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COVID-19

Information and evolving best practices

COVID-19 under the microscope

The need for information on COVID-19 is great, and more information is emerging on a continuous basis. As your academic partner, we have undertaken to gather the most useful information related to dentistry that is currently available. In order to make the information more accessible, we have divided it into four categories. This page is being updated continuously.

Current scientific literature on COVID-19 and SARS-CoV-2

Remdesivir for the Treatment of Covid-19 — Preliminary Report
This article reports on the positive findings that remdesivir is superior to placebo in shortening the time to recovery in adults hospitalized with COVID-19 and evidence of lower respiratory tract infection.
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COVID-19: what has been learned and to be learned about the novel coronavirus disease
This article attempts to provide a timely, comprehensive helpful review of the basics of the epidemiology, etiology, virology, diagnosis, treatment, prognosis, and prevention of the disease.
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Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19
This editorial explains and argues for the importance of broadening SARS-CoV-2 testing to include asymptomatic persons in prioritized settings as part of the eventual need to relax current social distancing practices.
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Infection fatality rate of SARS-CoV-2 infection in a German community with a super-spreading event
This sero-epidemiological study conducted in a small German town following a superspreading event reports the following: the infection status in the study population was five-fold higher than the reported number of cases for the community (3.1%); ranked by odds ratios, significant, characteristic symptoms were loss of smell; loss of taste; fever; sweats and chills; fatigue, cough, muscle joint ache; chest tightness; headache; sore throat and nasal congestion; 22.2% of infected individuals were asymptomatic; participation in carnival festivities increased both infection rate and number of symptoms.
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Serological tests for Covid-19 antibodies: limitations must be recognised
Serological tests for COVID-19 antibodies have been hailed as a potential “game-changer” that could limit the spread of infection and lead to the relaxation of some of the current restrictions relating to social distancing. This article emphasizes the importance of recognizing the complexity and, especially, the limitations of these tests.
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Compassionate Use of Remdesivir for Patients with Severe Covid-19
An overview of the Remdesivir anti-viral agent: It is a nucleotide analogue prodrug that inhibits viral RNA polymerases and has shown in vitro activity against SARS-CoV-2. Remdesivir has been undergoing clinical trials for its effectiveness as an agent used in treatment of COVID-19. Preliminary results were leaked last week and then withdrawn but the final results are due for official release and publication soon. Remdesivir is also mentioned in the article ‘Mild or Moderate Covid-19’ referenced below.
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Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19)
This narrative review summarizes the ongoing efforts to identify effective drugs for the prevention and treatment of COVID-19. No proven effective therapies exist at present but clinical trials are under way looking at repurposing existing drugs, new investigational drugs and adjunctive therapies. The review also comments on current clinical treatment experience and recommendations.
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Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young 
This correspondence from the health system in New York City reports on five cases of large-vessel stroke in patients younger than 50 years of age. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients. The report raises the concern that the patients had not connected their symptoms with COVID-19 and suggests that this association in younger patients requires further investigation. 
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Mild or Moderate COVID-19
This article begins with a case vignette highlighting a common medical clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, if they exist. The article also provides an overview of ongoing clinical trials testing the effectiveness of a range of agents. The article ends with the authors’ clinical recommendations.
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Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine
This article from Wuhan University, School and Hospitality of Stomatology, China introduces relevant guidelines based on the knowledge, research and experience gained about COVID-19 and nosocomial infection in dental settings.
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Virology, Epidemiology, Pathogenesis, and Control of COVID-19
This article published 27 Mar 2020 aims to provide a comprehensive review and summary of the present understanding of COVID-19.
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Recognition of aerosol transmission of infectious agents: a commentary
Overview that outlines transmission terminology and discusses potential for intervention. The overview suggests that the most obvious sources of infection are the contacts outside of the professional environment as these are only partially under control. However, even if aerosol transmission in the clinical environment accounts for only a minority of cases they may also be the more severe and specific interruption is therefore required.
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Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1
Results on potential for transmission of SARS-CoV-2 indicate that aerosol and fomite transmission of SARS-CoV-2 are plausible since the virus can remain viable and infectious in aerosols for hours and on surfaces for days.
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The Untold Toll — The Pandemic’s Effects on Patients without Covid-19
This article looks at the challenge of offering continued support for patients without COVID-19 who may be reluctant to come forward for assessment and treatment.
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Recommendations for dental care during COVID-19

Management of Dental Problems During COVID-19 Pandemic
This links provides access to two documents authored by the SDCEP Scottish Dental Effectiveness Program with clear and helpful overviews on management of acute dental problems and drugs for management of dental problems during the COVID-19 pandemic.
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Possible aerosol transmission of COVID-19 and special precautions in dentistry
This review examines the new challenges and responsibilities for dental professionals associated with the emergence of COVID-19 to identify and introduce special precautions in addition to standard measures to prevent disease transmission from asymptomatic carriers.
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Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19
This two-page generic and illustrated pdf offers clear, practical explanations and guidance for two levels of personal protective equipment and the sequence of steps in donning and doffing at outset and completion of clinical patient contact and procedures.
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Recommendations for the re-opening of dental services: a rapid review of international sources
This living document from the Cochrane Oral Health offers a review of internationally produced guidance for re-opening dental services. The document includes a helpful rapid overview.
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Being a front-line dentist during the Covid-19 pandemic: a literature review
This article addresses all information collected to date on the virus, in accordance with the guidelines of international health care institutions, and provides a comprehensive protocol for managing possible exposure to patients or those suspected of having coronavirus.
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COVID-19 Transmission in Dental Practice: Brief Review of Preventive Measures in Italy
This article details the literature search, documented clinical experience and measures for professional prevention that forms the current basis of Italy’s recommendations for patient management and treatment in dental practice.
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Dental Care and Oral Health under the Clouds of COVID-19
This comprehensive review article starts with an explanation of the bare basics of SARS-CoV-2, its spread amongst humans and the challenge of transmission by asymptomatic/pre-symptomatic patients. It then moves on to discuss the oral health implications of SARS-CoV-2 and provision of dental care during the COVID-19 pandemic, before rounding off with a look ahead to the efforts needed for better future emergency preparedness.
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This site links to the latest recommendations from the Australian Dental Association as provision of dental care moves to level 2 restrictions: provision of dental treatments that are unlikely to generate aerosols or where aerosols generated have the presence of minimal saliva/blood due to the use of rubber dam.
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Transmission routes of 2019-nCoV and controls in dental practice
A summary of possible transmission routes in dental care settings compiled by Stomatology department in Wuhan, China and published March 2020. The summary also includes recommendations for cross infection control measures for dental practice to block person-to-person transmission.
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Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents
Review of existing literature on all available information on persistence on inanimate surfaces of human and veterinary coronaviruses.
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Considerations for everyday practice during COVID-19

The effect of rubber dam on atmospheric bacterial aerosols during restorative dentistry
This study from 2016 reports interesting findings associated with use of rubber dam that are relevant to PPE considerations for covering the head and neck areas of the treating clinician during this COVID-19 period. The study found that use of rubber dam resulted in significantly higher aerosol levels on various aspects of the clinician’s head than without it. 
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Non-compliant respirators/misrepresentation of NIOSH approval
This article from US CDC raises awareness of non-compliant respirator products that are falsely marketed and sold as being NIOSH-approved and may not be capable of providing appropriate respiratory protection to workers.
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Effect of single- versus double-gloving on virus transfer to health care workers’ skin and clothing during removal of personal protective equipment
This article from 2012 reports on a study where a harmless virus was used to obtain quantitative data on transfer during doffing of personal protective equipment. The study concluded that if incorporated into practice, double gloving can reduce the risk of viral contamination of health care workers’ hands during PPE removal.
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There is no time after COVID-19, only before and now.
This is a helpful overview compiled by two German oral maxillofacial surgeons offering their take on dental challenges and their management in the current COVID-19 situation.
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Understanding Mask Types
This one-page guide from the US ADA provides a helpful overview of surgical masks, N95 and N95-equivalent masks.
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The use of Povidone Iodine nasal spray and mouthwash during the current COVID-19 pandemic may reduce cross infection and protect healthcare workers
Proposal by a group of experts for a routine protocol use of intra-nasal and oral application of Povidone-iodine PVP-I for both patients and their attendant healthcare workers (HCWs) during the current COVID-19 pandemic to help limit the spread of SARS-CoV-2 from patients to healthcare workers and vice versa. The authors acknowledge that the proposal is based on extrapolation of in-vitro findings into the vivo setting and that assumptions have been made that under normal circumstances would have been confirmed with in-vivo data prior to recommendations for use.
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Maxillofacial surgery and COVID-19, The Pandemic!!
This review of the COVID-19 situation from an oral-maxillofacial perspective comments on the challenges, precautions and best management to minimize risk to the operating team and to help prevent community spread.
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Consistent Detection of 2019 Novel Coronavirus in Saliva
This study published Feb 2020 looks at the detection of the 2019 novel coronavirus (2019-nCoV) in self-collected saliva from 91.7% (11/12) of patients. The study concluded that saliva is a promising non-invasive specimen for diagnosis, monitoring, and infection control in patients with the 2019-nCoV infection. However, based on the findings the article also argues the case for use of surgical masks against transmission of 2019-nCoV directly or indirectly via saliva with patients who do not show coughing or other respiratory symptoms.
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Discussion of dental aerosols and coronavirus transmission risks
General information about aerosols and their droplet sizes, contamination areas/distances, transmission modalities/ability along with protective strategies against coronavirus in aerosols.
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Effectiveness of N95 Respirators Versus Surgical Masks in Protecting Health Care Workers From Acute Respiratory Infection: A Systematic Review and Meta-Analysis
This May 2017 comparison from between surgical masks and N95 respirators on the prevention of transmissible acute respiratory infections in protection of health care workers concluded that there was insufficient data to definitively determine superiority of N95 in the clinical setting.
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Correct donning and doffing of face masks
Clearly illustrated demonstration of safe use of ear loop surgical face masks (German language).
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Guidance on Preparing Workplaces for COVID-19
US Dept of Labor March 2020 general guidance for workplaces and personal protective equipment (PPE).
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What to Do if Someone on Your Staff Tests Positive for COVID-19
ADA recommended action steps in event of staff positive test for ensuring health and safety of others and reducing likelihood of additional transmissions.
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Disinfectants for Use Against SARS-CoV-2
Detailed list of products that meets US Environment Protection Agency's criteria for use against SARS-CoV-2 including product specific disinfection directions and information.
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National guidelines

Australia
The majority of Australia has been downgraded to Level 1 restrictions. This allows provision of all dental services with standard safety precautions for patients with no epidemiological and/or clinical risk factors. For patients with confirmed or suspected COVID-19 disease, all non-urgent treatment should be deferred.

The references here offer a link to descriptions of restriction levels 1-5 and decision tree for level 1 triage

Belgium and Luxembourg
This Belgian Union of Orthodontic Specialists and Belgian Society of Periodontology site provides information in Dutch and French on the resumption of dentistry as of May 4, 2020 and recommendations for Sars Covid-19 cross-infection control protocols.
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Chile
ORIENTACIONES PARA ATENCIÓN ODONTOLÓGICA EN FASE IV COVID-19:
This document in Spanish covers general protocols for safety including indications for personal protection and contact follow-up.
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China
Beijing Municipal Health Commission:
In China, since each region and city have different situations, there is no unified COVID-19 government guideline for general dental practitioners or even the medical industry. The guidelines are individually designed by each region or city.

As the capital of China, Beijing Municipal Health Commission latest guidance for hospitals:

  • You need an appointment for non-emergency treatment
  • The elderly and those with chronic illnesses are encouraged to make use of the community health service

Read more

Denmark
Dental services have returned to provision of regular care. However, dental procedures that represent great risk of cross-infection should not be carried out on COVID-19 positive patients. Where COVID-19 risk is judged to be present, the patient should be referred for testing first.
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France
Réouverture des cabinets - guide pratique à partir des recommandations d'experts validées - 7 mai:
This link offers practical guidance related to reopening dental practices following the COVID-19 lockdown.
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GUIDE SOIGNANT RECOMMANDATIONS TRANSITOIRES Version 1 du 5 mai 2020:
This link offers practical interim COVID-19 guidance for dental treatment.
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India
Dental care is restricted to emergencies (risk to patient life) and urgent (priority dental needs). Elective dental treatment should not be undertaken and where possible aerosol-generating procedures should be avoided. Triage is required to identify patients with symptoms, known contact with other COVID-19 positive persons and/or travel history to COVID-19 hot spots. Patients with suspected COVID-19 positive status should be referred to the local medical hospital. 
Download article (PDF)

Ireland
COVID-19 Guidance on Managing Infection Related Risks in Dental Services:
This link offers guidelines from HSE Health Protection Surveillance Centre for reopening dental practices in Ireland.
Download article (PDF)

Korea
Information from Korean Dental Association:
Dedicated website for COVID-19 information. It contains

  • Guidelines for dental clinics in practices
  • Required safety measures for the dental clinic
  • List of government supports for the dental clinic
  • Printable posters

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Netherlands
Regular dental care can resume for patients who have no COVID-19 symptoms or who have recovered from COVID-19 and been symptom-free for 14 days. Oral care should be postponed in patients with definite or suspected COVID-19 disease or in quarantine with COVID-19-positive persons. Emergency care should be referred to specific (CAM) units.
View guidance and associated useful links
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New Zealand
Now on Alert level 2 restrictions according to which NZ-based dentists, specialists, hygienists and therapists are able to provide routine dental treatment for all patients who are not suspected of having COVID-19, nor had contact with COVID-19 positive patients, or any links to recent overseas travel. This includes aerosol-generating procedures. PPE required is per standard existing guidelines detailed in this pdf.

For COVID-19 positive or suspected positive patients, urgent and emergency dental treatment can only be provided when the specified room and PPE requirements can be met. These are detailed in this pdf.

Switzerland
With effect from April 27, dental treatment can be carried out nationwide under the following circumstances:

  • Covid-19 Triage is undertaken prior to/on arrival at practice
  • Patients are encouraged to wear masks on arrival
  • Patient temperature is taken at entrance (max. accepted temperature 37.5 °C)
  • Patient disinfect their hands at entrance
  • Waiting time should be limited to 15 minutes with minimum 2-meter social distancing. Where possible use of waiting room avoided
  • Treatments limited to rooms that can be ventilated for 15 minutes between appointments
  • Patient should rinse with povidone-iodine or hydrogen peroxide before treatment
  • Dental hygiene procedures limited to use of hand instruments
  • Symptomatic patients and health care workers or those with known close contact to an infected person in the last 2 weeks should remain at home in isolation for 14 days
  • Covid-positive patients: only emergency treatments and only with dedicated equipment.

Download article in German (PDF)

UK
Management of Acute Dental Problems During COVID-19 Pandemic:
This link provides access to two documents authored by the SDCEP Scottish Dental Effectiveness Program with clear and helpful overviews on management of acute dental problenms and drugs for managment of dental problems during the COVID-19 pandemic.
Read more

UK FCDP COVID-19: latest guidance and resources for General Dental Practitioners:
Updates on the key instructions from government agencies compiled by the Faculty of General Dental Practitioners, UK 28 May 2020.

Dental practices may reopen from Monday 8 June for all face-to-face care, where practices assess that they have the necessary infection prevention and control together with personal protective equipment requirements in place. 

Sequencing and scheduling of patients for treatment as services resume should take into account:

  • The urgency of needs
  • The particular unmet needs of vulnerable groups
  • Available capacity to undertake activity

Download article (PDF)

USA
In order to protect staff and preserve personal protective equipment and patient care supplies, as well as expand available hospital capacity during the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) recommends that dental facilities postpone elective procedures, surgeries, and non-urgent dental visits, and prioritize urgent and emergency visits and procedures now and for the coming several weeks.
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ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission:
This guidance is divided into the three sections of before, during and after dental treatment.
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ADA Interim Guidance for Management of Emergency and Urgent Dental Care:
Three emergency and urgent dental care triage algorithms:

  • Algorithm 1: Triaging Patients for Emergency and Urgent Dental Care
  • Algorithm 2: Screening to Identify COVID-19 Infection for Emergency and Urgent Dental Patients
  • Algorithm 3: Minimize Risk of COVID-19 Transmission for Emergency and Urgent Dental Patients and HCP

Download article (PDF)

ITI Webinars

UK & Ireland Section COVID-19 open panel webinar
Section Chair and ITI Fellow Colin Burns leads a COVID-19 discussion surrounding the current dental situation and issues in the UK and Ireland. Among his discussion partners are Thomas Lamont from the Cochrane Oral Health Group for input from the ongoing review of international recommendations for re-opening of dental practices. ITI Fellow and Oral Maxillofacial Surgeon Bilal Al Nawas reports on experiences from the continued provision of dental care in Germany throughout the pandemic. Julia Furley and Victoria Holden provide current perspective on legal and indemnity aspects of reopening.
Watch webinar

 

Findings of COVID-19 in the Dental Medical Field - A Scientific Update by Professor Dr. med. Dr. med. dent. Bilal Al-Nawas
This webinar outlines the background of the pandemic situation, the idea of hygiene measures in the dental office and practical examples from around the globe.
Watch webinar

 

ITI Canada Section webinar: Impact of COVID-19 on the dental profession and how do we open our practices?
This webinar is hosted by ITI Canada Section Education Delegate and ITI Fellow, Majd Al Mardini. After opening remarks by ITI President-elect Charlotte Stilwell, the invited speaker from University of Toronto, Faculty of Dentistry, Michael Glogauer, provides an overview of the impact of COVID-19 on dentistry going forward and how the profession can best prepare for this. This is followed by a Q&A session.

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