ADA Coronavirus (COVID-19) Center for Dentists
The COVID-19 outbreak and its impact on our daily lives is rapidly evolving. Here are some resources and guidance to help dentists navigate this unprecedented time for their practices, staff and patients
Ethical practice during the COVID-19 pandemic
Ethical practice during the COVID-19 pandemic
Q: As a practitioner, I have had to balance many conflicting demands, agendas, and needs, both personal and professional, during the COVID-19 pandemic. Keeping current with guidance at the local, state, and national level is challenging, and I am wondering what my ethical responsibilities are during this difficult time.
Members of the Ethics Subcommittee of the Council on Ethics, Bylaws and Judicial Affairs include Dr. Donald F. Cohen, Dr. Michael A. Kurkowski, Dr. Robert J. Wilson Jr., Dr. Guenter J. Jonke, Dr. Onika R. Patel, Dr. Renee P. Pappas, Dr. Daniel W. Hall, and Ms. Anisha Pandya.
Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, IL 60611.
Disclosure: The authors did not report any disclosures.
Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA) or guests of CEBJA, in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, IL 60611, e-mail firstname.lastname@example.org.
The views expressed are those of the authors and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA.
COVID-19 Resources and Microbiology and Protective Procedures
Efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: A systematic review
The authors of this systematic review aimed to evaluate the efficacy of preprocedural mouthrinses in reducing the number of microorganisms disseminated by means of the aerosol generated via dental procedures when compared with a placebo, water, or no mouthrinse.
Types of Studies Reviewed
The authors included only randomized clinical trials. They searched MEDLINE (PubMed), Embase, Google Scholar, and Latin American and Caribbean Health Sciences Literature databases through May 31, 2019. They performed random-effects meta-analysis for reduction of the number of colony-forming units (CFU) in the dental aerosol.
Of 770 potentially relevant articles, the authors included 13 randomized clinical trials in which researchers studied the efficacy of chlorhexidine, essential oils, cetylpyridinium chloride, and herbal products. Meta-analysis of 12 studies showed that mouthrinses with chlorhexidine, essential oils, and cetylpyridinium chloride significantly reduced the number of CFU. Overall, the use of a preprocedural mouthrinse resulted in a mean reduction in the number of CFUs of 64.8% (95% confidence interval, 50.4% to 79.3%; I2 = 37%) compared with control. None of the included studies presented a low risk of bias.
Some dental procedures result in dissemination of microorganisms in the aerosol in the dental office. There is moderate evidence that preprocedural mouthrinses significantly reduce the number of microorganisms in the dental aerosol.
Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling
J Am Dent Assoc. 2015 Jan;146(1):27-33. doi: 10.1016/j.adaj.2014.10.001. Ep
Aerosols and spatter are concerns in health care owing to their potential adverse health effects. The Isolite illuminated isolation system (Isolite Systems) and a saliva ejector were compared for aerosol and spatter reduction during and after ultrasonic scaling.
Fifty participants were randomized to control (n = 25, saliva ejector) or test (n = 25, Isolite) groups and received a prophylaxis with an ultrasonic scaler. Aerosols were collected in a petri dish containing transport media, dispersed, and plated to anaerobic blood agar to determine colony-forming units (CFUs). The authors analyzed the data using a t test.
No significant difference occurred between groups in aerosol and spatter reduction (P = .25). Mean (standard deviation) of log10 CFUs per milliliter collected during ultrasonic scaling in the control and test groups were 3.61 (0.95) and 3.30 (0.88), respectively. All samples contained α-hemolytic streptococci, and many samples contained strictly oral anaerobes.
A significant amount of contamination occurred during ultrasonic scaling in both groups, as indicated by high numbers of CFUs and the identification of strictly oral anaerobes in all plates.
Neither device reduced aerosols and spatter effectively, and there was no significant difference in reduction between the 2 devices. Additional measures should be taken with these devices to reduce the likelihood of disease transmission.
Evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques
William O. Dahlke, DMD1, Michael R. Cottam, DMD, MS2, Matthew C. Herring, BS3, Joshua M. Leavitt, BS4, Marcia M. Ditmyer, PhD5, Richard S. Walker, DDS, MEd6*
J Am Dent Assoc. 2012 Nov;143(11):1199-204. doi: 10.14219/jada.archive.2012.
The authors conducted a study to compare the effectiveness of two dry-field isolation techniques with that of a control technique (no isolation) in reducing spatter from a dental operative site.
The authors designed a benchtop experiment to evaluate spatter patterns after performing simulated occlusal surface preparations on three typodont teeth in a dental manikin. Fluorescein dye served as the marker to enable visualization of the spatter distribution. The authors compared the effectiveness of a nonisolated control consisting of high-volume evacuation (HVE) alone with that of two dry-field isolation techniques: a dental dam with HVE and the Isolite system (Isolite Systems, Santa Barbara, Calif).
The authors performed a two-way analysis of variance. Both the Isolite device and the dental dam with HVE exhibited a significant decrease in the number of contaminated squares (P < .001) compared with that for the nonisolated control. In addition, overall, the results showed no statistically significant difference between the Isolite system and the dental dam with HVE (P = .126).
The study results showed that use of a dental dam with HVE or the Isolite system significantly reduced spatter overall compared with use of HVE alone.
Isolation with a dental dam and HVE or with the Isolite system appears to aid in the reduction of spatter during operative dental procedures, potentially reducing exposure to oral pathogens.
Standard and Transmission-Based Precautions
Jennifer A. Harte, DDS, MS,
J Am Dent Assoc. 2010 May;141(5):572-81. doi: 10.14219/jada.archive.2010.
Standard Precautions are the foundation of all infection control programs and include infection control practices that apply to all patients and situations regardless of whether the infection status is suspected, confirmed or unknown.
The author reviewed Standard Precautions, including two new elements introduced by the Centers for Disease Control and Prevention in 2007: safe injection practices and respiratory hygiene and cough etiquette. Standard Precautions sometimes are referred to as the first tier of precautions because for some diseases and circumstances, transmission cannot be interrupted completely with Standard Precautions alone and it is necessary to use second-tier Transmission-Based Precautions. The author reviewed the three categories of Transmission-Based Precautions—Airborne, Droplet and Contact—with an emphasis on their use in dental health care outpatient settings.
Conclusions and Clinical Implications
Dental health care personnel (DHCP) should update their infection control programs to ensure that safe injection practices and respiratory hygiene and cough etiquette measures are used routinely. In addition, with the emergence of new pathogens, re-emergence of variant organisms and more patients seeking care in ambulatory care facilities, DHCP need to be aware of additional measures to take when treating patients in their offices who are actively infected with certain organisms to protect fully other patients, their staff members and themselves.
The views expressed in this article are those of the author and do not reflect the official policy of the U.S. Department of Defense or other departments of the U.S. Government.
Severe acute respiratory syndrome and dentistry: A retrospective view
Lakshman P Samaranayake, Malik Peiris
J Am Dent Assoc. 2004 Sep;135(9):1292-302. doi: 10.14219/jada.archive.2004.
Severe acute respiratory syndrome, or SARS, which has created panic in Asia and in some parts of North America, is the first epidemic of the new century. Although it has been well-contained, sporadic cases continue to emerge.
The authors trace the emergence of the SARS outbreak from southern China and its spread worldwide, discuss the viral etiology of the infection and its clinical features, and review the infection control guidelines issued during the outbreak by the health authorities in Hong Kong, the Centers for Disease Control and Prevention, the World Health Organization and the American Dental Association. They also review the prospects for a new outbreak and preventive measures.
The disease, which is caused by a novel coronavirus termed the “SARS coronavirus,” or SARS-CoV, essentially spreads through droplet infection and affects people of any age. It has a mortality rate ranging from 10 to 15 percent. A major hallmark of this disease has been the rate at which it has affected health care workers through nosocomial transmission; in some countries, up to one-fourth to one-third of those infected were in this category. However, no dental health care worker has been affected by SARS in a nosocomial or dental setting.
Conclusions and Clinical Implications
Researchers believe that a combination of factors, including the universal infection control measures that the dental community has implemented and/or the low degree of viral shedding in the prodromal phase of SARS, may have obviated the spread of the disease in dental settings. The dental community should reflect on this outbreak to reinforce the currently applied infection control measures.
Respiratory Protection in the Era of COVID-19 (Recorded Webinar)
This course will describe the interim recommendations from the Organization for Safety Asepsis and Prevention (OSAP) for personal protective equipment (PPE) in dental settings. As an essential component of delivering care that is safe for dental personnel and for patients, PPE selection, fit, and use are critical. Due to the COVID-19 crisis, dentistry has been introduced to a new level of PPE; the respirator. This course will focus on the steps necessary to introduce the use of N95 and other respirators in dental settings according to OSAP. The speakers will provide practical tips for developing the OSHA respiratory protection program, including fit-testing, medical evaluation, and training. Different levels of surgical masks and how they compare to N95 respirators will be reviewed. In addition, the course will describe the proper steps for donning and doffing of all PPE.
Eve Cuny, MS, Director of Environmental Health and Safety, University of the Pacific, Arthur A. Dugoni School of Dentistry
Kathy Ecklund, RDH, MHP, Director of Occupational Health and Safety and Forsyth Research Subject and Patient Safety Advocate, The Forsyth Institute