Article_7_3_7-1
ORTHODONTICS www.stomaeduj.com
RETURNING TO THE ORTHODONTIC PRACTICE AMID
Review Article
COVID-19 CRISIS
Letizia Perillo1a , Ludovica Nucci1b , Oded Yitschaky2c , Gennaro Carrino1d , Rossella Carrino1e , Stella Chaushu2f*
1
Multidisciplinary Department of Medical-Surgical and Dental Specialties, School of Dentistry, University of Campania Luigi Vanvitelli, Naples, Italy
²Department of Orthodontics, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
a
MD, MS, PhD, Professor, Head, Dean; e-mail: letizia.perillo@unicampania.it; ORCIDiD: https://orcid.org/0000-0001-6175-7363
b
DDS, PhD Student; e-mail: ludortho@gmail.com; ORCIDiD: https://orcid.org/0000-0002-7174-7596
c
DMD, MA; e-mail: oyits76@gmail.com; ORCIDiD: https://orcid.org/0000-0002-5732-532X
d
MD, MS, PhD; e-mail: gencarrino@gmail.com; ORCIDiD: https://orcid.org/0000-0002-9179-0751
e
DDS, Postgraduate Student; e-mail: rossella.carrino1@gmail.com; ORCIDiD: https://orcid.org/0000-0003-0417-5791
f
DMD, MSc, PhD; e-mail: drchaushu@hadassah.org.il; ORCIDiD: https://orcid.org/0000-0001-9571-8338
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(3).art.7
Background The coronavirus disease (COVID-19), caused by the novel severe acute respiratory virus syndrome
(SARS)-CoV-2, was defined as pandemic on March 11, 2020. All health care providers are at risk of a COVID-19
infection; however, dentists pose the highest risk since SARS-CoV-2 is transmitted through breathing and
aerosol, coughing and droplets and direct or indirect contact with infected skin and surfaces. Guidelines for
minimizing the risk of transmission in general dental clinics have been published and are regularly updated.
Objective The present article aims to specifically address the concerns of the orthodontic profession amid the
COVID-19 crisis, and suggest recommendations for orthodontic care settings, infection prevention measures
and delivery of clinical procedures.
Data Sources An electronic search was conducted via PubMed/MEDLINE, Google and health organization
websites from two independent data abstractors.
Study Selection All kinds of manuscripts describing guidelines for health care providers to follow during the
COVID-19 pandemic were included. No language restrictions were considered. Any disagreements on study
inclusion were resolved by discussion between the two reviewers.
Data Extraction Information on guidelines and suggestions on the management of clinical orthodontic
practice were extracted from studies identified for inclusion in the review.
Data Synthesis Orthodontists are at a very high risk for COVID-19 infection and all published guidelines
should be followed for the patient and DHCPs safety. The care settings, the infection protocols, and the
delivery of AGP clinical procedures must be continuously revised and modified to overcome the threat of the
SARS-CoV-2 infection in the orthodontic practice.
KEYWORDS
COVID-19; Saliva; Aerosol; Orthodontists; Clinical Practice.
1. INTRODUCTION CoV). SARS-CoV-2 mainly attacks the respiratory sys-
tem, due to its affinity to angiotensin-converting en-
The coronavirus disease 2019 (COVID-19) is a clinical zyme 2 (ACE2) cell receptor, highly expressed in the
syndrome caused by the novel Severe Acute Respira- lungs and the heart [1]. COVID-19 appears to have a
tory Syndrome Coronavirus 2 (SARS-CoV-2), a patho- lower case-fatality rate (3.4%) as compared to SARS-
gen closely related to the Severe Acute Respiratory CoV (10%) and MERS-CoV (3.4%) [2], but is more trans-
Syndrome Coronavirus (SARS-CoV) and Middle East missible, therefore posing a major public health
Respiratory Syndrome Related Coronavirus (MERS- threat. Most people infected by COVID-19 present
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Perillo L, Nucci L, Yitschaky O, Carrino G, Carrino R, Chaushu S. Returning to the orthodontic practice amid COVID-19 crisis. Stoma Edu J.
2020;7(2):209-215.
Received: July 03, 2020; Revised: July 20, 2020; Accepted: July 21, 2020; Published: July 23, 2020
*Corresponding author: Prof. Dr. Stella Chaushu, Professor and Chair, Department of Orthodontics, Faculty of Dental Medicine, Hebrew University-
Hadassah, Jerusalem, Israel, Address: PO Box 12272
Tel.: 972-2-6776184; Fax: 972-2-6427613; e-mail: drchaushu@hadassah.org.il
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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mild, inconsequential respiratory symptoms. How- and without AGP. Each of them must be faced with
Review Article ever, a minority of often aged individuals with other proper Personal Protective Equipment (PPE) [13]. The
medical conditions, develop a severe disease, clearly Centers for Disease Control and Prevention (CDC)
distinct from the well-known acute respiratory dis- recommended using N95 respirators and not surgical
tress syndrome. The disease is caused by a cytokine face masks, whenever AGPs are performed [7].
storm, a form of systemic unrestrained inflammatory Moreover, if AGP are needed for patients who have
response featured by the abundant release of pro- or are suspected of having COVID-19, airborne pre-
inflammatory cytokines [3]. cautions should be strictly followed in addition to ad-
This leads to alveolar injury, increased vascular per- equate PPE and a room with negative pressure, rela-
meability and extravascular accumulation of edema tive to the surrounding area, becomes mandatory
fluid, culminating in respiratory and heart failure, [16]. Unfortunately, at this moment, there is still no
thromboembolism and death [4]. COVID-19 was de- reliable and efficient test to identify asymptomatic
clared as a pandemic by the World Health Organiza- carriers, therefore everybody should be suspected to
tion (WHO) on March 11, 2020. be infective. Caprioglio et al. published an interesting
The current approaches to treatment include vaccine editorial article on the management of orthodontic
development and discovering new or re-proposed emergencies during the initial quarantine period, of
anti-viral and immunosuppressive medicines [5]. Un- COVID-19 pandemics [17].
fortunately, pharmacologic treatments and vaccines Recently, the American Dental Association (ADA) has
are not yet available and it is likely that a high number published interim guidelines for minimizing the risk
of asymptomatic carriers [6] contribute to the spread of COVID-19 transmission [18]. There are essential rec-
of the virus. Currently, isolation and social distancing ommendations for all dental practitioners and clearly
seem to be the most effective weapons against the they should be followed by orthodontists. How-
virus and its widespread [7]. ever, orthodontic treatment is different, since emer-
In this gruesome scenario, health care providers are gency service is seldom required [17], and many
extremely vulnerable and among them, dentists are orthodontic procedures do not generate AGP.
considered to be at the highest risk [8], although the Moreover, many treatment protocols can be modi-
exact risk is still unknown. SARS-CoV-2 is transmitted fied to decrease droplets production and thus mini-
by droplets loaded with viral particles emitted from mize the risk of cross contamination in the orthodon-
the respiratory tract of an infected individual. tic office.
Dentists come in close contact with the oral cav- The aim of this article is to focus on the orthodontic
ity and are exposed to aerosol from breathing and profession and suggest specific recommendations
coughing. Furthermore, droplets land on surfaces for care settings, infection control and treatment de-
and can spread infection in the dental office by direct livery amid the COVID-19 crisis. The article was writ-
or indirect contact [9]. ten as an international cooperation between the Uni-
Dental care procedures may also aerosolize viral versity of Campania Luigi Vanvitelli, Naples, Italy, and
particles from saliva during treatment in the same the Hebrew University-Hadassah Faculty of Dental
way as sneezing or coughing. Dental aerosol gen- Medicine, Jerusalem, Israel.
erating procedures (AGPs) are associated with the
use of ultrasonic instruments, air/water syringe and 2. ORTHODONTIC PRACTICE AND COVID-19
handpieces [10]. They have been charged to be re-
sponsible for the virus transmission and infection for 2.1. Before orthodontic treatment
healthy patients, but at the same time, they also rep- • An orthodontic practice usually has a high patient
resent a high risk for the dental health care personnel turnover, including a mixture of children and adults.
(DHCP) [11]. Scheduling of appointments should allow appropri-
AGPs can generate droplets having a diameter rang- ate “social distancing” in the waiting room.
ing from 0.1 µm to 900 µm. Liu Y, et al classified the Adults should be instructed to come without com-
droplets in five groups, with the largest group rang- panions; however, children are usually accompanied
ing from 0.25 µm to 1 µm [12]. The particles with this by guardians. In this case, pretreatment triage for
diameter can reach the alveoli. Droplets < 0.25 µm, signs and symptoms of COVID-19 should be per-
loaded with pathogenic microorganisms, can travel formed for both children and guardians.
up to 20 feet [13], so the 1-2-meter distance advised DHCP will collect the medical history and check
by WHO is not always enough to prevent cross infec- temperature to identify suspect patients until reli-
tion between patients and DHCP. able chairside tests for SARS-CoV-2 are developed
The minimal aerosol viral load necessary for infection [19]. Since the virus has been found on shoes, a shoe
is still unknown; However, in vitro experiments show wrapping machine can be installed at the entrance.
that aerosol contains viable virus for up to 16 hours Toys, books and other items which may carry the vi-
[14]. Infectiveness of aerosol finds the evidence when rus have to be removed from the waiting room.
COVID-19 gave an outbreak in buses and conference • The recall orthodontic appointments are usually
rooms [15]. Treatment sessions on the dentist chair short. Due to the time needed for room cleaning and
should be divided into two risk categories: with AGP disinfection, working on a single chair is extremely
210 Stoma Edu J. 2020;7(3): 209-215 pISSN 2360-2406; eISSN 2502-0285
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inefficient, whereas working on at least 2 chairs, al- • Intraoral scanning should be preferred whenever
Review Article
ternating working and disinfection, is preferred. The possible, especially for study models. Scanning does
minimal distance between the chairs is 2 meters and not reduce chair-time, but is more comfortable for
a separation box is needed as a physical barrier to the patient, minimizing gag reflex and difficulties in
minimize aerosol spreading [20]. breathing associated with conventional impressions
• Implementing tele dental applications can be par- [27]. Moreover, the intraoral tip of the scanner is au-
ticularly advantageous in this period. Records assess- toclavable.
ment and proposed treatment plans can be shared 2.2.2. Multibracket appliances
virtually online with the patients and discussed us- • Bonding requires etching of the enamel. Air/water
ing modern web-based communication tools [21]. All syringe is used to wash and dry the enamel after
communication with patients through virtual tools etching, as well as to spread the bonding resin into a
should be documented in the patients’ file for medi- thin layer before light curing. ADA is advocating the
colegal protection, as any physical appointment. use of a rubber dam for AGPs, to help minimize aero-
• ADA recommended antibacterial mouth rinses sol or splatter, as the saliva is washed away from teeth
(1.5% hydrogen peroxide) before treatment, to re- and aspirated with high power suction, before drying
duce the viral load, but there are no clinical studies to with the air syringe [11].
support it. Mouth rinses containing β-cyclodextrins The use of a rubber dam in orthodontics has been
combined with flavonoids agents have been pro- already proposed for bracket bonding in general an-
posed for COVID-19 [22]. Children should rinse only esthesia [28] and can be also adopted in the routine
under adult supervision. orthodontic practice. Conversely, a rubber dam can
introduce errors in bracket positioning, which can
2.2. During the orthodontic treatment be avoided by using indirect bonding techniques or
The CDC divides patient-care items in 3 categories: drawing marks on the teeth.
critical, semi critical, and noncritical, depending on • Self-etching primer, which eliminates the need for
the potential risk for infection. Critical items have the air/water spray washing and drying, is an excellent
greatest risk for transmitting infection and should al- alternative to the two-step conventional bonding
ways be sterilized using heat [23]. techniques.
This classification takes in consideration the risk of The bond strength with self-etching primers is clini-
bloodborne contamination. However, the transmis- cally acceptable and bonding duration is also slightly
sion modes of SARS-CoV-2 are respiratory droplets reduced [29].
and physical contact [10]. Under these circumstances, • Indirect bonding is an additional option which can
each item that has been in contact with the patient significantly shorten chair-time, by up to 30 min for
or maybe contaminated by aerosol, becomes critical. both arches [30] and reduce the DHCP exposure.
2.2.1. Records collection Thus, a combination of self-etching primer and indi-
• Extraoral radiographs, such as panoramic views, rect bonding significantly decreases the risk of aero-
should be preferred whenever possible since in- sol contamination during bonding procedures.
traoral radiographs may cause saliva secretion and • Visible-light curing units are a potential source of
coughing [19]. transmission due to contamination of the light cu-
• Clinical photos should be taken wearing clean ring tip, which directly contacts oral structures, and
gloves, masks, and glasses, since cameras are difficult the handle, which becomes contaminated with
to clean and disinfect. Double gloving allows han- blood and saliva from the DHCP gloves.
dling the camera with the inner gloves, after discard- Different infection control techniques, that meet the
ing the outer gloves. CDC-recommended standards, include sterilization
Anti-fog treatment of mirrors should be done with of curing tips, disposable barriers, or single-use plas-
warm water and not with air. Assistants should han- tic wrapping tip [31].
dle the plastic retractor and the mirror, thus four- 2.2.3. Removable appliances
handed orthodontics is mandatory [24]. The plastic Managing removable appliances in the clinic creates
retractor and the mirror should be autoclaved after a low risk for the transmission of SARS-CoV-2 [17].
use. An antibacterial cloth can be used for cleaning Impressions for appliances should be delivered to
the camera surface. the lab after proper disinfection [see above] and re-
• Dental impressions are potential sources of con- turned from the lab after ultraviolet (UV) sterilization
tamination through the adhered blood or saliva. [32] in a plastic bag sealed with a label.
ADA [19], CDC [24] require impression disinfection 2.2.4. Other orthodontic procedures
to prevent contamination. Irreversible hydrocolloid Inserting, tying, and removing archwires and/or mini-
impressions are effectively treated with 1:10 dilution screws are not AGPs and may be performed with the
of sodium hypochlorite for a ten-minute immersion conventional ADA interim precautions [18].
[25]. Disposable impression trays should not be re- 2.2.5. Aligners
processed since they are manufactured for a single Compared with fixed appliances, aligners offer the
use or for the use of one patient only, and not de- advantage of shorter chair-time and fewer overall
signed or intended for reuse [26]. appointments in the office, therefore decreasing the
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risk for airborne transmission. Whenever possible, 3. STERILIZATION OF ORTHODONTIC PLIERS
Review Article
treatment progress can be assessed, and further in-
structions can be given through online virtual meet- Orthodontic pliers touch patients’ mucosa/skin and
ings. Attachments can be bonded with the aid of therefore become critical items in the COVID-19 era,
self-etching primers similarly to bracket bonding [33] and must be sterilized by autoclave. Pliers should be
and refined manually. On the contrary, attachment maintained in sterile envelopes, opened just before
removal, like bracket debonding, is riskless only if a their use.
rubber dam is utilized. A larger supply of instruments is thus mandatory and
2.2.6. Interproximal enamel reduction if a plier is heat-sensitive, it should be replaced by a
Instruments used to slenderize teeth usually include heat-tolerant item. On the other hand, heat steriliza-
diamond disks or air rotor burs [34,35]. These meth- tion leads to less corrosion than cold disinfection [37].
ods inevitable create aerosol.
Manual interproximal enamel reduction with hand- 4. CONCLUSIONS
operated abrasive strips is more time consuming and
harder to use in posterior teeth, however it creates Similarly to other dental professions, orthodontists
less aerosol and should be preferred in this period. are at a very-high-risk for COVID-19 infection, and
Strip holders may aid in manual interproximal reduc- all published guidelines should be followed for the
tion [36]. patient’s and DHCP’s safety. In the past, DHCP protec-
2.2.7. Auxiliaries tion measures mostly addressed bloodborne infec-
Elastomeric ligatures, coils or other auxiliaries can tions. Presently, protection from COVID-19, which is
be cut in small pieces, inserted in pouches before highly transmissible through aerosol, droplets, and
treatment and delivered to the doctor by the dental contact, is the main global concern.
assistant. However, in case they are mistakenly con- In this period, the care settings, the infection proto-
taminated, the unused parts can be sterilized via cold cols, and the delivery of AGP clinical procedures must
sterilization. Disinfection of these materials in a 2% be revised and modified to overcome the threat of
glutaraldehyde solution for 10 minutes has no effect SARS-CoV-2 infection in the orthodontic practice.
on strength and distention [38].
2.2.8. Band application and removal List of abbreviations
No particular restriction is advised for these proce-
COVID-19 - Coronavirus disease 2019
dures, except for the use of air/water syringe. If used (SARS-CoV-2) - Severe Acute Respiratory Syndrome Coronavirus 2
and tried on in the mouth, bands should be steri- SARS-CoV - Severe Acute Respiratory Syndrome Coronavirus
lized in autoclave.When bands are removed, cement MERS-CoV - Middle East Respiratory Syndrome Related Coronavi-
breaks away and there is no need to use a handpiece. rus
ACE2 - angiotensin-converting enzyme 2
WHO - World Health Organization
2.3. End of orthodontic treatment AGP - dental aerosol generating procedure
2.3.1. Bracket debonding DHCP - dental health care personnel
Debonding and enamel cleanup is the orthodon- PPE - Personal Protective Equipment
tic procedure which produces the highest amount CDC - Centers for Disease Control and Prevention
ADA - American Dental Association
of aerosol and splatters [39]. Usually, brackets are
UV - ultraviolet
debonded with special task pliers, but the adhesive
remnants are removed with high speed or low speed Declarations
burs, discs, or ultrasonic scalers [40]. Dental dam can
prevent aerosol creation [10]. Remnants of bonding - Ethical Approval and Consent to participate – not applicable
- Consent for publication - all authors read and approved the final
material can also be removed manually, using adhe-
version of the manuscript.
sive removing pliers, although this method is more - Availability of supporting data – not applicable
time consuming and less efficient, leaving more adhe- - Competing interests - the authors declare that they have no com-
sive remnants on the teeth [41]. The use of ceramic peting interests.
brackets should be restrained for their frequent frac- - Funding – not applicable
ture during debonding and the consequent need to - Acknowledgements not applicable
use a turbine handpiece.
CONFLICT OF INTEREST
2.3.2. Retainers
Previous articles reported the bonding of retainers The authors declare no conflict of interest.
with a rubber dam in order to prevent failures [42].
During the current period, the rubber dam is even AUTHOR CONTRIBUTIONS
more recommended. Self-etching primers and indi-
rect bonding [43] can further shorten chair-time and LP, SC and GC conceived the protocol, wrote, and revised the
lower the risk of aerosol exposure, as explained above. manuscript. LN, RC and OY revised the literature and collected the
Alternatively, clear retainers can be performed using references.
intraoral scans and fixed retainer bonding postponed
at this stage.
Stoma Edu J. 2020;7(3): 209-215 pISSN 2360-2406; eISSN 2502-0285
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Letizia PERILLO
MD, MS, PhD, Professor, Head, Dean
Multidisciplinary Department of Medical-Surgical and Dental Specialties
School of Dentistry
University of Campania Luigi Vanvitelli
Naples, Italy
CV
Letizia Perillo is full Professor and Dean of the School of Dentistry, University of Campania Luigi Vanvitelli, Naples (Italy). She is
Visiting Professor at the University of Alabama (USA) and of Alexandria (Egypt). She was elected President of the Italian Society
of Orthodontics (2021), of the Mediterranean Orthodontic Integration Project (2022), and International Ambassador of the
American Association of Orthodontists (2018-2020). She is a member of many international dental organizations and of the
Editorial Board of several journals. She graduated in Medicine and Surgery and specialized in Orthodontics at the University of
Naples Federico II. She completed a postgraduate fellowship at the University of Michigan and a PhD in Interceptive Orthodontics
at the University of Florence. She is authored several publications and she is speaker at international courses and congresses.
214 Stoma Edu J. 2020;7(3): 209-215 pISSN 2360-2406; eISSN 2502-0285
Orthodontic practice in the covid-19 crisis
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Questions
Review Article
1. Dental aerosol generating procedures (AGPs) are associated with:
qa. The use of ultrasonic instruments;
qb. Air/water syringe;
qc. Handpieces;
qd. All of them.
2.When was Covid-19 declared a pandemic by the World Health Organization (WHO)?
qa. On January 31th, 2020;
qb. On February 11th, 2020;
qc. On March 11th, 2020;
qd. On April 12th, 2020.
3.Which dilution of sodium hypochlorite is effective for the disinfection of irreversible
hydrocolloid impressions?
qa. 1:10;
qb. 2:10;
qc. 3:10;
qd. 4:10.
4. Which is the diameter of particles that can reach the alveoli?
qa. From 0.1 µm to 1 µm;
qb. From 1 µm to 10 µm;
qc. From 10 µm to 100 µm;
qd. >100 µm.
Stoma Edu J. 2020;7(3): 209-215 pISSN 2360-2406; eISSN 2502-0285 215