected based on a risk assessment and the procedure to be performed. the precautions for infection control require wearing gloves, aprons, as well as eye and mouth protection (goggles and mask, such as medical masks and filtering face piece or fpp) for each procedure involving direct contact with the patient body fluids. whenever possible "single use" or "disposable" equipment should be used [10] (table 2) . if the necessary precautions are not taken, it is inevitable that operators can become infected through contact of the mucous membranes with blood, saliva, and aerosols from a potentially infective patient [10] . in healthcare setting, masks are used in order to: protect personnel from contact with patient infectious material; 2. protect patients from infectious agents carried by healthcare workers; 3. limit the potential spread of infectious respiratory aerosol between patients [19] . masks can be worn with goggles in order to protect mouth, nose and eyes, or with a face shield to provide more complete face protection. we must distinguish masks from particle respirators that are used to prevent inhalation of small particles which may contain infectious agents transmitted through the respiratory tract. the mouth, nose, and eyes are sensitive portals to the entry of infective pathogens, such as skin cuts. medical masks: • could be flat or pleated (some are like cups) and fixed to the head with straps or elastic bands; • does not offer complete protection against small particle aerosols (droplet nuclei) and should not be used during contact with patients with diseases caused by airborne pathogens; • they are not designed to isolate the face and therefore cannot prevent inhalation by the health personnel wearing them; • they must be replaced if wet or dirty. there are no standards that evaluate the efficiency of the medical mask filter. aorn (association of peri-operative registered nurses) recommends that medical (surgical) masks filter at least 0.3 µ particles or have a bacterial filtration efficiency of 90%-95% [126] . surgical masks (sm) are used to prevent that large particles (such as droplets, sprays or splashes), containing pathogens, could reach nose and mouth [127] . although their purpose is to protect patients from healthcare professionals (and healthcare team from patients) by minimizing exposure to saliva and respiratory secretions, they do not create a seal against the skin of the face and therefore are not indicated to protect people from airborne infectious diseases. masks are available in several shapes (modeled and unprinted), dimensions, filtration efficiency and attachment method (ribbons, elastic through the ear). masks are disposable and must be changed for each patient. instead, during the treatment of patients with respiratory infections, particulate respiratory masks must be worn. particulate respirators (with filtering percentage) in use in various countries include: [126] . ffp2 european respirators are comparable to n95, and they are indicated for prevention of infectious airborne diseases. however, ffp3 respirators offer the highest level of protection against infectious agents and are the only ffp class accepted by the health and safety executive (hse) as regards the protection in the healthcare environment in the united kingdom [126] . the powered air purifying respirator is also considered a standard part of ppe in certain situations, including aerosol generation procedures in high risk environments. in the event of a pandemic infection, any aerosol generation procedure on infected patients should only be carried out with an ffp3 respirator. non-urgent procedures should be postponed until the infection resolves. in the us, the national institute for occupational safety and health (niosh) defined the following particulate filter categories in 2011, in title 42 code of federal regulations, section 84 (table 3) . there are several models of ffp2 and ffp3 respirators, both with valves and without valves. however, this is not a filter but a valve that regulates the flow of air at the outlet and therefore makes it easier to exhale. therefore, these masks are designed to be able to filter very well the air that comes in the mouth, nose, and lungs of those who wear them. instead, these masks are not designed specifically to prevent the wearer from infecting someone else with their own breathing. in practice, if a mask has a valve, it can let out particles, even if it manages to block almost all the inlet ones. and therefore, a healthy person can use it effectively so as not to get infected. for a sick person or one who could be contagious, however, using it could infect others by letting germs pass from their breath outwards. it is important to say that there is no specific test that has been done to verify the possibility that the virus spreads from an infected person passing through a mask equipped with a valve [128] . surgical masks, on the other hand, are similar in both directions. they have been designed to prevent healthcare workers and surgeons in particular from infecting their own breath with patients, who may have open wounds on the operating table, but also work to protect the healthcare staff themselves against a potentially contagious person. their effectiveness, however, is much lower also because they do not prevent the breath from spreading and allow a lot of air to pass through and to the mouth and nose [128] . the choice of individual eye protection devices (such as goggles or face mask) varies according to the exposure circumstances, other ppe worn. and the need for personal vision [10] . in order to protect the eyes, eyeglasses and contact lenses are not considered suitable [129] . eye protection must be effective but at the same time comfortable and allow sufficient peripheral vision. there are different measures that improve the comfort of the glasses, for example anti-fog coating, different sizes, the possibility of wearing them on prescription glasses. although they provide adequate eye protection, glasses do not protect from splash or spray the other parts of the face. disposable or sterilizable face shields can be used in alternative to glasses. face shield protects the other areas of the face besides the eyes (glasses only protect the eyes). the face shields that extend from the chin to the forehead offer better protection of the face and eyes from spray and splashes [83] . the removal of a facemask, goggles, and mask can be safely performed after removing dirty gloves and after performing hand hygiene. gowns and coveralls are additional personal protective equipment in the health sector [83] . operator hygiene, including wearing appropriate clothing and ppe, has a dual purpose: on the one hand, to defend the operator himself in an environment where the infectious risk is high, and on the other hand to prevent the operator from becoming responsible transmission of infections. to increase the protective function of the uniform or to carry out those procedures in which high contamination is expected, additional disposable clothing can be worn [83] . these clothes can be ppe certified for biological risk and for this recognition must comply with the requirements of the technical standards, namely european standards are en 14126 and iso 16604 (dpi) and en 24920 (dm). the material constituent is mainly tnt (texture not texture), which is suitable for "disposable" use in this specific area. to offer greater protection of the part front of the body, the most exposed to risk, it is required that such lab coats have standard features within the heterogeneity of the models, for example: back closure, covered or heat-sealed seams, long sleeves with cuffs tight and high collar. obviously, for these devices, comfort and practicality are also required, so the operator must be able to move freely and perceive good perspiration [83] . different types of gowns and overalls are available with varying levels of protection. the level of protection depends on various factors including the type of tissue, the shape and size of microorganisms, the characteristics of the conveyor, and various external factors [130] . in high-risk environments, it is recommended to use waterproof and fluid-resistant gowns or overalls. during minor oral surgery, surgical gowns must be worn with tight cuffs that must be inserted under the gloves. fabric work uniforms must be washed daily on a hot 60 • c cycle. fabric uniforms are not considered ppe since the material they are made of is absorbent and therefore offer little protection against infectious pathogens. during all dental procedures, it is impossible to avoid contact of the hands with blood and saliva [10] . that is why all operators must wear protective gloves before performing any type of procedure on patients [10] . gloves must be changed with each patient and at every contact with contaminated surfaces to prevent cross-infection [10] . not only the dentist, but also other dental team members must wear gloves during dental procedures [10, 131] . gloves used in dental clinic can be distinguished basically in two categories: those for purely use clinical and those for instrumentation reordering procedures and of the operational area. when cleaning dental appliances and instruments, more durable gloves should be worn than normal non-sterile gloves to prevent injury [10] . regarding clinical gloves, a clear distinction must be made between them procedures that require invasive action on the patient, or however at clear biological risk, and the procedures that do not require them, or in any case present a negligible biological risk for the operator. the two types of gloves resulting from this distinction are found in the words "inspection gloves" and "surgical gloves" one commonly used nomenclature [83] . both disposable products, from a macroscopic point of view usually have some obvious differences: • surgical gloves in general always distinguish the right side from the left, they are long enough to be worn over the cuffs of the gowns and always packaged in sterile pairs, • the inspection glove is usually an ambidextrous device, shorter and thinner than the previous one and rarely sterile [132] . in general, clinical gloves are made of latex, nitrile or vinyl. latex and nitrile have proven to be more resistant than and therefore are generally preferred. gloves contain powder to make them easier to wear, but which can cause skin irritation [10] . powder-free gloves exist on the market and they should be used when such reactions occur [10] . some people may experience allergies and contact dermatitis due to latex [10] . latex-free gloves for allergy sufferers are also available [10] . also, the weather of use is an absolutely relevant parameter in terms of protection. the use of the glove, especially if in latex, involves development not perceived of microperforations which become particularly significant from a numerical point of view after 60 min and which induce an increase in biological risk [133] . the simultaneous use of two pairs of gloves considerably reduces the passage of blood through microperforations [134] . there are no significant reductions in manual skills and the sensitivity of the operator wearing the double glove [132] . it was confirmed that the formation of microperforations can be also induced by washing gloves with soap, chlorhexidine, or alcohol. moreover, particular attention should be paid also while waiting for the total drying of the alcoholic substances applied on the hands, which has also proven to be potentially harmful to the integrity of the device, before wearing gloves [132] . other personal protective equipment include the disposable cap (headgear) and shoe covers. a disposable cap device is recommended for clear hygienic reasons, such as containment operator contamination and prevention of dispersion of dandruff in the environment, and even more generic protective functions for the worker, such as: interlocking with subsequent tearing of hair and possibly scalp from a part of moving and/or rotating organs, the burning of the hair due to flames or incandescent bodies, and hair fouling due to various agents, including powders and drops of blood-salivary material [83] . dentist personal hygiene is an absolute necessity for infection prevention [23] . the image that the doctor presents of himself and his study is related to the trust that the patient will show towards the doctor and the treatment itself, in an era in which there is increasing information and awareness of the risk. specific notes of hygiene include: • hair, if a doctor hair can touch the patient or dental equipment, should be attached to the back of the head or a surgical cap should be worn [23] ; • facial hair should be covered with a mask or shield [23] ; • jewels should be removed from the hands, arms, or facial area during the patient treatment [23] ; • nails should be kept clean and short to prevent the perforation of the gloves and the accumulation of debris [23] ; • full forearm and hand washing are mandatory before and after treatment [23] . it is very important to maintain an excellent level of hand hygiene in protection techniques that affects all members of the dental team [10] . "hand hygiene" includes several procedures that remove or kill microorganism on the hands [83] : • during handwashing, water and soap should be used in order to generate lather that is distributed on all surface of the hands and after rinsed off; • hand antisepsis, to physically remove microorganisms by antimicrobial soap or to kill microorganisms with an alcohol-based hand rub; • surgical hand rub procedure that kills transient organisms and reduces resident flora for the duration of a surgical procedure with antimicrobial soap or an alcohol-based hand rub [135] . there are different types of soap: • plain soap, that have no antimicrobial properties and works physically removing dirt ad microorganism; • alcohol-based hand rub, used without water, kills microorganism but does not remove soil or organic material physically; antimicrobial soap kills microorganism and removes physically soil and organic material [135] . in 1975 and in 1985, the cdc published a guideline on how to wash the hands, stating that the hands should be washed with antimicrobial soaps before and after procedures performed on patients [10] . the use of gloves is not an alternative to hand washing [10] . hand washing is different if it is a routine procedure or a surgical procedure: in the first case, normal or antibacterial soaps are sufficient [89] . alcohol-containing agents are preferable [10] . cold water must be of choice when washing hands because the repeatedly use of hot water can cause dermatitis [10] . it is recommended to wash hands using liquid soap for a minimum duration of 60 s. it is very important to reduce the number of microorganisms before each surgical procedure; that is why applying antibacterial soaps and acts a detailed cleaning followed by liquids containing alcohol is recommended [10] . despite the fact that the antibacterial effects of alcohol containing cleansers arise quickly, such antiseptics including compounds of triclosan, quaternary ammonium, chlorhexidine, and octenidine must be included [10] . before surgical hand washing, rings, watches, and other accessories must be taken off and no nail polishes or other artificial must be present [11, 89] . the use of disposable paper towels is preferable for drying hands. after every procedure and after taking off the gloves, it is highly recommended to wash hands once again with regular soaps. if soap and water are not readily available, it can be used an alcohol-based hand sanitizer that contains at least 60% alcohol [10] . • must consider all sharp objects contaminated with the patient blood and saliva as potentially infectious; • do not hood the used needles in order to avoid an accidental injection [83] ; • put all used sharp objects in suitable puncture resistant bins [83] . it is necessary to clean all instruments with detergent and water before sterilization [10] . during washing, it is advisable to avoid splashes of water a wear gloves and face protection. the instruments that penetrate the tissues must be sterilized in an autoclave [83] . it is advisable to heat sterilize items that touch the mucosa or to at least disinfect them, for example, with the immersion in a 2% glutaraldehyde solution in a closed bid, naturally following the instructions of the producer [83] . anything that cannot be autoclaved must be disinfected. the handpieces should be able to drain the water for two minutes at the start of the day. not autoclavable handpieces can be disinfected using viricidal agent. after sterilization, all instruments must be kept safely in order to avoid recontamination for a maximum of 30 days, 60 days if closed in double bags [83] . sterilization completely kills all vital agents and spores too. the classic sterilization procedure expects the use autoclave, with cycles at 121 • c for 15-30 min, or at 134 • c for 3-4 min [23, 83] . it is necessary to thoroughly wash and dry all items before sterilizing them as dirt and water can interfere with sterilization [83] . steam sterilization cannot be used for all facilities and a possible alternative can be the use of chemical sterilization using ethylene oxide gas, formaldehyde gas, hydrogen peroxide gas, liquid peracetic acid, or ozone [83] . the disinfection processes do not destroy the bacterial load, rather reducing it to acceptable levels. commonly used disinfectants are described below (table 4 ). the action of cleaning and disinfection can be manual or automatized. for example, it is possible to use ultrasonic baths in order to clean complex, articulated, or notched stainless-steel instruments such as cutters. the washer-disinfectors provide a high temperature passage (generally 90 • c for one minute), which drastically reduces the microbial contamination of the items. the final rinse must be carried out with high quality water (table 5 ). it is necessary to have always a perfect protection of operative room with disinfected surfaces [10] . there are two ways to make a surface aseptic [23] : • clean and disinfect contaminated surfaces [23] and • prevent surfaces from being contaminated by using surface covers [23] . a combination of both can also be used [23] . the following chemicals are suitable for surface and equipment asepsis: • chlorine, e.g., sodium hypochlorite • phenolic compounds • water-based, water with ortho-phenylphenol, tertiary amylphenol, or o-benzyl-p-chlorophenol • alcohol-based ethyl or isopropyl alcohol with ortho-phenylphenol or tertiary amylphenol • iodophor-butoxy polypropoxy polyethoxy ethanol iodine complex [23] . in the literature there are still little information on 2019-ncov. similar genetic features between 2019-ncov and sars-cov indicate that covid-19 could be susceptible to disinfectants such as 0.1% sodium hypochlorite, 0.5% hydrogen peroxide, 62%-71% ethanol, and phenolic and quaternary ammonium compounds [4] . it is important to pay attention to the duration of use, dilution rate, and especially the expiration time following the preparation of the solution [4] . a recent paper pointed out that surface disinfection could be performed with 0.1% sodium hypochlorite or 62%-71% ethanol for one minute in order to eliminate sas-cov-2 [139] . after each treatment, work surfaces should be adequately cleaned and decontaminated with ethyl alcohol (70%). if blood or pus is visible on a surface, it is necessary to clean and disinfect that surface with sodium hypochlorite (0.5%). it is necessary to wear protective gloves and care taken to minimize direct skin, mucosal or eye contact with these disinfectants. in addition to disinfection with chemicals, a ultraviolet-c (uv-c) irradiation lamp can be used [140] . the uv light system for disinfection has several advantages, including: does not require room ventilation, does not leave residues after use and have a wide action spectrum in a very short time [140] . the uv-c lamp must be activated only when the room is empty, without staff and without patient. in the literature, there are no cases of damage to the materials present in the room; despite this, the acrylic material can be degraded if subjected to repeated exposure to uv-c light and for this reason it is recommended to cover it during disinfection with uv-c [141] . ultraviolet light has a wavelength between 10 and 400 nm, while ultraviolet-c (uv-c) light has a wavelength between 100 and 280 nm, and the greatest germicidal power is obtained with a wavelength of 265 nm [142] . the germicidal effect of uv-c light causes cell damage thus blocking cell replication [141] . in descending order of inactivation by uv-c light, there are bacteria, viruses, fungi, and spores [143] . uv-c rays can be generated by low pressure mercury lamps and pulsed xenon lamps which emit high intensity pulsed light with a higher germicidal action [141] . uv-c rays are equipped with high energy which decreases exponentially with the increase of distance from the light source: objects or surfaces closer to the uv-c source will have a greater exposure and therefore will have to be disinfected for less time than distant objects [142] . depending on the nature of the object affected by uv-c light, it can block the light rays or allow itself to be passed through allowing the irradiation of the objects placed behind it. for example, the organic material completely absorbs the uv-c light and blocks its diffusion. for this reason, the surfaces must be manually cleaned to remove the organic substances before decontamination with ultraviolet light [142] . the extent of inactivation of the microorganisms is directly proportional to the uv-c dose received and this, in turn, is the result of the intensity and duration of exposure [142] . therefore, according to the data in the literature, the use of uv-c rays for disinfection has proven effective in reducing the overall bacterial count and significantly more effective than just manual disinfection on surfaces [141] . in addition, to encourage the exchange of air, it is recommended to ventilate the rooms between one patient and another. if it is not possible to allow the exchange of natural air (at least 20-30 min), forced ventilation systems with high efficiency particulate air (hepa) filters must be used, paying attention to the periodic replacement of the filters. recommendations for environmental infection prevention and control in dental settings [136] : • establish a protocol for cleaning and disinfection of surfaces and environments of which health personnel must be informed; • cover with disposable films all the surfaces that are touched during the procedures (for example switches, it equipment) and change these protections between each patient; • surfaces that are not protected by a barrier should be cleaned and disinfected with a disinfectant after each patient; • use a medium level disinfectant (i.e., tuberculocidal indication) if a surface is visibly contaminated with blood; • for each disinfectant, follow the manufacturer's instructions (e.g., quantity, dilution, contact time, safe use, disposal) [136] (table 6 ). if proper maintenance is not carried out, microbial pathogens (e.g., pseudomonas or legionella spp.) can multiply in duwls. these organisms grow in the biofilm on the internal surfaces of the tubes, where they cannot be attacked with chemicals. to prevent the formation of this biofilm, the systems should be drained at the end of each day [144] . in dental unit water lines (duwl), water must flow and they must be washed regularly: it is recommended to rinse for two minutes at the beginning and end of each day and for 20-30 s between patients [144] . different agents for disinfection of duwl are available. all handpieces and ultrasonic meters must be equipped with backstop valves and must undergo periodic maintenance and inspection. the filters used in the duwl must be checked periodically or, if they are disposable, they must be changed daily. recommendations for dental unit water quality in dental settings: • use water compliant with environmental protection agency (epa) standards for drinking water (i.e., ≤ 500 cfu/ml of heterotrophic water bacteria), • follow the recommendations for water quality monitoring given by the manufacturer of the unit or waterline treatment product, • use sterile water or sterile saline for the irrigation during surgical procedures [136] . any waste containing human or animal tissue, blood or other body fluids, drugs, swabs, dressings or other infective material is defined as "clinical waste" and it must be separated from non-clinical waste [144] . used disposable syringes, needles, or other pointed instruments must be disposed of in a special rigid container, in order to avoid injury to operators and operators in charge of waste disposal. the waste must be kept in a dedicated area before it is collected, away from public access, and excessive accumulation of waste must be avoided [4, 144] . the whole dental team must be vaccinated against hepatitis b in order to increase personal protection [83] . individuals who have already been vaccinated should monitor their levels of immunity against hbv over time and make booster shots [145] . all dental health care professionals should also receive the following other vaccinations: flu, mumps (live-virus), measles (live-virus), rubella (live-virus), and varicella-zoster (live-virus) [10] . in addition, the rubella vaccine is strongly recommended especially for women who have pregnancy uncertainty [131] . the influenza vaccine is very useful for dental health professionals as they are at risk for respiratory droplets infections by working in close proximity to the patients [10] . when the covid-19 vaccine is ready, healthcare professionals should take it. as additional infection prevention and health care worker measures, rapid tests can be used in dental practices to diagnose covid-19 before each treatment. this is because, as mentioned above, a patient without symptoms is not necessarily a healthy patient. from all these data, it is evident that the dentist and his team need to use rigid and precise operating protocols in order to avoid infectious contagion [23] . several authors proposed some right procedures in the operative dentistry [2] [3] [4] 10, 23, 83, 139, [146] [147] [148] [149] . for this reason, we reassume them in a precise operative protocol organized for all the patients and characterized by some defined steps: prevention of infections must be a priority in any healthcare setting and therefore also in any dental clinic. to do this, staff training and information, adequate management of resources, and use of well-defined operating protocols is necessary. adequate management of the protection for operators (and therefore also for patients) begins with the roles of the secretariat. in order to better organize the workflow, the secretariat must provide a telephone triage. it would be advisable to phone each patient to make sure he is healthy on the day of the appointment. patients with acute symptoms of any infectious disease should be referred at the time of symptom resolution. the medical history of patients may not reveal asymptomatic infectious disease of which they are affected. this means the operator must adopt the same infection control rules for all patients, as if they were all infective. in addition, the secretariat must organize appointments in order to avoid crowding in the waiting room. it would be advisable for the patient to present himself alone, without companions (only minors, the elderly and patients with psycho-physical conditions can be accompanied). in some urgent and non-deferrable cases, it is necessary to treat the patient despite being in the acute phase of infection with any virus. examples of urgent treatments are: pulpitis, tooth fracture, and avulsion [2] . in these cases, the operator must implement the maximum individual protection measures. in the waiting room all material (e.g., magazines, newspapers, information posters) that can represent a source of contamination must be eliminated so that the room is easy to disinfect. patients are requested to go to the appointment without any superfluous objects. at the entrance of the dental structure, the patient must wear shoe covers, disinfect the hands with hydroalcoholic solution according to the following indications, affix any jacket on a special hanger and disinfect the hands again with hydroalcoholic solution. if there are several patients in the waiting room, they must be at least two meters away from each other. the correct hand disinfection procedure with hydroalcoholic solution is as follows: a) apply a squirt of sanitizer in the palm of hand, b) rub hands palm against each other, c) rub the back of each hands with the palm of the other hand, d) rub palms together with your finger interlaced, e) rub the back of fingers with the opposite palms, f) rotate thumbs in the other hand, g) do a circle on palm with finger clasped, h) once dry, hands are safe. the same procedure is performed for washing hands with soap and water. the operators must be adequately dressed in the correct ppe. healthcare professionals will need to remove any jewel before starting dressing procedures. all the necessary ppe must already be positioned clearly visible and intact, in a room that will be distinct from the one where the undressing phase will take place. in both areas, hydroalcoholic solution and/or items necessary for washing hands with soap and water should be available. in the dressing room there must be trays for the collection and subsequent disinfection of the non-disposable ppe and special containers for the collection of waste where to dispose of the disposable ppe. a dressing and undressing procedure is described below, imagining that the dentist has to operate under a high risk of infection. dressing and undressing procedures must be particularly considered. dressing procedure: a) eliminate jewels and personal items from the pockets of the uniform; b) long hair must be tied and inserted into a cap not mandatory for single use (no tufts of hair must come out of the cap); c) wear shoe covers; d) perform social hand washing or disinfection with antiseptic gel; e) wear the first pair of gloves of the right size; f) wear the water repellent gown by tying it on the back without double knots (first the upper part and then the lower part, the latter must be tied on the front) being careful not to leave parts of the uniform exposed; g) wear the mask (ffp2-ffp3) which must adhere well to both the nose and the mind; h) put on the disposable water-repellent cap and be tied under the chin, the excess ribbons must be inserted inside the gown; i) wear glasses/protective screen; j) wear a second pair of gloves for direct patient assistance. these gloves must cover the cuffs of the disposable gown. undressing procedure: a) remove the second pair of (dirty) gloves being careful not to contaminate the underlying gloves; b) gloves still worn with a hydroalcoholic solution are disinfected and a new pair of gloves is worn on them; c) the face shield is removed: if it is disposable it should be trashed, and if it is not disposable, it should be placed in a container with disinfectant; d) the second pair of gloves is removed without contaminating the underlying gloves; e) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; f) disposable gown removal starting from the top, then the bottom, rolling it up to touch the inside, clean; g) throw disposable shirts and second pair of gloves; h) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; i) remove the water-repellent cap; j) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; k) remove mask taking it by the elastics with the head bent forward and down; l) both the first pair and the second pair of gloves are removed; m) hands are disinfected with hydroalcoholic solution. before entering the surgical room, the patient must be dressed in a disposable gown and headgear worn in order to avoid any contagion on clothing and hair. 7. before dental session patient should rinse and gargle with a specific mouthwash. chlorhexidine is commonly used for pre-procedural oral rinses in dental offices, but its capacity of 2019-ncov destruction has not yet been demonstrated [4] . instead, pre-procedural oral rinses with oxidizing such as 1% hydrogen peroxide or 0.2% povidone-iodine are recommended [4] . so, the pre-procedural use of mouthwash, especially in cases of inability to use a rubber dam, can significantly reduce the microbial load of oral cavity fluids [3] . in fact, even if oral rinses seem to "limit" the viral load, virus can spread through the complete respiratory tract and it is not scientifically possible to guarantee that this reduction is constant during the operative manoeuvre (e.g., cough, sneezing, runny nose). then the following pre-operative procedure is recommended to the patient: a) 1% hydrogen peroxide 15" gargle followed by 30" rinse, b) do not rinse with water at the end of the rinse and continue with chlorhexidine 0.20% 60" rinse with final gargle of 15" [146] . at the end of the procedure, the patient must be appropriately undressed, and have another oral rinse performed before washing hands and face thoroughly. 8. after every patient, carefully clean all surfaces, starting from the least contaminated to the most potentially infected, taking care not to overlook the handles of the doors and the various drawers, worktops and all the devices used during the treatment and which are not disposable or autoclavable. cover switches, mice, computer keyboards, and anything else that may be more difficult to clean with disposable film. the worktops must be free from anything that is not strictly necessary to perform the service. an accurate disinfection of the surfaces includes a preventive cleaning of the same in order to eliminate the soil which otherwise would not allow the disinfectant to inactivate the microorganisms [29] . in the same way, if you want to use disinfectant wipes, you must use one to cleanse and after another to disinfect. as regards spray disinfectants, the percentage of dilution and the time of application vary from product to product: you must follow the instructions provided by the company. moreover, alcohol-based disinfectants (75%), 0.5% hydrogen peroxide, 0.1% sodium hypochlorite are recommended to be left to act on the surfaces for 1 min. disinfect the circuits of the treatment center at each patient change. between patients, the tubing of high-volume aspirators and saliva ejectors should be regularly flushed with water and disinfectant such as 0.1% sodium hypochlorite. always air the rooms after each patient (at least 20-30 min) or use germicidal lamps. clean floors with bleach at least two times a day. 9. during every procedure minimize the use of an air/water syringe: dry the site with cotton rollers when possible; use suction at maximum power (it might be an idea to use autoclavable plastic suction cannulas that have a greater suction capacity than normal disposable pvc cannulas) or use two saliva ejectors; in the case of exposed carious dentine, try to remove it as manually as possible using excavators; be sure to first mount the rubber dam, disinfect the crown with pellets soaked in 75% alcohol and recommend with the second operator to position the aspirator as correctly as possible to avoid excessive spraying and/or splashing; do not use air-polishing; avoid intraoral x-rays as they stimulate salivation, coughing and/or vomiting; prefer exams like opt (orthopantomography) or cbct (cone beam computed tomography). in case of extractions, it is preferable to use resorbable sutures to seal the post-extraction site. in the case of patients who are definitely positive for any infectious agent or on which there are greater possibilities of positivity highlighted by the medical history, it is necessary to plan their treatment at the end of the day. do not touch patient card and pens with dirty gloves. it is good practice to cough or sneeze into the elbow. the operator must avoid touching his eyes, nose and mouth with dirty gloves or hands. 10. isolation with rubber dam [4] . isolating the oral cavity with the use of rubber dams greatly reduces (about 70%) the spread of respiratory droplets and aerosols containing saliva or blood coming from the patient and aimed to the operator area of action [4] . after positioning the dam, the operator must provide an efficient high-volume intraoral aspiration in order to prevent the spread of aerosol and spray as much as possible [148] . if rubber dams cannot be used for any reason, the operator should prefer to use manual tools such as hand scalers [4] . 11. anti-retraction handpiece [4] . during the covid-19 pandemic, operators should avoid using dental mechanical handpieces that do not have an anti-retraction function [4] . mechanical handpieces with the anti-retraction system have valves (anti-retraction) that are very important in order to prevent the spread and dispersion of droplets and aerosol [148, 149] . 12. all instruments which have been used for the treatment of a patient or which have only been touched by operators during a session and which cannot be sterilized according to standard protocols, must be disinfected (e.g., immersed in a container with phenol) [23] . this tools bagged in disinfection solution must remain in solution for about 10 min [23] . some materials, such as polysulphide, polyvinylsiloxane, impression compound, and zoe impressing materials, after being in the patient mouth, are rinsed with water and immersed in a 5.25% sodium hypochlorite solution for about 10 min [23] . the alginate or polyether impressions are also rinsed with water, sprayed with a 5.25% sodium hypochlorite solution and placed in a container for about 10 min [23] . wax, resin centric relation records, and zoe are rinsed with water and sprayed with a 5.25% sodium hypochlorite solution and placed in a plastic bag for about 10 min [23] . provisional restorations and complete dentures removed from the patient mouth are immersed in a 5.25% sodium hypochlorite solution for 10 min [23] . otherwise, removable partial prostheses with metal bases are treated with 2% glutaraldehyde solution and placed in a plastic bag for 10 min [23] . a novel and useful indication is that of classifying each common dental procedure according to the likelihood of a contagion by one or more infective agents (via saliva, blood, droplets or aerosol) for the team and for the patient (under the cure or the subsequent), nevertheless its type and intrinsic operative difficulty (table 7) . according to this paradigm, all dental procedures involving the use of the air-water syringe and/or rotating/ultrasound/piezo tools are able to produce high levels of aerosols and droplets and for this reason the dentist must consider them dangerous for himself, the dental team, and the subsequent patients. meanwhile, procedures, even if refined (e.g., soft tissues biopsy for oral cancer suspicion) but characterized by a low/absent production of aerosol and droplets, must be considered not particularly threatening. for all these considerations, the dental team must reconsider its operative protocols and modulate the ppe use according to level of risk of common dental procedures of generating droplets or aerosols. table 8 presents the use of different ppes for each common dental procedure in pre-covid vs post-covid era. it is definitively clear that the use of air-water syringe and/or rotating/ultrasound/piezo tools able to produce high levels of aerosols and droplets need the use of the safest ppe in order to reduce/eliminate viral or other infectious agent diffusion within the dental setting. table 8 . proposal of modulation of personal protective equipment (ppe) according to level of risk or common dental procedures both in pre-covid and post-covid era (bold style means the introduction of the new ppe due the transition from a risk category to a higher one). in the face of the covid-19 pandemic, new biosafety measures are necessary to reduce contagion. dentistry is a profession that works directly with the oral cavity and is therefore very exposed to this virus or other infectious agents. because of this, some measures need to be taken to minimize contagion. in fact, dentists can play an important role in stopping the transmission chain, assuming correct procedures in order to reduce the viral agent diffusion, or in promoting undesirable infectious disease diffusion, if operating in adherence to adequate safety protocols. dental-care professionals must be fully aware of 2019-ncov and other viral agent spreading modalities, how to identify patients with active infections and, most importantly, to prioritize self and patient protection. 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expectations for safe care and human services infection control committee. guidelines on infection control practice in the clinic settings of department of health infection control committee of dh guidelines on infection control in dental clinics covid-19 surface persistence: a recent data summary and its importance for medical and dental settings comparison of uv c light and chemicals for disinfection of surfaces in hospital isolation units evaluation of an ultraviolet c (uvc) light-emitting device for disinfection of high touch surfaces in hospital critical areas ultraviolet-c decontamination of a hospital room: amount of uv light needed short-term exposure to uv-a, uv-b, and uv-c irradiation induces alteration in cytoskeleton and autophagy in human keratinocytes general medicine and surgery for dental practitioners: part infections and infection control infection control in the dental office projecting the transmission dynamics of sars-cov-2 through the postpandemic period the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination severe acute respiratory syndrome and dentistry approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic interim guidance for management of emergency and urgent dental care; ada: niagara falls plan estratégico de acción para el periodo posterior a la crisis creada por el covid-19 key: cord-258498-0mvxwo3w authors: shah, saleha title: covid-19 and paediatric dentistrytraversing the challenges. a narrative review date: 2020-08-21 journal: ann med surg (lond) doi: 10.1016/j.amsu.2020.08.007 sha: doc_id: 258498 cord_uid: 0mvxwo3w the coronavirus disease (covid-19) pandemic has become a major global public health emergency with a focus on preventing the spread of this virus for controlling this crisis. a dental setting is at a high risk of cross infection amid patients and dental practitioner's owing to the spread of infection via droplets suspended in the air by infected symptomatic or asymptomatic subjects. this review article informs about measures which reduce facility risk, manage symptomatic patients and protect personal health care and management with reference to paediatric dentistry. the routine aerosol generating procedures are not designed to offer protection against transmission of pathogens and the standard protective measures do not offer adequate effectiveness against patients generating aerosol in the incubation period, are unaware of the infection or conceal information regarding their infection. 5, 6 dental healthcare personnel (dhcp) are all paid and unpaid persons serving in dental healthcare settings with a potential for direct or indirect exposure to patients or infectious materials (body substance, contaminated medical supplies, devices, equipment, environmental surfaces, air). a dhcp is placed in the very high exposure risk category by osha via high potential for exposure to known or suspected viral sources for covid-19 during specific dental procedures. 5, 6, 7 the risk of sars-cov-2 transmission via aerosols generated during dental procedures cannot be eliminated when practicing in the absence of airborne precautions (airborne infection isolation rooms or single-patient rooms, respiratory protection program, n95 respirators). it is vital to reduce the risk of infections in a dental setting by infection control measures since unrecognized asymptomatic and presymptomatic infections have a likelihood of transmission in healthcare settings. sars-cov2 is sensitive to heat and ultra-violet rays. it is inactivated at 56°c for 30 minutes and by lipid solvents ethanol, 75% ether, disinfectants containing peracetic acid, chloroform and chlorine but not by chlorhexidine 7, 8 this is essential in the reliable and effective protection of dhcp from exposure to pathogens. it includes engineering controls, administrative controls and personal protective equipment (ppe). the optimal way to prevent airborne transmission is via a combination of interventions from the hierarchy of controls including elimination (physical removal of hazard), substitution (replacing hazard), engineering controls, administrative controls and ppe (least effective control owing to a high level of worker involvement and dependence on proper fit and correct use). source control entails coverage of the mouth and nose by a cloth face or a facemask to aid the reduction of risk of transmission of sars cov-2 from both symptomatic and asymptomatic people via respiratory secretions. 7,8, paediatric dental practice aims to maintain the well-being and safety of children during this pandemic by redesigning, reconsidering and reflecting on the dental care practices and staying up to date with the current evidence based guidance and recommendations for child oral health care. hence a risk assessment of the practice should be carried out to identify the measures required to minimize the risk of covid-19 transmission. administrative controls and work practices: these work practices and policies reduce or prevent hazardous exposures. the practice should be cleaned thoroughly and clutter removed to facilitate frequent cleaning and disinfection. toys, magazines and other frequently touched objects in the waiting area which cannot be cleaned or disinfected regularly are removed from the waiting area. devise a protocol for receiving mails and deliveries. the number of dental setting/hospital/outpatient patients is limited and screened for respiratory illness prior to healthcare. triage by telemedicine (telephones, video-call applications on cell phones, video monitoring or tablets) and manages patients suspected of covid-19 without a face to face visit. if the signs and symptoms are present then the appointment is rescheduled. clinical care is limited to one patient at a time. the essential personnel should only be allowed to enter a patient care area. limit dhcp during a procedure to those essential for procedure support and patient care. this avoids multiple room entry and bundling. entry of known or suspected covid-19 should be restricted by the dhcp or allowed to enter with ppe. dhcp at higher risk for severe illness from covid-19 (old age, chronic medical conditions, pregnant) should be excluded from caring for confirmed or suspected covid-19. dhcp recovered from covid-19 (protective immunity) care for covid-19 patient. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 dhcp should be monitored and managed with application of flexible sick leaves. hcp should monitor themselves regularly for fever and covid-19 symptoms. they should stay at home if they feel unwell and cover their faces or leave the workplace if they start feeling unwell at work. every hcp should be screened for fever and symptoms consistent with covid-19 (fever >100.0of, cough, shortness of breath, and sore throat) when their shift commences. testing should also be done if temperature is <100.0 o f or with other symptoms consistent with covid-19. if covid-19 is ruled out based on time and test and the dhcp has an alternate diagnosis (tested positive for influenza); the criteria for return to work should be based on that diagnosis. they should continue wearing a mask subsequent to returning to work, self-monitor for symptoms and reevaluate with a medical facility. 24, 27, 28, 29 a dhcp should be trained on the use of n95 respirators (putting on, removal, limitations, maintenance, check seal, repair, replace) when caring for patients in aerosol generating procedures. they should undergo medical clearance and fit testing. a qualitative fit test is a pass/fail test relying on individual sensory detection whereas a quantitative fit test is a numerical measure of the effectiveness. cohorting confirmed patients of covid-19 in one area to confine their care prevents patient contact and minimizes the use of respirators. just-in-time fit testing is the ability of a healthcare facility for larger scale evaluation, training and fit testing of hcp prior to receiving patients during a pandemic. an annual fit may be temporarily suspended during expected shortages. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 the set up should include clean or sterile accessible supplies and instruments for specific dental procedure only. instruments should be stored in covered storage (drawers and cabinets) to maintain decontamination. they should be supplied when needed and disposed when the dental procedure concludes. safety and quality assurance checks on radiographic equipment should be performed. aed should be tested as well. all the emergency drug kits should be checked for expiry. ensure that the rechargeable items are fully charged and operational. check the drinking water dispenser for staff use and recommission by manufacturer's instructions. the computer updates should be checked and installed. minimally invasive/atraumatic restorative techniques (hand instruments) should be prioritized, aerosol-generating procedures via dental handpiece and air/water syringe should be avoided and ultrasonic scalers discontinued. when aerosol-generating procedures are necessary use four-handed dentistry to droplet spatter and aerosols may be minimized via a high evacuation suction and dental dam. preprocedural mouth rinses (pmrs) with an antibacterial product (chlorhexidine gluconate, essential oils, povidone-iodine or cetylpyridinium chloride) may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures however (ppmr) do not have evidence regarding their clinical effectiveness to reduce sars-cov-2 viral loads or to prevent transmission. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 engineering controls: barriers (glass/plastic windows/curtains) in reception areas where patients report on arrival (intake desk, triage station, information booth, pharmacy and drop-off/pick-up windows are placed to reduce the risk of exposure between the potentially infectious patients and dhcp. aerosol-generating procedures for patients confirmed or suspected of covid-19 should take place in an airborne infection isolation room (aiir). air should be exhausted directly outside or filtered directly via a high-efficiency particulate air (hepa) filter before recirculating. the expedient patient isolation room method involves high-ventilation-rate, negative pressure, inner isolation zone within a "clean" larger ventilated zone by a portable fan device with high-efficiency particulate air (hepa) filtration. it increases effective air changes per hour of clean air to the room thereby reducing the risk to persons entering without respiratory protection. twelve air changes per hour are recommended for a renovation or new construction. the ventilated headboard is a special inlet system to provide an improved air intake for a corresponding high-efficiency particulate air (hepa) fan/filter unit ventilation system with proper engineering controls (filtration, exchange rate) should be installed and maintained to provide movement of airflow in a direction from a clean (dhcp workstation or area) to a contaminated area (sick patient/clinical patient) (appropriate filtration, exchange rate) should be installed and maintained. air supply in the receptionist area with return air louvers positioned in the waiting area achieves this effect. a heating, ventilation and air conditioning (hvac) professional can increase the filtration efficiency to the highest level without deviation from designed airflow as well as increase the percentage of outdoor air supply. demand controlled ventilation (temperature setpoint and/or occupancy controls) should be limited during occupied hours and up to 2 hours post occupancy to ensure that ventilation remains unchanged. bathroom exhaust fans should run continuously during work hours. a portable hepa air filtration unit may be considered during and following an aerosol procedure. these units reduce particle count (droplets) and turn over time in the room rather than just relying on the building hvac system capacity. a hepa unit should be placed within the vicinity (chair) of a patient but not behind dhcp and the dhcp should not be positioned between the unit and the patient's mouth. the position of a unit ensures that the air is not pulled into or past the breathing zone of the dhcp. an upper-room ultraviolet germicidal irradiation (uvgi) is used as an adjunct to higher ventilation and air cleaning rates. follow environmental cleaning and disinfection procedure with hospital-grade disinfectant 9, 10, 11, 12, 13, 31, 32, 33, 34, 35, 36 patient placement dental treatment should ideally be provided in an individual patient room when possible. in open floor plan dental facilities with open floor plans the spread of pathogens man be prevented by a distance of at least 6 feet between patient chair, easy-to-clean floor-to-ceiling barriers to enhance the effectiveness of a portable hepa air filtration systems without interfering with the fire sprinkler systems and physical barriers between chairs for patients. the dental operatory should be parallel to the direction of airflow where feasible. in vestibule-type office layouts consider patient orientation by placing the head near the return air vents, away from pedestrian corridors, and towards the rear wall. the maximum number of patients who can receive care at the same time in the dental facility safely is determined by the layout of the facility, number of rooms and the time needed to clean and disinfect the operatories. it is advised that dhcp should wait at least 15 minutes after the conclusion of dental treatment and exit of the patient to commence the room cleaning and disinfection process. this allows droplets to sufficiently fall from the air after a dental procedure. 3, 24 personal protective equipment: respiratory protection (ppe) standard precautions assume that each person is potentially infected or colonized with pathogens which may be transmitted in a healthcare setting. standard precautions entail a n95 (standard and surgical medical respirators) or facemask, eye protection (goggles, protective eye wear with solid waste shields, or a full face shield), and a gown or protective clothing during procedures which produce splash, spatter of blood or body fluid and known/suspected covid-19 patients. a respirator is a ppe device worn on the face, covering least the nose and mouth to reduce the risk of inhaling hazardous airborne particles (dust and infectious agents), gases, or vapors. respirators are certified by cdc/national institute for occupational safety and health (niosh). surgical respirators are indicated for respiratory protection in airborne pathogens (tuberculosis, measles, varicella) and fluid hazard (high-velocity splashes, sprays, splatters of blood or body fluid) hence preferred over a facemask. an effective face seal of a respirator requires qualitative or quantitative measurement. the highest level of surgical mask should be used. a faceshieid is worn over a standard n95 when a surgical n95 is unavailable. n95 masks need to be conserved during the crisis period. conventional capacity provides patient care sans any alteration in existing daily practices. contingency capacity practices may be used provisionally during expected periods of n95 respirator shortages without significant impact on patient care. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 alternatives to n95 masks include filtering facepiece respirators n99, n100, p95, p99, p100, r95, r99, and r100, elastomeric half-mask (replace filter cartridges) and full facepiece air purifying respirators, powered air purifying respirators (loose fitting hoods or helmets) reusable (paprs). all of these provide equivalent or higher protection than n95 respirators when worn properly. filtering facepieces with an exhalation valve are not used in a sterile surgical setting since the unfiltered exhaled air compromises a sterile field. n95 may be retained, reserved and used beyond the shelf life during shortage in the pandemic. they may be re-used by one hcp for multiple encounters with different patients but removed (doffing) after each encounter. the time in between re-use should not exceed the 72 hours expected survival time for sars-cov2. n95 contaminated with gross blood, respiratory or nasal secretions and/or other bodily fluids should be discarded. contamination may be reduced/ prevented by wearing a facemask over it. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 a facemask block respiratory secretions produced by the dhcp from contaminating other persons and surfaces (source control) when worn with instructions in symptomatic patients suspected of covid-19 or other respiratory infection (fever, cough) but not n95. dhcp should wear a facemask at all times while they are in the dental setting as a part of universal source control. they should be instructed to not touch or adjust their mask or cloth face cover and perform hand hygiene immediately before and after. cloth face covering should not substitute a respirator or facemask. dhcp whose job does not require ppe (clerical) may wear cloth face covering. dhcp (dentists, hygienists, assistants) may wear cloth face covering when not engaged in direct patient care and switch to a respirator or a surgical mask when ppe is required. dhcp when leaving the facility at the end of their shift should remove their respirator or surgical mask and wear cloth face covering. self-contamination is prevented by changing or laundering a cloth face covering saturated with respiratory secretions, soiled, dampened or posing difficulty for breathing. hand hygiene must be performed before and after touch/adjustment of face cloth or face mask.n95 and face mask should be used according to the type of activity. a dhcp at a distance greater than 6 feet from a symptomatic patient does not need a face mask or n95. facemask may be used in a dhcp within 6 feet of an asymptomatic patient for provision of direct patient care. in other countries respirators for occupational use are approved according to country-specific standards. manufacturers sans niosh approval should only include products approved by and received from china. if the remaining supply of n95 is absent consider hepa with facemasks. extended use of facemasks and respirators should is undertaken only when the facility is at contingency or crisis capacity and has implemented all likely applicable engineering and administrative controls. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23, 37, 38 hand hygiene: hand hygiene is indicated after all patient contact, contact with infectious material and prior to wearing and removing ppe (gloves) to remove any possible pathogen transfer to bare hands. abhr with 60-95% alcohol or washing hands with soap and water for at least 20 seconds is advisable. for visibly soiled hands use soap and water before abhr. hand hygiene supplies should be available for the dhcp in every care location. 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 22, 23 use eye protection (goggles, disposable face shield) and remove them prior to leaving the operatory. reusable eye protection (goggles) must be cleaned and disinfected according to manufacturer's instructions. the disposable eye protection should be discarded after use. personal eyeglasses and contact lenses are inadequate. 24, 25, 26, 27 gloves: clean and non-sterile gloves should be worn upon entering the patient care area. they should be removed and discarded followed by immediate hand hygiene. if they are torn or heavily contaminated they should be changed. they should be educated about the signs and symptoms and diagnoses of skin reactions associated with glove use 24, 25, 26, 27 gown: a clean isolation gown is worn upon entry; changed if soiled and removed to be discarded in a waste or linen container before leaving. cloth gowns are laundered post use. gown shortage should be prioritized for aerosol generating procedures, splashes and sprays where high-contact patient care activities favor transfer of pathogens to the hands and clothing of dhcp. 24, 25, 26, 27 sequences recommended for donning and doffing ppe: j o u r n a l p r e -p r o o f before entering a patient care area perform hand hygiene and don a clean protective clothing or gown that covers skin and personal clothing likely to be soiled by potentially infectious material like blood, saliva, or other materials. if a gown and protective clothing become soiled they should be changed. a surgical mask or respirator is worn and the mask ties are secured on the crown of the head (top tie) and base of the neck (bottom tie). if loops are present hook the mask around ears. respirator straps should be placed on the crown of the head and base of the neck and checked for a user seal check each time. eye protection should not include personal eyeglasses and contact lenses. hand hygiene is followed by putting on clean non-sterile gloves. they should be changed when torn or heavily contaminated prior to entering the room. 24 after completion of dental care gloves are removed and the gown or protective clothes are discarded in a dedicated container for waste or linen. disposable gowns are discarded after each use and protective clothes are laundered after each use. exit the patient care area and perform hand hygiene, remove eye protection carefully by grabbing the strap and pulling upwards and away from head without touching the front of the eye protection. clean and disinfect reusable eye protection prior to reuse by the manufacturer's reprocessing instructions but discard disposable eye protection after use. remove and discard surgical mask or respirator without touching the front. for a surgical mask untie (or unhook from the ears) and pull it away from the face carefully without touching the front. for a respirator remove the bottom strap by touching the strap only and bring it over the head carefully. for the top strap; grasp it and bring it over the head to pull the respirator away from the face without touching the front. finally perform hand hygiene to follow standard precautions. 24 before arrival: appoint each group of patients one personnel from the dental clinic who can be reachable 24/7 in case of an emergency in order to asses and determine the need to be seen. when scheduling appointments (elective) provide instructions to the patient to call ahead of the visit and discuss the need to defer/reschedule their appointment if they experience fever or symptoms of covid-19 on the day of their appointment/visit. impart advice about their own cloth face covering, irrespective of their symptoms before entering the dental facility. schedule an appointment for possible covid-19 patients by triage to determine the need for appointment versus management at home. if the patient has to attend an appointment they must call beforehand to inform triage personnel about their symptoms of covid-19 as well as follow appropriate preventive actions throughout the visit to contain the respiratory secretions. if a face cloth is difficult to tolerate hold a tissue instead). if a patient is arriving via transport by emergency medical services (ems) allow the healthcare facility to prepare for receiving the patient. 24 upon arrival and during the visit: monitor and limit the points of entry to the dental facility as well as post visual alert posters, signs in appropriate language for instructions on respiratory hygiene, hand hygiene, cough etiquette, facemask or face cover. provide 60-95% alcohol-based hand rub, tissues and no-touch receptacles for disposal at the entrances, waiting rooms, check-in, elevators and cafeterias. minimize overlap in dental appointments and ask the patients and attending visitors to wear a face covering or mask prior to entry irrespective of symptoms of fever and covid-19. set up physical barriers (plastic or glass windows) to limit close contact between triage dhcp and potentially infectious patients. establish an outdoor triage station to screen individuals prior to entering the facility. the triage dhcp must wear a respirator/mask, eye protection and gloves for taking vitals and assessing patients for care until covid-19 is considered unlikely. 24 prioritize triage of suspected symptomatic covid-19 patients. dhcp should inquire about the presence of fever, symptoms of covid-19, or contact with patients with possible covid-19 from every patient at the time of patient check-in. covid-19 symptomatic patient should be isolated in an examination room with door closed and waiting space separated by 6 feet or more with easy access to respiratory hygiene supplies. they should not be allowed to wait among other patients. if they opt to wait in a personal vehicle or outside the facility they may be contacted by mobile phone when their turn arrives. in an afebrile patient (temperature < 100.4˚f) and otherwise without symptoms consistent with covid-19 may be provided dental care using appropriate engineering and administrative controls, work practices, and infection control considerations. the patient should be asked to wear a face cover at the completion of dental care prior to leaving the treatment area. all new fevers and symptoms consistent with covid-19 should be monitored. inadvertent treatment of a patient confirmed to have covid-19 later may occur even when dhcp screen patients for respiratory infections. the patient should be therefore be requested to inform the dental clinic if they become symptomatic or are diagnosed with covid-19 within 14 days following the dental appointment. in a patient with fever strongly associated with a dental diagnosis (pulpal and periapical dental pain and intraoral swelling) but no other symptoms consistent with covid-19; care can be provided with appropriate protocols. 24 additional strategies to minimize chances for exposure: this depends on factors like level of sars-cov-2 community transmission, number of covid-19 being cared for at a facility, healthcare-associated transmission and anticipated ppe or staffing shortages. the potential for patient harm if care is deferred needs to be determined. it is better to modify or cancel inperson group healthcare activities and implement virtual methods or schedule smaller in-person group sessions with a face cover and a distance of 6 feet apart. postpone all the dental elective procedures, surgeries and non-urgent outpatients. if a patient with a dental emergency is highly likely to cause harm by deferring treatment it is advisable to provide care without delay in facilities less heavily affected by covid-19; provide care without delay in your facility as opposed to transferring them or provide care without delay while resuming regular care practices. 24, 25, 26 facility considerations: dental equipment considerations: the manufacturer's instructions should be reviewed for instructions for use (ifu) on dental equipment for office closure, period of non-use and reopening for all equipment and devices. it may require maintenance and/or repair after a non-use period. test the quality of water for duwl prior to dental care to ensure that the standards for safe drinking water are met (< 500 cfu/ml). assess the need to shock duwl of any devices and products that deliver water used for dental procedures. the standard maintenance and monitoring of duwl should be continued according to the ifus of the dental operatory unit and the duwl treatment products. in the presence of dampness or mold (musky smell), determine the source of water entry, clean it up and remediate. indoor temperature and humidity must be maintained within recommended ranges. 30, 31, 32, 33 the autoclaves and instrument cleaning equipment should be cleaned routinely and maintained in accordance with the manufacturer's schedule. sterilizers should be checked with a biological indicator and matching control after a period of non-use prior to reopening. maintenance air compressor, vacuum and suction lines, radiography equipment, high-tech equipment, amalgam separators and other dental equipment according to manufacturer's instructions. 30, 31, 32, 33, 34 semicritical items in contact with mucous membranes or non-intact skin have a lower risk of transmission. they are heat-tolerant hence sterilized by using heat. a semicritical heat-sensitive item is processed with high-level disinfection. noncritical care items have the least risk of transmission via intact skin hence cleaned only but if an article is visibly soiled it is cleaned following disinfection with an epa-registered hospital disinfectant. in case of visible contaminated with blood or opim use epa-registered tubercocidal hospital disinfectant. blood spill can be managed by an epa-registered hospital disinfectant effective against hbv and hiv, epa-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant) or an epa-registered sodium hypochlorite product. the central processing area should be divided into sections for receiving, cleaning, and decontamination; preparation and packaging; sterilization and storage. 34 the handpeice should be run to run to discharge water, air, or a combination for a minimum of 20-30 seconds after each patient to physically flush out material that may enter the turbine and air and waterlines heat methods can sterilize dental hand pieces and other intraoral devices attached to air or waterlines. manufacturer instructions should be followed for cleaning, lubrication, and sterilization should be followed to ensure their effectiveness and longevity of hand pieces. handles or dental unit attachments of saliva ejectors, high-speed air evacuators, and air/water syringes should be covered with impervious barriers which are refreshed after each use. visible contamination requires cleaning with an intermediate disinfectant prior to replacing the barriers. 30, 31, 32, 33, 34 radiograph cross-contaminate equipment and environmental surfaces with blood or saliva hence use an aseptic technique, wear gloves when taking radiographs and handling contaminated film packets, wear additional ppe (mask, eyewear, gown) for blood or other body fluid spatter. heat-tolerant intraoral radiograph accessories may be heat sterilized for semicritical items like film-holding and positioning devices before patient use digital radiography sensors and other high-technology instruments (intraoral camera, electronic periodontal probe, occlusal analyzers, lasers) are semicritical devices which may be cleaned, heat-sterilized or high level disinfected. 30, 31, 32, 33, 34 reprocess heat-sensitive critical and semi-critical instruments by using sterilant/high-level disinfectants or low temperature sterilization method (ethylene oxide). single-use devices are usually heat-intolerant cannot be reliably cleaned. syringe needles, prophylaxis cups and brushes, and plastic orthodontic brackets, prophylaxis angles, saliva ejectors, high-volume evacuator tips and air/water syringe tips, cotton rolls, gauze, irrigating syringes should be disposed after each use. endodontic burs, files, broaches, diamond and carbide burs should be considered single use. laboratory items (burs, polishing points, rag wheels, laboratory knives) should be heat-sterilized, disinfected or discarded. heat-tolerant items used in the mouth (metal impression tray, face bow fork) should be heat-sterilized. articulators, case pans and lathe should be cleaned and disinfected. semicritical instruments needed for immediate use or use within a short time may be sterilized unwrapped on a tray or a container system. critical instruments for immediate reuse can be sterilized unwrapped if the instruments are transported in a sterile covered container during removal from the sterilizer and transport to the point of use however critical items should not be stored unwrapped. 30, 31, 32, 33, 34 personnel subject to occupational exposure should receive training for infection-control in combination with standard precautions, engineering, work practice, and administrative controls to reduce occupational exposures to blood to prevent transmission of hbv, hcv, and hiv. dhcp are at a significant risk for acquiring or transmitting hepatitis b, influenza, measles, mumps, rubella and varicella which are vaccine-preventable. they should be vaccinated for hepatitis b vaccine however routine immunization for tb is not recommended. the vaccine for hepatitis c vaccine is still unavailable and the risk of hiv transmission in dental settings is extremely low. hbsag-positive persons should be counseled about hbv transmission prevention and for medical evaluation. 39 environmental infection control: environmental cleaning and disinfection procedures should be followed correctly and consistently. water should be run through pipes and taps in surgeries, kitchen, bathrooms and showers. a liquid chemical sterilant/high-level disinfectant should not be used as a holding solution or an environmental surface disinfectant. after working on a patient without suspected or confirmed covid-19; wait 15 minutes after completion of clinical care and exit of each patient to begin to clean and disinfect room surfaces of the dental operatory. this allows droplets to fall from the air after a dental procedure to perform sufficient disinfection. entrance in the operatory is delayed until time elapsed allows air changes to remove potentially infectious particles. cleaning and disinfection procedures include cleaning of frequently touched surfaces or objects and aerosol generating areas with cleaners and water followed by application of environmental protection agency-registered, hospital-grade disinfectant based on contact times shown on the product's label. alternative methods for disinfection which can be instituted include ultrasonic waves, high intensity uv radiation, and led blue light however their efficacy against covid-19 virus is unknown. sanitizing tunnels are not recommended for use by cdc. 39, 40, 41, 42, 43 the purpose of laundry is to protect the worker from exposure to potentially infectious materials throughout the stages of collecting, management and arranging of contaminated materials via ppe, work practice, containing, labels, ergonomics and hazard communication. hot water washing is recommended at 160°f (71°c) at least for a minimum of 25 minutes. chlorine residual of 50-150 ppm is attained during the bleach cycle and chlorine bleach is activated at 135°f-145°f (57.2°c-62.7°c) water temperature. rinse cycles add a mild acid (sour) to neutralize the alkalinity in water soap, or detergent. dry cleaning is an alternative cleaning process utilizing organic solvents (perchloroethylene) for removal of soil from fabrics that may have been damaged in conventional laundering. waste should be handled with ppe and wastewater treatment facilities include oxidation with hypochlorite (chlorine bleach) and peracetic acid and inactivation via uv irradiation. puncture-and chemical-resistant/heavy duty utility gloves should be worn for instrument cleaning and decontamination procedures. ppe should be worn during cleaning when splashing or spraying is anticipated. food service utensils should be managed in accordance with the infection control policy. 39, 40, 41, 42, 43 extracted teeth are potentially infectious hence disposed in medical waste bins. extracted teeth sent to a dental laboratory for shade or size comparisons should be cleaned, surface-disinfected with an eparegistered hospital disinfectant with intermediate-level activity (tuberculocidal). extracted teeth containing dental amalgam should not be placed in a medical waste container that uses incineration for final disposal since they may be given to recycling company. they may be returned to the patient on request hence standard maintenance does not apply. dental prostheses, appliances, and items used in fabrication (impressions, occlusal rims, bite registrations) must be managed by optimum communication and coordination between the laboratory and dental practice with appropriate cleaning and disinfection with an epa-registered hospital tuberculocidal disinfectant. parenteral medication should be administered with an aseptic technique. a single syringe should not be used for multiple patients even if the needle has been changed perform surgical hand antisepsis by an antimicrobial soap and water, or soap and water followed by alcohol-based hand scrub prior to wearing sterile surgeon's gloves. 39, 40, 41, 42, 43 risk assessment and work restrictions for dhcp with potential exposure to covid-19: the close contact with vulnerable individuals in dental settings requires a conservative approach to monitoring and applying work restrictions to prevent transmission from potentially contagious dhcp to patients, other hcp/dhcp and visitors. the contact tracing of exposed dhcp and application of work restrictions depends upon the degree of sars-cov-2 community transmission (minimal-no, moderate) and their resources. high-risk exposures involve exposure of dhcp eyes, nose, or mouth to material potentially containing sars-cov-2 particularly from aerosol-generating procedure (prolonged exposure for 15 minutes or more). exposure not included as higher risk include body contact with the patient without ppe and hand hygiene and touching the eye, nose, or mouth with the same hands. exposures can occur from a suspected case of covid-19 or from a person under investigation (pui). a record should be maintained for a dhcp exposed to puis. if the test results are delayed over 72 hours or the patient is covid-19 positive then the work restrictions apply. a dhcp with prolonged close contact with a patient, visitor, or dhcp with confirmed covid-19 should be excluded from work for 14 days after last exposure, self-monitored for fever or symptoms consistent with covid-19 and contact their medical evaluation and testing facility if fever or symptoms consistent with covid-19 develop. 44 dhcp with risk exposures other than high exposure risk do not require work restrictions. they should follow infection prevention and control practices by wearing a facemask at work, self-monitoring for fever or symptoms consistent with covid-19, not reporting to work when ill and undergoing screening for fever or symptoms consistent with covid-196 when their shift commences. a dhcp who develops fever or symptoms consistent with covid-196 should immediately self-isolate and contact a medical evaluation and testing facility. dhcp with travel or community exposures should inform their health facility for guidance on need for work restrictions. for covid-19 confirmed symptomatic individuals consider the exposure window to be 2 days before symptom onset through the time period. for covid-19 confirmed asymptomatic individuals determining the infectious period can be challenging. they must be considered potentially infectious commencing 2 days post exposure until they fulfill the criteria for discontinuation of transmission-based precautions. if the date of exposure is undetermined, use a starting point of 2 days prior to the positive test through the time period when the individual fulfills the criteria for discontinuation of transmission-based precautions. when reopening a practice post covid-19 shutdown follow the dental practice reopening guidelines. 44 dental caries risk assessment: it is based on patient specific risk indicators including prior caries experience and longitudinal evaluation of caries progression. longitudinal evaluation at each visit considers cavitation of white spot lesion and increased dimension. progression in the existing white spot lesion is considered an increased risk status. other caries risk factors include a high frequency of fermentable carbohydrate, maternal caries and socioeconomic status of the family. surgical management of the enamel carious lesions is based on visual detection, shadowing under the enamel and radiographic enlargement of lesion. active surveillance of caries monitors initial carious lesion progression instead of definitive treatment. active surveillance strategies include preventive therapy with compliance and recall. 45 children are considered at a low caries risk if they have no caries, no new lesion in 1 year, no white spot lesions and belong to a high socioeconomic status. they receive a clinical examination at twelve months and a diagnostic radiograph at twenty four months. preventive therapy includes tooth brushing twice a day with a fluoride toothpaste twice a day and fissure sealants. restorative therapy is not indicated. 45 children considered at a medium risk of caries have or have had one or more lesions per year and belong to a middle socioeconomic status. they require a diagnostic examination at twelve months and a radiographic assessment between twelve to fourteen months. preventive regimen includes tooth brushing with fluoride toothpaste, a six monthly application of topical fluoride and provision of fissure sealants. restorative therapy entails active surveillance of carious white spot lesions and proximal enamel lesions. progressive and cavitated carious lesions maybe managed by restorative therapy or by an aerosol free topical application of silver diamine fluoride. 45 children are considered to be at a high risk if they have or have had one or more proximal lesion, have more than two lesions per year, have white spot lesions or enamel defects, active caries in a mother or caregiver, wear appliances, have a high sugar consumption and belong to low socioecenonmic status. they require a clinical examination at an interval of three months, a radiograph at an interval of six months and dietary analysis. preventive care includes tooth brushing with a fluoride toothpaste twice a day, systemic fluoride supplements, professional topical fluoride application every 3 months, fissure sealants and brushing with a high potency fluoride gel in a child over 6 years of age. restorative care includes surveillance of white spot lesions, restoration of proximal caries and restoration of progressing and cavitated lesions or treatment with topical application of silver diamine fluoride. 45 early childhood caries (ecc): early childhood caries (ecc) is defined as one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child under 6years. severe early childhood caries (secc) is defined as any sign of smooth-surface caries in a child < 3 years of age, and from ages 3 through 5, one or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of greater than or equal to four (age 3), < than or = to five (age 4), or < than or = to six (age 5). 46 caries disease process initiates as early as the first year in the life of a child. this highly prevalent global chronic disease is cost intensive and impacts the quality of life of a child and their parents. cries management is child specific management of caries process via primary, secondary and tertiary prevention. ecc reduction approaches focus on inter-professional care to ensure access to oral health for infants/toddlers and raise awareness regarding the adverse sugar consumption effects. 47 primary prevention encompasses prenatal health care, avoidance of night time bottle feed with sugary drinks or milk, restricting sugar intake and frequency for children younger than 24 months, avoiding frequent/nocturnal breast or bottle feeding after 1 year, exposure to dietary fluoridate (water, milk, salt), use of an age appropriate amount of fluoride toothpaste containing at least 1000ppm fluoride for brushing at least twice a day, dental visit in the first year of life and regular applications of 5% fluoride. secondary prevention comprises of more frequent fluoride application with fissure sealing for arresting caries progression prior to cavity formation. tertiary prevention combines non-invasive and invasive management for cavitated lesions. topical application of silver diamine fluoride arrest and prevent noncavitated and progressive cavitated dentinal lesions in an aerosol free environment. 47 fluoride: fluoride is the cornerstone of caries prevention. it functions by arresting or inactivating carious lesions as a therapeutic agent in nrct (non-restorative caries treatment). addition of optimum fluoride level to community water supply (0.5 to 1.1 mg/l) helps reduce the caries prevalence safely and effectively. hence this stable public health practice benefits all the residents irrespective of their level of education, oral hygiene practices, socioeconomic background, employment status or access to oral health care. 48 brushing the teeth twice a day with a fluoridated toothpaste containing 1000ppm f at least and with an age appropriate amount on a tooth brush reduces caries effectively. the recommended use of fluoride toothpaste in a child upto first two years is 1000ppm f, twice a day with a grain sized amount of 0.125g. for a child between two to six years of age the recommended use of fluoride toothpaste is 1000ppm f, twice a day with a pea sized amount of 0.25g. in a child over six years of age the recommended use of fluoride toothpaste is 1450 ppmf, upto full length of brush amount of 0.5-1.0g. hence this is a convenient, widespread, inexpensive and culturally approved approach to caries prevention in a safe and effective manner. the amount of toothpaste used is important since children tend to swallow the toothpaste which poses a risk for fluorosis. the recommended use of fluoride toothpaste based on standard prevention in children less than 3 years is 1000 -1500ppm f. enhanced prevention for children over 3years includes 1350-1500 ppm f and for children over ten years includes 2800ppm f. 48 professional topical fluoride varnish application containing 5% f (22,600ppmf) or gel containing 1.23% f (12,300ppmf) may reduce caries in children. in a child over 6 years of age and at a high risk of caries 0.5% fluoride gels and pastes are recommended. fluoride supplements consisting of tablets/lozenges and drops may be considered in fluoridated water deficient area. their intake should not exceed 0.07mg/kg body weight daily and should be used with care to prevent oral topical effects. non-cavitated and cavitated dentinal lesions can be arrested or prevented successfully by the use of aerosol free sdf 38% silver diamine fluoride containing 5% fluoride (44,800ppmf). 48 minimally invasive dentistry: the current paradigm shift focuses on minimally invasive management strategies which arrest caries by assessing the caries risk, early detection of caries, implementing prevention measures, promoting enamel and dentine remineralization, instituting minimally invasive surgical interventions and repairing restorations conservatively as opposed to replacement. these techniques work well in conjunction with fluoride exposure and good oral hygiene for both non-cavitated and cavitated lesions. they allow the reversal of demineralized lesions (non cavitated) thereby arresting naturally. proximal non-cavitated lesions may be managed by a micro invasive infiltration method. cavitated lesions can be arrested by topical application of aerosol free 38% sdf (silver diamine fluoride). surgical intervention advocates a minimal cavity design, conservative caries removal from deep lesion and adhesive restorative material. 49 erosion: it is an irreversible tooth structure loss arising by chemical dissolution via intrinsic sources (gastric acid) or extrinsic sources (diet) but not bacterial acid. the thin and less mineralized enamel of primary dentition renders it more susceptible to erosion. bulimia erodes the lingual surface of upper incisors whereas gastrooesophageal reflux erodes the molars. dietary acid can erode any surface but it is avoidable by cutting down acidic food and beverage exposure. diagnosis necessitates the need for discerning the etiology if the diagnosis is by location and level of erosion. management includes regular monitoring and the use of a fluoride containing toothpaste or mouthwash containing stannous fluoride, addressing the etiology addressed and delaying the restorative intervention for monitoring. minimally invasive techniques may be applied for restoration of teeth which hurt. a medical referral is indicated for patients with dental erosion due to gerd and bulimia. 50 periodontal disease: periodontal assessment for primary teeth includes clinical and radiographic evaluation of the gingiva, periodontium, alveolar bone levels and tooth mobility. permanent dentition should be assessed subsequent to complete eruption. triaging helps evaluate conditions which may have four combinations. they may have healthy gingiva with healthy bone, healthy gingiva with diseased bone (eg hypophosphatasia), diseased gingiva with healthy bone (eg herpetic gingivostomatitis) and diseased gingiva with diseases bone (neutrophil defects). 51 generalized gingivitis continuing over 2 weeks is viral in origin due to an underlying systematic cause. they require periodontal culturing to rule out anaerobic bacteria triggering an aggressive immune j o u r n a l p r e -p r o o f response (papillon-lefevre syndrome or neutorpenias). a medical referral with regular follow up assists in ruling out chronic idiopathic neutropenia, cyclical neutropenia and leukemia. hypophosphatasia may be considered in a non-traumatic premature primary incisor loss before 4 years of age with a concomitant diagnosis of cementum pathology. langerhan's cell histiocytosis may be deliberated in premature eruption of primary molars in the neonatal period. diagnosis is confirmed upon presence of birbeck granule in specimen for gingival biopsy from the molar region. 51 effectiveness and compliance of medication for enhancing immune response in patients with systemic disease (gcf in cyclical neutropenia or insulin treatment in insulin-dependent diabetes) is ascertained by regular monitoring of gingival and periodontal health. stem cell transplant may be carried out to improve immunity for improved periodontal health in children in chronic granulomatous disease and leukocuyte adhesion deficiency disorder however it is very rare. 51 mih is a qualitative, enamel developmental defect which involves one or more posterior teeth with or without permanent anterior. they present as a demarcation, creamy/white to yellow to brown patches with or without post eruptive breakdown and sensitivity. it may range from mild to severe and impair tooth brushing. primary molars with hypomineralization predispose the permanent dentition to a higher risk of mih. early diagnosis concomitant with prevention and restorative care prevents subsequent progressive breakdown, hypersensitivity and pulpal inflammation. 51 the adhesive restorations should include sound enamel since bonding for sealants and composites is compromised. atypical amalgam restorations needing more retentive features may aggravate the tooth defect and result in a high failure. gic temporization despite a high failure rate can be utilized. aesthetics in mild incisors may be conservatively managed by combining etching, bleaching and sealing. severe cases may be managed by microabrasion or composite veneers and a full coronal coverage for the molars. restorations have a poor long term outcome in this dental anomaly. if one or more teeth are affected with severe mih and pain consider extracting the first permanent molars prior to the eruption of second permanent molars (8-9 y). the occlusion will determine the need for an orthodontic alignment. recall will prevent failure of restorations, recurrent caries and post eruptive breakdown. sensitivity may be managed by topical fluoride varnish application and arginine desensitization paste however hypersensitivity may require local anaesthesia for restorative management. 52 developing dentition: malocclusion in the developing dentition needs recognition, risk factor identification (environmental, etiologic, premature primary tooth loss), diagnosis and optimum treatment. this contributes to a stable, functional and aesthetic occlusion in the permanent dentition. the developing dentition is evaluated clinically (palpation), by radiographs and functional analysis for habits, airway, tooth size and shape, anomalies, anterior and posterior crossbite, skeletal discrepancy, periodontal health for achieving a diagnosis. breast feeding reduces non-nutritive habits which may otherwise require management appropriate for the child's development, comprehension, malocclusion and the ability to cope with treatment. space maintainers prevent space loss due to premature primary tooth loss. minor interceptive orthodontics can manage aesthetics in an increased overjet which predisposes the incisors to an increased risk of trauma. 53 special care dentistry: in special care dentistry basic advice and dental intervention have a high impact on pain management and clinical outcomes. during the pandemic triaging, ranking, conceding and making challenging choices have become a daily actuality. telecommunication can enhance communication and provide psychological counseling and advice for special needs patients however phobia, learning disabilities and attention deficit hyperactivity disorder (adhd) do not tolerate any form of local anaesthesia require sedation and general anaesthesia which is currently suspended. they can benefit from alternative techniques (gradual exposure, behavioral management, hypnotherapy, professional cognitive behavioral therapy (cbt), desensitization methods, virtual goggles for distraction) in a more adjustable dental service. there is a need to balance and weight the clinical decisions and review service capacity and patient's safety regularly. 54 dental emergency treatment: commonly presenting acute oral conditions/problems need a modified and consistent management approach. management of dental emergencies focuses on triage, relief from pain (analgesia) or infection (antimicrobial) and provision of care via remote consultation (videocall or telephone). referral is indicated in unmanageable severe or uncontrolled symptoms with adequate documentation. 55, 56 dental triage of usually presenting dental conditions categorizes patients into three types. the first type requires advice and self-help. they have mild -moderate symptoms which can be managed remotely by analgesics and antimicrobials. the second type requires urgent care. they have severe or uncontrolled symptoms which are unmanageable by a patient and require the patient to see a dentist in a designated urgent dental care center. the third type is emergency care for emergency conditions which require immediate attention. 55 acute apical abscess includes pain (localized to a single tooth); swelling of the gingiva, face or neck; fever, listlessness, lethargy and loss of appetite in children under 16 years of age. management by selfhelp includes analgesics and antibiotics (swelling/systemic infection) with a recall after 48-72 hours. urgent care by extraction or drainage is needed for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise or trismus. 55 acute periodontal abscess/perio-endo lesions include pain and tenderness of gingival tissue, increased tooth mobility, fever and swollen/enlarged regional lymph nodes, presence of swelling on gingiva and gingival suppuration. management by self-help includes analgesics and antibiotics (swelling/systemic infection) with a recall after 48-72 hours. urgent care is for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise or trismus. 55 acute pericoronitis includes pain around a partially erupted tooth, swelling of gingiva around the erupting tooth, discomfort on swallowing, limited mouth opening, halitosis (unpleasant mouth odour), fever, nausea and fatigue. advice and self help include analgesia, chlorhexidine mouthwash/gel or warm salt water mouthwash, gentle toothbrushing of the affected area with a small head toothbrush in combination with benzdyamine mouthwash, antibiotics (swelling/systemic infection) and recall after 48-72 hours. urgent care by extraction is for spreading infection without airway compromise or continuing or recurrent symptoms. emergency care is indicated for spreading infection with an airway compromise and/or severe trismus. 55 necrotizing ulcerative gingivitis/periodontitis include pain (localized/generalized), swelling, gingival bleeding, halitosis, gingival ulceration, fever and malaise. advice and self help include optimal analgesia, chlorhexidine or hydrogen peroxide mouthwash/gel, gentle toothbrushing of the affected area with a small head toothbrush in combination with benzdyamine mouthwash or spray and metronidazole as the antibiotic drug of choice. 55 reversible pulpitis includes intermittent or stimuli associated toothache with tenderness to percussion. advice and self help care recommend analgesia, repair of a missing filling with an emergency temporary repair kit from a pharmacy or online, avoidance of hot or cold food and to call back if the sypmtoms worsen. 55 irreversible pulpitis includes sharp and spontaneous pain which lasts for several hours and keeps the patient awake and pain which is difficult to localize to a single tooth, it may be dull or throbbing and worsened by heat and alleviated by cold. advice and self help recommend analgesia, cold water rinses and to call back if symptoms worsen. urgent care is needed when the severe and uncomfortable pain prevents sleeping or eating. management includes extraction at an urgent dental care centre. 55 dentine hypersensitivity includes sharp, sudden or short duration pain and exposed root surface secondary to gingival recession. advice and self help recommend application of desensitizing toothpaste to the affected area and avoidance of stimulus which include cold or acidic food and drinks. 55 dry socket includes pain which arises 24-48 hours after extraction in the vicinity of site of extraction. the socket is tender with an unpleasant taste or odour and occasional swelling. advice and self help include analgesis, warm salt water mouthwash and antibiotics in infection (spreading or systemic) or a patient who is immunocompromised. urgent care is required for dressing if the pain is severe, uncontrollable and prevents sleeping or eating. 55 post extraction haemorrhage entails bleeding which may be immediate, within a few hours secondary to inadequate initial hemostasis or within a few weeks due to possible infection. advice and self help include no spitting or rinsing, gentle rinses with warm but not hot salt water mouthwash to remove the excess blood, placing a rolled up piece of cotton or gauze moistened with saline or water on the socket and firmly biting on it to maintain a solid and continuous pressure for 20 minutrs prior to checking for bleeding. the patient is advised to avoid smoking, exercising, drinking alcohol or disturbing the clot after the bleeding has stopped. urgent care is required when the bleeding stops but is not brisk and persistent. emergency care is recommended when the bleeding fails to stop, is brisk and persistent. the patient should be asked about anticoagulant medication (warfarin, clopidogrel, aspirin). 55 oral ulceration include pain (lip and/or oral cavity), ulceration, inflammation, abnormal appearance and dehydration or listlessness or agitation if severe. advice and self help for ulcers less than three weeks include chlorhexidine mouthwash under 7y, analgesia or topical benzdyamine oromucosal spray, soft diet, keeping the dentures clean or use a repair kit for trauma from an adjacent tooth. if the ulcers are due to primary herpetic gingivostomatitis, herpes zoster infection or in an immunocompromised patient consider antiviral agents (acyclovir or penciclovir) in the early stages. urgent care is advised for ulcers persisting over three weeks. if the ulcers are due to an underlying medical condition then a medical practitioner should be consulted. emergency care is for oral ulceration with severe dehydration. 55 cracked, fractured, loose or displaced tooth fragments lead to pain (generalized or localized), tenderness to bite, sensitivity to hot cold and sweet food, open cavity, missing section of a tooth or filling, sharp edge on the tooth, mobile tooth or fragment, mobility or loss of restoration, soft tissue trauma (tongue, lip, cheek ), gingival inflammation or recurrent caries. emergency care is indicated for inhalation of a piece of tooth, filling or restoration. advice and self help for broken or fractured teeth and filling includes emergency temporart repair kit for sensitive teeth, analgesia and call back if pain persists. prosthesis (crown, bridge or veneer) may be repaired by an emergency repair kit with analgesics for pain relief. 55 ill fitting or loose dentures result in pain (general, localized), difficulty in speech and mastication. advice and self help include analgesia, removal of denture and routine dental care when the services have resumed. 55 trauma from a fractured or displaced orthodontic appliance causes pain and soft tissue injury. emergency care is required if the airway is compromised or the patient inhales or ingests pieces of a fractured appliance such as brackets. however brackets pass the bowel without incident. for advice and help the patient maybe referred to the orthodontic guidelines (british orthodontic society). 55 avulsed, displaced or fractured teeth encompass a fracture of tooth or loss of structure, increased tooth mobility or several teeth mobile as a unit, displacement or elongation or an empty socket. urgent care if a permanent tooth has been avulsed (knocked out) includes handling the tooth with care by the crown (white part) and avoid touching the root, washing the tooth briefly for ten seconds under cold running water if dirty, re-implant it in the socket and bite on it with a handkerchief gently to hold it in position. if it is not possible to re-implant the tooth, it may be transported in milk (not water) or in the mouth between molars and inside of the cheek. a permanent tooth which has moved out of its usual position to affect the bite should be referred to an urgent care center. a permanent tooth fracture involving pulp should also be referred to an urgent dental care center. a permanent tooth fracture of the enamel and dentine requires advice and self help for applying a desensitizing toothpaste, analgesia and soft diet. a primary tooth which has moved out of its position and interferes with the bite requires urgent care. if a primary tooth has displaced without affecting the bite advice and self help should include information about soft diet and analgesia. a primary tooth which has been avulsed (knocked out) requires advice and self help for analgesia and soft diet however it should not be re-implanted. 55 dento-alveolar injuries include pain, bleeding, swelling, teeth/dentures which do not meet together, mobility, praesthesia, other problems related specifically to bone fractures (nose bleed, diplopia, visual loss). emergency management is necessitated for severe bleeding which does not stop within 15-30 minutes, significant facial trauma, head injury or loss of consciousness and inhalation of a tooth or a tooth fragment. advice and self help for cases which do not have an emergency includes cleaning the affected area by gentle rinsing with a mild antiseptic, removing foreign objects from the mouth, applying ice pack to the soft tissue injury and swelling, applying pressure with a finger to stop bleeding and analgesia. antibiotics are not indicated for non-emergency situations. 55 hence successful outcomes depend on an optimum advice and timely emergency dental care. moderate dental pain can be managed in adults by paracetamol, 2 x 500mg tablets upto four times daily (4-6 hourly for 5 days or with ibuprofen, 2 x 200mg tablets upto four times a day (4-6 hourly) first after food. severe dental pain can be managed by increasing the dose of ibuprofen to 3 x 200mg tablets upto four times a day right after food or combining ibuprofen with paracetamol after food without exceeding the daily dose/frequency or by diclofenac, 1 x 50mg tablet upto three times a day in combination with paracetamol. maximum dose of drug in twenty four hours is 4 g paracetamol, 2.4 g ibuprofen and 150 mg diclofenac. contraindications for diclofenac and a high dose of ibuprofen (more than 1.6 g daily) include moderate or severe asthma, renal impairment or hypersensitivity to aspirin. the regimen for adult patient requiring a proton pump inhibitor include iansoprazole, 1 x 15 mg capsule daily for 5 days or omerprazole, 1 x 20mg capsule daily for 5 days. 56 analgesic doses for children: dental pain is managed in children by paracetamol suspension (120 mg/5 ml or 250 mg/5 ml) or tablet (500 mg). the age dependent dose can be given upto four times a day. the dose recommended for 6-12 month old is 120mg, 2-3 years is 180mg, 4-5 years is 240 mg, 6-7 years is 240-250 mg, 8-9 years is 360-375 mg, 10 -11 years is 480-500 mg, 12-15 years in 480 -750 mg and 16-17 years is 500mg -1g. the alternative drug is ibuprofen sugar free suspension (100 mg/5 ml) or tablet (200 mg). this age dependent drug is given upto three times a day. the recommended dose for 1-3 years is 100 mg, 4-6 years is 150 mg, 7-9 years is 200 mg and 10 -11 years is 300 mg. the doses for 6-11 months is 50 mg and x 400 mg tablet, three times a day. the dose of amoxicillin or phenoxymethylpenicillin may be doubled in severe infections (extra oral swelling, eye closing or trismus). 56 antimicrobials for children: dental infections in children can be managed by amoxicillin, phenoxymethylpenicillin or metronidazole. amoxicillin is administered as a sugar free oral suspension (125 mg/5 ml or 250 mg/5 ml) or capsule (250 mg). the age dependent dose can be given three times a day. the dose for 6-11 months is 125 mg, 1-4 years is 250 mg, 5-11 years is 500 mg and 12-17 years is 500 mg. the dose of amoxicillin for severe dental infections in children from 6 months to 11 years the may be increased upto 30 mg/kg (max 1g) for 3 times a day. for severe infection in children between 12-17 years the dose of amoxicillin maybe doubled. phenoxymethylpenicillin is available as a sugar free oral solution (125 mg/5 ml or 250mg/5 ml) or tablets (250 mg). the age dependent dose can be given upto 4 times a day. the dose for 6-11 months is 62.5 mg, 1-5 years is 125 mg, 6 -11 years is 250mg and 12 -17 years is 500 mg. for severe infections in children upto 11 years the dose of phenoxymethylpenicillin can be increased upto 12.5 gm/kg for four times a day. for severe infections in children aged 12-17 years the dose maybe increased upto 1g for four times a day. metronidazole is available as an oral suspension (200 mg/5 ml) or a tablet (200 mg). the dose dependent medicine can be administered upto three times a day unless indicated otherwise. the dose for 1-2 years is 50 mg, 7-9 years is 100mg and 10-17 years is 200 mg. the dose for 3-6 years is 100mg given twice a day as opposed to thrice a day. 56 first line of antimicrobials for dental infections: acute apical abscess, acute periodontal abscess/perioendo lesions are managed by a 5 day course of amoxicillin, phenoxymethyl penicillin or metronidazole whereas acute pericoronitis, necrotizing ulcerative gingivitis/ periodontitis can be managed by a 3 day course of metronidazole or amoxicillin. 56 it is necessary to check the patient's current use of analgesics before advising or prescribing analgesics. paracetamol in many over the counter preparations should be identified in all medications which have been ingested. an overdose is dangerous because it may cause fatal hepatic damage that is sometimes not apparent for 4-6 days. refer a patient for an emergency assessment if they ingest a therapeutic excess of more than the recommended daily dose [8 x 500 mg tablets for adults] and more than or equal to 75 mg/kg in any 24-hour period. paracetamol is the analgesic of choice for women who are breastfeeding. for a pre-term, or low birthweight infant seek advice from a gp. absorption, distribution, metabolism, or excretion of paracetamol may be affected by an underlying medical condition. paracetamol is a suitable analgesic option in most people with liver disease but dose reduction might be required for some patients with moderate or severe acute hepatitis. for people taking anticoagulants paracetamol is considered safer than aspirin or nsaids because it does not affect platelets or cause gastric bleeding. patients should have their usual inr check planned and inform their clinician if they have been using paracetamol regularly. use paracetamol and ibuprofen with caution in children (asthma). a gp should be contacted when uncertain about a patient's medical condition, current medication or suitable analgesia. 56 use nsaids with caution and if absolutely necessary use the lowest effective dose for the shortest time possible. patients already taking an nsaid (prescribed or not) regularly for a non-dental condition should not take an additional nsaid to control dental pain. ibuprofen should be prescribed with caution for patients taking low dose aspirin since the administration of additional nsaid may reduce the cardioprotective benefit of low dose aspirin and increases the risk of gi bleeds. in patients taking low dose aspirin, if an nsaid is necessary to control the pain, consider ibuprofen up to 1200 mg maximum daily with a ppi or contact the gmp for advice. elderly patients at increased risk of cardiovascular, renal, and serious adverse effects including gi bleeding and perforation, which may be fatal should be prescribed ibuprofen with caution not exceeding 1200 mg ibuprofen per day with a ppi. diclofenac is contraindicated. monitoring blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. avoid nsaid's in people with dehydration, due to risk of acute kidney injury. chronic alcoholism and alcohol dependence increases the gi risk is increased with nsaids hence avoid nsaids if possible or prescribe with a ppi. prescribe ibuprofen with caution to people with cerebrovascular disease, ischaemic heart disease, peripheral arterial disease, or risk factors for cardiovascular events like hypertension, hyperlipidaemia, diabetes mellitus and smoking. prescribe it with caution in cardiac impairment or mild to moderate heart failure (nsaids may impair renal function) but not in severe heart failure. prescribe up to 1200 mg per day as a first-line option (lower dose than the 4 x 400 mg per day regimen recommended in the bnf for dental pain). for higher doses liaise with the patient's gmp. monitor blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. liaise with the patient's gmp to discuss. if in doubt about the severity of the patient's heart failure or appropriate analgesics, consult with their gmp. prescribe nsaids with caution to people with inflammatory bowel disease (nsaids may increase the risk of developing or cause exacerbations of ulcerative colitis or crohn's disease). prescribe nsaids with caution to people with mild to moderate hepatic impairment (do not prescribe in severe hepatic impairment). dose reductions and monitoring of liver function may be necessary. prescribe nsaids with caution to people with severe renal impairment and avoid if possible since sodium and water retention may occur leading to deterioration in renal function and, possibly renal failure. if the patient cannot avoid using an nsaid and has impaired renal function, monitor renal function 1-2 weeks after starting or increasing the dose of an nsaid. avoid concomitant use of nsaids with anticoagulants (e.g. warfarin, dabigatran) if possible. all nsaids can cause gi irritation and reduce platelet aggregation, which can worsen any bleeding event. if concurrent use is necessary be aware of the potential risks of bleeding. consider giving gastroprotection. liaise with the patient's gmp if a ppi is required but is not currently prescribed. prescribe nsaids with caution for patients with bleeding disorders (e.g. haemophilia, von willebrand disease and clotting factor deficiencies). consult with the patient's gmp or haematologist. 56 discussion: the role of dental professionals in preventing the transmission of covid-19 is critically important since it has the most risk of spreading the virus than any profession in relation to covid-19. dentistry follows the principle of universal precautions for cross-infection control to safe guard the dental health care professionals and the patients. hence the strict cross infection control measures and the awareness of j o u r n a l p r e -p r o o f infectious diseases transmission are leading to a better level of infection prevention control and better personal protective measures in a dental setting. acute/chronic oral medicine issues are managed over the phone and medication regimens are continued as previously prescribed to avoid detrimental effects of sudden change in pharmacotherapy. organized urgent dental care delivered by dhcp in appropriate ppe (gowns, gloves, ffp3 masks and eye protection) with high-volume aspiration and other measures to reduce/avoid the production of droplets, splatter and aerosols by dental drills and saliva. the profound impact of the sars-cov2 pandemic on dentistry necessitates that a paediatric dentist stays up to date with the current resources and evidence based guidance on dental care for children. the revised consensus guidelines highlight revised infection control protocols, management of suspected and possible cases of covid-19 virus and risk based management of pediatric dental emergencies with medication or intervention. patients treated for covid-19 in icu will require care since they are at a high risk of deterioration of oral health. 57, 58 conclusion: covid-19 viral transmission concern necessitates the implementation of specific protocols to reduce the risk and spread of infection from patient to another person or medical tools and equipment. this narrative review article discusses and suggests the modification of patient management, clinical practice, introduction of devices and organizational practices during the covid-19 and the way forward with reference to paediatric dentistry. paracetamol is considered safer than aspirin or nsaids because it does not affect platelets or cause gastric bleeding. patients should have their usual inr check planned and inform their clinician if they have been using paracetamol regularly. use paracetamol and ibuprofen with caution in children (asthma). a gp should be contacted when uncertain about a patient's medical condition, current medication or suitable analgesia. 56 use nsaids with caution and if absolutely necessary use the lowest effective dose for the shortest time possible. patients already taking an nsaid (prescribed or not) regularly for a non-dental condition should not take an additional nsaid to control dental pain. ibuprofen should be prescribed with caution for patients taking low dose aspirin since the administration of additional nsaid may reduce the cardioprotective benefit of low dose aspirin and increases the risk of gi bleeds. in patients taking low dose aspirin, if an nsaid is necessary to control the pain, consider ibuprofen up to 1200 mg maximum daily with a ppi or contact the gmp for advice. elderly patients at increased risk of cardiovascular, renal, and serious adverse effects including gi bleeding and perforation, which may be fatal should be prescribed ibuprofen with caution not exceeding 1200 mg ibuprofen per day with a ppi. diclofenac is contraindicated. monitoring blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. avoid nsaid's in people with dehydration, due to risk of acute kidney injury. chronic alcoholism and alcohol dependence increases the gi risk is increased with nsaids hence avoid nsaids if possible or prescribe with a ppi. prescribe ibuprofen with caution to people with cerebrovascular disease, ischaemic heart disease, peripheral arterial disease, or risk factors for cardiovascular events like hypertension, hyperlipidaemia, diabetes mellitus and smoking. prescribe it with caution in cardiac impairment or mild to moderate heart failure (nsaids may impair renal function) but not in severe heart failure. prescribe up to 1200 mg per day as a first-line option (lower dose than the 4 x 400 mg per day regimen recommended in the bnf for dental pain). for higher doses liaise with the patient's gmp. monitor blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an nsaid. liaise with the patient's gmp to discuss. if in doubt about the severity of the patient's heart failure or appropriate analgesics, consult with their gmp. prescribe nsaids with caution to people with inflammatory bowel disease (nsaids may increase the risk of developing or cause exacerbations of ulcerative colitis or crohn's disease). prescribe nsaids with caution to people with mild to moderate hepatic impairment (do not prescribe in severe hepatic impairment). dose reductions and monitoring of liver function may be necessary. prescribe nsaids with caution to people with severe renal impairment and avoid if possible since sodium and water retention may occur leading to deterioration in renal function and, possibly renal failure. if the patient cannot avoid using an nsaid and has impaired renal function, monitor renal function 1-2 weeks after starting or increasing the dose of an nsaid. avoid concomitant use of nsaids with anticoagulants (e.g. warfarin, dabigatran) if possible. all nsaids can cause gi irritation and reduce platelet aggregation, which can worsen any bleeding event. if concurrent use is necessary be aware of the potential risks of bleeding. consider giving gastroprotection. liaise with the patient's gmp if a ppi is required but is not currently prescribed. prescribe nsaids with caution for patients with bleeding disorders (e.g. haemophilia, von willebrand disease and clotting factor deficiencies). consult with the patient's gmp or haematologist. 56 transmission of covid-19 to health care personnel during exposures to a hospitalized patient covid-19 in a long-term care facility -king county presentation published at cdc/niosh topic page: aerosols, national institute for occupational safety and health cdc guidance for dental settings: interim infection prevention and control guidance for dental settings during the covid-19 response novel coronavirus-important information for clinicians guidelines for infection control in dental health-care settings-2003 who.int. 2020. coronavirus situation report-83 suggestions on the prevention of covid-19 for health care workers in department of otorhinolaryngology head and neck surgery refining surge capacity: conventional, contingency, and crisis capacity impact of multiple consecutive donnings on filtering facepiece respirator fit aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 simple respiratory mask simple respiratory protection-evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. last update filtering out confusion: frequently asked questions about respiratory protection, fit testing osha's respiratory protection standard niosh-approved n95 particulate filtering facepiece respirators updated air purifying respirators for use in health care settings during response to the covid-19 public health emergency approved respirator emergency use authorization (eua)external icon recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings considerations for recommending extended use and limited reuse of filtering facepiece respirators in healthcare settings engineering controls to reduce airborne, droplet and contact exposures during epidemic/pandemic response in-depth report: expedient methods for surge airborne isolation within healthcare settings during response to a natural or manmade epidemic. cincinnati, oh: u.s. department of health and human services framework for healthcare systems providing non-covid-19 clinical care during the covid-19 pandemic the impact of the covid-19 epidemic on the utilization of emergency dental services discontinuation of transmission-based precautions and disposition of patients with covid-19 in healthcare settings criteria for return to work for healthcare personnel with suspected or confirmed covid-19 disinfectants for use against sars-cov guidance for reopening buildings after prolonged shutdown or reduced operation niosh testing and remediation of dampness and mold contamination guidance for reopening buildings after prolonged shutdown or reduced operation environmental control for tuberculosis: basic upper-room ultraviolet germicidal irradiation guidelines for healthcare settings tlvs and beis: based on the documentation of the threshold limit values for chemical substances and physical agents & biological exposure indices guidelines for infection control in dental health-care settings-2003pdf icon epa list n: disinfectants for use against sars-cov-2 (covid-19 laundry and bedding: guidelines for environmental infection control in health-care facilities clinical questions about covid-19: questions and answers interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings guidance for risk assessment and work restrictions for healthcare personnel with potential exposure to covid-19 iapd foundational articles and consensus recommendations: caries risk assessment and care pathways american academy of paediatric dentistry. caries risk assessment and management for infants, children and adolescents. reference manual iapd foundational articles and consensus recommendations: management of early childhood caries iapd foundational articles and consensus recommendations: use of fluoride for caries prevention iapd foundational articles and consensus recommendations: minimal invasive dentistry iapd foundational articles and consensus recommendations: management of dental erosion iapd foundational articles and consensus recommendations: paediatric periodontal disease iapd foundational articles and consensus recommendations: management of molar incisor hypomineralization iapd foundational articles and consensus recommendations: management of the developing dentition dentistry and coronavirus (covid-19)-moral decision-making drugs for the management of dental problems during covid-19 pandemic the workers who face the greatest coronavirus risk. the new york times evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators appoint each group of patients one personnel from the dental clinic who can be reachable 24/7 in case of an emergency in order to asses and determine the need to be seen water should be run through pipes and taps in surgeries, kitchen, bathrooms and showers when reopening a practice post covid-19 shutdown follow the dental practice reopening guidelines paracetamol in many over the counter preparations should be identified in all medications which have been ingested. an overdose is dangerous because it may cause fatal hepatic damage that is sometimes not apparent for 4-6 days. refer a patient for an emergency assessment if they ingest a therapeutic excess of more than the recommended daily dose [8 x 500 mg tablets for adults] and more than or equal to 75 mg/kg in any 24-hour period. paracetamol is the analgesic of choice for women who are breastfeeding. for a pre-term, or low birthweight infant seek advice from a gp. absorption, distribution, metabolism, or excretion of paracetamol may be affected by an underlying medical condition. paracetamol is a suitable analgesic option in most people with liver disease but dose reduction j o u r n a l p r e -p r o o f the following information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories then this should be stated. all authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. i do not have any financial or personal relationships with the other people or organizations which could inappropriately affect my work. all sources of funding should be declared as an acknowledgement at the end of the text. authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. if the study sponsors had no such involvement, the authors should so state. research studies involving patients require ethical approval. please state whether approval has been given, name the relevant ethics committee and the state the reference number for their judgement. authors must obtain written and signed consent to publish a case report from the patient (or, where applicable, the patient's guardian or next of kin) prior to submission. we ask authors to confirm as part of the submission process that such consent has been obtained, and the manuscript must include a statement to this effect in a consent section at the end of the manuscript, as follows: "written informed consent was obtained from the patient for publication of this case report and 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others, who have contributed in other ways should be listed as contributors.saleha shah-sole author j o u r n a l p r e -p r o o f in accordance with the declaration of helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. please enter the name of the registry and the unique identifying number (uin) of your study.you can register any type of research at http://www.researchregistry.com to obtain your uin if you have not already registered. this is mandatory for human studies only. trials and certain observational research can also be registered elsewhere such as: clinicaltrials.gov or isrctn or numerous other registries. name of the registry: unique identifying number or registration id: hyperlink to your specific registration (must be publicly accessible and will be checked): the guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish hence a risk assessment of the practice should be carried out to identify the measures required to minimize the risk of covid-19 transmission.added to refine the manuscript:the practice should be cleaned thoroughly and clutter removed to facilitate frequent cleaning and disinfection.devise a protocol for receiving mails and deliveries.dhcp recovered from covid-19 (protective immunity) care for covid-19 patient. 9, 10, 11, 12, 13, 14, 15, 30, 31, 32, 33, 34 safety and quality assurance checks on radiographic equipment should be performed. aed should be tested as well. all the emergency drug kits should be checked for expiry. ensure that the rechargeable items are fully charged and operational. check the drinking water dispenser for staff use and recommission by manufacturer's instructions. the computer updates should be checked and installed. key: cord-274305-mnyy41po authors: kumar, purnima s; subramanian, kumar title: demystifying the mist: sources of microbial bioload in dental aerosols date: 2020-07-27 journal: j periodontol doi: 10.1002/jper.20-0395 sha: doc_id: 274305 cord_uid: mnyy41po the risk of transmitting airborne pathogens is an important consideration in dentistry and has acquired special significance in the context of recent respiratory disease epidemics. the purpose of this review, therefore, is to examine (1) what is currently known regarding the physics of aerosol creation, (2) the types of environmental contaminants generated by dental procedures, (3) the nature, quantity, and sources of microbiota in these contaminants and (4) the risk of disease transmission from patients to dental healthcare workers. most dental procedures that use ultrasonics, handpieces, air‐water syringes, and lasers generate sprays, a fraction of which are aerosolized. the vast heterogeneity in the types of airborne samples collected (spatter, settled aerosol, or harvested air), the presence and type of at‐source aerosol reduction methods (high‐volume evacuators, low volume suction, or none), the methods of microbial sampling (petri dishes with solid media, filter paper discs, air harvesters, and liquid transport media) and assessment of microbial bioload (growth conditions, time of growth, specificity of microbial characterization) are barriers to drawing robust conclusions. for example, although several studies have reported the presence of microorganisms in aerosols generated by ultrasonic scalers and high‐speed turbines, the specific types of organisms or their source is not as well studied. this paucity of data does not allow for definitive conclusions to be drawn regarding saliva as a major source of airborne microorganisms during aerosol generating dental procedures. well‐controlled, large‐scale, multi center studies using atraumatic air harvesters, open‐ended methods for microbial characterization and integrated data modeling are urgently needed to characterize the microbial constituents of aerosols created during dental procedures and to estimate time and extent of spread of these infectious agents. bacterial pathogens; tuberculosis, and bacterial pneumonia, to name but a few. the proximity of the nasopharynx and lower respiratory tract to the oral cavity creates an open communication channel for movement of viruses and bacteria from these areas into the mouth. in this scenario, aerosol generating dental procedures on patients with infectious respiratory diseases become sources of contagion. in an immunocompetent individual, the risk of spread of infection by aerosolized particles is largely driven by the kinetics of the aerosol, presence of pathogen in the aerosol source, the type of pathogen, frequency of exposure, and the infectious dose. as dental professionals, it behooves us to protect ourselves, our patients and our staff from occupationally acquired diseases. the purpose of this review, therefore, is to examine what is currently known regarding the physics of aerosol creation, the types of aerosols generated by dental procedures, the nature, quantity, and sources of microbiota in these aerosols and the probability of disease transmission from patients to dental healthcare workers. in an attempt to establish context for reviewing the literature on dental aerosols, we begin this review by examining the reasons why definitions of aerosols vary widely. in general, aerosols refer to particles suspended in gas. although aerosols may be generated from a multitude of events, such as combustion, evaporation, industrial work etc., we will focus on aerosols generated in the healthcare environment. in 1934, wells pioneered the concept that airborne infections can be transmitted either as droplets or as aerosols. 1 according to his work, droplets are defined as those with particle sizes > 5 μm and typically carried on heavy colloids like mucus or saliva. droplets cannot remain suspended in air for long or travel long distances, hence, they are spread by close contact with (typically 1 m ) and in the presence of, the host. however, according to wells, droplets < 100 μm dry out before falling ≈2 m to the ground. when these droplets evaporate, they can be carried on airborne vectors and become aerosols. he estimated the particle size in aerosols to be < 5 μm (sometimes called droplet nuclei) and stated that these particles can stay airborne for long periods of time, carry viable pathogen as payload and settle on surfaces distant from the source (which is then referred to as a fomite). the vectors can be natural, namely, mist, fog, and vapor or anthropogenic, for example, smoke, dust, smog, and of particular importance to us, dental aerosol. however, in certain cases, for example, high ambient temperature or high airflow, large droplets can evaporate and acquire aerosol-like properties. because of their size, they can carry larger payloads than droplet nuclei (see below). aerosols have also been classified based on their deposition patterns. for example, using a semi-empirical model, the international commission on radiological protection (icrp) estimated that particles between 1to 10 μm or < 0.5 μm are most likely to deposit in the tracheobronchial and pulmonary regions of the lungs, whereas particles ≤5 μm have the highest probability of entering the lower airways of the average adult during oral inhalation. 2 because the nose offers a greater filtration efficiency than the mouth, only particles ≤3 μm have a high probability of entering the lower airways during nose breathing. particles with diameters between 1 and 3 μm or <0.5 μm have the greatest probability of entering the lung, thereby the highest potential of initiating an infection at this site. the infectious diseases society of america (idsa) has defined "respirable particles" as having a diameter of ≤10 μm and "inspirable particles" as having a diameter between 10 μm and 100 μm, nearly all of which are deposited in the upper airways. 3 other studies on infectious disease transmission indicate that droplets >5 μm are trapped in the upper respiratory tract whereas droplets ≤5 μm can be inhaled into the lower respiratory tract. 4 in this review, we will use the 10 μm diameter to distinguish between aerosolized and non-aerosol particles, because they have important implications for time of settling, penetration depth into airways and requirements for ppe. another important characteristic of aerosolized particles that impacts their definition is settling time. in still air, it has been estimated that particles 0.5 μm take 41 hours to settle over a distance of 5 feet, and that the time exponentially decreases as the size increases. for example, 1 μm sized particles take 12 hours to settle whereas 10 μm take 8.2 minutes and 100 μm take a mere 5.8 seconds. 5 however, this characteristic is heavily influenced by the direction and velocity of air currents (such as those created by foot traffic, opening of doors, position and setting of room air circulation systems etc.), humidity, the forces of attraction/repulsion between aerosolized particles and the size of the agglomerates/coaggregates (see below). in the presence of turbulence, particles nearer the floor continue to follow the settling times described above, but other factors begin to influence those that are two feet or more above the surface, for example, particle impaction, electrostatic forces etc. when vector particles and aerosol droplets collide with each other, they might coalesce or coaggregate, changing the particle size, in which case, the classifications described above do not apply anymore. in certain situations, these aggregates break down into numerous smaller conglomerates, generating a new generation of payload. together, these collisions randomly create a heterogeneous mixture of large and small particles with highly variable electrical charges, aerodynamic diameter, diffusion dynamics, and terminal velocity. 6 it is therefore unsurprising that, in real life scenarios, each aerosol responds in a highly variable manner to gravitational forces. temperature and humidity of the environment, and the superimposition of new aerosol further impact aerosol dynamics. 6 the characteristics and behavior of aerosolized particles are important determinants of defining an aerosol, and for this reason, definitions have to be contextualized. for example, size and penetrability-based definitions have important implications for selecting appropriate face masks, while settling-characteristicsbased definitions are impactful in deciding nature and time of surface decontamination. hence, studies on aerosol transmission must account for these confounding variables in order to be interpreted in the appropriate clinical context. as we shall see below, most studies on aerosol generating medical/dental procedures (agm/dp) have used simplistic calculations, for example, estimating particle size to compute aerodynamic diameter (this has limited use outside of regular sized particles such as inhalable drugs) and applying stokes' law to calculate terminal velocity of a particle in a fluid (the assumptions of stokes' law fail for particles <1 μm). 6 one of the most important considerations in any study is the investigational methodology. early studies employed impaction on solid and liquidized interfaces to measure aerosol volume and properties. 7, 8 advances in visualization technology have enabled greater temporal and spatial visualization of aerosol generated particles and their trajectories. among the various methodologies used to visualize aerosols, laser capture imaging, particle counters, air samplers, and droplet capture methods are the most popular. 9 similarly, methodologies for microbial characterization have demonstrated tremendous advances from the early days of culturing and microscopy to targeted methods such as polymerase chain reaction (pcr) to quantitative pcr to collectively sequencing entire microbial communities. 10-12 a third component is development of computational models of human behavior and predicting patterns and paths of spread. 13 although these advances in pathogen detection, airflow measurement, and disease modeling have had a major impact on understanding the spread of diseases such as ebola 14 and changed our perception of older diseases such as tuberculosis and measles, 15 several questions still remain to be addressed. for instance, although molecular microbiology has allowed us to identify infectious agents earlier and at much lower concentrations, it is not unclear if these doses are clinically relevant, how the relevance is modified by the type of populations (adult versus children, immunocompetent versus compromised, ambulatory versus hospitalized, and individual versus group living) and most importantly, how many of these organisms are viable. 16 similarly, the very act of air-sampling can generate an aerosol as well as destroying the organisms being captured. 17 importantly, computer machine learning relies on large and granular datasets for accuracy, and when studies from the field are unable to capture all the required components, the model is not reflective of real-life scenarios. thus, any investigation of aerosol characteristics must use well-validated methods of aerosol capture, incorporate appropriate positive and negative controls to allow standardization of microbial payload, and be sufficiently powered to reduce the ''noise'' generated by random behavior of aerosol particles. most importantly, they must be quantitative, because pathogen dose is an important element of infectivity. as we will see in the next few sections, much of what we currently know about dental aerosols falls far short of the most basic principles of scientific rigor and reproducibility. until recently, the viral constituents of the oral microbiome had only been examined in the context of their ability to cause disease and spread contagion. we now know that viruses are normal inhabitants of the healthy oral microbiome, 18, 19 and that a diverse population of both dna and rna viruses is found in saliva and subgingival plaque of healthy individuals. 20 the most common oral viruses are cytomegalovirus, herpesvirus one through nine and papilloma virus. 21 the types of viruses that inhabit an individual are highly subject-specific, much more so than the types of bacteria. 22 the oral virome also demonstrates significant gender-specificity. 19 the type of viral exposure an individual has had, and the nature of the shared living environment are two major determinants of individual viral signatures. 23 it is also established that the majority of viral particles are derived from gram-positive and gram-negative bacteriophages rather than free-living viruses. 18 once acquired, these viruses demonstrate remarkable colonization stability in the absence of extraneous influences such as local or systemic disease. 22 studies exploring the role of saliva as a diagnostic tool for viral diseases such as dengue, west nile, sars, chikungunya, mers-cov, ebola, zika, and yellow fever have further expanded our knowledge of non-oral viruses. 24 most of these investigations have reported that whereas viral rna and viable virus were detected in saliva early in the course of disease, viral shedding did not persist after resolution of symptoms. 25, 26 however, influenza a and b were detected in 20 to 60% of asymptomatic individuals. 27 taken together, these studies suggest that (a) the oral viral community is acquired through a non-random process of microbial assembly that is partly dictated by individual genotype (b) viral communities are temporally stable once acquired and (c) exogenous viruses are present in saliva during acute phase infection, but most do not persist following resolution of disease. like viruses, respiratory bacterial pathogens have been detected in saliva during acute and symptomatic phases of respiratory illnesses, 28, 29 as well as in institutionalized and hospitalized, elderly individuals. 30, 31 however, unlike viruses, certain bacterial respiratory pathogens have been identified in the oral cavities of systemically healthy and asymptomatic individuals, especially smokers. 32, 33 for instance, bacteria such as streptococcus pneumoniae can be isolated more frequently and consistently from saliva than from naso-pharyngeal or oro-pharyngeal swabs. 34 these pathogens are known to reside in the subgingival crevice, the buccal mucosa and saliva. 28, [35] [36] [37] [38] [39] however, exogenous pathogens are not dominant members of the oral microbiome, which is one of the most diverse in the human body with over 20 billion microbial cells. 40 moreover, in states of health, a robust interbacterial interaction limits or reduces colonization with exogenous pathogens. for instance, bacteriocins such as ls1 (produced by the oral commensal lactobacillus salivarius) contribute to controlling the growth of s. aureus and s. pneumoniae, 41, 42 and hydrogen peroxide (which is produced by several commensal species) prevents colonization by serratia marcescens, s. agalactiae, s. pneumoniae, haemophilus influenzae and mrsa. 43, 44 in summary, a large body of evidence supports saliva as a potential source of respiratory pathogens, however, many of these studies lack quantitative data. therefore, there is an urgent need for studies that quantify the salivary bioload of these species in non-infected individuals and for investigations on whether these microbial loads are high enough to create a biologically relevant infectious dose. although agm/dp have been implicated in spread of viral contagion, it must be remembered that aerosols are generated during normal physiological activities such as breathing, talking, coughing, and sneezing. studies on healthy volunteers have demonstrated that mouth breathing produces 1-98 particles per liter, 45 with a median diameter of 0.3 μm; with only about 2% of the particles >1μm and none > 5 μm. 46, 47 during speaking, 1 to 50 particles in the 1 μm range are emitted per second (0.06 to 3 particles per liter) 48 ; with some ''super-seeders'' expelling as many at 200 particles per second while speaking loudly. singing creates six times as many droplet nuclei as talking and is equivalent to coughing. 49 sneezing can expel nearly 40,000 droplets between 0.5 to 12 μm at speeds of almost 100 m/sec, while coughing may generate up to 3000 droplet nuclei. 50, 51 collectively, studies such as these demonstrate that healthy individuals generate particles sized between 0.01 and 500 μm, underlining the fact that dispersal of expelled particles does not occur exclusively by airborne or droplet transmission but by both mechanisms concurrently. although healthy and diseased individuals generate aerosols during normal activities, evidence that these aerosols contain an infectious agent is equivocal. for example, streptococcus pneumoniae, staphylococcus aureus, methicillin-resistant staphylococcus aureus (mrsa), escherichia coli, klebsiella pneumoniae, pseudomonas aeruginosa, acinetobacter baumannii, stenotrophomonas maltophilia, haemophilus influenzae, legionella pneumophila, mycoplasma pneumonia, chlamydia pneumonia, and mycobacterium tuberculosis can be detected in 36% of patients with symptomatic respiratory diseases. 10 however, although 89% of nasal swabs were positive for live virus in 142 patients diagnosed with influenza a, only 39% of individuals exhaled live viral particles in their breath, 52 and the number of particles shed declined significantly within 3 days of onset of symptoms. 12,52 importantly, these particles failed to land on targets placed at a distance of 0.1 and 0.5 m. 53 furthermore, when a patient wore a surgical mask, it reduced the viral shedding in aerosol by 3.4 fold. 54 on the other hand, p. aeruginosa can travel 4 m and persist in the aerosol for 45 minutes subsequent to a coughing episode. 11 wearing surgical masks for 10 to 40 minutes reduced the levels of respiratory pathogens by more than four-fold. 55 collectively, there is a large body of evidence that patients in the acute phase of respiratory infections are capable of disseminating large numbers of airborne microorganisms during activities such as breathing, talking, singing, coughing, and sneezing. this shedding can be mitigated by the simple act of wearing a mask and is effective against viral as well as bacterial pathogens. the sars-1, 2009 h1n1 mers, ebola and zika outbreaks were instrumental in drawing attention to medical aerosols as sources of infection to health-care personnel. two broad categories of agmp have been documented in the literature: those that induce the patient to express the contents of the lower respiratory tract by stimulating cough reflex (sputum induction), and those that mechanically disrupt the contents of the respiratory tract. the latter procedures typically include intubation/extubation, cardiopulmonary resuscitation, bronchoscopy, noninvasive ventilation, tracheotomy, airway suctioning, manual ventilation, and administering oxygen or nebulized medication. 56 all these procedures are conducted on patients who are typically experiencing active disease, and therefore, the aerosols and droplets generated from sites with active pathogen colonization could potentially contain high numbers of respiratory pathogens. however, even though magp have been the subject of at least 400 different studies, questions still remain regarding the amount of aerosols generated, the size and concentration of medically aerosolized particles, and whether such aerosols could transmit viable pathogens to hcp or to other patients. for instance, the review by davies et al. 56 and by o'neil et al. 57 suggests that although the potential for aerosol production exists with agmp, there is little evidence that these procedures actually do create aerosols. during dental procedures, the "wet environment" created by saliva and water coolant combined with high-speed instrumentation generates a large spray which disperses in many forms as dictated by the physics of aerosol creation (see section on characteristics of aerosols, above). thus, the spray can initially take the form of spatter, droplets, droplet-nuclei, a true aerosol, or some combination thereof; and continue to evolve based on room temperature, humidity, airflow dynamics, electrostatic forces etc. the term "dental aerosol", therefore, is somewhat of a misnomer, because it does not encompass the various airborne particles that can be created during an agdp. to avoid confusion, we will use the word spray unless the study specifically measured aerosols. there are four main sources of dental sprays: air-water syringes, ultrasonic instruments, high-speed turbines, and lasers. there is no literature on sprays from air-water syringes, so we will examine the evidence from the rest of instruments below. the quantity of sprays, spatter, or aerosol generated by ultrasonics, the distance travelled by the aerosolized particles and their composition have been studied using air samplers, 58-60 bacterial growth medium placed at strategic locations, 58-67 filter paper strips (with and without dye) on the patient and operator, 68, 69 and heme-detectors. 70 sprays are generated during all types of procedures using ultrasonic instruments, whether it be supragingival scaling, subgingival scaling of periodontally diseased teeth or endodontic instrumentation. the amount of spatter and aerosol generated by sonic, ultrasonic or piezoelectric devices and distance travelled by airborne particles from these devices is similar or comparable. 58, 64, 71, 72 these sprays expose the inhabitants of the operatory to 1.86 × 10 5 particles per cubic meter of space, and the contaminants settle to a great extent on the dominant arm of the operator, and eyewear and chest of the patient and to a lesser extent on the non-dominant arm and chest of the operator and assistant. 66, 68, 69, 73 they can also be detected as far away as 2 to 11 m from the treatment site. 59, 66 however, in the absence of a coolant, the aerosol is limited to an 18 inch radius. 72 the levels of aerosolized particles return to preoperative levels within 30 minutes 68 to 2 hours. 60 in summary, there is unequivocal evidence that some of the spray from all types of ultrasonic devices is converted to aerosol, and while the spatter settles on the person of the operator, assistant and patient, the aerosolized particles can travel much larger distances and settle up to 2 hours after creation. high speed handpieces can generate spatter containing blood and other components, 59, 61, 63, 74, 75 and the amount of microbial bioload varies with the tooth being treated. 74 as well as the caries level of the patient. 65 it has been reported that microbial fallout from restorative procedures can extend up to 1.5 to 2 m, however, this study did not report the type of evacuators that were used during the procedures. 76 when a laser is used to cauterize blood vessels and incise tissue by vaporization, it generates a gaseous material known as surgical smoke plume, which is composed of 95% water. the remaining 5% has been reported to contain blood, particulate and microbial matter. 77 the particle size generated by lasers ranges from 0.1 to 2 μm. all class iv lasers (surgical lasers) carry the risk of plume hazard. although there is no evidence on lasers used in dental operatories, escherichia coli, staphylococcus aureus, human papillomavirus, human immunodeficiency virus, and hepatitis b virus have been detected in surgical laser plumes used in dermatology and otolaryngology. 78 although every single study to date has demonstrated that all forms of mechanical instrumentation in the oral cavity create aerosols and spatter with a significant bioload, critical gaps in knowledge still exist. the first of these is the source of the aerosolized microbiota. it is easy to point to saliva as a source. if this were indeed true, then one would expect a high degree of variability in the clinical studies because of differences in salivary volume, flow rate and composition between patients. however, all the literature detailed in this review report remarkably homogeneous findings in terms of aerosol volume, quantity of contagion, and distance and time of spread. this is in spite of variability in operators, instruments, procedures, subject characteristics, and data collection methods. moreover, if saliva were the source of microbiota in dental aerosols, one would expect a certain level of microbial heterogeneity between the studies. however, the bacteria most frequently identified in all studies were staphylococcus aureus, beta hemolytic streptococci, escherichia coli, spore-forming bacteria, fungi belonging to the genera cladosporium and penicillium, and micrococccus 66, [79] [80] [81] 82 another study documented the presence of high levels (10 5 cfus) of legionella, pseudomonas and non-tuerculous mycobacteria in water lines. 83 thus, there is plausible evidence to suggest that water might contribute to a large fraction of the microbial payload in dental aerosols. this plausibility is further supported by the fact that ultrasonic devices and high-speed handpieces use water as a coolant with a typical flow rate of 10 to 40 ml per minute, 84 whereas the flow rate of saliva during the same time period is 0.4-0.5 ml. 85 thus, the dilution ratio varies between 1:20 to 1:100. that is not to say that saliva does not contribute to the microbial payload in aerosols. in fact, a strong correlation was observed between the number of decayed teeth in a patient and the levels of beta hemolytic streptococci on the operator's mask, 65 and reductions in aerobic and anaerobic colony forming units (cfus) have been reported following pre-procedural mouth rinsing. 65, [86] [87] [88] however, as described above, most the culturable bacteria identified thus far in dental aerosols are of environmental origin, bacterial profiles in aerosols demonstrate remarkably low ''noise'' between studies and the dilution factor because of water coolants is very high. in the absence of evidence demonstrating a salivary source for these bacteria, the microbial similarities between water lines and aerosols is the only evidence that can be brought to bear upon this argument. although the amount to effort invested in studying dental aerosols is commendable, these studies suffer from critical flaws in design and methodology that preclude robust decision making. 8 for instance, none of the studies used a control group where the aerosol was generated in the absence of a patient. this would provide invaluable information on the source of the microbial payload. there is also incredible diversity in the methodologies used. for instance, several studies originating from the indian subcontinent and south east asia have not used any form of aspiration of oral fluids, whereas most studies from europe and the united states have used high or low volume aspirators. because the amount of aerosol directly correlates with the partial pressure of fluid in the mouth, this important variable does not allow for comparisons to be made between studies. perhaps the most important gap in knowledge stems from the use of rudimentary cultivation-based approaches to characterize microbiota. such approaches have created very simplistic views of the microbial contaminants (e.g. gram positive versus gram negative, gross counts of cfu, catalase activity, and other such basic characterizations), have hampered our ability to pinpoint the source of the aerosol and completely ignored the viral, fungal and other constituents of the microbial payload. hence, these studies have allowed room for liberal interpretation of the data, and in some instances, this has served to create a certain level of misinformation. before we examine the statistics on cross-infection in dental settings, it must be acknowledged that lack of reporting poses a huge barrier to obtaining accurate data. an excellent review by volgenant et al. 89 examines the several potential routes of transmitting infections in the dental office. these include blood-borne, contact, and aerosol transmission. several instances of transmission of blood-borne pathogens to patients and health-care personnel have been documented. these are attributable both to poor infection control practices, 90 as well as to blood exposure accidents. 91 however, the risk appears to be very low, with only five cases reported between 2003 and 2016. 92 aerosol-transmitted diseases have been documented, although dental unit water lines appear to be the microbial source. 93, 94 especially, legionellosis has been connected to dental treatment in two case reports. 95, 96 moreover, dentists in certain areas have been shown to have higher antibody levels to legionella when compared to nondental professionals, 97 adding further credence to dental unit water lines as the source of aerosol microorganisms. a careful and contextualized review of the currently available evidence on dental aerosols reveals the following: 1. viral shedding occurs in saliva during acute phases of all respiratory diseases, and influenza viruses have been reported in post-recovery and asymptomatic patients. 2. respiratory bacterial pathogens are present in saliva of asymptomatic individuals; however, their relative abundances are very low. 3. aerosols are generated by all individuals during all times of the day during all types of activities. 4. the microbial payload in physiological aerosols correlates with disease severity for respiratory diseases. 5. aerosols are created during most dental procedures. the four main aerosol emitting devices are ultrasonics, handpieces, air-water syringes, and lasers. 6. there is little evidence to definitively implicate saliva as the primary source of bacteria in these aerosols. although absence of evidence is not evidence of absence, the available evidence currently points to environmental sources, particularly dental unit water lines, as a major basis of aerosol bacteria in the dental environment. large-scale, multi center studies using atraumatic air harvesters and integrated data modeling that is superimposed on a geographic map of the physical space have enabled the medical community to identify patterns of aerosol spread, model disease transmission, and create human and instrument flow paths to reduce risk of infection. 98 similar studies to determine the creation and spread of aerosols during dental procedures and to estimate time and extent of spread are urgently needed. purnima s kumar and kumar subramanian contributed equally to the literature review, writing and reviewing the manuscript. the authors have no conflicts of interest or financial relationships impacting this manuscript. o r c i d purnima s kumar 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healthcare workers: meta-analysis in occupational epidemiology nosocomial transmission of emerging viruses via aerosol-generating medical procedures key: cord-023913-pnjhi8cu authors: foreman, stephen; kilsdonk, joseph; boggs, kelly; mouradian, wendy e.; boulter, suzanne; casamassimo, paul; powell, valerie j. h.; piraino, beth; shoemaker, wells; kovarik, jessica; waxman, evan(jake); cheriyan, biju; hood, henry; farman, allan g.; holder, matthew; torres-urquidy, miguel humberto; walji, muhammad f.; acharya, amit; mahnke, andrea; chyou, po-huang; din, franklin m.; schrodi, steven j. title: broader considerations of medical and dental data integration date: 2011-10-08 journal: integration of medical and dental care and patient data doi: 10.1007/978-1-4471-2185-5_4 sha: doc_id: 23913 cord_uid: pnjhi8cu dental health insurance coverage in the united states is either nonexistent (medicare and the uninsured), spotty (medicaid) and limited (most employer-based private benefit plans). perhaps as a result, dental health in the united states is not good. what public policy makers may not appreciate is that this may well be impacting medical care costs in a way that improved dental benefits would produce a substantial return to investment in expanded dental insurance coverage. have been rising at double digit rates. most employers have been dropping health care coverage rather than expanding it ( kaiser family foundation 2010 ) . medicare trust funds are bankrupt (social security and medicare boards of trustees 2011 ). adding coverage would exacerbate an already alarming problem. medicaid funding is a major source of state government defi cits. many states are slashing medicaid coverage during this time of crisis (wolf 2010). improving medicaid dental coverage during times of budget crisis would meet substantial political resistance. strikingly, strong and increasing evidence suggests relationships between oral health and a range of chronic illnesses. for example, recent fi ndings show relationships between periodontal infl ammatory conditions and diabetes, myocardial infarction, coronary artery disease, stroke, preeclampsia and rheumatoid arthritis. this suggests that improved oral health may well have the potential to reduce the incidence of chronic diseases as well as their complications. if chronic disease incidence is reduced it may be possible to avoid medical care costs related to treating them. it would be important to know more about the extent to which improved oral health could reduce health care costs and improve lives. there are few, if any, studies of the costs of providing medicare dental benefi ts, the costs of improving the medicaid dental benefi t or the cost of providing dental insurance to the uninsured. there are a few studies that indicate that periodontitis increases medical care costs, perhaps by as much as 20% (ide et al. 2007; albert et al. 2006) . 1 ideally there should be a controlled study to assess the benefi t of providing dental coverage through a government payer system. for a preliminary inquiry we can consider work already done and using some cost and benefi t estimates, determine whether it is possible that benefi ts of extending dental coverage may outweigh costs. the failure of medicare to cover dental care has engendered some (albeit not much) public debate. in 2003, congress enacted the medicare prescription drug, improvement, and modernization act (medicare part d). by 2009 medicare provided $56.6 billion in benefi t payments for outpatient prescription drugs and medicaid paid 15.7 billion for outpatient prescription drugs (center for medicare and medicaid services 2010 ) . benefi ciaries provided billions more in the form of monthly part d premiums. the expense of the medicare prescription drug program and the controversy surrounding its enactment may well have eroded public support for increased medicare coverage. so while there has been no shortage of effort paid to improving medicare, the one common theme in all of the recent initiatives is that dental care has been conspicuously 1 a new study by hedlund, jeffcoat, genco and tanna funded by cigna of patients with type ii diabetes and periodontal disease found that medical costs of patients who received maintenance therapy were $2483.51 per year lower than patients who did not. cigna, research from cigna supports potential association between treated gum disease and reduced medical costs for people with diabetes, http://newsroom.cigna.com/newsreleases/research-from-cigna-supports-potential-association-between-treated-gum-disease-and-reduced-medical-costs-for-people-with-diabetes. omitted. as a result, 43 million medicare recipients in 2009 (us census bureau 2011 ) continue to have no dental insurance coverage through medicare. 2 medicaid dental coverage is an optional benefi t that states may or may not elect to provide. in medicaid, both the state and the federal government provide funds to cover healthcare services to eligible patients. the bulk of the money comes from the federal government. because the medicaid dollars are limited and coverage for systemic diseases has precedence, medicaid coverage of dental care has been spotty. even where it has been provided, payments to dental providers have been so low as to make it diffi cult or impossible for medicaid benefi ciaries to obtain adequate dental care (broadwater 2009 ) . the 2008 recession increased the number of medicaid eligible individuals nationwide. further, the federal budget defi cits of the past few years have reduced the federal contribution to state medicaid programs. the combination of increases in the number of benefi ciaries and diminished revenues has caused a number of states to eliminate or curtail medicaid dental coverage (ehow 2011 ; mullins et al. 2004 ) . the result, 49 million medicaid benefi ciaries in the us (us census bureau 2011 ) in 2009 either had no dental insurance coverage or inadequate coverage. approximately 52 million people in the united states do not have health insurance (kaiser family foundation 2010 ) . presumably, they have no dental insurance either. further, not every employer provides dental insurance. a 1995 cdc survey found that 44.3% of adults do not have dental insurance coverage (centers for disease control 1997 ) . a 2006 montana survey found that 53% of employers who offer health insurance do not offer dental insurance coverage (montana business journal 2006 ) . in 2009 there were approximately 202 million people enrolled in health insurance plans (us census bureau 2011 ) . if half (a rough combination of the cdc and montana percentages) of them do not have dental insurance it is likely that an additional 101 million (nonelderly, non-poor) people in the us do not have dental insurance coverage. finally, the term "dental insurance" is actually a misnomer. 3 dental policies cover routine treatments, offer discounts for more complex treatment and impose a low yearly on total payments. in fact, it has been called "part insurance, part prepayment and part large volume discount" (manski 2001 ) . effectively, many (if not most) people who have dental insurance fi nd it coverage to be quite restrictive. for example, many impose a small yearly cap ($1,500 is common) or large coinsurance amounts (50% for orthodontia, for example) (rubenstein 2005 ) . even with discounts it is easy for many people to exceed the annual limit. given the lack of dental insurance coverage it is not surprising that the status of oral health in the us is not particularly good. in 2002 approximately 26.5% of adults between the ages of 35 and 44 had untreated caries, 42% had decayed, missing and fi lled tooth surfaces and more than one-half of adults had gingival bleeding (dental, oral and craniofacial data resource center of the national institute of dental and craniofacial research 2002 ) . three fourths of adults in the us have gingivitis and 35% have periodontitis (mealey and rose 2008 ) . if these levels of untreated disease were applied to most systemic diseases, there would be public outcry. over the past decade evidence has been building that there is a relationship between dental disease, particularly periodontal disease, and chronic illnesses. mealey and rose note that there is strong evidence that "diabetes is a risk factor for gingivitis and periodontitis and that the level of glycemic control appears to be an important determinant in this relationship" (mealey and rose 2008 ) . moreover, diabetics have a six times greater risk for worsening of glycemic control over time compared to those without periodontitis and, periodontitis is associated with an increased risk for diabetic complications. for example, in one study more than 80% of diabetics with periodontitis experienced one or more major cardiovascular, cerebrovascular or peripheral vascular events compared to 21% of the diabetic subjects without periodontitis (thorstensson et al. 1996 ) . also, a longitudinal study of 600 type 2 diabetics found that the death rate from ischemic heart disease was 2.3 times higher in subjects with severe periodontitis and the death rate from diabetic nephropathy was 8.5 times higher (saremi et al. 2005 ) . clinical trials have demonstrated that treatment of periodontal disease improved glycemic control in diabetics (miller et al. 1992 ) . moreover, investigations have found an association between periodontal disease and the development of glucose intolerance in non-diabetics (saito et al. 2004 ) . while it is diffi cult to establish causality and it is possible that other factors infl uence periodontal disease and medical complications, these studies suggest that treatment of periodontitis substantially improves health and greatly reduces medical complications related to diabetes. similarly, periodontitis is associated with cardiovascular disease and its complications including ischemia, atherosclerosis, myocardial infarction and stroke. a study by slade and colleagues found both a relationship between periodontitis and elevated serum c-reactive protein levels (systemic marker of infl ammation and documented risk factor for cardiovascular disease) as well as a relationship among body mass index, periodontitis and crp concentrations (slade et al. 2003 ) . hung and colleagues evaluated the association between baseline number of teeth and incident tooth loss and peripheral arterial disease. they determined that incident tooth loss was signifi cantly associated with pad, particularly among men with periodontal disease potentially implying an oral infection-infl ammation pathway (hund et al. 2003 ) . the same group of researchers used the population enrolled in the health professionals' follow-up study (41,000 men free of cardiovascular disease and diabetes at baseline) to assess the relationship between tooth loss and periodontal disease and ischemic stroke. controlling for a wide range of factors including smoking, obesity, and dietary factors, the researchers found a "modest" association between baseline periodontal disease history and ischemic stroke . as early as 1993 destefano and colleagues found that among 9760 subjects, those with periodontitis had a 25% increased risk of coronary heart disease relative to those without. the association was particularly high among young men. the authors questioned whether the association was causal or not, suggesting that it might be a more general indicator of personal hygiene and possibly health care practices (destefano et al. 1993 ) . in 2000 wu and colleagues used data from the first national health and nutrition examination survey and its epidemiologic follow-up study to examine the association between periodontal disease and cerebrovascular accidents. the study found that periodontitis was a signifi cant risk factor for total cva, in particular, for non-hemorrhagic stroke (wu et al. 2000 ) . in addition to diabetes and coronary artery disease, associations have been found between periodontal disease and rheumatoid arthritis and respiratory disease. this is not surprising given the role of periodontal disease in the production of infl ammation related proteins. dissick and colleagues conducted a pilot study of the associate ion between periodontitis and rheumatoid arthritis using multivariate regression and chi square tests. they found that periodontitis was more prevalent in patients with rheumatoid arthritis than in the control group and that patients who were seropositive for rheumatoid factor were more likely to have moderate to severe periodontitis than patients who were rf negative and also that patients who were positive for anti-cyclic citrullinated peptide antibodies were more likely to have moderate to severe periodontitis (redman et al. 2010 ) . paju and scannapeico investigated the association among oral biofi lms, periodontitis and pulmonary infections. they noted that periodontitis seems to infl uence the incidence of pulmonary infections, particularly nosocomial pneumonia in high-risk subjects and that improved oral hygiene has been shown to reduce the occurrence of nosocomial pneumonia. they found that oral colonization by potential respiratory pathogens, for possibly fostered by periodontitis and possibly by bacteria specifi c to the oral cavity contribute to pulmonary infections (paju and scannapeico 2007 ) . the implications for these fi ndings are profound. professionally, they suggest that managing patients with chronic illness and periodontal disease will require teamwork and a deeper knowledge base for dentists and for physicians (mealey and rose 2008 ) . dentists will need to be alert for early signs of chronic illness among their patients and physicians will need to be alert for signs of dental disease. both will need to consider wider treatment options than their specialty indicates. dentistry and medicine have operated as professional silos in the past. the relationship between dental disease and chronic medical conditions suggests that continued separation is detrimental to patient centered care. beyond treatment implications, there are extremely important health policy concerns. if treatment of periodontitis and other dental problems leads to reduced incidence of chronic illness, fewer complications from chronic diseases and reduced morbidity among chronically ill patients, increased access to dental services could signifi cantly reduce health care costs. the diseases associated with periodontitis are among the most common illnesses, the fastest growing and the most expensive diseases that we treat. a recent robert wood johnson report notes that approximately 141 million americans have one or more chronic conditions, that the number of people with chronic conditions is expected to increase by 1% per year for the foreseeable future and that the most common chronic conditions include hypertension, disorders of lipid metabolism, upper respiratory disease, joint disorders, heart disease, diabetes, cardiovascular disorders, asthma and chronic respiratory infections (anderson 2010 ) (see fig . 4 .1 ). one in four americans has multiple chronic conditions. ninety-one percent of adults aged 65 and older have at least one chronic condition and 73% have two or more of them (anderson 2010 ) . people with chronic conditions account for 84% of all healthcare spending. seventy eight percent of private health insurance spending is attributable to the 48% of privately insured persons with chronic conditions. seventy three percent of healthcare spending for the uninsured is for care received by the one third of uninsured people who have chronic conditions. seventy nine percent of medicaid spending goes to care for the 40% of non-institutionalized benefi ciaries who have chronic conditions (anderson 2010 ) (see fig. 4 .2 ). further, health care spending increases with the number of chronic conditions (anderson 2010 ) (see fig. 4 .3 ). more than three fi fths of healthcare spending (two thirds of medicare spending) goes to care for people with multiple chronic conditions. those with multiple chronic conditions are more likely to be hospitalized, fi ll more prescriptions, and have more physician visits (anderson 2010 ) . in 2002 the american diabetes association estimated direct medical expenditures for diabetes at $91.8 billion: $23.2 billion for diabetes care, $24.6 billion for chronic complications and $44.1 billion for excess prevalence of general medical conditions. approximately 52% of direct medical expenditures were incurred by people over 65. indirect expenditures included lost workdays, restricted productivity mortality and permanent disability -a total of $39.8 billion. all told, diabetes was found to be responsible for $160 billion of $865 billion in total expenditures. per capita medical expenditures totaled $13,000 annually for people with diabetes and $2600 for people without diabetes (hogan et al. 2002 ) . more recently, dall and colleagues estimated that the us national economic burden of prediabetes and diabetes had reached $218 billion in 2007, $153 million in higher medical costs and $65 billion in reduced productivity. annual cost per case was estimated at $2,900 for undiagnosed diabetes and 10,000 for type 2 diabetes (dall et al. 2010 ) . the costs of caring for people with diabetes have risen both because the numbers of diabetics has been increasing and because the per capita costs of care have increased. the number of diabetics increased from 5.8 million on 1980 to 14.7 million in 2004 (ashkenazy and abrahamson 2006 ) . a recent report by the unitedhealth group center for health reform & modernization provides a dire estimation -that more than 50% of adult americans could have diabetes (15%) or prediabetes (37%) by 2020 at a cost of $3.35 trillion over the decade. this compares with current estimates of 12% of the population with diabetes and 28% with prediabetes, or 40%. these estimates conclude that diabetes and prediabetes will account for 10% of total healthcare spending in 2020 at an annual cost of $500 billion, up from an estimated $194 billion in 2010 (unitedhealth center for health reform and modernization 2010 ) . average annual spending over the next decade by payer type is $103 billion for private health insurance, $204 billion for medicare, $11 billion for medicaid and $16.6 billion for the uninsured. what about cardiovascular disease and rheumatoid arthritis? among the top ten health conditions requiring treatment for medicare benefi ciaries in 2006 approximately 50% of benefi ciaries suffered from hypertension, 25% from heart conditions, 33% had hyperlipidemia 24% had copd, 23% had osteoarthritis and 22% had diabetes (thorpe et al. 2010 ) . the american heart association estimates the 2010 cost of cardiovascular disease and stroke to be $324 billion in direct expenditures and $41.7 billion for productivity losses due to morbidity and $137.4 billion in lost productivity due to mortality (present value of lost wages at 3%) (lloyd) . the centers for disease control estimates that during 2007-2009 50 million americans had selfreported doctor diagnosed arthritis, 21 million of them with activity limitations (cheng et al. 2010 ) . cisternas and colleagues estimated that total expenditures by us adults with arthritis increased from $252 billion in 1997 to $353 billion in 2005. most of the increase was attributable to people who had co-occurring chronic conditions (cisternas et al. 2009 ) . the cisternas study appears to aggregate all medical care expenditures by people with arthritis (which would include expenditures to treat diabetes and cardiovascular disease). an earlier cdc study focused on the direct and indirect costs in 2003 attributable to arthritis that estimated $80.8 billion in direct costs (medical expenditures) and $47 billion in indirect costs (lost earnings) (yelin et al. 2007 ) . in short, current cost estimates for direct health care expenditures (excluding productivity losses) related to diabetes are approximately $190 billion, for cardiovascular treatment, $324 billion, and for rheumatoid arthritis, approximately $111 billion (estimating that the $80.8 billion in 2003 costs have grown approximately 6% per year), a total of $625 billion of the $2.6 trillion that will be spent in the us in 2010. moreover, given current growth in the prevalence of diabetes, the unitedhealth estimate of $500 million in 2020 spending for diabetes alone is not unreasonable. if health care costs attributable to diabetes, cardiovascular disease and rheumatoid arthritis only increase by 100% over the next decade (even given added demand produced by the aging baby boomer population), annual costs of these chronic diseases will exceed $1.2 trillion in 2020. if we use the unitedhealth estimates for the proportions of diabetes costs paid by private insurance (48%), medicare (38%), medicaid (6%) and the uninsured (8%) and estimate total costs based on the 2010 studies projecting a 50% increase in 5 years and a 100% increase in 10 years we can obtain an estimate of future costs for treating diabetes, cardiovascular disease and arthritis. table 4 .1 set forth below, summarizes these cost estimates. by 2020 medicare costs for these chronic illnesses would be approximately $475 billion. the estimated costs to medicaid will be approximately $75 billion. the costs for the uninsured will be approximately $100 billion. any intervention that has the potential to substantially reduce these costs will produce meaningful results. unfortunately, even though there had been a substantial numbers of studies that show relationships between dental disease and chronic illness that are have been very few studies that actually test whether improved dental treatment reduces the incidence of chronic illness and complications due to chronic illness. the potential for large health care cost savings through an active and aggressive program of dental care is so large that such studies are clearly indicated. suppose, for example, that 10% of all medical care costs required to treat diabetes, cardiovascular disease and arthritis could be avoided through an active aggressive program of dental care. 4 what this would mean is that in 2020 private health insurers could see a $60 billion reduction in healthcare costs, medicare would see a $47.5 billion reduction and medicaid pay $7.5 billion reduction. recent health reform has provided for the issuance of health insurance to the uninsured by state exchanges. aggressive dental care that saved 10% of costs attributable to diabetes, cardiovascular disease and arthritis could save the exchanges $10 billion per year. and, if greater proportions of costs can be saved or if the 2020 estimates of costs are low, potential benefi ts will be even larger. once again, it would be important to know whether aggressive dental care could produce such savings and how much. ide and colleagues found that people who were treated for periodontitis incurred 21% higher health care costs than those who were free of periodontal disease (ide et al. 2007) . similarly, albert, et al., found medical costs associated with diabetes, cardiovascular disease and cerebrovascular disease were signifi cantly higher for enrollees who were treated for periodontitis than for other dental conditions (albert et al. 2006) . additional studies of this nature would be important to support a measured approach to expanding dental coverage. so what do we mean by an aggressive dental treatment plan? suppose we were to provide dental insurance to all medicare benefi ciaries at the level of current private dental insurance coverage and strongly encourage benefi ciaries to receive dental treatment. suppose we were to provide for medicaid payment for all benefi ciaries at the level of current private dental insurance coverage. suppose health care insurers provided dental coverage in order to reduce their costs and that such coverage was consistent with current private dental insurance coverage. suppose health insurance companies, understanding the benefi ts from dental care, were to require their private employer customers to cover the costs of dental care. how much would all of this cost? how would it compare to the benefi ts that may be available? in order to estimate the potential costs of providing enhanced coverage for dental care we start use the cms estimates of national health care spending for dental services and statistical abstract of the us estimates for medicare enrollment, medicaid enrollment, private health insurance enrollment and uninsured persons. based on the estimate that half of private employers with health insurance provided dental insurance coverage we estimate that of the private health insurance enrollment one half would have dental insurance coverage and one half would not. table 4 .2 sets forth the national health care expenditures for dental services in millions and enrollment in private dental plans, medicare, medicaid, the uninsured without health insurance and dental insurance, the uninsured with health insurance and dual eligibles. from this we derive a cost per enrollee for private dental insurance, medicare dental benefi ts and medicaid dental benefi ts. in order to estimate the annual cost of providing full dental coverage to medicare benefi ciaries we subtracted dual eligibles (who receive some dental insurance) from total medicare enrollees to determine the number of persons who would need coverage. in our 2009 example there were 43 million medicare benefi ciaries including 9 million dual eligibles. accordingly, the estimates would cover the 34 million medicare benefi ciaries that are not dual eligible at a cost equal to the per capita cost of private dental insurance ($494.66) less amounts that medicare is already paying for dental services ($6.73 per person). the result provides an estimate of the cost of covering all medicare benefi ciaries for dental services at a level equivalent to private health insurance. using the 2009 example the cost of providing full dental insurance coverage to medicare benefi ciaries would have been $16.6 billion. in addition, we used the cms national health expenditure fi gures to determine administrative costs for private health insurance, medicare and medicaid as a percentage of program expenditures for medical care. we found that the administrative costs of the medicare program were 6.2% on average for 1966-2009. in order to fully estimate the cost of medicare dental coverage we added 6.2% to the cost health insurers will be in the same position as medicare and medicaid regarding dental coverage. if quality dental coverage saves health care costs attributable to diabetes, cardiovascular disease and rheumatoid arthritis then the exchanges will have an incentive to provide quality dental coverage to reduce costs. accordingly, we estimated the cost of providing dental coverage equivalent to private dental insurance coverage through the exchanges. again we assume that the costs of such coverage will be equivalent to the number of uninsured persons multiplied by the annual per capita cost of coverage. 5 for the 2009 example, this would refl ect coverage for 52 million people at $494.66 per person, a total of $24.9 billion. with administrative costs, the cost of providing dental insurance coverage to the uninsured at a level equivalent to private dental coverage would be $26.8 billion. finally, given the evidence that improved dental care has the potential to reduce health care costs private health insurers may wish to expand health insurance to cover dental care. 6 here, we estimate the cost of providing dental insurance to the 50% of the workforce whose employers currently do not provide dental insurance benefi ts. once again, we multiply the number of covered lives by the estimated annual per capita cost. for the 2009 example we estimate 101 million adults will receive dental coverage at $495 per person: $50 billion for dental services and $3.8 billion for administrative costs or a total of $53.8 billion. of course, as noted a number of times above, these estimates are based on providing full "universal" dental insurance coverage at levels equivalent to current benefi t levels for private dental insurance. it may be that an appropriate package of dental services that deals specifi cally with periodontitis can be provided for less than the full cost of private dental insurance. once again, further research should provide better information. 7 5 the health reform law does not attempt to provide coverage to all 52 million people without health insurance. estimates are that only 31 million people will be covered by the bill. even though this is the case we prepare our estimates using all 52 million uninsured americans. 6 indeed, the failure of 50% of employers to cover dental services may well constitute a classic externality in the market for health insurance. internalizing this externality may well provide better effi ciency. 7 it is also possible that dental care for persons with greater incidence of chronic illness as is the case with medicare benefi ciaries may require even higher levels of spending per benefi ciary. again, it would be good to know scientifi cally if this is the case. as noted in sect. 6 above, 2010 costs for diabetes, cardiovascular disease and arthritis will be $300 billion for private health insurance, $238 billion for medicare, $38 billion for medicaid and $50 billion for the uninsured. costs of providing "full" dental coverage will be $17.6 billion for medicare, $18.2 billion for medicaid, $26.8 billion for the uninsured and $53.8 billion for private health insurance. given this, if 7.4% or more of the medicare costs can be "saved" through improved dental care, medicaid dental insurance will pay for itself and will provide a positive return on investment. see table 4 .3 . similarly, private health insurers could justify providing dental insurance coverage to employees who do not have it so long as they spend 17.9% or more of their chronic care costs for diabetes, cardiovascular disease and arthritis. on the other hand, it would appear that medicaid expansion would require cost savings of approximately 48% and that health care insurance coverage of the uninsured would require savings of approximately 54% in order to justify coverage. while it is possible, it may not be likely that full dental coverage would be justifi ed for these programs. of course, these estimates do not consider indirect costs in the form of lost wages or premature death. these costs are externalities to the health insurance programs. to the extent that they represent a social benefi t that a national dental insurance program might internalize, it would be appropriate to consider their impact in the cost-benefi t analysis. in any event, better understanding of the potential for deriving savings in health insurance costs related to chronic diseases like diabetes, cardiovascular disease and arthritis would be crucial to any determination whether to expand insurance coverage for dental care. heretofore the case for expanding medicare coverage to include dental care has taken the form of "benefi t" to patients rather than benefi t to health insurance programs and society and has been cast in emotional and political terms. for example, oral health america grades "america's commitment to providing oral health access to the elderly" (oral health america 2003 ) . in truth, there is no american commitment to providing oral health access to any age group, much less the elderly. rubenstein notes that "at least one commentator has suggested that the dental profession should join with senior citizen groups when the time is right to ask congress to expand medicare to cover oral health" (rubenstein 2005 ) . rubenstein emphasizes that "calls for action" are "mere words" unless they are accompanied by political actions that health policy professionals and the dental profession must help promote (rubenstein 2005 ) . another commentator has suggested that "as soon as the debate over medicare prescription drug coverage and, the debate to provide dental care coverage for the elderly may soon begin" (manski 2001 ) . rubenstein, again suggests that "the dental community must convince americans, and particularly aging boomers, that oral health is integral to all health, and for that reason, retiree dental benefi ts are an important issue". in truth, a decade of defi cit spending and public distaste for out of control program costs in the medicare and medicaid programs as well as the unpopularity of the process that was used to provide medicare prescription drug coverage (with perceived abuses by the health insurance and drug lobbies) and national health reform makes it unlikely that the public would be willing to approve expansions in insurance coverage for dental care "for its own sake" or "as the right thing" or to "benefi t seniors." what this political climate has produced is an arena in which a good idea that could provide appropriate return on investment for society might well be rejected out of hand based on political history of health insurance coverage. as a result, it is incumbent on policymakers, medical and dental research scientists and health economists to investigate and confi rm the potential savings that expansion of dental insurance coverage has the potential to produce and to develop hard evidence regarding potential costs of the expansion prior to, not as a part of, political efforts aimed at dental coverage expansion. a responsible, well informed effort to expand dental coverage may well go far to restore public confi dence in the health policy process. joseph kilsdonk and kelly boggs the adage of "putting your money where your mouth is" is often referenced when being challenged about public statements or claims. in this instance, we use it literally. in 2008 health care costs in us were $2.2 trillion. there have been numerous reports on health disparities, the burden of chronic diseases, increasing healthcare costs and the need for change. long-term economic benefi ts associated with the cost of care are dependent upon integrating oral health with medicine. this is particularly true as it relates to the management of those conditions which impact the economics of healthcare the most. as examples, 96% of medicare costs and 83% of medicaid costs are in managing chronic health conditions (partnership for solutions national program offi ce 2004 ) . more than 40% of the u.s. population has one or more chronic condition (cartwright-smith 2011 ) and in 2006, 76% of medicare spending was on patients with fi ve or more chronic diseases (swartz 2011 ) . effective management of health care resources and information are critical to the economic well-being of our healthcare system. we can no longer afford to manage care in isolation. integration of care between medicine and dentistry holds much promise in terms of reducing the cost of care and an integrated medical-dental electronic healthcare record (iehr) is the vehicle that will lead to downstream cost savings. in the united states the center for medicare & medicaid services (cms) has conducted demonstration projects around chronic disease management. section 121 of the benefi ts improvement and protection act of 2000 mandated cms to conduct a disease management demonstration project. april 1, 2005, as an effort to reduce the cost of care and improve quality associated with chronic diseases, cms partnered with ten premier health systems to effectively manage chronic diseases in a medicare physician group practice demonstration (pgp). it was the fi rst pay-for-performance initiative for physicians under the medicare program (center for medicare and medicaid services 2010 ) . it involved giving additional payments to providers based on practice effi ciency and improved management of chronically ill patients. participants included ten multispecialty group practices nationwide, with a total of more than 5,000 physicians, who care for more than 200,000 medicare benefi ciaries (frieden 2006 ) . the chronic diseases that were targeted were based on occurrence in the population and included diabetes, heart failure, coronary artery disease, and hypertension (frieden 2006 under the pgp, physician groups continued to be paid under regular medicare fee schedules and had the opportunity to share in savings from enhancements in patient care management. physician groups could earn performance payments which were divided between cost effi ciency for generating savings and performance on 32 quality measures phased in during the demonstration as follows: year 1, 10 measures, year 2, 27 measures and years 3 and 4 having 32 quality measures. for each of the 4 years only the university of michigan faculty group practice and marshfi eld clinic, earned performance payments for improving the quality and cost effi ciency of care. a large part of the success of this project was attributed to being able to extract, evaluate, and monitor key clinical data associated with the specifi c disease and to manage that data through an electronic health record (table 4 .4 ). during the third year of the demonstration project marshfi eld clinic, using a robust electronic health record succeeded in saving cms $23 million dollars; that's one clinic system in 1 year. as a result of such demonstration projects and as of this writing, cms is looking to establish accountable care organization's as the medical front runners to new care delivery methods for quality and cost control. accountable care organization (aco) is a term used to describe partnerships between healthcare providers to establish accountability and improved outcomes for the patients. in a cms workshop on october 5, 2010, don berwick, the administrator of cms, stated "an aco will put the patient and family at the center of all its activitiesâ�¦" an emerging model of an aco is the patient-centered medical home (pcmh). pcmh is at the center of many demonstration projects. acos were derived from studies piloted by cms. since funds provided by cms, do not cover routine dental care as part of the patient management or quality and cost objectives cms aco studies are limited if they become models for the pcmh, due to the exclusion of dental. more recently, organizations representing the major primary care specialtiesthe american academy of family practice, the american academy of pediatrics, the american osteopathic association, and the american college of physicianshave worked together to develop and endorse the concept of the "patient-centered medical home," a practice model that would more effectively support the core functions of primary care and the management of chronic disease (fisher 2008 ) . in 2011 geisinger health system, kaiser permanente, mayo clinic, intermountain healthcare and group health cooperative announced they will be creating a project called the care connectivity consortium. this project is intended to exchange patient information. although progressive in their approach their project does not include dental. these benefi ts however, are yet to be adapted in the arena of oral health. as of this writing, dentistry remains largely separate from medical reimbursement mechanisms such as shared billing, integrated consults, diagnosis, shared problem lists, and government coverage. for example, cms does not cover routine dental care. dentistry is also working to establish its own "dental home" with patients. however to reap the economic benefi ts of integrated care, a primary care "medical-dental" home is what needs to be created. according to an institute of oral health report ( 2010 ) it is widely accepted across the dental profession that oral health has a direct impact on systemic health, and increasingly, medical and dental care providers are building to bridge relationships that create treatment solutions. the case for medical and dental professionals' comanaging patients has been suggested for almost the past century, in 1926 william gies reported that "the frequency of periodic examination gives dentists exceptional opportunity to note early signs of many types of illnesses outside the domain of dentistry" (gies 1926 ) . as described by dr. richard nagelberg, dds "the convergence of dental and medical care is underway. our patients will be the benefi ciaries of this trend. for too long, we have provided dental care in a bubble, practicing -to a large degree -apart from other health-care providers. even when we consulted with our medical colleagues, it was to fi nd out if premedication was necessary, get clearance for treatment of a medically compromised patient, or fi nd out the hba1c level of a diabetic individual, rather than providing true patient co-management. we have made diagnoses and provided treatments without the benefi t of tests, reports, metrics, and other information that predict the likelihood of disease development and progression, as well as favorable treatment outcomes. we have practiced in this manner not due to negligence, but because of the limitations of tools that were available to us" (nagelberg 2011 ) . integrated medical/dental records need to be a tool in a providers' toolbox. in the case of marshfi eld clinic, dental was not included in their past cms demonstration project as dental is not a cms covered benefi t, and thus not part of the demonstration. however, as a leader in healthcare, the marshfi eld clinic recognizes the importance of data integration for both increased quality and cost savings. "marshfi eld clinic believes the best health care comes from an integrated dental/medical approach," said michael murphy, director, business development for cattails software. integration enhances communication between providers and can ultimately lead to better management of complex diseases with oral-systemic connection, avoidance of medical errors, and improved public health. while the cms pgp and other demonstration projects along with independent studies have shown to improve quality and reduce costs through integration, greater results may be afforded if studies are not done in isolation from dental data. in fact, if healthcare does not fi nd a way to manage the systemic nature of the 120 pathogens known to the oral cavity the economic impact and cost savings around chronic disease management will hit a ceiling. the economic opportunity of having clinical data for integrated decision making is readily identifi ed by the insurance industry. the effective management of clinical data around chronic and systemic oral and medical disease as part of an iehr is the greatest healthcare cost savings opportunity associated with such a tool. the insurance industry sustains itself through risk management [obtaining best outcomes] using actuarial analysis [data] and controlling costs [reduction of costs] in order to ensure coverage [profi tability]. as such they have pursued the economic and outcome benefi ts of integrated medical -dental clinical decision making. as an example, in 2009 there was a study conducted by the university of michigan, commissioned by the blue cross blue shield of michigan foundation ( 2009 ) , the study included 21,000 blue cross blue shield of michigan members diagnosed with diabetes who had access to dental care, and had continuous coverage for at least 1 year. with regular periodontal care, it was observed diabetes related medical costs were reduced by 10%. when compounding chronic health complications were also examined, the study showed a 20% reduction in cost related to the treatment of cardiovascular disease in patients with diabetes and heart disease. a 30% reduction in cost related to treatment of kidney disease for patients with diabetes and kidney disease. and a 40% reduction in costs related to treating congestive heart failure for patients with diabetes and congestive heart failure. according to a joint statement by lead researchers, and blue cross blue shield of michigan executives, "our results are consistent with an emerging body of evidence that periodontal diseaseâ�¦it addresses quality of care and health care costs for all michigan residents." also, at the institute for oral health conference in november 2007 joseph errante, d.d.s., vice president, blue cross blue shield of ma reported that 2003 blue cross blue shield of massachusetts claims data showed medical costs for diabetics who accessed dental care for prevention and periodontal services averaged $558/month, while medical costs for diabetics who didn't get dental care were about $702/month (errante 2007 ) . similarly insured individuals with cardiovascular diseases who accessed dental care had lower medical costs, $238/month lower than people who did not seek dental treatment (errante 2007 ) . the cost is $144 less per visit for those diabetics who accessed prevention and periodontal services. those savings could be translated into access to care or additional benefi ts for more individuals. in the case of neonatal health there is similar research. over 12% of all births in the u.s. are delivered preterm, with many infants at risk of birth defects ( martin et al. 2009 ) . according to a january 2006 statement issued by cigna, announcing their cigna oral health maternity program, "the program was launched in response to mounting research indicating an increased probability of preterm birth for those with gum disease. these research-based, value-added programs are designed to help improve outcomes and reduce expense" (cigna 2006 ) . the program was initially designed to offer extended dental benefi ts free of charge to members who were expecting mothers, citing "research supporting the negative and costly impact periodontal disease has on both mother and baby." according to research cited by cigna, expecting mothers with chronic periodontal disease during the second trimester are seven times more likely to deliver preterm (before 37th week), and the costs associated with treating premature newborns is an average of 15 times more during their fi rst year, and premature newborns have dramatically more healthcare challenges throughout their life. cigna also cited the correlation between periodontal disease and low birth weight, pre-eclampsia, gestational diabetes as additional rationale to support extended dental benefi ts to expecting mothers. six months later cigna initiated well aware for better health, an extended benefi ts free of charge program for diabetic and cardiovascular disease patients aimed at "turning evidence into action by enhancing dental benefi ts for participants in disease management" programs. it is interesting to note, not only does cigna offer extended dental benefi t to targeted groups, they also reimburse members for any out-of-pocket expenses associated to their dental care (co-pays, etc.) in 2006, columbia university researchers conducted a 2-year retrospective study of 116,306 aetna ppo members with continuous medical and dental insurance, exhibiting one of three chronic conditions (diabetes mellitus, coronary artery disease, and cerebrovascular disease) (aetna 2008 ) . researchers found members who received periodontal treatments incurred higher initial per member per month medical costs, but ultimately achieved signifi cantly lower health screening (episode risk group/erg) risk scores than peers receiving little or no dental care. convinced by the data and understanding lower risk scores ultimately leads to healthier people and cost savings, aetna initiated the dental/medical integration (dmi) program in 2006. aetna's dmi program offers enhanced benefi ts in the form of free-of-charge extended benefi t dental care to aetna's 37.2 million indemnity, ppo and managed choice medical plan members, specifi cally targeting members deemed at-risk, including those who are pregnant, diabetic, and/or have cardiovascular disease and have not been to a dentist in 1 year as a result of various outreach methods during the pilot, 63% of at-risk members who had not been to a dentist in the previous 12 months, sought dental care (aetna 2008 ) . "the fi ndings from this latest study we conducted continue to show that members with certain conditions who are engaged in seeking preventive care, such as regular dental visits, can improve their overall health and quality of life," said alan hirschberg, head of aetna dental (aetna 2008 ) . delta dental of wisconsin understands the connection between oral and systemic health and has created a program that is designed to offer members with certain chronic health conditions the opportunity to gain additional benefi ts. more than 2,000 groups now offer delta dental of wisconsin's evidence-based integrated care plan (ebicp) option (delta dental of wisconsin 2011 ) . ebicp provides expanded benefi ts for persons with diseases and medical conditions that have oral health implications. these benefi ts include increased frequency of cleanings and/or applications of topical fl uoride. they address the unique oral health challenges faced by persons with these conditions, and can also play an important role in the management of an individual's medical condition. ebicp offers additional cleanings and topical fl uoride application for persons who are undergoing cancer treatment involving radiation and/or chemotherapy, persons with prior surgical or nonsurgical treatment of periodontal disease and persons with suppressed immune systems. the ebic offers additional cleanings for persons with diabetes and those with risk factors for ie, persons with kidney failure or who are on dialysis and for women who are pregnant. the iehr provides the insurance industry in partnership with the healthcare industry an integrated tool to facilitate these health and subsequently economic outcomes across medicine and dentistry. in addition to the anticipated savings through better outcomes using integrated clinical data, an example of a positive economic outcome associated with an integrated record as related to increased effi ciency and patient safety is found in the united states veterans administration (va) hospitals and clinics. the va is one of the few institutions that have implemented the shared electronic medical-dental record successfully. the va has the ability to be the "one stop shop" for their patients. an april 2010 press release published on the department of veterans affairs website highlighted the success of va's health information technology in terms of cost reductions and "improvements in quality, safety, and patient satisfaction" (department of veterans affairs 2010 ) . the press release spotlighted a recent study conducted by the public health journal, health affairs, which focused on va's health it investment from 1997 to 2007. the study confi rmed that while va has spent $4 billion on their technology initiative, a conservative estimate of cost savings was more than $7 billion. after subtracting the expense of the it investment, there was a net savings of $3 billion for the va during the 10 years covered by the study (mcbride 2011 ) . furthermore, the study estimated that "more than 86 percent of the savings were due to eliminating duplicated tests and reducing medical errors. the rest of the savings came from lower operating expenses and reduced workload." independent studies show that the va system does better on many measures, especially preventive services and chronic care, than the private sector and medicare. va offi cials say "its [integrated] technology has helped cut down hospitalizations and helped patients live longer" (zhang 2009 ) . recently, the journal of obstetrics and gynecology reported on a tragic loss of life due to the systemic nature of oral health. a study found oral bacteria called fusobacterium nucleatum was the likely culprit in infecting a 35-year-old woman's fetus through her bloodstream (carroll 2010 ) . the doctors determined that the same strain of oral bacteria found in the woman's mouth was in the deceased baby's stomach and lungs. integrated records would provide critical data to the obstetrician including oral health issues and when the patient had her last dental exam. how does one measure the economic impact of a life not lived and another derailed by such tragedy? in a randomized controlled study, lopez et al. ( 2005 ) determined that periodontal therapy provided during pregnancy to women with periodontitis or gingivitis reduced the incidence of preterm and of low birth weight. the institute of medicine and national academies estimate that preterm births cost society at least $23billion annually . data integration of the iehr enables the effective management between the dentist and obstetrician to ensure proper periodontal therapy has been provided during pregnancy. such management based on the lopez et al. study, will have direct impact in reducing the prevalence per preterm births leading to reduced health care costs. there have also been studies indicating a correlation between poorer oral hygiene or defi cient denture hygiene and pneumonia or respiratory tract infection among elderly people in nursing homes or hospitals (rosenblum 2010 ; ghezzi and ship 2000 ; scannapieco 2006 ) . one such study of 141 elderly persons in two nursing homes in japan (adachi et al. 2002 ) concluded that "the number of bacteria silently aspirating into the lower respiratory tract was lower in the group who received professional oral care, which resulted in less fatal aspiration pneumonia in that group." over the 24 month period of the study, of the 77 patients receiving professional oral care, 5% died of pneumonia versus 16.7% of the 64 patients that died of the same cause who maintained their own oral hygiene. lack of access is certainly a key factor to consider. however, lack of available data respective to the interrelationship between oral health and systemic health also contributed to the apathy in these cases. as identifi ed above, complications are correlated to cost. as conditions compound, costs go up. marshfi eld clinic, as part of their iehr is creating a shared problem list that identifi es both oral and medical conditions and history to recent visits and medication lists for monitoring at point of care [be it a medical or dental visit], such cross access to clinical data and care management milestones serves as a tool to prevent conditions from compounding and escalating costs such as those described above. several other areas of economic impact will be seen as iehr's become broadly deployed. some of these are listed as follows: medication management. a great deal of provider and allied support time is â�¢ spent obtaining medication information between dentistry and medicine [and vice versa] including current medications, contraindications, tolerances, etc. marshfi eld clinic cattails software has created a dashboard that readily identifi es this for both the medical and dental providers. not is time saved but chances for complications or escalation of conditions is reduced [both of which impact cost]. for example an integrated record allows medical providers treating respiratory infections to include or exclude oral fl ora as the possible source of the infection which would lead to more knowledgeable prescribing decision on the antibiotic used. coordination of care has a direct impact on cost for the system and the patient. â�¢ for example, in 2008 55.6% of the us population aged 2 years and older that was diagnosed diabetes had been to the dentist in the past year (healthy people 2020 (2010 )). the us government's program healthy people 2020 includes an initiative to increase the proportion of people with diagnosed diabetes who have at least an annual dental examination. the american diabetes association recommends that diabetic patients be seen semi-annually and more if bleeding gums or other oral issues are present. the american diabetes association also recommends the consultation between the dentist and doctor to decide about possible adjustments to diabetes medicines, or to decide if an antibiotic is needed before surgery to prevent infection. the target from the healthy people 2020 is a 10% improvement at 61.2%. integrated medical/dental records could allow for the coordination of efforts between providers to include communication of treatment plan and services leading to quicker resolution, increased patient compliance, and less patient time away from work or home and potentially less travel. similarly, integrated records also create a platform to integrate clinical appointing â�¢ between medicine and dentistry. as such, combative patients or severely disabled patients needing anesthesia in order for care to be delivered can be treated with one hospital sedation vs. multiple sedations. family health center of marshfi eld, inc. (fhc) dental clinics shares an iehr with marshfi eld clinic and uses it integrated scheduling feature to complete dental care, lab work, ent care, woman's health, preventive studies, all in one visit. follow up care management can be more focused and coordinated. for example, â�¢ without the knowledge or dental conditions, medical providers could spend months attempting to control diabetes with periodontal disease. however, with access to an iehr, the practitioner or allied care manager can determine patient's oral health status immediately to determine possible infl uence of periodontal disease. similarly an iehr with a shared patient data dashboard brings to light history â�¢ and physical examination data without having to have patients be the historian to their physician on their last dental visit or for the dentist to have to rely on the patient's recall of medications or medical diagnosis. for example, if an integrated record saved providers 5 min per hour of patient care, that would be 40 min per day. imagine giving a physician or dentist 40 min more a day. in a capitated system, this allows for more patients to be seen in a day for roughly the same amount of expenditure. in a production based clinic this allows more patients to be seen and more charges per day. in either case, the investment into informatics is covered. in an underserved area, more patients get care quicker, which creates the opportunity for quicker resolution, which can lead to a healthier society, which in turn may lead them back to a productive livelihood sooner. an iehr results in one system for acquisition, orientation, training and support. â�¢ pc based owners who also own a mac and mac owners who also have to operate a pc can relate. need we say more? imagine if your pc function just like a mac [or your mac function just a pc]. no cross learning of software quirks. not having to purchase two separate units to begin with. reduced costs, increased space. not having to jump from one computer to the other computer to get data from one data from another to create a report. not having to call two separate computer companies for service or updates. third party coordination. having an iehr creates a platform for interfacing â�¢ with third party payers. a common system and language for timely reimbursement. in part, the result of an iehr is driving the diagnostic coding for dentistry. such an integrated interface provides a tool to bridge with healthcare payors that historically kept payment as segregated as the oral and medical health professions. the iehr overcomes that limitation. timely payment, consolidation of payment, expansion of covered patient and provider benefi ts based on clinical integration, and a viable system for interfacing are all potential economic benefi ts of iehr clinical data. the iehr creates new horizons for research that will lead to cost saving discov-â�¢ eries. as example, knowing the benefi ts of research, marshfi eld clinic research foundation (mcrf) has created an oral and systemic health research project (oshrp). the creation of oshrp, led by dr. murray brilliant, will allow mcrf to capitalize on its existing and growing strengths in the areas of complex disease interactions and personalized health care (phc) to advance oral health and the health of the rest of the body. the oshrp has three specifi c goals: understand the connections between oral and systemic health (diabetes, heart disease, pre-term births) understand the causes of oral diseases and determine the effect of genetics, diet, water source (well/city + fl uoridation) and microbiome. understand how improving oral health aids systemic health (comparative effectiveness) and bring personalized health care (phc) to the dental arena. the oshrp research resource will be unique in the nation. as mcrf has done â�¢ with other projects, it will share this resource with qualifi ed investigators at other academic institutions both within and outside of wisconsin. oshrp will advance scientifi c knowledge, improve healthcare and prevention, reduce the cost of oral healthcare, and create new economic opportunities. such knowledge will have a direct economic impact on the cost of care and care management. the iehr creates an ability to have an integrated patient portal to comprehen-â�¢ sively maintain their health. portals are becoming more and more popular in the healthcare industry as a means to helping maintain compliance with care management recommendations and preventative procedures. portals provide patents a tool to stay up to date on their care and recommendations. portals can take iehr clinical data, adapt it through programming, and provide creative visual reinforcement for patients as they monitor their health status. the more patients engage in owning their health status, the more preventative services are followed through with. the more medicine and dentistry can leverage the prevention potential [which insurance companies have come to realize] the more likely costly conditions can be avoided. the link between oral health and systemic health is well documented. the separation of dental and medical is not a sustainable model in modern healthcare delivery. a new model of integrated care is necessary. aristotle said, "the whole is greater than the sum of its parts." increased access to combined medical and dental histories and diagnosis at the providers' fi ngertips makes vital information available. shared diagnosis between physicians and dentists could aid in formulating interventions and to accelerate decision making abilities by allowing for prioritizing of medical/ dental procedures. clinical management and treatment of the patient would be expedited with immediate access to both records. quality could be improved through a complete picture of the patient through the dashboard. all of which have a direct or indirect economic benefi t. the iehr will be the tool that facilitates such delivery and the studies and scenarios described in these pages point to signifi cant economic benefi ts to patients, payors, and providers. if increased access, multi-provider monitoring, shared problems lists with enhanced decision making abilities from iehr could reduce healthcare costs. the greatest cost reduction will be with using the iehr to manage chronic disease. a combined dental-medical electronic record with a shared data informatics platform is most likely to yield the best long-term economic solution while maintaining or enhancing positive patient outcomes. this section reveals viewpoints from a variety of medical and dental providers. one section focuses on optimal use of ophthalmic imaging, which should show how that the challenges of clinical data integration go beyond those encountered in the effort to bring oral health and systemic health together. wendy e. mouradian , suzanne boulter , paul casamassimo , and valerie j. harvey powell oral health is an important but often neglected part of overall health. historically separate systems of education, financing and practice in medicine and dentistry fuel this neglect, contributing to poorer health outcomes for vulnerable populations such as children, while increasing costs and chances for medical error for all patients. advances in understanding the impact of oral health on children's overall health, changing disease patterns and demographic trends strengthen the mandate for greater integration of oral and overall healthcare, as reviewed in two recent institute of medicine reports (iom 2011a, b ) . the pediatric population could realize substantial benefit from oral disease prevention strategies under a coordinated system of care enhanced by integrated electronic health records (ehr). this approach would benefit all children but especially young children and those from low socioeconomic, minority and other disadvantaged groups who are at higher risk for oral disease and difficulties accessing dental care. this section focuses on the pediatric population and the need for close collaboration of pediatric medical and dental providers. first we consider how a child's developmental position and their parents' level of understanding might affect oral health outcomes. next we address the importance of children's oral health and the urgency of seizing missed opportunities to prevent disease. we then briefl y outlines some steps to preventing early childhood oral disease utilizing some of the many health providers that interact with families. finally we examine one pediatric hospital's approach to choosing an integrated ehr technology. children have unique characteristics which distinguish their needs from those of adults. children's developmental immaturities may increase their risks for poor oral health outcomes ( fig. 4 all children, but especially young children, are limited in their ability to care for their own health and must depend upon adults. a child's parent/caregiver may also lack basic oral health knowledge and an awareness of their child's oral health needs, and/or suffer from poor oral health themselves. low oral health literacy is prevalent among patients and health professionals alike in america; individuals of low socioeconomic status or from ethnically diverse backgrounds may be at particular risk for low oral health literacy (iom 2011a ) . without appropriate education, a parentâ�¦. may not correctly interpret a child's symptoms or signs of oral disease â�¢ may not know that caries is an infectious disease that can be spread to a child by â�¢ sharing spoons, for example, may not know the potential value of chewing gum with xylitol, â�¢ may not fully grasp the importance of good oral health hygiene habits, â�¢ may not grasp the consequences of a child consuming quantities of sugared â�¢ foods or beverages, may have diffi culty controlling the child's consumption of sugared foods or bev-â�¢ erages in or out of the home, may not realize the consequences of chronic use of sugared medications, â�¢ may not know the potential for systemic spread of disease from a toothache, or â�¢ for liver damage due to overuse of acetaminophen or other analgesics, may not grasp the long-term consequences of early childhood caries, â�¢ may live in a community without fl uoride in the tap water and not know about â�¢ alternative sources of fl uoride, may overlook oral health due to the stress of living in poverty, â�¢ may be fearful of dentists or oral health care due to their own experiences, â�¢ may have diffi culty locating a dental provider accepting public insurance, or â�¢ have other problems navigating the health care system. parents in turn depend on access to medical and dental providers with current understanding of the most effective ways to prevent caries and promote the child's oral and overall health. an important element in helping families is the provision of culturally-sensitive care to a diverse population. children are the most diverse segment of the population with 44% from minority backgrounds compared with 34% of the overall population (us census bureau 2010 ) . the separation of medical and dental systems and the lack of shared information can create additional barriers for families, especially for those with low health literacy or facing linguistic or cultural barriers. all pediatric health professionals have increased ethical and legal responsibilities to promote children's health, including advocacy for them at the system level (mouradian 1999 ) . although many factors can infl uence children's oral health outcomes, caries is largely a preventable disease. despite this, national trends and other data on 4 broader considerations of medical and dental data integration children's oral health attest to this persistent national problem ) . some important facts include the followingâ�¦. caries is the most prevalent chronic disease of childhood, â�¢ caries is a preventable disease unlike many chronic diseases of childhood, â�¢ yet according to (nicdr 2011) 42% of children 2-11 have had dental caries in â�¢ their primary teeth; 23% of children 2-11 have untreated dental caries. further, "21% of children 6-11 have had dental caries in their permanent teeth; 8% of children 6-11 have untreated decay." overall "[c]hildren 2-11 have an average of 1.6 decayed primary teeth and 3.6 decayed primary surfaces," the latest epidemiologic evidence shows increasing rates of caries for young-â�¢ est children, reverse from the healthy people 2010 goal of decreasing caries. according to (nicdr 2011), overall "dental caries in the baby teeth of children 2-11 declined from the early 1970s until the mid 1990s. from the mid 1990s until the most recent (1999) (2000) (2001) (2002) (2003) (2004) ) national health and nutrition examination survey, this trend has reversed: a small but signifi cant increase in primary decay was found. this trend reversal was more severe in younger children." disparities in children's oral health and access to care persist by age, income â�¢ level, race and ethnicity, and parental education level (edelstein and chinn 2009 ) . of concern, the latest increase was actually in a traditionally low-risk group of young children (dye and thornton-evans 2010 ) . the human and economic costs of early childhood caries are substantial â�¢ (casamassimo et al. 2009 ) . according to catalanotto ( 2010 ) , health consequences includeâ�¦ extreme pain, spread of infection/facial cellulitis, even death (otto 2007 ) diffi culty chewing, poor weight gain falling off the growth curve (acs et al. 1999 ) risk of dental decay in adult teeth (broadbent et al. 2005 ; li and wang 2002 ) crooked bite (malocclusion) -children with special health care needs (cshcn) may be at higher risk for oral â�¢ disease and diffi culties accessing care. analyzing data from the national survey of children with special health care needs, (lewis 2009 ) found that "cshcn are more likely to be insured and to receive preventive dental care at equal or higher rates than children without special health care needs. nevertheless, cshcn, particularly lower income and severely affected, are more likely to report unmet dental care need compared with unaffected children." children who were both low-income and severely affected had 13.4 times the likelihood of unmet dental care needs, dental care is the highest unmet health care need of children; 4.6 million children â�¢ had unmet dental care needs because families could not afford care compared with 2.8 million with unmet medical needs for the same reasons (cdc 2008 ) , according to the national survey of children's health, children are 2.6 times as â�¢ likely to lack dental as medical insurance (lewis et al. 2007 ) , there is evidence that children who get referred to a dentist early may have lower â�¢ costs of care and disease. savage et al. ( 2004 ) reported that children "who had their fi rst preventive visit by age 1 were more likely to have subsequent preventive visits but were not more likely to have subsequent restorative or emergency visits" and concluded that preschool "children who used early preventive dental care incurred fewer dentally related costs," ramosgomez and shepherd ( â�¢ 1999 ) , in their "cost-effectiveness model for prevention of early childhood caries," conclude that preventive ecc interventions could reduce ecc by 40-80% for a particularly vulnerable population of children, and that part of the costs of interventions will be offset by savings in treatment costs. as these facts convey, and the deaths of more than one child from consequences of untreated caries make painfully clear, there is an urgent need for more attention to the oral health needs of children. a more coordinated system for oral health care including integrated ehr would be an important advance. a glance at table 4 .5 , an ideal model, reveals that intervention should begin before birth and that a range of medical and oral health professionals can contribute to the child's oral health. early intervention is necessary because of the transmissibility of cariogenic bacteria from mother/caregiver to infant, and importance of oral health practice in preventing disease. the following professionals may be involved: â�¢ pediatric medical provider family physician pediatrician pediatric nurse nurse practitioner in pediatric/family practice physician assistant in pediatric /family practice other appropriate allied health professionals â�¢ the availability of some of these professionals can be affected socioeconomic status, health insurance, place of residence, or by a child's special health care need. one obvious limitation on developing a "relay" as in table 4 .5 , with a "hand-off" from family care to obstetric care to pediatric care is the education of the medical providers. as part of pre-conception and perinatal healthcare, providers should address oral health, but may lack the knowledge to do so. additionally, as noted by ressler-maerlaender et al. ( 2005 ) , "some women may believe that they or their table 4 .5 timeline of some oral health interventions to prevent early childhood caries (ecc) -birth to 3 years age (marrs et al. 2011 ; lannon et al. 2008 ; han et al. 2010 ; ezer et al. 2010 ; aap 2008 ; mouradian et al. 2000 ) child's age intervening professional(s) planning conception, prenatal and perinatal family physician the physician and/or obstetric provider educates mother-to-be about good maternal oral hygiene and infant oral health issues, including transmissibility of caries. mother's dentist assesses and treats caries, gingivitis or other oral health problems and educates the mother-to-be obstetrician/nurse midwife obstetric nurse general dentist obstetric nurse obstetric nurse advises new mother to chew xylitol gum, limit salivary contact between mother and infant, and help child avoid sugar intake (exposure) while asleep and from common sugar sources (medicines, sugared water, bottle feeding on demand at night with fl uid other than water -following tooth eruption, certain foods), and to schedule dental exam at 1 year age 6 months pediatric medical provider first dental examination recommended by aapd when the fi rst tooth comes in, usually between 6 to 12 months pediatric/general dentist educate mother about optimal fl uoride levels 1. assess the woman's oral health status, oral health practices, and access to a dental home; 2. discuss with the woman how oral health affects general health; 3. offer referrals to oral health professionals for treatment; 4. educate the woman about oral health during pregnancy, including expected physiological changes in the mouth and interventions to prevent and relieve discomfort; and 5. educate the woman about diet and oral hygiene for infants and children and encourage breastfeeding a combination of anticipatory guidance, with continuity from prenatal and perinatal care to pediatric care, can help move infant oral health from "missed opportunities" to "seized opportunities." others who may be of assistance to families in closing these gaps are professionals at the women, infants and children's (wic) supplemental nutrition program, early head start/head start and neurodevelopmental/birth to three programs. together medical, dental and community professionals can help create a system of care to improve maternal and child oral health. for the envisioned model in table 4 .5 to be realized, the mother requires access to a general dentist with accurate information on her oral health during pregnancy and on her infant's oral health, including the need for an early dental visit. the mother and child then need access to a pediatric medical provider who will provide oral health screening/counseling, and who will guide the family to establishing the child's dental home by age 1. success in dental referral requires access to a pediatric or general dentist willing and able to provide infant oral health. (dela cruz et al. 2004) , in a discussion of the referral process mentioned that among the factors in assessing the likelihood of a dental referral were the medical providers' "level of oral health knowledge, and their opinions about the importance of oral health and preventive dental care." since young children are much more likely to access medical than dental care, the medical provider plays an important role in promoting children's oral health. (catalanotto 2010 ) recommends, as part of a pediatric well child checkup: an oral screening examination, â�¢ a risk assessment, including assessment of the mother's/caregiver's oral health, â�¢ application of fl uoride varnish â�¢ anticipatory guidance (parental education) including dietary and oral hygiene â�¢ information, attempted referral to a dental home. â�¢ the aap recommends that child healthcare providers be trained to perform an oral health risk assessment and triage all infants and children beginning by 6 months of age to identify known risk factors for early childhood caries (ecc). the oral health component of pediatric care is integrated into the aap's "recommendations for preventive pediatric health care (periodicity schedule)" (aap 2008 ) . to what extent are medical and dental and providers aware of recommendations for a fi rst dental visit for a child by age one, as recommended by the aap, the american academy of pediatric dentistry (aapd), and the american dental association? (wolfe et al. 2006 ) reported that 76% of licensed general dentists in iowa were familiar with the aapd age 1 dental visit recommendation and that most obtained the information through continuing education; 11% believed that the fi rst dental visit should occur between 0 and 11 months of age. however, according to (caspary et al. 2008 ) , when pediatric medical residents were asked the age for the fi rst dental visit, the average response was 2.4 years, while 35% reported received no oral health training during residency. in a national survey of pediatricians ) reported that less than 25% of had received oral health education in medical school, residency, or continuing education. finally (ferullo et al. 2010 ) surveyed allopathic and osteopathic schools of medicine and found that 69.3% reported offering less than 5 h of oral health curriculum, while 10.2% offered no curriculum at all. other workforce considerations relevant to preventing early childhood caries include the training of dentists in pediatric oral health (seale et al. 2009 ) , the number and diversity of the dental workforce, the number of pediatric dentists, and the use of alternative providers such as dental therapists, expanded function dental assistants and dental hygienists (mertz and mouradian 2009 ; nash 2009 ) . examples of integrated care models do exist, such as that presented by (heuer 2007 ) involving school-linked and school-based clinics with an "innovative health infrastructure." according to heuer, "neighborhood outreach action for health (noah)" is staffed by two nurse practitioners and a part-time physician to provide "primary medical services to more than 3,200 uninsured patients each year" in scottsdale, arizona. heuer counts caries among the "top ten" diagnoses every year. mabry and mosca ( 2006 ) described community public health training of dental hygiene students for children with neurodevelopmental/intellectual disabilities. they mentioned that the dental hygiene students had worked together with school nurses and "felt they had impacted the school nurses' knowledge of oral disease and care." the decision to acquire an integrated ehr as pediatric clinicians (both medical and dental) work more closely together, they require appropriate ehr systems that integrate a patient's medical and dental records. following is a set of local "best practices" from nationwide children's hospital in columbus, ohio, which may help other children's hospitals in planning acquisition of an integrated pediatric ehr system. integrated (medical-dental) ehr technologies are becoming more widely available outside the federal government sector (see integrated models e1 and e2 in fig. 1.3 ). nationwide children's 'drivers' for the acquisition process were, in 2011: 1. minimize registration and dual databases . patient registration takes time and requiring both a stand-alone dental and a medical patient registration inhibits cost-effective fl ow of services. integration allows for the use of single demographics information for all clinics in the comprehensive care system serving the patient. clinicians always have an updated health history on patients, if they have been a patient of record. if not, and for a dental clinic that sees walk-ins, a brief "critical" dental health history can be completed on paper by a parent and scanned into the emr. in designing an integrated medical-dental record for patients of record, the system can sort essential health history elements into a brief focused dental history without the detail needed by other medical specialty clinics. kioskdriven electronic health histories for those children who are new to clinic similar to those used in airline travel could be considered if feasible in busy clinics. 2. for charting, no more key/mouse strokes than with paper . some commercial dental record products try to accomplish too much. moving from paper to electronics should be driven in part by effi ciencies. the tooth chart, which is an essential part of any dental record, must be such that examination fi ndings can be transferred quickly and accurately to either paper or electronic capture. a helpful exercise is visualization of the functionality of the charting process, including both the different types of entries (caries, existing restorations and pathology) and how these are entered in the paper world. if charting will be able to be used for research the system should be able to translate pictures to numerical values, often a complex programming function. dental practitioners and faculty may want to use drawings of teeth or graphics of surfaces because that is their current comfort level. a true digital charting is possible with no images of teeth, but some habits are hard to change. 3. maximizing drop downs with drop down building possible . duplication of paper chart entries using drop downs which can be upgraded as more clinical entities are found is a staple of an emr. the paper process usually relies on a clinician's wealth of medical-dental terms since inclusion of every possible, or even the most common fi ndings, is prohibitive on a paper chart. the emr drop down requires front-end loading of the most common clinical fi ndings with opportunity for free-hand additions. being able to add terms to any drop down is a needed capability. 4. don't design a system for uncommon contingencies, but for your bulk of work . a pediatric dental record should be primarily designed around dental caries, with secondary emphases on oral-facial development (orthodontics) and a lesser capability to record traumatic injuries and periodontal fi ndings. these second and third level characteristics can be hot-buttoned and should not drive the design of the basic system which is caries charting for 98% of our patients. sadly in most dental schools, the chart is slave to every teaching form, few of which ever exit with the dds into practice! these forms may have little relationship to patient care and only create "signature black holes" that need to be addressed, usually after treatment is completed. 5. progress notes should be designed for the routine entries with free-hand modification possible . student learners tend to write too much and a carefully crafted progress note format with standard entries in required fi elds helps patient fl ow and record completion. in federally funded clinics and residencies, attending reconciliation of student/resident service delivery is a compliance requirement. a well-designed emr system can "stack" required co-signing tasks on a computer screen, offer standard entries as well as free-hand options, and create a process far faster than paper records for an attending's validation (same as reconciliation?). 6. tie examination results to treatment planning and treatment planning into billing . a good system allows easy transfer of clinical fi ndings needing treatment into some problem "basket" and ideally in a tabulated format. an alternative is a split screen that allows a clinician to visualize clinical fi ndings, radiographic fi ndings while compiling a treatment plan. again, in clinical settings where compliance to medicaid/medicare regulations is required, the design of the record should give attention to auditing principles and security. a good emr system allows portals of entry for billing and compliance personnel. 7. plan for users of different skill levels and different periods of exposure . the teaching hospital or dental school environment often involves learners and attendings with varying skill levels and computer experience who may be there for brief periods of time. this reality adds signifi cant security and userfriendliness issues. some medical record systems are far too complex for shortterm or casual users. a well-integrated medical-dental emr allows navigation of the depths of the medical side should a user want to explore, but should focus on the dental portion. some suggestions in design: initial opening or logging into the dental portion for dental users, rather than â�¢ opening into the medical portion, clearly indicated options for exploration of medical portions, â�¢ orientation of major dental component (examination, radiographs, treatment â�¢ plan) in a logical dental treatment fl ow to replicate the way dentistry works rather than trying to reshape dentistry's normal fl ow to the record, minimization of seldom-used functions on the main dental screen, such as â�¢ specialty medical clinics, old laboratory tests and hyperfunctionalities like letter writing, clear identifi cation of existing non-caries dental portions like orthodontics or â�¢ trauma, so a novice user need not randomly search to see if a patient has any of these records. unfortunately, many pediatric hospitals do not yet have an ehr system that supports convenient communication among a pediatric patient's medical and dental providers. evidence of this state of affairs was provided unintentionally by (fiks et al. 2011 ) . some pediatric hospitals may have an awkward mix of systems serving physicians, dentists, and orthodontists and their shared patients. this section demonstrates how closely medical and dental professionals must collaborate to deliver appropriate oral health care for infants and children. such collaboration is especially important given the developmental vulnerabilities of children and the urgency of the oral health needs of many children, especially those from underserved populations. collaboration is made more diffi cult by the long-standing separation of medical and dental systems and poor oral health literacy of parents and medical professionals alike. teamwork in the delivery of pediatric care requires appropriate electronic patient record technology to facilitate sharing of patient information, to avoid patient record discrepancies between systems, and to create effi ciencies by maintaining only a single repository for patient demographics. only comparatively recently have appropriate integrated systems become available to support a range of clinical sites from pediatric special needs clinics to the largest children's hospitals. nationwide children's has given practical examples of effi cient decision-making in identifying an integrated system to acquire. much more work will be needed to develop the means to move towards integrating offi ce and community-based care for children through the sharing of electronic health records. oral health is an oft neglected area in the care of patients who have chronic kidney disease. furthermore, the provision of care by dentists and physicians to the same patient is fragmented as communication between the two health care providers is scant. emerging data suggesting the periodontal disease is closely linked to chronic kidney disease highlights the importance of proper oral health and the importance of communication between dentists and physicians in the care of the patient. investigators used data from nhanes iii, including information on 11, 211 adults who had an oral examination by a dentist who categorized each patient as having no periodontal disease, periodontal disease or edentulous to examine the relationship between numerous risk factors for moderate to severe chronic kidney disease, as determined by calculation of estimated gfr through use of the mdrd formula (fisher et al. 2011 ) . no chronic kidney disease was defi ned as an estimated gfr of 60 ml per min per 1.73 m 2 . three percent of the patients had ckd, 22.5% were hypertension and 4.4% had diabetes (2.4% with glycated hemoglobin of 7% or higher). four models were constructed to examine the potential relationship between periodontal disease and ckd. in model one adults with either periodontal disease or edentulous had an adjusted odds ratio of 1.83 (with 95% confi dence intervals of 1.31-2.55) of having ckd, independent of the other risk factors for ckd including of age above 60 years, ethnicity, hypertension, smoking status, female gender and c-reactive protein elevation. the fourth model contained 15 potential risk factors including the periodontal disease score and for every 1-unit increase in the score, the risk of having ckd increased by 1% controlling for the other risk factors. the authors hypothesized from their results that the relationship between periodontal disease and ckd was bidirectional in that ckd may increase the risk of periodontal disease which in turn increases the risk of ckd. grubbs et al. ( 2011 ) also used nhanes data to look more closely at the relationship between periodontal disease and ckd, using dental examinations obtained from 2001 to 2004 (n = 6,199 adults, 21-75 years) (grubbs v, et al. 2011 ) . in this analysis edentulous subjects were excluded and those with albuminuria were included in the defi nition of ckd. in the entire population ckd was present in 10.6%, but in those with moderate to severe periodontal disease this increased to 21.6%. other associations with moderate to severe periodontal disease were being older, male, nonwhite, less educated and poor. there was a strong relationship between periodontal disease and ckd (2.5 unadjusted odds ratio). when adjusted for age, gender, tobacco use, hypertension, diabetes, ethnicity, poverty and educational attainment, the odds ratio for the association of periodontal disease and ckd was still signifi cant (1.55). in some groups (mexican american, poor, and poorly educated) dental care was not received on an annual basis in the majority of this segment of the population. periodontal disease has been associated with an increased risk of death in hemodialysis patients (kshirsagar et al. 2009 ). this relationship has been poorly studied in peritoneal dialysis patients. this requires further study but it appears possible that periodontal disease might hasten loss of residual kidney function and perhaps contribute to atherosclerosis in dialysis patients and therefore, contribute to the high mortality in this population. patients who desire a kidney transplant are required to undergo a thorough evaluation beforehand including an oral examination by a dentist. some patients on dialysis have inadequate insurance which does not cover dental care, leading to a situation in which a kidney transplant is denied because the patient cannot afford the dental examination. communications between dentists and physicians in the care of the patient is scant. if oral surgery is required in a dialysis patient, the surgeon generally requires a brief summary from the nephrologist with recommendations. these might include suggestions for prophylactic antibiotics, avoidance of vasoconstrictor agents to an excess locally (which can elevate blood pressure) and the increased risk of bleeding of a dialysis patient. for more routine dental examinations no information is requested which could potentially lead to drug interactions or a dangerous situation. most nephrologists and health care providers in the dialysis unit do not inquire of the patient concerning dental health and examination of the mouth is quite uncommon. although the dialysis patient is seen monthly at a minimum, there is little conversation or documentation of oral health. connecting the electronic health records of in-patient care, the out-patient dialysis unit and the dentists' offi ce could potentially have a large impact in improving the care of those with end stage kidney disease. integrating medical and dental records in ehr's may or may not be the "golden ring." first, we need to integrate the clinical thinkingâ�¦something we both realize is important, but not likely to be solved by an inert computer. i also think that integrated records will be very cumbersome, given the fact that the language used by the separate disciplines is so different, and the kind of detail required to support good decisions and good work is so different. it could be doneâ�¦but for many professionals on either "side," they would never open the other module. to me, a more sensible solution may be to have a condensed "nugget" of information that could cross populate. "moderate periodontal disease" may be what the medical doctor needs to know, plus know what a treatment plan may include. she won't need to know the number of the teeth with the deepest pockets and erosions but will need to support the patient's determination to follow through. on the other hand, if the patient has shown remarkable initiative in gum care and has successfully migrated to a lower severity index, that would be important for congratulation and reinforcementâ�¦and also to encourage similar diligence in managing, let's say, the hypertension that is not optimally controlled. in the other direction, the dentist should know that a patient has been erratic in clinical follow up, does not self-test blood glucose, uses hypoglycemic drugs only intermittently, and has failed several appointments for eye exams. this would lead to a rather different set of approaches from a highly motivated grandmother who is enrolled in a community cultural center's senior exercise club, and is learning to become a lay community teacher for diabetes. right now, i don't think even this superfi cial degree of information is exchanged. we need to support each other's efforts, but we probably do not need to share minute details. the benefi ts of an electronic health record are well described. ehrs allow for legible standardized documentation and easier sharing of patient data between providers at multiple locations. they are less prone to loss and require much less space to store. they have the potential to result in a reduction in the cost of health care. a distinct disadvantage of the ehr, in its current confi guration, is the problem of information overload. simply put, there is often too much information presented in a way that is diffi cult to review and digest. the ehr equivalent of thumbing through a chart quickly is not yet available. as a result we frequently see practitioners look only at the last note or two as they review a patient's history. we require a way to communicate information directly relevant to patient diagnosis, treatment and prognosis among subspecialists and primary care providers. we require a way to identify subclinical cerebrovascular disease in a patient, independent of blood pressure and other traditional risk factors. we require a way to recognize which patients with cerebrovascular disease are two to four times more likely than average to develop a stroke in the next 3 years. we have a way -retinal imaging. the eye is the one place in the body we can directly observe arteries, veins and a cranial nerve in a noninvasive manner. routine imaging of the retina and optic nerve could allow primary care providers to assess retinal, and by proxy systemic, end organ damage from atherosclerosis in an effi cient manner. the key to optimal use of the medical record and effi cient yet effective communication among providers may lie with the familiar adage; a picture is worth a 1,000 words. traditionally, when ophthalmologists communicate with primary care providers they send brief letters regarding the fi ndings seen during a yearly dilated examination and the presence, absence or progression of diabetic retinopathy. these letters end by exhorting the virtues of improved blood sugar, blood pressure and lipid control, a sentiment that the primary care provider likely shares. this system of communication does not provide particularly useful information for the primary care provider, except to serve as a notice that the standard of care screening guidelines have been met. the box has been checked. if primary care providers, cardiologists, nephrologists had access to routine ophthalmic imaging, they would be able to directly visualize the effect that suboptimal blood sugar control is having on their diabetic patients. as importantly, they would be equipped with information directly predictive of congestive heart failure, stroke, and cardiovascular mortality for their patient with hypertension, hyperlipidemia and for those who smoke. large clinical studies have shown that assessment of retinal vascular changes such as retinal hemorrhages, microaneurysms and cotton wool spots provides important information for vasculopathy risk stratifi cation. as an example, wong et al. showed that the presence of retinopathy indicates susceptibility to and onset of preclinical systemic vascular disease, independent of and qualitatively different from measuring blood pressure or lipids (wong and mcintosh 2005 ) . in the atherosclerosis risk in communities (aric) study, individuals with hypertensive retinopathy signs such as cotton wool spots, retinal hemorrhages and microaneurysms were two to four times more likely to develop a stroke within 3 years, even when controlling for the effects of blood pressure, hyperlipidemia, cigarette smoking and other risk factors (wong et al. 2001 ) . in a recent study by werther et al., patients with retinal vein occlusions were found to have a two-fold increased risk of stroke compared to controls (werther et al. 2011 ) . in addition, the aric study group reported that individuals with retinopathy were twice as likely to develop congestive heart failure as individuals without retinopathy, even after controlling for pre-existing risk factors (wong et al. 2005a ) . interestingly, even among individuals without pre-existing coronary artery disease, diabetes or hypertension, the presence of hypertensive retinopathy was associated with a three-fold increased risk of congestive heart failure events (wong et al. 2005a ) . in the beaver dam eye study, cardiovascular mortality was almost twice as high among individuals with retinal microaneurysms and retinal hemorrhages as those without these signs ( wong et al. 2003a, b ) . the aric and beaver dam eye studies have also shown that, independent of other risk factors, generalized retinal arteriolar narrowing predicts the incidence of type ii diabetes among individuals initially free of the disease (wong et al. 2002a (wong et al. , 2005b . a primary care provider with access to patients' retinal photographs may therefore have the evidence needed to suggest which patient with either established systemic vascular disease or preclinical systemic vascular disease requires a more aggressive treatment and risk factor modifi cation. they could do this without wading through the electronic equivalent of piles of records. one photograph could refl ect both acute changes in blood pressure (retinal hemorrhages, microaneurysms and cotton wool spots) and chronic changes resulting from cumulative damage from hypertension (av nicking and generalized arteriolar narrowing) (sharrett et al. 1999 ; wong et al. 2002a ; leung et al. 2004 ) . in brown et al. 23 out of 24 patients, excluding those with known diabetes, that presented with a single cotton wool spot or a predominance of cotton wool spots on examination of the retina were found to have underlying systemic disease (brown et al. 1985 ) . systemic work-up revealed diagnoses including previously undiagnosed diabetes, hypertension, cardiac valvular disease, severe carotid artery obstruction, leukemia, metastatic carcinoma, systemic lupus erythematosus, aids and giant cell arteritis (brown et al. 1985 ) . these fi ndings illustrate the importance of retinal fi ndings on a systemic level. the utilization and integration of ophthalmic imaging may serve to achieve more effective communication among subspecialists and primary care providers and ultimately to provide improved diagnosis and treatment for delivery of optimal quality of patient care. moreover, the improved integration and maximal use of resources may serve to reduce overall health care cost and perhaps decrease provider frustration with the electronic health record (fig. 4 .5 ). there are cotton wool spots, exudates, intraretinal dot-blot hemorrhages and microaneurysms. av nicking is also present especially along the superior arcade just as the vessel leaves the optic nerve ( fig. 4.6 ) . av nicking, tortuosity of vessels, intraretinal hemorrhages and dry exudates are seen ( fig. 4.7 ) . there is edema of the optic nerve head, with cotton wool spots and fl ame shaped hemorrhage along the disc margin. there are several cotton wool spots along the vascular arcades and scattered dot hemorrhages throughout the posterior pole and periphery ( fig. 4.8 ) . notice the cholesterol plaque in the vessel just as it exits the optic nerve head and the pallor in the superior macula corresponding to retinal ischemia and edema ( fig. 4.9 ). the cholesterol embolus has resulted in lack of blood fl ow to the superior arcade ( fig. 4.10 ) . there is pooling of subretinal blood just superior to the optic disc with a central fi brin clot and associated vitreous hemorrhage (fig. 4.11 ) . optic disc edema, fl ame hemorrhages and venous congestion are seen in a patient with severe hypertension. biju cheriyan in clinical practice, an otolaryngologist often needs a dental consult not only because of the topographically adjacent nature of the structures but also because most structures are supplied by the same neurovascular bundle and therefore there is overlapping of symptoms. the converse scenario can also apply. apart from this, there are many systemic medical conditions (for example: bleeding diatheses, diabetes) a hypertensive optic neuropathy dentist encounters throughout his or her practice which can determine the outcome of a successful treatment. sometimes, providers may observe a cluster of diagnostic criteria which may have to a single source. in the sections below, i will explore a few of these scenarios and conditions, and indicate where and how an integrated electronic health record (ehr) could optimize delivery of health care by dentists and otolaryngologists. cleft palate/cleft lip : cleft lip and cleft palate (cl/cp) are congenital conditions that require multidisciplinary management by dentists, oral and maxillofacial surgeons, orthodontists, otolaryngologists, speech pathologists and plastic surgeons a number of studies report that a multidisciplinary approach is essential for better treatment outcomes (wangsrimongkol and jansawang 2010 ) and for post operative rehabilitation (furr et al. 2011 ). these multidisciplinary approaches may lead to new ways to manage and treat cl/cp patients (salyer et al. 2009 ). hutchinson's teeth : notching of the upper two incisors is typically seen in individuals infl icted with congenital syphilis. macroglossia refers to enlarged tongue in relation to oral cavity. macroglossia is an important sign. it can indicate important systemic diseases like systemic amyloidosis, congenital hypothyroidism, acromegaly, or down syndrome. a common complaint that dentists and otolaryngologists encounter in their practice is the common headache. because of the special nature of the neurovascular bundle of the head and neck this symptom can be presented to both dentists and otolaryngologists (ram et al. 2009 ). any sinus pathology can present as a headache to an otolaryngology practice. since the maxillary sinus fl oor is in close proximity to the maxillary premolars and molars, it is imperative to obtain a dental evaluation in persistent cases of headache. there are a number of causes for headache from the dental and otolaryngology perspective. a mal-aligned denture patient with chronic headache, whom i saw in my practice was shuttled between departments and an array of investigations only to fi nd at the end that an ill-fi tting denture caused the intractable headache. in these cases, an integration of fi ndings is extremely important in providing quality treatment to the patient and also saves money and time for the whole health care system. hence it is important to have an integrated patient record for this particular symptom alone. trigeminal neuralgia is facial pain of neurogenic origin experienced along the distribution of the trigeminal nerve(fi fth cranial nerve). it can present as a dental pain and can also be triggered by brushing teeth among other trigger factors. as a result, patients with dental pain without obvious causes are required to have a physicians' consultation to rule out this obscure condition. sometimes it is diagnosed by omission (aggarwal et al. 2011 ; rodriguez-lozano et al. 2010 ; spencer et al. 2008 ). any tumor of the nasal sinuses (specifi cally maxillary and ethmoids) can erode the lower bony wall and present in the oral cavity (usually the maxillary arch) as dental pain, loose tooth, etc. therefore, these are areas of interest to both dentists and otolaryngologists. such tumors most commonly present fi rst to a dentist or could also be an accidental fi nding. cancers of the naso/oro/laryngo pharynx can also present as toothache to a dentist as these structures have a common nerve supply from cranial nerves 5,7 and 9. therefore, an integration of the patient record may even help in early diagnosis of the tumor. the same principle applies to all oral tumors, tumors of the nasopharynx, the oropharynx etc. this is especially true of malignant lesions of the oral cavity as these may help in early detection and treatment of cancer. in these cases, an early biopsy and histopathology can save the life of the patient. therefore, it is imperative to say that a collaborative patient record can save patients' lives. ulcers of the oral cavity from aphthous ulcers to carcinomas can present both to a dentist and an otolaryngologist. oral ulcers can be of dental origin. contact ulcers from sharp edges of a mal-aligned tooth can result in intractable ulcers, where a simple smoothing of sharp edges may eradicate the ulcer and terminate it as a chronic condition and can even prevent the ulcer turning into a malignancy. if you have an integrated electronic health record (ehr) these problems are immediately addressed and managed. otherwise, the condition will consume valuable time of both the patient and the physician concerned. in addition to this, there are a few conditions which require special attention: aphthous stomatitis (canker sore), which may indicate oral manifestation of defi ciencies of iron, vitamin b12, folate deficiency and oral candidiasis, which can be a sign of diabetes mellitus or of an immunocompromised patient (e.g. aids). temperomandibular joint (tmj) disorders can present in a variety of symptoms to both dentists and otolaryngologists. they can present as a headache, earache, toothache, or as facial pain. there can be a number of causes for this including osteoarthritis of the tmj, recurrent dislocation, bruxism, or even an ill fi tting denture. there have been cases where patients have been subjected to removal of teeth for chronic toothache only to discover at the end that the symptom was a referred pain from tmj! therefore, an integrated ehr can prevent misdiagnoses and resulting impairment or disability to patients. trismus (lock jaw) can indicate important diagnoses such as tetanus and rabies.it is due to a spasm of muscles of mastication, which is an important oral manifestation of widespread muscle spasm. apart from these conditions, other causes of trismus are peritonsillar abscesses, and scleroderma. other problems dentists and otolaryngologists encounter in clinical practice are concurrent systemic diseases (patients with multiple problems): patients with bleeding diatheses, diabetes mellitus and a hidden primary malignancy. a non-healing ulcer in the oral cavity may hide a primary malignancy behind it. in these cases, you have to look for it specifi cally. similarly, one has to be aware of oral manifestations of internal pathology. some of them are crohn's disease, ulcerative colitis and gastro-intestinal tract malignancies. often dentists see patients after a tooth extraction with intractable bleeding to fi nd that they have a bleeding diathesis. so, this may be the fi rst presentation of these patients' bleeding disorder. when this patient undergoes any elective procedure in future, it will be a great help to surgeons to be aware of this information to prevent any inadvertent complications. therefore an integrated ehr can prevent unwanted complications where a patient's life may be in jeopardy. the source of otalgia or earache can be from a number of sites other than ear itself. technically ear lobe and ear canal are supplied by four different cranial nerve branches (5th, 7th, 9th, 10th). therefore, an area with a common nerve supply can present as earache. common dental problems which present as referred otalgia are (1) dental caries (2) oro-dental diseases or abscesses (3) an impacted molar tooth (which is a common cause) (4) malocclusion (5) benign and malignant lesions of oral cavity and tongue (kim et al. 2007 ) . therefore, it is essential these two departments collaborate with each other in diagnosing and treating these diseases, and one way of facilitating it is through an integrated ehr system. there is a lot of overlap between dentists and otolaryngologists in the diagnosis and treatment of patients with halitosis (delanghe et al. 1999 ; bollen et al. 1999 ) . poor oral hygiene is the most common cause for this common complaint. oral causes include tooth caries, oral ulcers, periodontal diseases, unhealthy mucosa of the oral cavity. it is interesting to note that a simple oral ulcer can form an abcess eroding the fl oor of mouth and becoming a life-threatening oral cellulitis (ludwig angina). once the cellulitis has developed, it becomes a medical emergency. therefore, it is essential to prevent it before it can progress into a life-threatening condition, which of course is possible. causes pertaining to otolaryngologists include: chronic sinusitis or mucociliary disorder, chronic laryngitis or pharyngitis, pharyngeal pouches-related pathology, tumors or ulcers of naso/oro/laryngopharynx, diseases or conditions that impair normal fl ow of saliva such as salivary gland diseases or stones preventing fl ow of saliva, medications which cause dryness of mouth: antihistamines, antidepressants; local manifestation of systemic disorders: auto immune disorders, sjã¶gren syndrome, dehydration from any cause, diabetes mellitus and gastro esophageal refl ux disorder (gerd). gerd is caused by improper neuro-autonomy of the lower esophageal sphincter (les). the les does not close tightly after food intake which causes gastric content to enter the esophagus. over time this can erode mucosa and cause various diseases even becoming cancerous (friedenberg et al. 2010 ). this disorder is attributed to life style. fast food consumption habits (oily fried foods) and eating habits (swallowing food without properly chewing) are partly responsible for this disorder (lukic et al. 2010 ; al-humayed et al. 2010 ) . here again an early diagnosis can manage the disease process before it is fully developed. at present there are no integrated ehr systems serving these specialties (dentistry and otolaryngology). an integrated ehr would facilitate effi cient communication between a dentist and an otolaryngologist who are providing care to the same patient and addressing a problem with a shared focus between the two disciplines. such integrated communication, may only require consulting the available medical or dental record of the patient, based on the particular circumstance. even enabling this simple communication would avoid duplication of effort, clarify the context of certain symptoms and reduce stress endured by the patient. it also has the potential to reduce healthcare delivery costs, and in some cases, even contribute to saving the patient's life. henry hood, allan g. farman, and matthew holder in this chapter, the authors attempt to put forth a justifi cation for precisely this kind of collaborative approach through a summary and discussion of a series of actual clinical cases. the protocols discussed in the management of each of these clinical cases illustrate the value in providing whole-person, interdisciplinary health care to this complex patient population. there is arguably no single patient population for whom the provision of collaborative, interdisciplinary health care is more challenging than for patients with neurodevelopmental disorders and intellectual disabilities (nd/id). in planning and delivering the generally-accepted standard of health care to this unique population, myriad biomedical, psychosocial and sociopolitical realities converge to create a landscape that is, at best, daunting for patients with these disorders, and for the clinicians who are charged with their care. anecdotal and scientifi c evidence suggest that this landscape has produced a paucity of physicians and dentists who are willing and able to provide care to patients with nd/id, and that american medical and dental schools are providing little training focused on their care (holder et al. 2009 ; wolff et al. 2004 ) . in february of 2002, 16th surgeon general david satcher issued a report, which documented that americans with nd/id experience great diffi culty accessing quality health care (thompson 2002) . in that same report, former health and human services secretary tommy thompson said, "americans with mental retardation and their families face enormous obstacles in seeking the kind of basic health care that many of us take for granted." (thompson 2002) the disparities identifi ed by dr. satcher and secretary thompson require that physicians and dentists approach this population in a spirit of collaboration, compassion, and teamwork in order to produce positive health outcomes for them. perhaps, an even greater imperative driving the need for collaboration between medicine and dentistry in this arena is the fact that many patients with intellectual disabilities have developed this cognitive impairment as the result of an underlying neurodevelopmental disorder that is often undiagnosed. and it is this neurodevelopmental illness and the constellation of potentially devastating complications associated with that illness that create a biomedical fragility and a vulnerability that neither begins nor ends at the oral cavity, and that leaves these patients at risk in almost every aspect of their daily lives. when, for example, patients with nd/id are dependent upon publicly-funded programs for their health care, and when these systems fail to provide the health services that biomedically complex cases require because they fail to account for and accommodate the link between medical and dental pathologies, the risk of a negative outcome is greatly enhanced. such was the case for an intellectually disabled woman in michigan who, in october of 2010, was unable to access dental services through the state's public medical assistance program, and who fatally succumbed to a systemic bacteremia resulting from an untreated periodontal disease (mich. dent. assoc. 2009 ). the american academy of developmental medicine and dentistry (aadmd) defi nes a neurodevelopmental disorder as a disorder involving injury to the brain that occurs at some point between the time of conception and neurological maturationapproximately age 21 or 22 (zelenski et al. 2008 ). examples of frequently-encountered neurodevelopmental disorders would include fragile x syndrome, a genetically acquired neurodevelopmental disorder caused by a mutation at the distal end of the long arm of the x chromosome (see fig. 4 .12 ), trisomy 21, another genetic disorder, which features extra genetic material at the chromosome 21 site (see fig. 4 .13 ), and cerebral palsy, a prenatal or perinatal, acquired neurodevelopmental disorder (see fig. 4 .14 ). patients with neurodevelopmental disorders tend to present clinically with one or more of fi ve frequently-encountered, objective symptom complexes or primary complications. these fi ve, classic primary complications include intellectual disability (aka: mental retardation), neuromotor impairment, seizure disorders, behavioral disturbances, and sensory impairment (aadmd). additionally, multiple secondary health consequences can derive from the fi ve primary complications; and any one of these secondary health consequences, or a combination of them, can produce profound morbidity. an example of a common secondary health consequence seen in patients with nd/id, which is derived from intellectual disability and / or neuromotor impairment, is the patient who is unable to care for his or her own mouth, and who develops ubiquitous caries and advanced periodontal disease as a result (see: fig. 4.15 ). another example would be the patient who suffers from the secondary health consequence of gastroesophageal refl ux disease (gerd) as a result of the neuromotor impairment associated with multiple neurodevelopmental disorders; and whose tooth enamel and dentinal tissues become chemically eroded as a result of the chronic intraoral acidity produced by gerd (see: fig. 4.16 ) . the diagnosis and management of these secondary health consequences provide dentists and physicians with a unique opportunity to work together to improve the quality of health and quality of life for their patients by implementing a team approach, which crosses the traditional interdisciplinary lines of communication, and which expands each clinician's ability to make meaningful treatment options available. indeed, it is often the case that quality primary care provided in one discipline will provide potentially valuable information to an attending clinician from another discipline. such is the case with the patients featured in figs. 4.16 and 4.17 . the patient whose intraoral photograph is featured in fig. 4.14 is a 19 year-old male patient who presented to a special needs dental clinic accompanied by his mother. the mother indicated that her son was exhibiting hand-mouthing behaviors that she believed suggested he was experiencing mouth pain. a comprehensive radiographic and intraoral exam revealed, among other maladies, notched incisors, multiple diastemas, grossly decayed mulberry molars, and advanced periodontal disease. the patient also exhibited moderate to severe intellectual disability. these fi ndings were all consistent with a diagnosis of congenital syphilis. 6 however, in developing the medical history with the mother, it was learned that no previous diagnosis of syphilis had been discussed with the mother, nor was it included in the health history. in cases like this, a comprehensive dental treatment plan should always include consultation with the primary care physician for purposes of moving forward with confi rmation of the clinical diagnosis by serologic testing, and consultation with a cardiologist to assist in the management of potential cardiovascular sequelae. as the dental treatment plan is being developed, consideration should also be given to human immunodefi ciency virus (hiv) testing for this patient, as coinfection is a common fi nding 7 . this issue could easily be attended to by a primary care physician, an internist or an infectious disease specialist. in the absence of any of these team members, the dentist should feel entirely comfortable ordering hiv testing. the primary care physician and the developmental dentist should continue to advise each other and their respective consultant specialists of any signifi cant developments or new information, which could in any way impact either the medical or the dental treatment plan. as treatment progresses, both the physician and the dentist should expect improvement in the patient's periodontal status, which will likely be refl ected in a decrease in the frequency of immune-related illnesses, and in the maladaptive behaviors produced by chronic oral pain. it is quite often the case in this patient population that, with a reduction in maladaptive behaviors, comes a reduction of the use of psychotropic medications prescribed in a frequently futile attempt to manage behaviors that were born of an undiagnosed medical or dental illness. gerd is defi ned as the refl ux of gastric contents into the esophagus. gerd is primarily associated with incompetence of the lower esophageal sphincter; however there are numerous co-contributors, which may predispose a patient to gerd or exacerbate an existing refl ux problem. these co-contributors include a diet high in fat, neuromotor impairment associated with functional abnormalities such as dysphagia, neuromotor impairment associated with impaired ambulation and prolonged periods of recumbence, and the use of multiple medications including anxiolytics, calcium channel blockers, and anticholinergics. gerd is thought to affect approximately 25-35% of the general us population. it has been established in the literature that the incidence of gerd in patients with intellectual disabilities is signifi cantly higher than in the neurotypical population, and that the relative number of unreported cases of gerd is much higher in patients with a neurodevelopmental diagnosis, as well. patients who have gastric refl ux as a function of a neurodevelopmentally-derived neuromotor impairment and a coexisting intellectual disability are impaired in their ability to voice the complaint that would, in the neurotypical patient, commonly lead to an encounter with either a family physician or a gastroenterologist and, ultimately, to a diagnosis. this inability to voice a complaint can be problematic in that, left untreated, gerd can produce maladaptive and sometimes aggressive behaviors in this population. and, of even greater concern, is the fact that undiagnosed esophageal refl ux can lead to more complex conditions that can produce signifi cant morbidity or even mortality -maladies such as barrett's esophagus or adenocarcinoma of the esophagus. chronic gerd can also produce an acidic intraoral environment, which can lead to the chemical erosion of the enamel and dentinal tissues of the teeth. ali et al. have established a link between erosion of the enamel and dentinal tissues of the teeth and gerd. there is additional anecdotal evidence suggesting a link between tooth enamel erosion and gerd, and related maladies. a special needs dental clinic in the eastern united states serving 1,000 patients with nd/id, has reported that, of nine patients referred to gastroenterology who presented for dental exam with a fi nding of either tooth enamel erosion or ubiquitous caries, two cases were diagnosed with gerd, two with barrett's esophagus, three with gastritis, and one with duodenitis. in all cases, medical treatment was required. in light of all that is known about the incidence of gerd and of the gerdrelated risks unique to this patient population; and in light of the link between tooth enamel erosion and gerd, it is incumbent upon any dentist encountering tooth enamel erosion in a patient with an intellectual disability to immediately refer that patient to gastroenterology for a work up, which should include esophagogastroduodenoscopy (egd) and ph monitoring. a dentist encountering gerd in a patient with an intellectual disability must be aware that he or she may be the fi rst and only link between that patient and the diagnosis of a potentially life-threatening illness. phenytoin-induced gingival enlargement can appear as either an infl ammatory lesion or a more dense, fi brotic hyperplastic lesion. the infl ammatory lesion is one in which the gingival tissues are swollen and bleeding, and in which pain is often a component. this type of gingival enlargement is the more acute lesion, frequently seen in patients who are currently taking phenytoin. in advanced cases of infl ammatory gingival enlargement, the tissues can appear botryoid, with a characteristic grape-cluster appearance. in advanced cases of phenytoin-induced gingival enlargement, the lesion can sometimes shroud entire sections of the dentition. phenytoin has long been a common medication used to treat seizure disorders in patients with neurodevelopmental disorders and intellectual disabilities. however, the gingival enlargement it produces, and the obstacle this lesion can pose to effective oral hygiene -especially in a population in which oral hygiene is typically compromised -can, over time, lead to periodontal disease, edentulism, and in advanced cases, systemic bacteremias. gingivectomy performed to reduce phenytoin-induced gingival enlargement will typically fail unless the patient is weaned off the offending medication, and another anti-seizure medication is titrated to effect. multiple alternative anti-seizure medications are currently available, which do not have the side effect profi le of phenytoin, and most patients who are weaned off phenytoin will demonstrate a virtual 100% resolution of the infl ammatory lesion within a matter of 3 or 4 months. the image in fig. 4 .18 is of a 22 year-old, microcephalic african-american male with intellectual disability, neuromotor impairment, and a seizure disorder. figure 4 .17 illustrates the appearance of this patient's gingival tissues while he was currently on phenytoin. figure 4 .18 features the same patient 4 months after being weaned off phenytoin and placed on topiramate. these images illustrate the dramatic result that can be achieved when a dentist and a physician work in collaboration in the best interests of the patient. it is worth noting that this particular collaboration required only one intervention to achieve this result: the patient was weaned off phenytoin and was placed on a safer alternate anti-seizure medication. any dentist caring for a patient with an intellectual disability who presents with phenytoin induced gingival enlargement should immediately contact either the primary care physician or neurologist managing the patient's seizure disorder, and strongly urge that the patient be weaned off phenytoin and placed on a safer alternative anti-seizure medication. edentulism and bacteremia need not be a side-effect of a seizure management protocol. the patient seen in fig. 4 .19 is a 20 year old male patient with idiopathic intellectual disability who presented to an outpatient dental clinic for comprehensive dental evaluation and treatment. he was accompanied by his father. his father was referred to the clinic by the staff at his son's day program workshop. the day program staff had observed hand-mouthing behaviors, and they had voiced concern that the patient may be in pain. in the waiting room, the patient exhibited behaviors consistent with neurodevelopmental dysfunction. he was non-communicative, and his gaze aversion and tactile defensiveness were suggestive of autism. he was resistant and somewhat combative when directed to the dental chair, and effective behavior management in both the waiting room and operatory required the combined efforts of his father and two staff fig. 4.19 the adult patient suspected of having fragile x syndrome members. the patient's health history was positive for attention defi cit hyperactivity disorder (adhd), and there was no history of seizure or neuromotor impairment. the father indicated that, at age ten, the patient was admitted to an inpatient psychiatric unit for evaluation of his uncontrollable behavior. the following day, the parents were told that managing the patient's behavior was beyond the ability of the psychiatric unit staff, and the parents were asked to take the child home. the father also indicated that the psychiatric unit staff described the child's behavior as overwhelming. the patient was last seen by a dentist 12 years prior to presentation; examination and treatment at that time were carried out in the operating room under general anesthesia. effective oral examination of this patient required utilization of papoose board and molt mouth prop. multiple options for behavior management, including utilization of general anesthesia in the operating room, were discussed with the father, and informed consent to utilize medical immobilization techniques for purposes of this examination was obtained and documented prior to taking the patient into the operatory. in the operatory a dental examination was performed, and a baseline panel of digital radiographs was obtained. the head and facial features of this patient were suggestive of fragile x syndrome (see: fig. 4.20 ) . the body of the mandible was somewhat elongated; the nose was prominent; the head had somewhat of a triangular shape, and the patient readily averted his gaze. upon further inquiry, the father reported that the patient also exhibited macroorchidism, although he indicated that no physician or dentist had ever suggested a work up for fragile x. fragile x syndrome is a disorder with which many clinicians are unfamiliar. yet it is the second leading genetic cause of intellectual disability in the united states, and it is the leading known cause of autism in the u.s. in addition to the phenotypic fi ndings noted in this case, there are other frequently-encountered physical characteristics consistent with fragile x that may move a clinician toward this diagnosis. they include pectus excavatum or funnel chest (see fig. 4 .21 ) and joint laxity (see fig. 4.22 ) . gaze aversion, as previously mentioned, is a typical fi nding in autism and in fragile x syndrome. indeed, in conjunction with non-verbal behaviors, gaze aversion is often the fi nding that initially alerts the clinician to the possibility of a neurodevelopmental diagnosis featuring autism as a complication. figure 4 .22 features a photograph of fi ve children at a school for children with special needs. four of the children have been diagnosed with autism, and a fi fth child is a neurotypical child who was visiting his brother on the day the photograph was taken. the reader is left to decide which child is the neurotypical child. any physician or dentist who encounters a patient with an obvious intellectual disability, who does not have an established underlying neurodevelopmental diagnosis, and who presents with additional fi ndings, which may include gaze aversion, shyness, a prominent chin, pectus excavatum, a large nose or large ears, should suspect a possible fragile x diagnosis. the primary care clinician -physician or dentist -should discuss with the guardian or family member the importance of establishing a neurodevelopmental diagnosis. the family member or guardian should be informed that genetic counseling should be made available to all members of the extended family, since fragile x syndrome is a genetic disorder that can be passed from parents to offspring. once this discussion has taken place, a referral to a geneticist for a complete genetic work up is indicated. both the dentist and physician should feel entirely comfortable making this referral. in remote areas where the services of a geneticist may not be available, the attending physician or dentist may order a high resolution chromosomal analysis and a fragile x dna test, and have those results sent to a remote location for interpretation by a geneticist. consultation with a psychiatrist or a clinical psychologist may also be advisable, as patients with fragile x can sometimes experience enhanced social integration as a benefi t of behavioral therapy. the healthcare access problem for americans with neurodevelopmental disorders and intellectual disabilities is, at its core, a healthcare education problem -an education problem resulting from a long-standing defi ciency in professional training focused on the care of this patient population. and it is clear that the medical and dental professions share equally in responsibility for these defi ciencies. eighty-one percent of america's medical students will graduate without ever having rendered clinical care to a single patient with a neurodevelopmental disorder or intellectual disability; and the graduates of 90% of america's medical residency programs will graduate from those residencies having had no formal training whatsoever -didactic or clinical -in the care of this patient population. 1 additionally, 50% of graduating dentists have never treated a single patient with a disability. 2 it is no wonder that patients like those whose cases were discussed in earlier sections of this chapter have such diffi culty accessing quality health care. as robert uchin, dean of nova southeastern university college of dental medicine observed in a speech in 2003 to his faculty, "not only do we not have enough doctors to care for these patients; we don't have enough teachers to teach them how to care for them." as a result of these defi ciencies in professional education, few clinicians with any expertise in developmental medicine or developmental dentistry are to be found in communities across america. the experts in developmental medicine and dentistry, for the most part, tend to be physicians and dentists who work at the few remaining intermediate care facilities, and at special needs outpatient clinics, psychiatric hospitals, and nursing homes. these physicians and dentists possess the knowledge and expertise in these disciplines because they are the physicians and dentists with the clinical experience. unfortunately for the patients with neurodevelopmental disorders who are clamoring for quality care, there are too few of these clinicians. national experts in developmental medicine and dentistry, however, have begun to collaborate in the creation of patient care protocols; and they have produced multidisciplinary curricula in both dvd and online format. the aadmd has made available 9 hours of online curriculum in developmental medicine, developmental dentistry, and developmental psychiatry (see: list of urls). the curriculum program is entitled, the continuum of quality care , and it teaches collaborative patient care in three disciplines through an interdisciplinary format. the aadmd, through a grant from the wal mart foundation and the north carolina developmental disabilities council, and in collaboration with the north carolina mountain area health education center and the family medicine education consortium, has also established the national curriculum initiative in developmental medicine. this initiative, which is scheduled for completion in 2012, will develop curriculum standards for physicians in the primary care of adults with nd/id. the curriculum stresses the importance of a collaborative approach, which includes medicine, dentistry, podiatry, optometry, and multiple ancillary health professions. if the disparities in access to healthcare for americans with nd/id are to be resolved, physicians and dentists must be willing to cross professional boundaries and work together to plan and deliver whole-person healthcare to their patients with nd/id. interdisciplinary protocols in the diagnosis of neurodevelopmental disorders and in the management of the secondary health consequences associated with these disorders must be established. additionally, clinicians with expertise in these arenas must be willing to work and teach in our nation's medical and dental schools. the clinicians with expertise must be willing to develop predoctoral and postdoctoral curricula, and the deans of america's professional schools must be willing to include these curricula as part of their larger programs in primary and specialized care. the clinicians with expertise in developmental medicine and dentistry must also be willing to conduct patient-focused, interdisciplinary, clinical research in an effort to solve the myriad problems that create obstacles to the delivery of the standard of care for patients with nd/id. they must be willing to obtain institutional review board approval for this research, and they must be willing to make this research available to their colleagues through publication in peer-reviewed journals and text books, and in professional lecture forums. the patient featured in figs. 4.23 and 4.24 is a man named james. he is a 48 year old patient with idiopathic intellectual disability who presented to a dental clinic for evaluation of a painful facial swelling. a comprehensive intraoral exam revealed a cellulitis resulting from multiple grossly decayed teeth, and a generalized advanced periodontitis. no fewer than fi ve clinicians became involved in this patient's care. they included a general dentist, two oral surgeons, a family practice physician, and a geneticist. over the course of several months, as the treatment plan was completed, and as the chronic dental and periodontal infections were eliminated, james experienced signifi cant improvement in his overall state of health. a comparison of these two photographs reveals not only signifi cant improvement in his aesthetic appearance, but also in his skin turgor and color. these improvements in the patient's health translated to improvements in his daily life. he found gainful employment, and his caregivers now report that he smiles constantly -at work and at home. these photographs were entered into evidence in 2007 before a congressional subcommittee investigating the death of a young african-american boy who died as a result of an untreated dental abscess. the photographs were intended to make the point that patients with intellectual disabilities need not die as a result of medical illnesses derived from untreated dental disease. this patient's case illustrates that, when physicians and dentists are willing to work together toward a common goal of whole-person health for their patients, profoundly positive outcomes can be achieved. in a larger context, if our nation's medical and dental professions are willing to commit to a shared agenda, one which promotes the idea of collaborative, interdisciplinary care as a foundational concept, signifi cant improvements in quality of health and quality of life can be realized, not just for americans with neurodevelopmental disorders, but for every patient seeking quality care. in light of the events of 2001, bioterrorism has become subject of increased attention from all members of society. government agencies, professional associations, academia, etc. have expressed their determination to wage war on such threats by all means available. dentists can also participate in this effort by providing assistance at interested groups and the general public (flores et al. 2003 ) . in this chapter we will examine the elements and components that may play a role in the establishment of an electronic network for the dental profession for supporting the fi ght against bioterrorism. in this section we review the threats, the public health system, current electronic surveillance systems, regulations and ethical issues, the computerization of dentistry, and how dentistry can serve in improving biosurveillance efforts. the aftermath of september 11 and the anthrax incidents in october 2001 ( lane and fauci 2003 ) , made the us government reorganize its priorities and reform its current structure (white house offi ce of the press secretary 2003 ) . in response to these incidents, president bush proposed the "health security initiative" (white house letter 2002 ) in february 2nd of 2003. this effort labeled the "bioshield initiative," (white house letter 2002 ) has the purpose to stimulate research and development of medical countermeasures against bioterrorism attacks. however, despite all these efforts, terrorist attacks are likely to happen in the future and even the best work from intelligence and security agencies will be unable to prevent such events (betts and richard 2002 ; council on foreign relations 2003; baker and koplan 2002 ) . to cope with this threat, a report published by an independent task force sponsored by the council on foreign relations "america-still unprepared, still in danger" (council on foreign relations 2003 ) , suggested a series of steps to assist the government in preparing to better protect the country. one of these suggestions is the bolstering of the "public health systems". baker et al. defi ne the u.s. public health system as a system that consists of a broad range of organizations and partnerships needed to carry out the essential public health services, such as hospitals, voluntary health organizations, other non-governmental organizations and the business community (baker and koplan 2002 ) which can collaborate with local, state and federal public health entities. after the unfortunate incidents in 2001 the public health system was revisited and the realization that "the nation's public health infrastructure is not fully prepared to meet this growing challenge" (frist 2002 ) became clear. to address this need, congress and president bush enacted the public law (p.l.) 107-188 titled "public health security and bioterrorism preparedness and response act of 2002" (frist 2002 ; 107th congress 2002 ) . the main purpose of this law was to improve the public health capacity by means of increasing funding and fostering other measures. frist ( 2002 ) , described the law as a "good start" and that "to be prepared for bioterrorism, it is imperative that we develop a cohesive and comprehensive system of ongoing surveillance and case investigations for early detection". in this way, several early detection systems have been implemented with different levels of success among different geographic regions in the us. one of the most important initiatives over the years has been the establishment of the national electronic disease surveillance system (nedss) (baker and koplan 2002 ; nedss 2001 ) . the national electronic disease surveillance working group establishes that the "nedss is a broad initiative focused on the use of data and information systems standards to advance the development of effi cient, integrated, and interoperable surveillance systems at the state and local levels. the long-term objectives for nedss are the ongoing automatic capture and analyses of data needed for public health surveillance". the purpose of this system is to take into consideration and integrate the information of current public health systems implemented at different health department levels: county, state and fi nally at the centers for disease control and prevention (cdc). another initiative spearheaded by the cdc is biosense (looks 2004 ) . the purpose of this program is to develop advance detection capabilities of health related events including disease outbreaks. in addition, its emphasis is to improve situational awareness by integrating advanced analytics to process data generated by different health providers and other entities in the us. now that we have examined the general aspects, we will continue our background review focusing on the aspects that pertain to the specifi cs of the dental profession. this section will provide some perspective of the structure of the dental profession in comparison with its medical counterpart. "there are approximately 150,000 active dentists in the united states" (mertz and o'neil 2002 ) . in 1990 the dentistto-population ratio was of 60-100,000. and it is expected that by the year 2020 the ratio will be 52.7, which translates into one dentist for every 1,898 people. " in contrast, the physician-to-population ratio has been increasing for the past 40 years and now stands at 286 per 100,000, about one physician for every 349 people." eighty percent of the dentists are in general practice. during march 27 and 28 of 2003, the american dental association and the us public health service sponsored the conference "dentistry's role in responding to bioterrorism and other catastrophic events" (palmer 2003 ; national institute of dental and craniofacial research 2004 ) . this meeting reviewed several aspects of bioterrorism and the dental profession: the nature of biological pathogens and its oral manifestations, what needed to be communicated, how dentists should participate, etc. dr. michael c. alfano described the diffi culties that biological pathogens create for clinicians because "they are so insidious." while discussing the anthrax mailings after september 11th he pointed out that: "â�¦ early symptoms appeared so they resembled the aches, fever, and malaise of fl u so those affected delayed seeking treatment, a delay that has proven fatal in some cases". lieutenant colonel ross h. pastel of the us army medical research institute of infectious disease (usamriid) listed the "category a" pathogens as defi ned by the centers for disease control and prevention, and those are: smallpox, anthrax, plague, botulinum toxin, tularemia and viral hemorrhagic fever. he also described an outbreak of smallpox in yugoslavia in 1972 and the measure that had to be taken to control it. dr. michael glick described the oral manifestations of smallpox showing "signs 24 hours before skin rash. these oral signs include tongue swelling, multiple mucosa vesicles, ulceration, and mucosal hemorrhaging. oral signs are also evident in inhalation and gastro-intestinal anthrax. in oropharyngeal anthrax the mucosa appears edematous and congested; there may be neck swelling, fever, and sore throat" . dr. ed thompson, deputy director of the centers for disease control and prevention mentioned that "none of the new counter-bioterrorism measures can be effective unless local health practitioners are vigilant in observing and reporting a possible disease outbreak. such surveillance-knowing what to look for and whom to report to-is critical and applies not only to suspected bioterrorist agents, but to a list of reportable diseases which has grown to include such entities as west nile virus and sever acute respiratory syndrome (sars)." dr. sigurs o. krolls presented the response at the local level and he "stressed the importance of communication and the need for redundant systems", "to keep all the parties informed". he also posed the question "can dentists recognize signs and systems of contagious diseases?", and emphasized that education can be essential. dr. louis depaola made several connotations that can be key in the scope of this paper by saying "dentists can contribute to bioterrorism surveillance by being alert to clues that might indicate a bioterrorism attack. such surveillance would note if there is an infl ux of people seeking medical attention with non-traumatic conditions and fl ulike or possibly neurological or paralytic symptomsâ�¦ or even specifi c signs of a bioterrorist agent. patterns of school of work absence, appointment cancellations or failures to appear, could also be indicators." dr. depaola made clear that in cases of limited release of bioterrorist agents, dentists "have little to offer" but "a widespread attack can certainly tap into dental professional skills in recognition, isolation and management". in addition, dr. guay ( 2002 ) lists all the possible roles in which dentists can participate including "education, risk communication, diagnosis, surveillance and notifi cation, treatment, distribution of medications, decontamination, sample collection and forensic dentistry." dental informatics must pay attention to these and other recommendations, in order to develop integrated systems that take these recommendations into consideration. it is also important to understand that informatics has to work with technologies already in place like the computer-based oral health record and current standards. the fi nal recommendation from the meeting stated that to play an important role in biodefense, a serious amount of coordination and preparation will be required, not only from dentists but from other groups, most likely requiring medical and dental data integration. the cohr as described by rhodes ( 1996 ) "can provide a structure for documentation that goes beyond the concept of a blank form on a page, it includes a glossary of dental terminology for the entire content of the form as well as knowledge bases and expert systems that can enhance the practitioner's diagnostic and treatment planning decisions". he also acknowledges that one of the advantages of this type of documentation is that it "is much more transportable". he also recognizes the need for standardized methods for collecting information from dentists. schleyer and eisner ( 1997 ) defi ned several scenarios where the cohr is used in a "shared" environment where several healthcare providers interact and information is seamless communicated, improving the decisions made by clinicians. delrose and steinberg ( 2000 ) discuss how the "digital patient record" enhances clinical practice by providing "better quality information" to the clinician. although all of these benefi ts sound promising and encouraging some still express concern of the lack of standards among different information systems, which translates in communication breakdowns (schleyer 2003 ) . on the other hand, heid and colleagues ( 2002 ) mention a list all the steps that are currently being taken by different organizations such as the ada in order to produce a standardized cohr. other examples of standardization can be found in a paper presented by narcisi ( 1996 ) where ada's participation as a voting member in the american national standards institute has allowed edi or the cohr to be discussed and improved at a national level. additional infl uences in the standardization of the cohr are the security regulations mandated by hipaa, the health insurance portability and accountability act of 1996. dentists are required to "adopt practices necessary for compliance" (sfi kas 2003 ; chasteen et al. 2003 ) . these and other regulations (szekely et al. 1996 ) will encourage the homogeny among different system vendors. computer ownership, on the other hand, has increased steadily during the last 25 years. according to schleyer et al. ( 2003 ) in 1976 only 1% of dental professionals used computers in their practices compared to 85% in the year 2000. additionally similar trends in internet connectivity where described. the issues mentioned above describe the issues that have to be considered in order to create surveillance system against bioterrorism for the dental profession. this review has tried to be inclusive by covering different aspects starting with the current state of affairs and environment, treats, technology, law, etc. next we present a blueprint for developing a biosurveillance system. the purpose of developing an electronic health surveillance system is to gather information from patients directly ( wagner et al. 2006 ) by detecting signs and/or symptoms, or indirectly by obtaining other types of information such as over the counter medication sales, patients' no-shows, usage of internet search engines keywords, etc. in this particular case, the proximity of contact between the dentist and the patient is equivalent to a medical inspection in terms of immediacy and/or closeness. such signs and symptoms can be easily detected if the dentist is properly prompted to search for them. this is just one example of ways how a system could provide assistance in the detection of a bioterrorism incident. but, before describing our proposed system, it would be important to address the fact that current syndromic surveillance systems have certain advantages in terms of its particular technological implementation . the rods laboratory obtains data directly from chief complains in the emergency departments from hospitals. the advantage of this surveillance system is that the implementation has to be made with only a limited number of parties (hospitals, clinics, health systems, etc.). on the other hand, our system would have to deal with thousands of different implementations (one in each dental offi ce). this and other challenges have to be considered when designing the proposed system: the proposed system should work at multiple levels: the system would have to provide a mechanism to alert the dentist if there is â�¢ suspicion that a bioterrorist attack may be happening. the mechanism would increase the dentist's awareness in case of fi nding suspicious signs or symptoms in a patient. this can be triggered by the patient's characteristics such as geographic location of residence, etc. automated collection of information from the patient's oral health record. the â�¢ system would report to a central database signs or symptoms of interest. the aggregation of this data could generate information that would eventually identify the presence of patterns that may lead to the early detection of such events. collection of additional information, which combined with other sources, can be â�¢ useful in terms of detecting or tracing some incident. patients' "no-shows" is the primary example, that, if combined with others such as work or school absenteeism can provide a relevant pattern for public health offi cials. dr. x, who practices in a community 20 min away from capitol city, installed a new clinical management system 2 months ago. among the features that were included in this new clinical management system (cms), a bioterrorism detection module was added. she felt curious because of recent news she read in the newspaper about possible attacks against the us and decided to install such feature. he read about how the module would work in combination with the cms she just bought. the educational information provided with the software instructed dr. x, that in case that a patient victim of a bioterrorism attack happens to be seen in her practice, the software would collect information and would send it to public health offi cials. when installing the software, dr. x was asked if she agreed to share such information with authorities. she was provided the option to receive notifi cation in case some information was sent but she decided not to enforce it. during the last week a patient walked into dr. x's dental offi ce. the patient presented some signs that indicated the presence of a disease; still its origin was not clear. an epidemiologic study later would show that the patient was present at the football stadium when an infectious agent was released (fig. 4.25 ) . although, at that time his medical history showed no indication of a systemic disease, the presence of multiple oral vesicles prompted the dentist to make an annotation into the cohr. the system, by using a natural language processing engine, detected such sign and sent this information to a central database. the patient was discharged and instructed to take some support medication to treat the oral ulcers. the next day, the central database pinpointed the presence of an out of the ordinary increase in the number of cases with the same signs and symptoms around that region. when the presence of this peak was detected, the central server sent a request to the dentist computer for additional information. one of the requested elements was if there was any use of medication for treating oral ulcers. fortunately this information was available. the central database crossed this with the information of other surveillance systems together with the information from other patients that happen to have similar clinical signs and/or symptoms. dr. x received an email from a public health offi cial asking her to communicate to the local health department to discuss information about one her patients. the case depicted above simulates the release of smallpox during a football game. in the case of smallpox oral symptoms include tongue swelling, multiple oral mucosal vesicles, ulceration, and mucosal hemorrhaging (national institute of dental and craniofacial research 2004 ) . dentists could be alerted by an electronic system to search for such signs or they can be detected automatically. in case of a high incidence within a group of patients, in a confi ned area, public health offi cials get to be notifi ed. in our hypothetical case there are issues that need to be addressed in order to make such detection system feasible: as described by schleyer et al. ( 2006 ) , 85% of dentists in the us use a computer in their practices. this fi gure would generate an estimate of 127,500 computers in dental practices. this prevalence of computers represents an opportunity for public health data collection. the creation of a software application for surveillance purposes must rely on existing technology. currently there are approximately 20 major clinical management software packages in the market (dentistry today 2003 ) . out of these 20, 17 clearly permit direct database manipulation. this characteristic can easily allow the creation of a "querying" application that would look for specifi c information within the data stored by those packages. additionally, a natural language processing engine could be embedded into the application in order to detect variations in data input on the computer oral health record. nevertheless, it is necessary to obtain a detailed list of the oral manifestations of diseases that are likely to be found on patients. successful implementations of similar systems have been shown to work successfully (chapman et al. 2001 ; ivanov et al. 2002 ) and using the same approach for our system seems technically feasible. this collected information later would be send to a central server in order to be analyzed and interpreted. the components of our system would be as follows (fig. 4.26 ) : thin client: a software application distributed for data collection. it would be â�¢ conformed of a "querying" mechanism, combined with a natural language processing engine and a communication module. this software client should be as thin as possible to reduce the work load on the dentist's equipment and should be embedded as a plug-in for current clinical management systems. vendors should be contacted to ask for their collaboration in the development of such application to ensure maximum compatibility and integrity of data collection. central servers: server software in charge of integrating all the data collected â�¢ from dental offi ces. it has to be capable of handling simultaneous requests from multiple users. this server would integrate all the data and would perform an analysis with the intention of detecting anomalies. it would be recommended that redundant servers should be located in different data centers with mirroring capabilities to guarantee their survivability in case of technical diffi culties. communication network: the transmission of information should be done using â�¢ the internet. this, of course, would essentially depend on the practitioner's current connectivity. if that is not available, backup connection to the central servers should be established. dentistry uses several standards for transmission of health related information. clinical management systems use standard-based technology to transmit information (narcisi 1996 ; chasteen et al. 2003 ; szekely et al. 1996 ; dentrix dental systems 2011 ) . dentists are aware of these standards and use them in a day-to-day basis to transmit information to insurers. additionally, in order to interact with other surveillance systems such as the nedss, our application should rely on the same standards. the software both client and server should be thoroughly verifi ed to be secure in terms of being safe against hacker attacks. on the server side, redundancy should be provided so downtime is reduced from design. the system should be developed so mirrored servers are always up and running. data integrity mechanism should also be considered. privacy and confi dentiality are important issues that need to be incorporated as part of a robust biosurveillance system and distinct regulations such as hipaa require protecting patient information (frist 2002 ; chasteen et al. 2003 ; bayer and colgrove 2002 ; etzioni 2002 ; ivanov et al. 2002 ) . in our hypothetical case we describe the use of several sources of information for detecting a bioterrorist attack. we described how syndromic information is transmitted to a central database which initially should be de-identifi ed. later, after the suspicion a bioterrorist attack more information is requested (medications) and more inferences are made. this, although technically possible, would require changing our processes and also the will to share clinical information. this leads to the discussion mentioned in the background section about "individual rights" vs. "common good". although hipaa addresses public health , some other implications may arise and the health professionals including dentists, physicians, public health offi cials and patients should discuss and address such issues. as discussed earlier, legislators face a diffi cult task in terms of determining what is best on behalf of the individuals they were asked to represent. legislation may have to be passed in order to guarantee the functioning of such a system. individual freedom and privacy are important values which may pose a confl ict when collecting individuals' information even for their own good. in any case, careful consideration has to be given to which information is required to detect a bioterrorist attack and also, by keeping in mind that it is always important to reduce, as much as possible, the collection and transmission of patients' information over the internet or any other network. a detection algorithm has to be created or adapted in order to determine the presence of a bioterrorist attack. some algorithms have proven their effectiveness (wong et al. 2003a, b ) and it is likely that from these, a new analysis should be done in order to select or create one that addresses the particular needs of our system. a study was conducted to assess the feasibility of using oral manifestations in order to detect disease outbreaks (torres-urquidy et al. 2009 ) . it was found that for diseases such as botulism and smallpox it would be feasible to gather data that contains oral manifestations that would allow creating a detection signal using natural language processing followed by the use of statistical methods such as moving average to serve as part of a detection algorithm. the system should also be thoroughly evaluated, before and after implementation. to perform the evaluation before the system implementation computer simulation can be used to assess the effectiveness and likelihood of detection. simulation and modeling techniques (reshetin and regens 2003 ) have been used to estimate the effects of a bioterrorist attack. the same techniques can be used to evaluate our system. in case of the study by torres-urquidy ( 2009 ) , the investigators utilized synthetic outbreaks to test the performance of different signals. from their evaluation process, they learned, for instance, how many cases would be necessary to occur for the system to reach certain detection thresholds. several dental organizations have shown publicly their support of measures against bioterrorism. the american dental association and the national institute of dental and craniofacial research are two organizations who could play an important role in the development, deployment and ongoing support for our system. local dental societies also would also play an important role in the deployment of the proposed system. similarly, local, state and federal public health agencies should engage in activities that could make these mechanisms for health surveillance feasible. if dentists want to play an active role in the fi ght against bioterrorism, they should commit to collaborate with public health entities as well as to seek a way to integrate their information with the rest of electronic biosurveillance systems. professional organizations such as the american dental association can also participate by endorsing such efforts and by collaborating in the educational process of the dental professionals and their patients. as mentioned by dr. depaola (national institute of dental and craniofacial research 2004 ) dentists "have little to offer" in the current biosurveillance state of affairs. however, the integration of different technologies can change this perception. goldenberg et al. ( 2002 ) described over-the-counter medication sales as a technique for discovering disease outbreaks and stated that their approach may be "more timely" than traditional medical or public health approaches. medical cases that result from bioterrorism attacks do not produce symptoms until they have fully developed, so it is likely that different patterns can be detected before the patients start reaching the emergency department. as stated earlier (torres-urquidy et al. 2009 ) , it may be possible to have dentists participating of biosurveillance efforts, if we solve the proper organizational and technical challenges. dr. john r. lumpkin ( 2001 ) states that "hippocrates noted the health of the community was dependent on characteristics of a community and the habits of the people who lived there." dr. krolls (nidcr 2003) in his fi nal remarks during his presentation at the dentistry's role conference against bioterrorism, said, "dentists may pick up telltale information about what is happening in the community. after all, dentists spend more time with their patients than any other health specialty". kass-hout t, zhang x. biosurveillance: methods and case studies. muhammad f. walji maintaining patient records are essential for both clinical care and research. clinical research often occurs in the context of also providing patient care, yet the systems that are used for each are different and often cannot exchange data. the lack of data exchange between systems pose signifi cant barriers to effi ciently treating patient and conducting clinical research in dentistry. the purpose of this section is to review the benefi ts and challenges of integrating electronic health record (ehr) used for patient care and electronic data capture (edc) which is used for clinical research such as clinical trials. an increasing number of dentists routinely use ehrs (schleyer et al. 2006 ) . most dental schools in north america also use ehrs. benefi ts of using ehrs include increased legibility, portability, and improved patient safety (buntin et al. 2011) . recent federal incentives, although not directly benefi cial to dentists, will also likely spur the adoption of ehr (blumenthal and tavenner 2010 ) . clinical researchers, especially those conducting clinical trials, are also discovering benefi ts of using electronic data capture compared to paper. a clinical trial is a process in which new treatments, medications and other innovations are tested to evaluate safety and effi cacy. a standard part of health care, clinical trials are often lengthy and costly due to myriads of regulatory oversight. recent estimates set the cost of drug development in excess of $800 million (grabowski et al. 2002 ) . accurately documenting data with suffi cient detail is critical for providing patient care and conducting clinical research. while the medical record is the foundation for patient care, the case report form is the foundation in a clinical trial. not all clinical research is clinical trials. clinical trials whose data will be submitted to the fda as a new therapy or device have additional requirements relating to the collection and transmission of the data. similarly for patient care data, ehrs need to meet the privacy and security requirements of hipaa. case report forms (crf) are a medium in which research study sites collect subject data in pre-defi ned formats for communication with clinical trial sponsors (rondel and webb 2000 ) many clinical trials data are collected on paper (rondel and webb 2000 ) . data measurement, collection, and recording are considered the "most crucial stage" in the data management process (hosking et al. 1995 ) . traditionally, study coordinators often record information in a case report form and subsequently mail or fax the crf to the centralized coordinating center. there, data entry staff, sometimes with the aid of optical character recognition systems, input crf data into a computer. errors made during this second data entry process are diffi cult to detect and correct (hosking et al. 1995 ) . lengthy guidelines in literature discuss methods for developing paper case report forms to reduce data entry mistakes (hosking 1995 ) . a well-designed crf may allow a user to effi ciently collect and record pertinent data. however, forms are often revised and redesigned during a clinical trial due to changes in protocol, unforeseen outcomes, or oversight (singer and meinert 1995 ) . there has been a recent drive to use electronic case report forms (ecrf). direct data entry at a study site shortens time to analysis and provides opportunities to audit data at time of entry. this could reduce data errors that might otherwise be caught weeks after submission. for quality control purposes, some studies require double data entry using computers and paper (day et al. 1998 ) , though alternative solutions have been explored including the use of data sampling (king and lashley 2000 ) and probability statistics to select only those forms likely to contain errors (kleinman 2001 ) . ecrfs may also facilitate data collection from existing electronic information systems such as lab systems. however, ecrfs are almost always reside in a separate system that is not linked to a patients record. although many clinical research studies are still being conducted using paper, an increasing number of studies are using ecrfs and electronic data capture (edc). for example, a review of canadian clinical trials found that 40% use edc (el emam et al. 2009 ). studies that are sponsored by a pharmaceutical company and are multicenter appear to use edc at a higher rate than those sponsored by government or a university. the cost of a commercial edc is substantial. recently a freely available edc has become popular amongst universities called redcap. a tool originally developed at vanderbilt university, it is now being used at over a 100 institutions worldwide (harris et al. 2009 ). however, such tools are generally not integrated with the institutions ehr. although moving from paper to electronic will afford benefi ts there is a great need to allow data exchange between the patient care and clinical research components of information systems. although ehr and edc are similar, several challenges remain unresolved that prevent integration. one of the major barriers is likely to be different workfl ows for patient care purposes and to collect data for research. research is needed in defi ning an optimal workfl ow that can streamline the tasks associated with patient care and research, while at the same time providing a unifi ed information system that support these activities. also, the data that are collected for care and research are likely to differ. a researcher may require far more granularity of an oral health measurement than a clinician seeking to provide care. in cases when conducting a double blind placebo controlled clinical trial, the investigator may not even know the type of treatment that has been delivered to the patient. due to complexities of each domain, and large differences in goals, to date mutually exclusive workfl ows have arisen. a clinician investigator who sees a patient for both care and research, will likely need to enter data on this same patient twice; once in the ehr and once in the edc system. despite the availability of electronic systems, a major barrier is the integration and compatibility of disparate health information systems to converse with one another. the languages are important because they can help data sharing. clinical trials are not usually conducted in isolation, but are part of conventional medical care. therefore sharing data by clinical trials, patient care and laboratory systems becomes especially important with the adoption of ehrs in dentistry. in biomedical informatics, standardized terminologies are recognized as a critically important area to help better represent and share data for use in electronic systems (cimino 2000 ) . the systematized nomenclature of medicine clinical terms (snomed-ct), developed by the college of american pathologists, is the most comprehensive medical terminology (strang et al. 2002 ; chute et al. 1996 ) and is used in a number of health informatics applications. the us department of health and human services ( 2010 ) has also licensed snomed-ct, allowing access throughout the us at no charge. therefore snomed-ct is even more likely to be the vocabulary used in electronic formats of patient records in the future. the medical dictionary for regulatory activities (meddra) is terminology used by the fda and drug development industry to classify, retrieve, present, and communicate medical information throughout the medical product regulatory cycle (brown et al. 1999 ) . in particular it is used to record and report adverse drug event data. therefore standard languages are essential in sharing clinical trials data between sites, and also with regulatory agencies. no one single terminology is suited for all tasks. snomed-ct is likely to be more comprehensive to code clinical encounters, while meddra is more suited to help adverse event reporting. however, it is important that terminologies are widely adopted and used for similar purposes. even when standard terminologies are agreed upon, such information needs to be interchanged in standard formats. health level 7 (hl7) is an important organization whose standards are widely adopted in healthcare to exchange information between computer systems. the clinical data interchange standards consortium (cdisc) is also an important group that helps to defi ne different data standards specifi cally for clinical trials research, such as clinical trials or regulatory submissions. one particular challenge in oral health has been the lack of a standardized terminology to describe diagnoses. although icd contains oral health concepts, they are often not granular enough to be useful for some patient care or research purposes. recently a dental diagnostic terminology has been developed by a group of dental schools, and has already been adopted by several institutions and used within dental ehrs (kalenderian et al. 2010 ) . the american dental association (ada) has also been developing snodent, but is not yet publically available for clinical use (goldberg et al. 2005 ). another link between ehr data and clinical research is the potential to fi nd human subjects. recruiting suffi cient numbers of patients that meet eligibility requirements within an allotted time frame for clinical trials is challenging. as ehrs contain detailed information about patients, they can be used to fi nd patients that meet specifi c inclusion and exclusion criteria. informatics for integrating biology and the bedside (i2b2), an open source data warehousing platform, has been found to be a useful tool for cohort selection especially if the source data from an ehr is represented in a structured format (deshmukh et al. 2009 ). further, with health information increasingly available to patients through the internet, it is possible interested patients will be more effective in fi nding clinical trials than investigators looking for patients. many clinical trial registers are now available online. the national institutes of health (nih) have made available their database of nih funded research (mccray 2000 ) . there is currently no single repository for patients to fi nd all trials studying a health condition. a recent study assessed the comprehensiveness of online trial databases concerning prostate and colon cancer and found that online trial registries are incomplete, especially for industry-sponsored trials (manheimer and anderson 2002 ) . a more collaborative effort between government and industry-sponsored research groups to compile and standardize information may be a mutually benefi cial effort. it is not clear how many patients now enroll in clinical trials through online discovery. ehr data originally collected for patient purposes can be potentially used for research. aggregating data from multiple sources can provide a large dataset that could otherwise not be available. electronic health records (ehr) contain a wealth of information and are a promising source to conduct research. data extracted from ehrs differ from other sources such as population surveys or data obtained from payers, as they provide a more detailed and longitudinal view of patients, symptoms, diseases, treatments, outcomes, and differences among providers. therefore ehr data in dentistry can potentially provide valuable insight into oral health diseases, and treatments performed on a large cohort of subjects. ehrs also play an important role in enhancing evidence-based decision-making in dentistry (ebd) and improving clinical effectiveness through decision support (atkinson et al. 2002 ; walji et al. 2007 ; valenza and walji 2007 ; taylor et al. 2007 ; spence et al. 2007 ; chambers et al. 2007 ; langabeer 2nd et al. 2008 ; walji mf et al. 2009 ). the consortium of oral health related informatics (cohri) provides an example of how dental ehrs are used for research purposes (schleyer et al. 2006; stark et al. 2010 ) . cohri was formed in 2007 by a group of dental schools who used the same ehr platform and who are interested in sharing clinical and education data. through funding from the national library of medicine, four dental schools are participating in a pilot project to develop an inter-university oral health research database by extracting and integrating data from ehrs. one promising area where data repositories derived from ehr data can be used for new discoveries is in the area of comparative effectiveness research. comparative effectiveness research is defi ned as "a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients." (congressional budget offi ce 2007 ) further, such research includes focusing on the clinical benefi ts and risks of each option (clinical effectiveness), and an analysis on the costs and benefi ts (cost effectiveness analysis). comparative effectiveness research (cer) is also likely to reduce costs of dental care and increase access to the majority of the population who currently receive no dental care. unfortunately many recent systematic reviews focusing on cer questions in dentistry have been inconclusive due to the lack of existing evidence in the scientifi c literature. secondary analysis of the data that reside in dental electronic health records (ehr) is a particularly appealing approach to facilitate cer and generate new knowledge. ehr data has the potential to provide a comprehensive picture of patients' histories, treatments, and outcomes, and if integrated with similar data from other dental clinics can include a large and diverse set of patients. however, numerous challenges must be solved before ehrs can be used for cer. first, data suitable for cer must actually be collected from ehr systems. second, this data, which often resides in proprietary systems, must be accessible and retrievable. and lastly, this data should be structured in a format that can be integrated with data from other sources or institutions. practice-based research networks (pbrn) are groups of primary care clinicians and practices working together to answer community-based health care questions and translate research fi ndings into practice. pbrns engage clinicians in quality improvement activities and an evidence-based culture in primary care practice to improve the health of all americans. in 2005, the national institute of dental craniofacial research funded three such research networks. the dental pbrn's to date have been conducting both prospective and retrospective research. for example, barasch et al. conducted a case controlled study to investigate risk factors associated with osteonecrosis of the jaws . many prospective studies conducted as part of pbrns still require separate data collection systems for the research data. ehr data contained in practices as part of pbrns are beginning to be used for secondary purposes. for example fellows et al. conducted a retrospective analysis of data contained in electronic health records to estimate incidence rates of osteonecrosis of the jaws ( fellows et al. 2011 ) . pbrns provide great promise of how ehr and clinical research data can be used effectively to promote both patient care and new discoveries. another area that intersects both the patient care and research realm are patient registries. patient registries are ways to track groups of patients who have had specifi c diseases or have had certain treatments. while ehr data would contain information on all types of patients, their diseases, and treatments, registries would allow focus on specifi c diseases or treatments of interest. registries would not be as costly in terms of resource requirements like a traditional clinical trial, but would require specifi c eligibility criteria, informed consents, and collection addition to that collected as part of routing care. dentistry has lagged far behind in forming data registries, primarily because dentistry is practiced in small offi ces and not in large hospitals making the process of integrating data very diffi culty. however, dental schools which themselves house large clinical operations are ideally positioned to create disease specifi c registries that can potentially use data collected for patient care and extend for research purposes. there is great potential for providing new insight in oral health by the integration of patient records and clinical research from both a workfl ow and information systems perspective. the technology challenges of developing systems that can exchange data, and use standardized terminologies appear solvable. however, the socio-technical issues such as determining how to incorporate optimal workfl ows for conducing both patient care and research with minimal additional overhead appear to be the greatest challenge before widespread adoption. similarly, there appears to be great potential in using ehr data originally collected for patient care for the secondary use of research and discovery. this will require collaboration between patients, providers and researchers from all healthcare disciples, and institutions with friendly policies for sharing data to improve both patient care and drive new discoveries. amit acharya , andrea mahnke , po-huang chyou , and franklin m. din more recently there has been a strong push from the united states federal government for the adoption of the electronic health record (ehr) within the healthcare industry. as a result, $19.2 billion is made available to incentivize the physicians, dentists and hospitals for the adoption of the ehr through the health information technology for economic and clinical health (hitech) act. as the nation head towards adoption of the ehrs, there has also been a growing interest with the majority of the u.s. dental schools to implement ehrs within the educational setting. fifty of the fi fty-six u.s. dental schools, as well as dental schools in canada and europe, are either using or in the process of adopting some aspects of a common dental ehr framework (white et al. 2011 ) . a group of dental schools known as consortium for oral health-related informatics (cohri) was formed in 2007 which used this common dental ehr framework -axium (stark et al. 2010 ) . currently there are about 20 dental schools within cohri. the ehr will not only support clinical care, but will also result in training the next generation dental students and to conduct innovative research that was not possible earlier. however, not much is known about how many of these dental schools' electronic dental records are integrated with their respective university's electronic medical record. a common medical-dental ehr model at healthcare universities would enable a holistic approach to providing patient care and provide the much needed electronic infrastructure to study interrelationship between the various oral-systemic diseases. recently a group of researchers from marshfi eld clinic in wisconsin, us conducted a survey to investigate the current states of health information technology and informatics within the dental school in the us. list of us dental schools were identifi ed through the american dental education association (adea) web site. dental schools were contacted to determine who the most appropriate person to take the survey would be. once the list of contact was developed from each dental school, an email was sent to 55 us dental schools with a link to a survey created in surveymonkey. the survey was administered on tuesday march 1, 2011. reminder survey emails were sent to all recipients on march 9 and march 17. the survey was closed on march 31. the anonymous survey was at most 23 questions, depending on how questions were answered. the survey focused on topics such as presence of dental informaticians within the dental schools, use of fi nancial and clinical information systems, interest in federal stimulus support for ehr adoption provided through american recovery and reinvestment act and meaningful use of ehr, relationships with health care entities and bidirectional nature of the dental and medical ehrs. the study was approved as exempt from the marshfi eld clinic institutional review board under section 45 cfr 46.101(b) and waived requirement for an authorization. thirty out of the fi fty fi ve dental schools responded to the survey (response rate of 55%). however, fi ve of the thirty dental schools representative did not complete the survey and hence their response was not included in the analysis. regarding the question about the presence of a dedicated department or a center for information technology (it) or informatics within the dental school in us, 80% (n = 20) of the responding dental schools had a dedicated it/informatics department or center (p-value of 0.0027). the it or the informatics department size (in terms of the number of personnel) at the 20 dental schools is illustrated in fig. 4 .27 . thirty fi ve percent (n = 7) of the us dental schools that housed an it / informatics departments had personnel with not only it training but also dental informatics training. while 40% (n = 8) of the dental schools were considering integration of dental informatics personnel within their department or center. twenty fi ve percent (n = 5) of the dental schools did not have any plans of integrating personnel with dental informatics personnel within their department or center (see fig. 4 .28 ). partial responses to additional questions in the section 1 of the survey is provided under table 4.6 . the majority of the responding dental schools were currently using financial electronic systems (fes) (p-value of <0.0001) and electronic dental records (edr) (p-value of 0.0001). the use of fes outnumbered the use of edrs in the dental schools (see fig 4.29 ) . about 77% of the dental schools that were currently utilizing the edrs used it in all the clinical modules (p-value of 0.0105), while 23% of the dental schools used the edrs in some of the clinical modules. when asked about the commercial edr system that the dental schools were using, axium (exan group, canada) was by far the most implemented edr system. two dental schools had salud (two-ten health limited, ireland) implemented and two dental schools had gsd academic (general systems design group, iowa, us) implemented. combinations of two ehr systems (home grown and dentrix) were implemented at two dental schools. one school had a dentrix only implementation, while another had developed its own edr system (home grown) (see fig. 4 .30 ). there were 13 dental schools which had implemented an edr fi ve or more years ago, 3 dental schools 3-4 years ago, 4 dental schools 1-2 years ago and 2 dental schools less than a year ago (see fig. 4 .31 ) (p value of 0.0029). when the dental schools were asked the question as to whether they were expecting to apply for the medicaid meaningful use incentive program, majority (52%) of the dental schools did not know and only 28% of the dental schools were expecting to apply within the next 4 years (fig. 4 .32 ) (p-value of 0.0044). challenges or barriers identifi ed by some of the dental schools in complying with the meaningful use objectives were (a). lack of certifi ed edr and information regarding it, (b). issues with getting auxium certifi ed and (c). qualifi cations of the edr as many of the meaningful use objectives do not apply to dentistry and lack of specifi c information about it. only 44% of the responded dental schools were part of a health system. fifty two percent (n = 13) of the responded dental schools had a formal relationship with other health care delivery entities in terms of sharing facilities, patient transfer, training programs. some of the types of relationship mentioned by the dental schools that had a formal relationship with other health care delivery entities included: (a). a gpr program and an emergency dental unit in the hospital, (b). affi liated hospital, (c). affi liation agreements, (d). oral and maxillofacial surgery (omfs), anesthesia and pedodontics all have some portion of education in medical health center, (e). omfs residents are also residents of medical health center, (f). residents providing care under contract with area hospitals, (g). sharing patients wand facilities with the health center, (h). students rotating in the community health centers and (i) collaborative grand programs. eighty fi ve percent of the dental schools that had a formal relationship with the health care delivery entities had routine interaction with them because of their existing relationship (p-value of 0.0015). their usual method for exchanging information was through informal medium such as phones, emails and faxes and formal medium such as memorandums, letters and contracts. when the dental schools were asked about the communication between the health systems' emr and the school's edr, majority of the dental schools did not have any communication (60%) or did not know is such a communication existed (25%) (p-value of <0.0001) (see fig. 4 .33 ). out of the 60% (n = 15) of the responded dental schools who's edr did not communicate with the health system's emr, 47% (n = 7) of the dental schools stated that they did not need to exchange patient information electronically as a reason for the non-communication, while 33% (n = 5) dental schools states that they would like to exchange patient information electronically but there were barriers that prevent them from doing so. some of the barriers identifi ed by these dental schools were (a). the hospitals and the dental school are not part of the same medial system and hipaa concerns prevent sharing data, (b). the dental school currently neither did have an edr nor the infrastructure to support one and (c). hospital is not interested and has high and perhaps unrealistic security standards. the remaining 20% (n = 3) of the dental schools expected to exchange patient information electronically in the near future (next 5 years). some of the information categories that were shared between the edr and emr in the small number of dental schools are illustrated in fig 4. 34 . finally when asked about any research projects under way in their dental school to investigate discrepancies between medical and dental records for the same patient, only 1 (4%) dental school was currently undertaking such project. in all common diseases, including those that affect the oral cavity, both the environment and genetics are pathogenic conspirators. unfortunately, we currently know little about the specifi c mechanisms underlying any common disease; and oral diseases are among the least understood. elucidating the etiology of chronic oral diseases will involve a synthesis of results from careful experiments of environmental exposures such as diet and tobacco use, the oral microbiome, co-morbidities, largescale, well-designed genetic studies, and the various interaction effects. with regard to genetics, the past few decades have witnessed transformative developments in our ability to interrogate the entire genome for genes that contribute to disease. while dramatic advances in experimental designs, statistical approaches, and clinical insights have greatly aided this scientifi c campaign, the central driver of this progress has been the development of high-throughput, inexpensive genetic technologies. following initial molecular studies using variant forms of enzymes, or allozymes, a major breakthrough was the use of highly informative dna-based markers throughout the genome (botstein et al. 1980 ) . this idea of directly assaying existing dna variation to conduct linkage and association studies in genetics began a revolution in disease gene mapping. recent interest from commercial entities has produced a feverish pace of technological innovation, markedly reducing cost and expanding the depth of inquiry. previously unfathomable, the testing of over one million single nucleotide polymorphisms (snps) in thousands of patients and controls is now commonplace (wellcome trust case control consortium 2007 ; schaefer et al. 2010 ) ; and very recently, next generation sequencing technologies have progressed to the point where sequencing of the entire protein-coding portion of the genome (exome) or even the entire genome is a costeffective method to examine disease traits across the entire spectrum of genetic variants in small numbers of affected individuals (ng et al. 2010 ) . there is little doubt that soon whole genome sequencing will be applied to nuclear family-based designs, studies among distantly-related affected individuals in extended pedigrees, and case/control studies involving thousands of individuals. this unprecedented scope of inquiry made possible by large-scale genetics, has begun to yield fascinating resulting into predisposition to oral cancers, caries, and periodontal disease that will molecularly redefi ne these pathologies, explicate unique biological connections with related diseases, give impetus to the development of directed therapeutics, and indeed personalize medicine. still, much more genetic focus on oral disease phenotypes is required if we are to realize this medical impact in a timely fashion. as genetic technologies have allowed the progression of interrogating single protein variants to single dna markers to entire genes to markers across the genome, and now to the entire genome sequence, the promises of these large-scale genetic studies have understandably undergone monumental expansion. it may be reasonable to expect the results from whole genome sequencing to decidedly revolutionize medicine within the next two decades. however, this new scientifi c capacity comes at a cost. as genetics, and biology in general, transitions to a data-rich science, practitioners have found themselves woefully unprepared to store and analyze the volume of data generated. once analyzed, interpretation and integration of these abundant and multifaceted results into medical practice will also be an appreciable challenge. insuffi cient assimilation of genetic fi ndings into merged dental and medical records will severely limit the ability of clinicians to appropriately treat patients. inadequately addressing these informatics issues will severely derail efforts in the basic sciences efforts as well as the translational and clinical sciences. this chapter explores the current state of genomics studies, what we have learned from genetic investigations into oral diseases, and where we may be headed. genetic studies have much to offer investigations of disease etiology. why do some acquire diseases and others do not? for those affected, why do some progress more rapidly than others? what causes some patients to respond to therapies, while others suffer from adverse reactions? these are all fundamental questions in both biology and medicine, whether the focus is on the gastrointestinal tract, the hippocampus, the lymphatic system, metabolic disorders, or oral diseases. speaking generally across disease areas, a portion of the answers to these questions often lies in described environmental effects. in numerous chronic diseases, infectious agents are likely contributors to the disease process -periodontitis, for example, is initiated by gram negative anaerobes in susceptible individuals (holt and ebersole 2005 ) . surely, unique and latent environmental exposures provide a random component to common disease susceptibility and progression. through twin studies, studies of risk in close relatives, and quantitative traits experiments, it is well-understood that heritable factors, including but not limited to dna variation, are typically responsible for 30-90% of the phenotype variability for common diseases. this section will attempt to cover, at least at a cursory level, the major salient developments affecting genetic insights into chronic and aggressive periodontitis, with some comment on genetic factors infl uencing susceptibility to caries and oral cancers. while it would be extremely naã¯ve to view genetic studies as an immediate panacea for our ills, the discovery of disease-causing genes does illuminate hitherto unknown biological pathways and molecular mechanisms, draws unforeseen connections with other traits, may improve prognostic models applicable for individuals, and suggests specifi c therapeutics. industrialization has brought forth increased lifespan and wellness through vaccination, modern sanitation practices, public health policies, and advances in medical science translated into practice. however, the accompanying physical inactivity coupled with a high calorie diet are probable contributors to an extremely common, chronically infl amed metabolic syndrome (hotamisligil 2006 ) that is thought to give rise to a multitude of intimately related disease traits: insulin resistance, compromised insulin signaling, hyperglycemia, obesity, dyslipidemia, hypertension, impaired kidney function, elevated liver enzymes and steatohepatitis, poor wound healing, neurodegeneration, vascular disease, pregnancy complications, accelerated immunosenescence, and periodontal disease (ford et al. 2002 ; ferrannini et al. 1991 ; eaton et al. 1994 ; holvoet et al. 2008 ; speliotes et al. 2010 ; eckel et al. 2005 ; d'aiuto et al. 2008 ) . these diseases often co-occur within the same patient and could be considered variable expression complications arising from a state of aberrant caloric fl ux that induces metabolic dysfunction and chronic, systemic infl ammation. these features constitute a disruption in a fundamental homeostatic mechanism with intensifying pathogenic consequences. the rapidly increasing incidence and decreasing age of onset for this pathophysiological state have generated a major source of mortality and morbidity in modern cultures (ford et al. 2002 ; ferrannini et al. 1991 ; weiss et al. 2004 ) . it is becoming increasing clear that many chronic diseases have an infectious component. there is relatively convincing evidence that many systemic, t-cell mediated autoimmune disorders may be initiated by infections. for example, from archaeological data, it is believed that an infectious agent -currently unknown -is necessary for rheumatoid arthritis (firestein 2003 ) , and both guillain-barre syndrome and rheumatic fever have well-described pathogeneses triggered by specifi c infections in susceptible individuals (bach 2005 ) . in many instances, oncogenesis and tumor progression can be traced to pro-infl ammatory responses at the site of chronic infection (coussens and werb 2002 ) , although it is not known whether these effects are mediated through the actions of the immune system, the infectious agents, or a combination thereof. several cancers fall into this category including gastric adenocarcinoma (uemura et al. 2001 ) , cervical cancer (walboomers et al. 1999 ) , hepatocellular carcinoma (saito et al. 1990 ) , and kaposi's sarcoma (dictor 1997 ) , all having unequivocal infectious agent etiologies. recent fi ndings of antiinfl ammatory pharmaceuticals, particularly those that inhibit cox-1 and cox-2, reduce the incidence of certain classes of cancers are consistent with this view (dannenberg and subbaramaiah 2003 , rothwell rothwell et al. 2010 ) . in addition, there is moderate evidence that several bacteria -the most studied is chlamydia pneumoniae -play a role in atherosclerosis and myocardial infarction (saikku et al. 1988 ; watson and alp 2008 ) , however the studies are not conclusive and antibiotic treatment does not appear to be effective (andraws et al. 2005 ) . chronic periodontal disease is fi rmly footed at the intersection of infection, chronic infl ammation, and metabolic dysfunction. chronic periodontitis is characterized by infl ammation of the periodontal membrane, slowly causing gingival recession and eventual bone loss. the proximate cause of periodontitis is the virulent oral microbiome. the involvement of gram negative anaerobes has been fi rmly established for the disease. aside from the known oral pathogenic species p. gingivalis , t. denticola , and t. forsythensis , the so-called "red complex" (holt and ebersole 2005 ) , new bacterial species associated with chronic periodontitis have also been described (kumar et al. 2003 ) . the advent of an extensive database covering the oral microbiome will surely propel such investigations . numerous studies have shown that periodontal disease covaries with many diseases, presumably due to overlapping molecular etiologies. compelling meta-analyses demonstrate a highly signifi cant synchronicity of obesity and periodontal disease (chaffee and weston 2010 ) . in addition, the correlation between periodontal diseases/ alveolar bone loss and frank metabolic syndrome is repetitively observed (nesbitt et al. 2010 ; andriankaja et al. 2010 ) . extensive work has also shown a strong role for both infl ammation-related genes and circulating infl ammatory markers in periodontal disease (nikolopoulos et al. 2008 ; bretz et al. 2005a, b ) . treatment studies further support the link between periodontal disease and immuno-metabolic syndrome. these experiments have demonstrated a signifi cant improvement in intermediate molecular markers of infl ammation when chronic periodontitis in the presence of metabolic syndrome (acharya et al. 2010 ) or type 2 diabetes (iwamoto et al. 2001 ) was treated. conversely, treatment of periodontal disease with reduction of bacterial load leads to greater glycemic control among diabetic patients (simpson et al. 2010 ; stewart et al. 2001 ) . given the high prevalence of periodontitis and the co-morbidity of metabolic syndrome with periodontal disease, these treatment experiments appear to suggest that the virulent oral microbiome could play an important role in the pathogenesis of systemic infl ammatory metabolic syndrome, and is exacerbated by the syndrome. certainly, further studies are needed to defi nitively answer this question. as chronic periodontal disease seems to be a critical feature of sustained, systemic dysfunction of both metabolic and infl ammatory networks, uncovering the genetic variants carried by susceptible individuals would not only provide much needed insight into the molecular pathogenesis of chronic periodontal disease, but would also markedly aid our understanding of the infl ammatory metabolic syndrome and how it drives related co-morbidities. such genetic studies may also shed light on the specifi c mechanisms that appear to improve cardiovascular, infl ammatory, and diabetic outcomes when periodontal disease is treated, potentially leading to therapies and medical/dental intervention with greater effectiveness. such studies may also provide clues to which subsets of individuals respond more effectively than others and why they do so. periodontal disease can also present in a rapid manner with aggressive bone loss and early-onset. this is termed aggressive periodontitis (lang et al. 1999 ) . in contrast to chronic periodontitis, there is often a greater degree of familial aggregation with aggressive periodontitis, and it is hypothesized that most aggressive cases may affl ict individuals with one or more defective immune genes (zhang et al. 2003 ; amer et al. 1988 ; machulla et al. 2002 ; carvalho et al. 2010 ; toomes et al. 1999 ; hart et al. 2000 ; hewitt et al. 2004 ) . mutations in the lysosomal protease, cathepsin c, have been shown to be responsible for some forms of aggressive periodontitis, along with complications associated with other infl ammatory diseases (laine and busch-petersen 2010 ) . the specifi c hla variants thought to play a role in aggressive periodontitis, are also involved in infectious disease susceptibility and autoimmunity; and, interestingly, two of the non-mhc-linked regions, fam5c and a locus on chromosome 9p21, have been implicated in myocardial infarction (connelly et al. 2008 ) and may have action as a tumor suppressor in tongue squamous cell carcinoma (kuroiwa et al. 2009 ) . as with chronic periodontal disease, an infectious microbiome is heavily involved. however, in general, microbiome differences could not explain the presence of chronic versus aggressive forms of the disease, although in some aggressive periodontitis patients, a highly leukotoxic a. actinomycetemcomitans strain may contribute to the disease process (mombelli et al. 2002 ) . we currently do not fully know the differences between the genetic susceptibility factors for the chronic and aggressive forms of the disease. the most prevalent chronic disease in both children and adults is dental caries (national institute of dental and craniofacial research) . caries formation is a complex disease with several interacting components form the environment and host genetics. similar to gingivitis and periodontitis, caries have an infection-initiating etiology with acidifi cation leading to localized demineralization. epidemiological studies have long shown that diet is a strong predictor of caries formation; and the reduction in ph is exacerbated by high consumption of carbohydrates. the principal pathobacterial species are streptococcus mutans and lactobacillus ( van houte 1994 ) . there are also several reports of positive correlations of caries with infl ammatory diseases, although the association is not always repeatable. it is also not clear what proportion of the putative association with infl ammatory disease is due to innate upregulation of immune networks in contrast to the immuno-modulating pharmaceuticals prescribed to those with infl ammatory disease (steinbacher and glick 2001 ) . much of the effect is reported to result from lack of saliva volume (steinbacher and glick 2001 ) . interestingly, the presence of epilepsy may be associated with higher caries rates (anjomshoaa et al. 2009 ) . fluoride is an effective antimicrobial agent that interferes with bacterial growth and metabolism (wiegand et al. 2007 ) . hence, topical fl uoride administration as well as ingestion of fl uoridated water inhibits cariogenesis and caries progression (ripa 1993 ) . amelogenesis is a key process involved in modifying the rate of caries formation. both common variation and rare mutations in enamel formation genes such as amelogenin and enamelin are involved in caries rates (patir et al. 2008 ; kim et al. 2004 ; crawford et al. 2007 ) , the molecular actions of which are beginning to be revealed (lakshminarayanan et al. 2010 ) . over 35,000 new cases of cancers affecting the oral cavity and pharynx were expected in the united states for 2009, with deaths numbering 11,000 (jemal et al. 2009 ) . the majority of these malignancies involved solid tumors originating from cancerous changes in squamous cells of the mouth. again, oral cancers have a complex etiology existing of entangled genetic, epigenetic, infectious, and dietary causes, further modifi ed by tobacco, alcohol and other environmental exposures. as with most cancers, it is reasonable to expect that both germline and somatic genetic changes will be involved in carcinogenesis, tumor growth, and metastasis. promoter hypermethylation of genes central to cellular growth, differentiation, dna fi delity, apoptosis, and metabolic stability is an important facet of these cancers (poage et al. 2010 ) . indeed, methylation-mediated silencing of genes involved in tumor suppression (e.g. the cyclin-dependent kinase inhibitor 2a), detoxifi cation (e.g. mgmt ), and apoptosis (e.g. the death-associated protein kinase-1) are commonly found in oral squamous cell carcinoma samples (ha and califano 2006 ) . to quantify the proportion of the variance in a phenotypic trait that is due to variance in genetic factors, population geneticists defi ned the concept of heritability (visscher et al. 2008 ; falconer and mackay 1996 ) . researchers subsequently developed several methods for estimating heritabilities using the measure of a trait (e.g. occurrence of disease/not-disease) in combinations of relatives (e.g. parentoffspring, or monozygotic-dizygotic twins). in general, the higher the measured heritability of a variable phenotype, the larger the contribution of genetic factors is in comparison to environmental effects. it is fallacious to assume that the heritable variation is composed entirely of alleles residing in the dna sequence, for heritability studies simply examine the covariance between relatives without comment on specifi c molecular mechanisms. hence, any heritable variation such as methylation patterns, vertically-transmitted infectious agents, as well as dna variation can contribute to the heritability measure. heritability results are important because they not only give a rough estimate of the collective effects of heritable factors, but also can provide a measure to quantify how much of the total genetic effect is accounted for by specifi c loci examined. for periodontal disease, four twin-based studies of heritability have been performed (michalowicz et al. 1991 ; corey et al. 1993 ; michalowicz et al. 2000 ; mucci et al. 2005 ) . although varying in sample size and methodological details, all four arrived at consistent results, with 30-50% of the variance in periodontal disease being attributed to genetic variability for chronic periodontitis. given the segregation patterns described in the literature, it is reasonable to assume that aggressive periodontal disease exhibits a higher heritability. therefore, given the prevalence of periodontal disease, heritable factors within the population at large are likely appreciable. using 314 twin pairs, bretz and colleagues reported substantial heritability values for multiple traits related to caries ranging from 30% to 56% (bretz et al. 2005a, b ) . lastly, mutagen sensitivity studies of head and neck cancer patients suggest a signifi cant effect of genetic factors for the carcinogenesis of oral cancers (cloos et al. 1996 ) . hence, there is every reason to believe that a sizable pool of genetic and/or epigenetic factors await discovery for oral diseases. once the development of pcr (saiki et al. 1985 ) was applied to the idea of using naturally-occurring dna variation (botstein et al. 1980 ) , large-scale dna-based studies of disease underwent a substantial acceleration (schlotterer 2004 ) . genotyping of short, tandem repeated sequences (weber and may 1989 ) -microsatellites -spurred on a wave of genome-wide linkage studies, which evaluate the co-segregation of disease state with microsatellite markers, for both rare mendelian disorders as well as more common diseases with complex inheritance patterns. while the rarer traits with more coherent transmission patterns generally relinquished their genetic secrets to linkage analysis, more common diseases did not. in the mid-to late 1990s, several theoretical studies had shown that the power to detect disease-causing alleles is higher with association-based designs such as a case/control experiment or association in the presence of a linkage signal as in the transmission/disequilibrium test if the frequency of those alleles is high and the effects are moderate (kaplan et al. 1995 ; risch and merikangas 1996 ; jones 1998 ; long and langley 1999 ) . however, to conduct genomewide association studies presented an ominous obstacle for the genetic technologies at the time. the number of markers required to effectively cover the genome was prohibitively large as the chromosomal blocks in population-based samples used in association designs were expected to be small. even within large extended families, the limited number of recombination events generates substantial chromosomal blocks passed through the pedigree, but researchers had both theoretical and empirical evidence that the blocks in population-based samples were on the order of 50 k base pairs for most large human populations. as the reader can imagine, the mean length of blocks that are shared by descent is inversely related to the product of recombination rate, the number of affected individuals and the number of meioses separating the affected individuals. in practice, even very large extended families segregate regions shared by affected members on the order of several million base pairs in length. however, once geneticists seriously considered large-scale studies using a case/control design where individuals are separated by say 5,000 meioses, it became clear that to adequately cover the much smaller shared regions across the entire genome, hundreds of thousands of markers would be required (kruglyak 1999 ) . utilizing the human genome sequence (venter et al. 2001 ; lander et al. 2001 ) , a number of studies at celera diagnostics provided an intermediate solution, where approximately 30,000 putative functional snps primarily located in genes were assayed through allelespecifi c pcr in a number of common diseases using a staged case/control design. these studies were successful in identifying several gene-centric polymorphisms associated with common diseases (begovich et al. 2004 ; cargill et al. 2007 ) (fig. 4.35 ) . concurrently, several groups had performed extensive sequencing and genotyping across the genome to produce a genome-wide map of haplotype structure (hinds et al. 2005 ) , useful in linkage disequilibrium mapping. within 2 years, technology for snp hybridization arrays had advanced so as to enable genome-wide association studies capable of capturing most of the common genetic variation in the genome either through direct genotyping or indirect interrogation using linkage disequilibrium -the term linkage disequilibrium is a measure of the correlation of alleles at closely-linked sites (see fig. 4 .36 ). these investigations were met with numerous successes (klein et al. 2005 ; kathiresan et al. 2008 ; graham et al. 2008 ; gudmundsson et al. 2009 ) . inexpensive genotyping platforms and urging from theoreticians ensured that these genome-wide association studies were, in general, highly powered to detect all but very mild effects from high frequency alleles. these efforts, led by large academic consortia such as the wellcome trust, the international multiple sclerosis genetics consortium, and the broad institute and commercial entities such as decode genetics and perlegen have greatly expanded our understanding of the basic biology of common diseases: we now know, for example, that (i) autophagy-related genes are involved in crohn's disease (rioux et al. 2007 ) , (ii) there are a number of genes such as the protein tyrosine phosphatase, ptpn22 and the interleukin-23 receptor, il23r , that exhibit ample pleiotropic effects among autoimmune conditions (lopez-escamez 2010 ; safrany and melegh 2009 ) , (iii) in the case of age-related macular degeneration, predictive models using the genetic results enable fairly accurate prognosis of individuals who are at high risk of disease (seddon et al. 2008 transcription factor tcf7l2 plays a role in type 2 diabetes (grant et al. 2006 ) , and (v) aberrant il-7 signaling likely contributes to multiple sclerosis susceptibility (gregory et al. 2007 ) . the plot shows the tremendous progress in genotyping technology where, a decade ago, very little of the genome was accessible for disease studies using association designs through the current wave of viable sequencing-based whole exome studies (2010) (2011) and whole genome studies (2012) (2013) . in fig. 4 .37 , the average distance between adjacent genetic markers is plotted as a function of year of introduction to the disease mapping community. impressively, the total number of genetic markers has increased a million-fold over the past decade. although successful in uncovering numerous pathogenic pathways for common diseases, results from the current wave of genome-wide association studies, with a few exceptions, explain little of existing disease heritability. the reasons for this are cryptic and the subject of heavy debate (manolio et al. 2009 ) . multiple rare sequence variants generating high levels of allelic heterogeneity, functional de novo mutations, structural mutations such as copy number variants and large deletions, and epigenetic effects constitute four of several possible disease models that could account for the heritability discrepancy. the answer will almost certainly consist of a conglomeration of these and other effects. bringing forth the new genome-wide technologies that illuminate these previously non-or under-interrogated properties of the genome to bear on this enigma is a reasonable next step for all complex traits including oral diseases. the most commonly used measure of ld in a sample of chromosomes is linkage disequilibrium (ld) is a measure of the correlation between alleles at two sites in a sample of chromosomes. for two biallelic sites, if the a1 allele is always paired with the b1 allele, and the a2 allele is always on the same haplotype as the b2 allele, then the two sites are said to be in perfect ld. successive recombination diminishes ld. interrogating one site for disease association allows investigators to indirectly interrogate other sites in sufficiently high ld with the interrogated site. a key feature explicitly studied in molecular population genetics and implicitly used in disease gene mapping studies is the site frequency spectrum; that is, the distribution of allele frequencies at single sites in the genome that vary in the human population studied. from both diffusion models (kimura 1970 ) and coalescent theory (hudson 1991 ) in theoretical population genetics, we know that the vast majority of realistic models generate many more rare variants compared to common polymorphisms. this is particularly true for expanding populations. are these rare variants the source of much of the missing heritability? recently, with the application of high-throughput sequencing technology to human studies over the past decade, empirical studies have clearly verifi ed these predictions -the large majority of variants have low frequencies (the international hapmap 3 consortium 2010 ) . the distribution of deletions appears to be skewed toward more rare frequencies, presumably due to the deleterious effects of such variants. individual mutations appearing de novo typically are extremely rare events per locus, but collectively are numerous. other types of genetic variability, such as copy number repeats, span both ends of the frequency spectrum with the preponderance of the markers being rare. thus, there is a sizable pool of low-frequency variants in human populations that have yet to be thoroughly investigated. over the past few years it has become increasingly clear that structural variants exist in the human genome at a far higher rate than previously thought. structural variants can exist in a multitude of forms including deletions, copy number variants, and inversions among others. due to the nature of these genetic changes, many are considered to be highly disruptive of molecular function if they lie in functional motifs. indeed, there are several mendelian diseases are caused by fully-penetrant structural variants impacting a chromosomal region (lupski 2007 ) . numerous structural variants have recently been reported to be associated with common diseases, particularly in the neurological fi eld (sebat et al. 2007 ; stefansson et al. 2008 ; elia et al. 2010 ) , infectious disease susceptibility (gonzalez et al. 2005 ) , and drug metabolism (zackrisson et al. 2010 ) . although they have improved dramatically over the past few years, algorithms using snp-based data from hybridization arrays to infer copy number variants have had high error rates, perhaps explaining the rather low rates of replication of structural variation association results for common diseases. nevertheless, given the high frequency of structural variants, their pathogenic potential, and that we are on the precipice of a sequencing revolution in genome-wide studies, examination of these variants should be a high priority for new sequencing-based studies in oral disease susceptibility, progression, and related pharmacogenetic applications. as different technologies examine different portions of the site frequency spectrum (i.e. genome-wide snp scans interrogate variation that is common in the hapmap populations, whereas sequencing-based studies typically interrogate the entire frequency spectrum), where one believes genetic causation is harbored should infl uence the selection of genotyping technology. if common genetic variation contains the vast majority of heritable effects on disease phenotypes, then an investigator would be wise to employ a snp-based experimental design. if, however, there is reason to believe that a signifi cant portion of the genetic load of the disease studied exists in the highly populated portion of the distribution -the rare variants -then a sequencing-based study may be better suited to unravel causative alleles. the studies of heritability discussed previously show that there is heritable variation underlying a substantial portion of the variance observed in oral diseases. as discussed above, sequencing technologies may address many aspects of dna variation including copy number loci, rare haplotypes, inversions, and insertions/deletions, but it is also worthwhile to repeat that the molecular mechanisms for disease heritability are not necessarily limited to variation at the dna level. for a disease state, the covariance between relatives could be driven by co-inherited chromosomal regions or other phenomena. chief alternative heritable mechanisms include dna methylation (hammoud et al. 2009 ) , modifi cations to the histones (bestor 2000 ) , complex rna zygotic transfer (rassoulzadegan et al. 2006 ) , and vertical transmission of infectious agents. additionally, transgenerational effects offer an intriguing class of epigenetic mechanisms (nadeau 2009 ) . in a thorough review on epigenetics and periodontitis, gomez et al. make a strong argument for consideration of both cpg dinucleotide methylation and deacetylation actions on cytokine expression as a credible avenue for further investigation in periodontal disease etiology (gomez et al. 2009 ) . genome-wide epigenetic studies have been successfully conducted for oral cancers (poage et al. 2010 ) . the scale of this study on head and neck squamous cell carcinomas allowed these researchers to show a global pattern of tumor copy number changes signifi cantly correlated with methylation profi les that was not detectable at the individual gene promoter level. with advanced chromatin immunoprecipitation and new methods to study dna methylation, efforts to apply highthroughput epigenetic methods to oral diseases should be accelerated. numerous studies have been conducted in oral disease traits using a candidate gene approach. there are two large reviews of the existing candidate gene results (nikolopoulos et al. 2008 ; ) . laine and colleagues have recently put together a comprehensive review article covering gene polymorphisms. there are some suggestive fi ndings for cyclooxygenase-2 gene, cox-2 , the cytokineencoding genes, il6 and il1b , the vitamin d receptor, vdr , a polymorphism immediately upstream of cd14 , and the matrix metalloproteinase-1 gene, mmp1 . however, these initial results will require further confi rmation, for the association patterns are inconsistent across independent studies, the statistical signifi cance is moderate, and the posterior probability of disease is decidedly bland. the striking pattern that emerges from the laine et al. summary data is the lack of coherent replication of genetic association for the vast majority of polymorphisms examined. the situation is reminiscent of genetic association studies prior to large-scale snp studies where poor repeatability of results plagued the fi eld. in a pivotal study from 2002, hirschhorn and colleagues (hirschhorn et al. 2002 ) examined the state of genetic association studies, fi nding that "of the 166 putative associations that had been studied three or more times, only six have been consistently replicated." the dearth of robust results was largely remedied when large-scale genetic studies were applied to very substantial numbers of well-characterized patients and geneticallymatched controls and stringent statistical criteria enforced. one can only suspect that a similar state of affairs is operating in genetic studies of chronic periodontitis. perhaps efforts to (1) reduce the heterogeneity of the disease state through detailed clinical and laboratory assessments, (2) drastically increase sample sizes, and (3) expand the scope of inquiry to larger numbers of genes/regions, and examine a more comprehensive set of variants/epigenetic effects will improve the current situation. the second large study is a meta-analysis of 53 studies, where nikolopoulos and colleagues analyzed six cytokine polymorphisms linked to il1a , il1b , il6 , and tnf-alpha (nikolopoulos et al. 2008 ) . two of these, an upstream snp in il1a and a snp in il1b , exhibited signifi cant association with chronic periodontal disease risk. although the results were not particularly strong, as is typical with complex diseases, the results do suggest the importance of infl ammation-response variability in chronic periodontitis predisposition. perhaps the strongest, most replicable genetic association fi nding with coronary heart disease and myocardial infarction is centered on the short arm of chromosome 9 (9p21.3) (mcpherson et al. 2007 ; helgadottir et al. 2007 ) . two studies of periodontal disease showed that the same alleles at the 9p21.3 locus confer risk for aggressive periodontitis (schaefer et al. 2009 ; ernst et al. 2010 ) . the discovery of such a pleiotropic locus may explain a portion of the aggregation of periodontal disease with other co-morbid conditions. further studies investigating overlapping genetic susceptibility factors between periodontitis and cardiovascular disease, diabetes mellitus, metabolic syndrome, rheumatoid arthritis, and other related diseases may be a fruitful strategy for honing in on shared genes affecting these immuno-metabolic disorders. using patients from 46 families from the philippines, the fi rst genome-wide linkage study for caries was completed in 2008 (vieira et al. 2008 ) . the study identifi ed fi ve loci which exhibit suggestive statistical evidence (lod scores exceeding 2.0): 5q13.3, 14q11.2, xq27.1, 13q31.1, and 14q24.3. the latter of which overlapped with a quantitative trait locus discovered from mapping work in the mouse. further work is necessary to refi ne these signals and localize the variants that may be driving these linkage signals. aggressive periodontal disease and rarer dental diseases have also been subjected to linkage analysis. results from linkage studies for dentinogenesis imperfecta type i, for example, have gone on to produce the novel gene fi ndings of the dentin sialophosphoprotein-encoding gene on 4q21.3 being responsible (song et al. 2008 ; crosby et al. 1995 ) . a linkage study in african american families examining localized aggressive periodontitis found a strong linkage signal in a region covering approximately 26 megabases on chromosome 1 (li et al. 2004 ) . several interesting genes are in this region. in a study earlier this year further mapping from carvalho et al. in brazilian families identifi ed haplotypes in this region on 1q in fam5c which were associated with aggressive periodontitis (carvalho et al. 2010 ) . the function of the fam5c protein is not fully understood. fam5c is localized in the mitochondria and it appears to play a role in vascular plaque dynamics and risk of myocardial infarction (laass et al. 1997 ) . it should also be noted here that other types of mapping analyses such as homozygosity mapping to identify have yielded gene discoveries. for example, the lysosomal protease cathepsin c gene for the recessively-inherited papillon-lefevre syndrome which is characterized by aggressive and progressive periodontitis was effectively mapped using homozygosity mapping (fischer et al. 1997 ; connelly et al. 2008 ) . cathepsin c is highly expressed in leukocytes and macrophages and is a key coordinating molecule in natural killer cells (rao et al. 1997 ; meade et al. 2006 ) . although sparse, these linkage results are undoubtedly encouraging. employing very large extended families subjected to genome-wide genotyping or sequencing will surely shed much needed light on chromosomal regions and genes relevant to oral disease research (fig. 4.38 ). for periodontitis, a single study has employed a genome-wide association design in an effort to uncover aggressive periodontal variants (schaefer et al. 2010 ) . this study by schaefer and colleagues discovered and replicated an intronic snp, rs1537415, in the glycosyltransferase glt6d1 which is signifi cantly correlated with aggressive periodontal disease in both german and dutch samples. often, seemingly signifi cant results from large studies are due to the effect of reporting the top result from a great many statistical tests -this is called the multiple testing problem. in this situation, the strength of the fi nding, along with the replication across three case/control studies, argues for true association with aggressive periodontal susceptibility. the snp may modulate the binding affi nity of gata-3. the association with glt6d1 is currently one of strongest genetic associations for aggressive periodontal disease, testifying to the power of genome-wide studies to generate novel, relevant molecular pathophysiology for complex diseases. it seems unlikely that glt6d1 would be extremely high on a candidate gene list, and it was only through a genome-wide scan that it appeared. like many excellent studies, the fi nding by schaefer et al. raises more questions than it answers and will undoubtedly provide fertile ground for ensuing molecular work. after a somewhat sluggish start, due to a lack of critical mass of investigators aiming to collect large numbers of patient samples and bring high throughput genetic technologies to caries susceptibility, gingivitis, and periodontal disease traits, the future of genetic studies in oral health is bright. scientifi c progress in revealing the molecular pathogenesis of oral diseases is dependent on genome-wide genetic studies; and i have argued that progress in related immuno-metabolic diseases is also dependent on these large-scale genetic studies in periodontal disease. to study sporadic disease, substantial patient collection efforts are required for the application of these technologies. this may involve a combination of new recruitment and consortiumrelationships with existing collections. the beginning of such a collection for sporadic aggressive periodontitis in europe has shown extremely intriguing initial results, but more patients are needed to examine rare variants of moderate effect. both the german/dutch collection of aggressive periodontitis and the brazilian collection have begun to revolutionize the study of periodontal disease susceptibility with the discovery of glt6d1 snps and fam5c -linked haplotypes. there is little doubt that subsequent molecular work on these two genes will uncover novel mechanisms for the predisposition to aggressive periodontal disease. focus should also be placed on the collection of extended families segregating these diseases. applying sequencing technologies to large pedigrees can be an effective method of identifying rare variants and structural variants in a highly-refi ned phenotype. furthermore, applying these methods to the entire genome would make for a comprehensive genetic study. several trends in large-scale genomics science hold promise to signifi cantly advance our understanding of oral disease pathogenesis: the sociology of biological sciences has changed over the past 15 years so as to â�¢ become more collaborative. essential for association-based designs, consortiumbased genetic research has blossomed over that time period, increasing sample sizes and therefore the power to detect disease-causing variants. there currently is consortium-based research in periodontal disease and oral cancer. further expanding these efforts will enhance subsequent studies, particularly those investigating rare alleles and/or rare epigenetic effects. through over a century of laboratory work, the collective knowledge of bio-â�¢ chemical pathways, signal transduction, cell physiology, regulatory mechanisms, and structural biochemistry is weighty. incorporation of this information into etiological models may substantially advance oral disease work as well as the fi eld of complex disease genetics in general. sophisticated analysis techniques are needed to perform this task. recent advances merging results from network science with probability theory within the context of computer science have produced the fi eld of machine learning. this rigorous framework can be used to identify those factors responsible for disease status and can also be used to develop robust predictive models using known biological networks and genetic data. the output from such models, typically the probability of disease, an estimate of disease progression rate, or a probability of adverse reaction, can be used by physicians and dentists to personalize medical care. until relatively recently, population genetics did not contribute a great deal to â�¢ human genetics research. that has changed in the past decade where effort spent on association studies surpassed that spent on family-based studies. those investigating disease gene mapping began to collaborate with population geneticists and population geneticists took up a wide-spread interest in fi nding disease alleles. incorporation of population genetics theory into such studies markedly improved association studies on several levels: confounding by population stratifi cation was effectively treated using population genetics, linkage disequilibrium patterns. use of population genetics theory in large-scale oral disease mapping studies may accelerate discoveries. sequencing technology has rapidly progressed over the past decade. currently, â�¢ sequencing studies across the exome can be accomplished at reasonable cost and yield data for all known genes in the genome. within the next few years, sequencing costs will depreciate to a point where whole-genome sequencing studies will be commonplace, using both family-based and population designs. application of these technologies to oral disease studies is imperative for comprehensive studies of etiology. high-throughput dna methylation and chromatin immunoprecipitation studies â�¢ will enable large-scale epigenetic studies in oral diseases (meade et al. 2006 ; ehrich et al. 2005 ; bibikova et al. 2006 ; ren et al. 2000 ; pokholok et al. 2005 ) . these have already started to play an important role in delineating mechanisms responsible for oral cancers (poage et al. 2010 ) . additional application of these techniques to studies of gingivitis, caries, and periodontal diseases may generate novel fi ndings. molecular biologists and pharmacologists have increasingly become able to â�¢ develop and evaluate highly targeted pharmaceuticals based on genetic discoveries. the use of such genetic information may improve the chances of developing effi cacious therapies. geneticists and disease researchers are beginning to realize that oral diseases â�¢ both impact and are intrinsically tied to susceptibility and progression of other common diseases. a synthesis of genetic fi ndings from immuno-metaboliclinked disorders would seem to greatly increase the knowledge of these diseases and better pinpoint their respective etiologies. as the new high-throughput genomics and epigenomics technologies become â�¢ implemented in oral disease research, the storage, management, analysis, and interpretation of the ensuing colossal amounts of data will be critical to enable clinicians to use these results in daily practice. advances in dental and medical informatics will facilitate these steps. we are in exciting times where advances in genetic technologies will uncover the genetic causes of diseases, including those that affect the oral cavity. with more focus in the area of oral disease genomics and the harnessing of new high-throughput sequencing and epigenetic technologies, novel insights into the pathways driving these diseases are imminent. these discoveries will, in turn, motivate directed therapies, aid in illuminating the molecular etiology of related disorders such as diabetes, and increase the level of personalized medicine. joseph kilsdonk the title of this section reinforces a 1995 institute of medicine (iom) report titled "dental education: at the crossroads." to quote yogi berra, a baseball sage: "when you come to a fork in the road, take it." the implication being that dental education must take action and move beyond its crossroads. these crossroads are described in the fi rst third of the section. it includes a summary and recommendations of the iom report and three transitional reports that followed: the 2000 surgeon general's report identifying oral health as a silent epidemic, the josiah macy foundation report, and a "pipeline" study funded by both the robert wood johnson and the california foundations. having been at the crossroads for a decade or so, the middle portion of the section highlights educational models that may lead to a more promising future. the later third of this section describes an alternative path of action for dental education which emphasizes the central roles of clinic-based education and dental informatics in dental education curriculum. it is unknown how traditional dental educators may view this model; however, it is effectively a logical conclusion and responsive to the reports. in 1995 the institute of medicine (iom) published "dental education at the crossroads" (field 1995 ) . the title was apropos as the authors' analysis concluded: (1) economics surrounding dental education were unsustainable ; (2) student service learning opportunities and access to care for patients were limited; and (3) new dental schools were not replacing those forced to close due to the economic climate. the iom report additionally proposed key recommendations to reform dental education and service delivery. fifteen years later, we remain at "the crossroads" as these issues remain largely unresolved. furthermore, these recommendations have retained their validity. their implementation would directly impact structures and services for contemporary models of dental education in the future. the following iom recommendations (field 1995 ) are intrinsic to the proposed dental education reform: recommendation 2 : to increase access to care and improve the oral health status of underserved populationsâ�¦ recommendation 3 : to improve the availability of dental care in underserved areas and to limit the negative effects of high student debtâ�¦ recommendation 5 : to prepare future practitioners for more medically based modes of oral health care and more medically complicated patients, dental educators should work with their colleagues in medical schools and academic health centers to: move toward integrated basic science education for dental and medical â�¢ students; require and provide for dental students at least one rotation, clerkship or â�¢ equivalent experience in relevant areas of medicine and offer opportunities for additional elective experience in hospitals, nursing homes, ambulatory care clinics and other settings; continue and expand experiments with combined md-dds programs and â�¢ similar programs for interested students and residents; increase the experience of dental faculty in clinical medicine so that they, â�¢ and not just physicians, can impart medical knowledge to dental students and serve as role models for them. recommendation 6 : to prepare students and faculty for an environment that will demand increasing effi ciency, accountability, and evidence of effectiveness, the committee recommends that dental students and faculty participate in effi ciently managed clinics and faculty practices in which the following occurs: patient-centered, comprehensive care is the norm; â�¢ patients' preferences and their social, economic, and emotional circumstances â�¢ are sensitively considered; teamwork and cost-effective use of well-trained allied dental personnel are â�¢ stressed; evaluations of practice patterns and of the outcomes of care guide actions to â�¢ improve both the quality and the effi ciency of such care; general dentists serve as role models in the appropriate treatment and referral â�¢ of patients needing advanced therapies; larger numbers of patients, including those with more diverse characteristics â�¢ and clinical problems, are served. recommendation 17 : because no single fi nancing strategy exists, the committee recommends that dental schools individually and, when appropriate collectively evaluate and implement a mix of actions to reduce costs and increase revenues. potential strategies, each of which needs to be guided by solid fi nancial information and projections as well as educational and other considerations, include the following: increasing the productivity, quality, effi ciency, and profi tability of faculty â�¢ practice plans, student clinics, and other patient care activities; pursuing fi nancial support at the federal, state, and local levels for patient-â�¢ centered predoctoral and postdoctoral dental education, including adequate reimbursement of services for medicaid and indigent populations and contractual or other arrangements for states without dental schools to support the education of some of their students in states with dental schools; rethinking basic models of dental education and experimenting with less â�¢ costly alternatives; raising tuition for in or out-of-state students if current tuition and fees are low â�¢ compared to similar schools; developing high-quality, competitive research and continuing education â�¢ programs; consolidating or merging courses, departments, programs, and even entire â�¢ schools. in summary, the iom report identifi ed that: (1) an outdated curriculum continues to be retained which refl ects past dental practice rather than current and emerging practice and knowledge; (2) clinical education does not suffi ciently incorporate the goal of comprehensive care, with instruction focusing too heavily on procedures; (3) medical care and dentistry are not integrated; and (4) the curriculum is crowded with redundant material, often taught in disciplinary silos. the 1995 iom's report was followed by the surgeon general's report on oral health in 2000 and a subsequent supplement by the surgeon general in 2003 called "the national call to action" (u.s. department of health and human services 2003 ) . five signifi cant fi ndings and recommendations from the surgeon general's report(s) that have implications pertaining to the envisioned structure and services of new models for dental education include: changing the perception of oral health so that it will no longer be considered â�¢ separate from general health; improving oral health care delivery by reducing disparities associated with popu-â�¢ lations whose access to dental treatment is compromised by poverty, limited education or language skills, geographic isolation, age, gender, disability, or an existing medical condition; encouraging oral health research, expanding preventive and early detection pro-â�¢ grams, and facilitating the transfer of knowledge about them to the general population; increasing oral health workforce diversity, capacity, and fl exibility to overcome â�¢ the underrepresentation of specifi c racial and ethnic groups in the dental profession. in this regard, the national call to action urged the development of dental school recruitment programs to correct these disparities and to encourage parttime dental service in community clinics in areas of oral health shortage; increasing collaboration between the private sector and the public sector to cre-â�¢ ate the kind of cross-disciplinary, culturally sensitive, community-based, and community-wide efforts to expand initiatives for oral health promotion and dental disease prevention. spurred by the 1995 iom report and the 2000 surgeon general's report, the josiah macy foundation ( 2004 ) conducted a study entitled "new models of dental education." the study was prompted by concerns about declines in dental school budgets and the diffi culties experienced by schools in meeting their educational, research, and service missions. the macy study concluded that: financial problems of dental schools are real and certain to increase. â�¢ current responses of schools to these economic challenges are not adequate. â�¢ most promising solutions require new models of clinical dental education. â�¢ macy study lead researcher dr howard bailit, and his team recently concluded in reference to points one and two above, that: "if current trends (to aforementioned) continue for the next 10 years, there is little doubt that the term crisis will describe the situation faced by dental schools. further, assuming that it will take at least ten or even more years to address and resolve these fi nancial problems, now is the time for dental educators, practitioners, and other interested parties from the private and public sectors to come to a consensus on how to deal with the coming crisis. clearly, these fi nancial problems will not be solved by minor adjustments to the curriculum, modest improvements in the clinical productivity of students or faculty, or even signifi cant increases in contributions from alumni. the solutions 'must involve basic structural changes in the way dental education is fi nanced and organized' (bailit et al. 2008 ) ." this statement is supported by the fact that in the past 25 years more dental schools have closed than opened. specifi cally eight schools have closed, whereas to date a couple has opened and a handful is pending. curriculum relevance was also a focus of the study. findings concluded that "changing the curriculums in dental schools to allow students to spend more time in community venues would be highly benefi cial to both society and student. society benefi ted from having underserved patients cared for while students were assessed as being fi ve to ten times more productive, more profi cient, more confi dent, more technically skilled and more competent in treating and interacting with minority patients" (brodeur 2008 ) . macy study (formicola et al. 2005 ) outcomes represented signifi cant and foundational guideposts for assessing and planning any future models for dental education. their report led to the robert wood johnson foundation pipeline study ( 2007 ) , a major research study funded by the robert wood johnson foundation and the california endowment (tce). the goal of the dental pipeline program was to reduce disparities in access to dental care. the pipeline study provided over $30 million for the start up or expansion of 15 schools and student clinical programs that incorporated services to underserved extramural clinical settings (primarily community health centers). the following recommendations from the surgeon general's report structured â�¢ the goals of the pipeline's initiative: increase the number of under-represented minority and low-income students enrolled in the dental schools participating in the pipeline program so that there would be a voice of minority and low-income students at all the funded schools. provide dental students with courses and clinical experience that would prepare â�¢ them for treating disadvantaged patients in community sites. have senior dental students spend an average of 60 days in community clinics â�¢ and practices treating underserved patients. increasing the community experience of dental students was expected to have an immediate impact on increasing care to underserved patients (brodeur 2008 ) . this third point is pivotal to future success of dental curricula and dental education economics. recently published in a supplemental volume to the journal of dental education , february, 2009, the pipeline study reported the following outcomes: minority recruitment of low-income students increased by 27%; â�¢ the rate of recruitment for under-represented populations was almost twice that â�¢ of non-pipeline schools; the length of time dental students spent in extramural rotations increased from a â�¢ mean of 16 days to a mean of 39 days over a period of 4 years. procedural profi ciency increased compared to that of their non-extramural peers. of the 15 pipeline-funded programs, only four schools achieved the goal of â�¢ 60 days of extramural rotations; through extra funding from tce, the four schools extended extramural rotations to an average of 198 days; based on this publication, it appears that only a handful of pipeline schools defi -â�¢ nitely plan to sustain their extended extramural rotations. financial concerns were highlighted as the major problem in sustaining future recruitment and placement of students beyond the timeframe of the study; a survey of program seniors indicated a mean of 26% [range of 14-60% by â�¢ school] were planning to devote â³ 25% of their practice to serving minority patients. only 9% [range of 3-22% by school] were planning to practice at community clinics. in the context of these outcomes, discussion indicated that the unwillingness of students to practice in underserved settings was based on several factors: students that participated were already enrolled in traditional programs and were â�¢ not necessarily seeking a pipeline experience or a future in community service. concern over future reimbursement as a provider in a community setting; â�¢ limited time spent in underserved settings; â�¢ limited loan forgiveness scholarship opportunities. â�¢ the fact that the large majority of pipelines were unsustainable was attributed to lack of productivity in the school clinics while the students were on rotation at community based clinics. schools generate meager, yet necessary revenue streams on intramural student clinical activity to support the costly clinical and faculty infrastructure. currently, similar economic constraints involved with outsourcing students to serving rural and underserved populations impacts the ability of tradition dental schools to participate in sustained outreach programs. most recently, the pew center on the states national academy for health policy ( 2009 ) released "help wanted: a policy makers guide to new dental providers". this report provided an excellent summary outlining workforce needs, access issues, and strategies for dental-related services to help states and institutions develop creative ways to solve oral health access and care issues. the guide proposes the following relevant components and trends for consideration in development of future sustainable school models: dental colleges are willing to bear a large and disproportionate share of the burden â�¢ in terms of access to care, particularly during a time of incredibly scarce resources. expanded, extensive, and/or creative extramural rotations have been developed â�¢ in recent years under the conceptual umbrella of service-learning. these often involve clinics providing direct or indirect payment to dental schools or clinics managed in some way by dental schools. dental education has certain obligations. first, education must adhere to accreditation standards with the goal of producing competent practitioners. second, education must remain responsive and impact the societal need for care. lastly, the delivery of dental education must be economically sustainable. the macy, rwjf, and iom reports note that improved oral health, sustainable dental education economic models, and competent workforce pipelines converge around community health centers (chc). university of michigan researchers fitzgerald and piskorowski ( 2009 ) reaffi rm this conclusion in an evaluation of an ongoing 7-year program, stating that: (the chc model) is self-sustaining and can be used to increase service to the underserved and increase the value of students' clinical educational experiences without requiring grant or school funding, thus improving the value of dental education without increased cost. self-sustaining contracts with seven federally qualifi ed health centers (fqhcs) have resulted in win-win-win-win outcomes: win for the underserved communities, which experienced increased access to care; win for the fqhcs, which experienced increased and more consistent productivity; win for the students, who increased their clinical skills and broadened their experience base; and win for the school in the form of predictable and continuing full coverage of all program costs (fitzgerald and piskorowski 2009 ) (fig. 4.39 ). however, unlike medicine that outsources their students to clinical sites, dental education programs retain the majority of the student time within their own "clinical laboratories" as documented by the aforementioned studies, this limits students' exposure to extramural experiences. costs to operate such intramural clinical programs are ever increasing and many schools' clinical operations run defi cits. if that component can be outsourced to community-based resources such as a chc, then the burden of cost is shifted away from the school. an example would be a.t. still university's arizona school of dentistry and oral health (asdoh) which matriculated its fi rst class in 2003. at the prompting of the state's community based clinics, asdoh designed a program that placed students into community-based settings for up to 6 months, an unprecedented length of time for an extramural rotation. they also saw this as an opportunity to use an adjunct centric faculty that signifi cantly reduced traditional education overhead. through this innovation, the school was able to develop a program that was sustained by "fair market" value tuition and trained students where community needs were greatest for up to 6 months (which was then unprecedented). conversely, if the chc can rely on student service-learning to care for patients, the cost of care is reduced. other schools are also advancing with innovative education and care delivery. adea's charting progress (valachovic 2009 ) fig. 4.39 the synergy between access to care, student competency, and fi nancially sustainable dental education converge around chc/fqhcs little rock, arkansas; and the university of southern nevada in south jordan, utah. western university is planning placement of 50% of their fourth year class in community health centers, while east carolina is seeking to set up rural clinical campuses as well as clinical partnerships with the state's fqhc. at the time of this publication, several existing schools are expanding or looking to expand including the university of north carolina, marquette university, midwestern university in downer's grove, il. such expansions will contribute to solving the existent access supply and demand issues. however, it was observed even with all the start ups and expansions, graduation numbers will not approach the output of schools in the late 1970s and early 1980s. these creative models establish the foundation for a sustainable clinic structure by generating self-sustaining revenue through student service-learning, which, unlike medical student services, are billable. simultaneously these new models provide access to care for the needy while student exposure to clinical experiences that are often not available in academic patient pools. these models also shift some of the cost of providing clinical education from the dental college to community-based clinics. however, this innovation is not without criticism. schools are dependent on the success of their clinics and clinic partnerships. one author cautions: "however, these creative models also may present potential political strategic risk or confl ict: private practitioners may organize and protest higher than normal reimbursement schemes. potentially, such protests could even jeopardize the very existence of such models (dunning et al. 2009 ) ." notably, community health centers have historically received strong bipartisan support. for example, during the bush administration, fqhc funding was doubled and most recently expanded through health reform legislation by the obama administration. according to the institute for oral health, "the group practice of the future is the dentist working with the physician" (ryan 2007 ) . the ada reported "multidisciplinary education must become the norm and represent the meaning and purposes of primary care as it applies to dentistry. educational sequences should include rotation strategies across discipline specialties in medicine and dentistry, clerkships and hospital rotations, and experience in faculty and residency clinics." (barnett and brown 2000 ) the models alluded to, were school-based attempts at improving educational outcomes. perhaps the proverbial fork in the road regarding the future of dental education leaves two paths for consideration. is it better to travel down a road that leads a school to develop and operate a clinic? or is the road less traveled, where a clinic becomes a school, the better of the two options? the answer, perhaps, is that a combination of both will accomplish the desired outcome. for example, didactic knowledge is measured by examination whereas competency as a practitioner is measured by clinical demonstration. at a minimum, the result must achieve learner competency, quality, and sustainability. however, the road less traveled has not been taken yet. william gies, in his revered report written 85 years ago on the state of american dental education, wrote "dental faculties should show the needâ�¦. for integrated instruction in the general principles of clinical dentistry and in its correlations with clinical medicine" (gies 1926 ) . basic sciences aside, could a clinicalbased educational training center have an advantage over a school-based clinical center? soon-to-be-implemented new commission on dental accreditation (coda) standards will require schools to demonstrate competency in patient-centered care (valachovic 2010 ) . might an enterprise profi cient at running a successful clinical business model have an advantage running a professional, patient-centered clinical training program as compared to a pedagogical business model attempting to run a clinical training model? these questions should challenge us to reexamine why our thinking about educational models should be limited to schools being the starting point for the development of a profession that demands clinical competency, patientcenteredness, and integration as outcomes. the clinic based model may serve as an equivalent starting point and, have some distinct advantages for achieving responsiveness to recommendations and directions cited in this section. beginning in november 2002 through august 2010, the family health center (fhc) of marshfi eld, inc, marshfi eld, wisconsin, launched of a broad network of developing dental clinics, targeting dental professional shortage areas with the provision of dental services to the underserved communities whose dental needs were not being adequately met by the existing infrastructure. fhc-marshfi eld is a federally qualifi ed health center (fqhc). as an fqhc, fhc receives cost-based reimbursement for its dental services to medicaid populations. along with the cost-based reimbursement, fqhcs are obligated to provide care to anyone regardless of their ability to pay. presently, fhc is the nation's largest federally qualifi ed dental health center. to date, this network of dental clinics has served over 58,000 unique patients, 85% of whom were under 200% of poverty. notably, service was provided to a signifi cant number of cognitively and developmentally disabled patients in special stations developed for serving patients with special needs. these patients frequently travel the furthest to get to our dental centers for care. beginning in 2008, fhc stepped up the pace of dental clinic expansion, constructing two new dental centers in 2009, two in 2010, and two more are slated to open in 2011. when fully operational, this will establish capacity to serve 66,000 patients annually. each site has proactively included dedicated clinical and classroom training space for dental residents or students, thus laying the framework for clinic-based training of new dental professionals. the plan is to continue to stand up new dental centers until they have the capacity to serve 158,000 patients annually or approximately 50% of the 300,000 underserved patients in the rural service area. in addition to the capacity for training residents and students, a dental post-baccalaureate program is being considered in partnership with regional 4 year under graduate campuses. the post-baccalaureate program is aimed at preparing students from rural and underserved areas who desire to practice in rural and underserved areas for acceptance and success in dental schools. presently fhc in partnership with marshfi eld clinic is moving forward with plans to develop dental residencies at these sites and a dental post baccalaureate training program to better prepare pre-doctoral students from rural and/or underserved backgrounds to be successful in dental school as a means to create a dental academic infrastructure responsive to rural environments which have been classically underserved. marshfi eld clinic has a long-standing history in medical student education and multiple medical residency programs. creating access for the underserved population was the major motivational force driving the establishment of the dental clinic network back in 2002. the fi ndings of the iom, macy, and rwjf reports became the foundational framework for developing the vision of a dental education model that would realize the major recommendations found in the reports. by establishing clinical campuses in regional underserved dental health professional shortage areas, access to care where care is needed most was provided. sustainment of a work force for provision of care across the dental clinic network is accomplished by schools contracting with fqhc's for service learning, thus circumventing challenges associated with releasing dental students at traditional dental schools to distant extramural training sites as discussed previously. this model is however not without its own set of challenges including calibration of faculty, supervision and evaluation of students in training, and achieving accreditation acceptance. however, through video connectivity and iehr technology curriculum, learning plans, competency assessment, progression, performance, faculty development, and learner evaluations can be centrally calibrated. additionally, this dental service-learning model based in a community health center setting offers students unique state-of-the-art exposures to alternative access models, cutting-edge informatics (including access to a combined dental-medical record) and a quality-based outcomes-driven practice. given the novelty of such an extended extramural dental clinical training model, there is limited data on the success of rural placement leading to retention to practice in a rural setting. the pipeline study piloted a model for getting students into underserved communities. however, that experiment was limited to 60-day rotations. outcome driven programs may provide a predictive surrogate for purposes of comparative analysis. for example, the rural medical education "rmed" program of the university of illinois medical school at rockford, has sustained a longstanding program in illinois. over 17 years in duration with over 200 student participants of whom 70% have been retained as primary care medicine practitioners in rural illinois. rabinowitz et al. ( 2008a ) further reinforced that medical school rural programs have been highly successful in increasing the supply of rural physicians, with an average of 53-64% of graduates choosing to practice in rural areas. they also noted rural retention rates of 79-87% among the programs (rabinowitz et al. 2008 a) . recently, the university of wisconsin school of medicine and public health (uwsmph) launched the wisconsin academy for rural medicine (warm program). the warm program places medical students in rural academic medical centers during their third and fourth years in medical school. marshfi eld clinic is one of those sites. warm students affi liating with marshfi eld clinic's system would ultimately share learning experiences with dental students, clinical rotations, team-based rounding, lectures, and exposure to a combined medical-dental patient record. in an analogous manner, the marshfi eld clinic dental education model will incorporate a curriculum that embeds students in rural clinical practice for up to 2 years. a secondary but not insignifi cant outcome of placing residents and students in clinical campuses focused on developing competency and providing care where needs are often greatest is the cost savings to taxpayers associated with the public care of patients. these savings are accomplished through the "service-learning" of the student. for example, in the model described where clinical training is embedded within the fhc clinics, the stipend resident or unpaid student learner provides the patient care as part of their service learning training while requiring oversight from one paid faculty per four to six learners. as a result, an academic based clinical partnership creates a model that reduces the cost for care provided to underserved patients. an additional benefi t to the community based clinic might be realized through tuition assistance by the academic program to help support patient procedures that develop learner competencies. in educational quality and infl uence, dental schools should equal medical schools, for their responsibilities are similar and their tasks analogous (william gies 1926 ) . the commission on dental accreditation (coda) notes that one of the learning objectives of an advanced education general dentistry (aegd) residency is to have the graduate function as a "primary care provider". to function competently in this role, the graduate needs to have a strong academic linkage to primary care medicine. at a 2010 dental deans forum, 84 years after the gies report, dr polverini made the statement "dentistry has never been linked to the medical network but unless dentistry becomes part of the solution to the challenge of providing comprehensive patient care, it will be looked on as part of the problem, and ultimately, all dental schools will be called into question." (polverini 2010 ) the use of dental informatics and an integrated record are elements essential to this competency. on april 1, 2010, fhc and marshfi eld clinic successfully transitioned all of their dental centers to a new practice management and electronic health record system that fully integrates medical and dental; one of the fi rst such systems in the nation. along with the benefi ts derived in fig. 4 .39 , chc placement also exposes students to an integrated medical-dental care setting where learners can develop skills in system-based practice to include the interdependence of health professionals, systems, and the coordination of care. on the administrative side, dental and medical appointments can be coordinated to enhance convenience for patients and improve compliance with preventive dental visits. in 2009, marshfi eld clinic's research foundation biomedical informatics research center hired their fi rst dental informatician, dr. amit acharya, bds, ms, phd. with dedicated biomedical informatics and research resource centers, the marshfi eld clinic has laid the groundwork for true medical/dental integration with appropriate electronic health record decision support and is positioned to develop a dental education curriculum capable of implementing the iom recommendations. downstream benefi ts of using such a curriculum are the ability of future practitioners to use informatics to improve quality of care and reduce the burden of disease. according to an institute of oral health report ( 2010 ) it is widely accepted across the dental profession that oral health has a direct impact on systemic health, and increasingly, medical and dental care providers are building to bridge relationships to create treatment solutions. as early as 1926, william gies recognized that "the frequency of periodic examination gives dentists exceptional opportunity to note early signs of many types of illnesses outside the domain of dentistry" (gies 1926 ) . the following examples show how integration of dental and medical care can impact patient outcomes, underlining the importance of this concept in dental curriculum design. a 2009 study of 21,000 blue cross blue shield of michigan (bcbs) members with diabetes, who had access to dental care lead researchers, and bcbs executives to conclude that treatment of periodontal disease signifi cantly impacts outcomes related to diabetes care and related costs (blue cross blue shield of michigan 2009 ) . another example is found in the context of preterm delivery and miscarriage. according to research cited by cigna ( 2006 ) , expecting mothers with chronic periodontal disease during the second trimester are seven times more likely to deliver preterm (before 37th week), and have dramatically more healthcare challenges throughout their life. cigna also cites the correlation between periodontal disease and low birth weights, pre-eclampsia, gestational diabetes. equally important is the opportunity to develop and implement the team-based curriculum that trains future dentists and physicians in the management of chronic disease as an accountable care organization (aco) in a patient-centered environment. as an example, joseph errante, d.d.s., vice president, blue cross blue shield of ma, reported that medical costs for diabetics who accessed dental care for prevention and periodontal services were signifi cantly lower than those who didn't get dental care (errante 2007 ) . these data suggest that team based case management of prevalent chronic health conditions have considerable cost savings opportunities for government payers, third party payers, employers and employees (errante 2007 ) . these economic benefi ts to integration as it relates to the iehr are discussed elsewhere in this book, but begin with the ability of providers to function in a team based environment and as such, underscore the importance of training in such an environment. dentists trained in a fqhc iehr integrated educational model will be well positioned to function successfully within an aco model. an aco is a system where providers are accountable for the outcomes and expenditures of the insured population of patients they serve. the providers within the system are charged with collectively improving care around cost and quality targets set by the payor. within this system, care must be delivered in a patient-centered environment. the patient-centered environment according to the national committee for quality assurance (ncqa), is a health care setting that cultivates partnerships between individual patients and their personal physicians and, when appropriate, the patient's family. care is facilitated by registries, information technology, health information exchange and other means to assure that patients receive defi ned, timely and appropriate care while remaining cognizant of cultural, linguistic and literacy needs of the patient being served. the model includes the opportunity to deliver patient care that is patient-centric, incorporates the patient in the care planning, considers the patient's beliefs and views, and incorporates the patient's families as needed. the model allows providers to deliver care that is inclusive of needs, attentive, and accessible. the model equips payers to purchase high quality and coordinated care among teams of providers across healthcare settings. while this describes the medical home, most dental practices also follow this process. many dental practices function in this regard with insured populations and refl ect elements of the model that medicine is creating. william gies would be proud. training in the delivery of accountable and patient-centered medical-dental care must be done purposefully. commenting on the inadequate training relative to the integration of medical and dental education, baum ( 2007 ) stated that "we need to design new curricula with meaningful core competencies for the next generation of dentists rather than apply patches to our existing ones." while this statement was made in reference to the basic sciences, the same holds true for patient-centered system-based practice competencies. utilizing state-of-the-art electronic medical records as a tool and the fhc infrastructure as the service venue, meaningful patient-centered system-based practice core competencies achievement becomes possible in a manner highly responsive to societal needs. by defi nition, fqhcs must provide primary medical care, dental care, and behavioral health. fqhc have also historically been utilized as healthcare workforce training centers and the affordable care act of 2010 reinforced their role as healthcare training centers. specifi cally, this legislation serves to promote fqhcs as the entity through which the primary care workforce (including dental) will be developed and expanded. in combination, fqhcs and primary care centers are positioned to be the front runners in a medical/-dental home training model which will be essential to preparing future practitioners for practice in an aco. critical to this success is the ability to train these practitioners on an integrated medical-dental record and informatics platform. use of this platform imprints most strongly during the learner's formative years of training; instructing and guiding disease management, decision making, patient care coordination, prevention, and both outcome-based and comprehensive care. training in this hybrid academically orientated clinically integrated setting moves dental education off its crossroads and creates the highway to its future. concerns with the new models extend to their ability to integrate medical and dental disciplines at the clinical and informatics level. while the 1995 iom report identifi ed the need to integrate medical and dental curriculum, success at the curricular and technological level within schools, has been limited. three major factors have contributed to the limited progress: access priorities. creating access to care has outranked the need to integrate â�¢ care. in part, this refl ects societal need for care and public demand to reduce the burden of the "silent epidemic." schools play an important role as a safety net to care for the uninsured and underinsured through intramural clinical service learning. even though "dental colleges seem to be willing to bearing a large and disproportionate share of the burden in terms of access to care" (dunning et al. 2009 ) , schools were challenged as part of iom, surgeon general, and macy reports, to expand that role. while these reports have prompted creative educational solutions to increase access, the reports understate the tremendous opportunity, quality and cost benefi ts that could result from an integration of medicine and dentistry. it is diffi cult to change the culture and structure of existing schools. this is not â�¢ unique to dentistry. however, the 1995 iom report specifi cally recommended that schools "eliminate marginally useful and redundant courses and design an integrated basic and clinical science curriculum". the challenges with this are many. examples include: some schools may not have other disciplines to draw from to create an inte-grated curriculum; a number of schools use a faculty senate to determine curriculum. this can result in curriculum that preserves the current faculty structure; changing curriculum is associated with expense and can be fi nancially pro-hibitive to some schools physical changes may be needed and represent an expense and/or may, in some instances, may not be practicable based on structure of existing facilities. public school programs may direct the fi nal curriculum, as boards or regent's one or two steps removed from the curriculum often have fi nal authority conversely, private schools may specify business or mission objectives that determine fi nal design. perhaps most germane to this text is the lack of a common technology plat-â�¢ form between disciplines in a learning environment. an integrated curriculum requires an integrated platform to accomplish delivery and evaluation. this is particularly essential to clinical management of the patient by professionals in training as part of a healthcare delivery team. some progress in establishing shared basic sciences curricula has been documented in the literature. to date, no single integrated electronic health (medical-dental) record has been meaningfully adapted for educational purposes, including incorporation of assessment of the learner relative to integrated competencies, integrated case-based and problem-based curriculum, and integrated evaluation and assessment. another concern with new educational programs emerging in response to these reports and relative to creating a transformational integrated curriculum is that some of the programs are focusing primarily on creating clinicians with no value or emphasis on integrating training with research and/or scholarly activity. integrated training models counter such concerns. research will be fundamental to measuring the relative benefi ts and outcomes associated with treatment of patients in a shared curriculum setting and will be the catalyst for the development of integrated medical-dental informatics incorporating educational capabilities. additionally, accreditation will also need to evaluate its response to such models. presently it is unclear how accrediting bodies will view an integrated crossdisciplinary curriculum. further, due to its integrated nature, such a curriculum would lie outside of the expertise of a single traditional accrediting body focused on one particular discipline. it has yet to be determined how accrediting bodies will review and appraise such cross-disciplinary competencies. lastly, it is important to recognize that a successful education model with innovative informatics is only successful if its focus is patient care. graduating learners with competency only in the use of informatics will be limited unless adapted to training and delivery programs that result in patient centric care. research and reports over the past 15 years support the need to reform dental education. first steps have been taken and lead the way for continued innovation around clinic-based education and integrated curriculum. the models identifi ed point to a strong partnership and interrelationship with chcs for creative, cost saving, effective and sustainable delivery methods. moreover, chc's must be more involved in a training curriculum integrated with informatics. chcs, in turn, benefi t from residents and students through service-learning to help meet a societal and workforce need, while the learners benefi t from increased competency. in order to train an evidence-based, patient-centered, medical-dental workforce, it is imperative that medical and dental data and record accessibility be incorporated into these training and care delivery initiatives. in order to keep moving away from the 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