BDJ Minimum Intervention Dentistry Themed Issue CLINICAL

Managing dental caries against the backdrop of COVID-19: approaches to reduce aerosol generation

Ece Eden,*1 Jo Frencken,2 Sherry Gao,3 Jeremy A. Horst4,5 and Nicola Innes6

Key points Uncertainty and the emerging evidence that There are evidence-based treatments including use This risk reduction approach for aerosol SARS-CoV-2 may be transmitted via airborne of high-viscosity glass-ionomer sealants, atraumatic generation may guide practitioners to overcome routes has implications for practising dental restorative treatment, silver diamine fuoride, the less favourable outcomes associated procedures that generate aerosols. the Hall Technique and resin infltration, which with temporary solutions or extraction-only remove or reduce aerosol generation during the approaches in caries management. management of carious lesions.

Abstract The COVID-19 pandemic resulted in severe limitation and closure of dental practices in many countries. Outside of the acute (peak) phases of the disease, dentistry has begun to be practised again. However, there is emerging evidence that SARS-CoV-2 can be transmitted via airborne routes, carrying implications for dental procedures that produce aerosol. At the time of writing, additional precautions are required when a procedure considered to generate aerosol is undertaken. This paper aims to present evidence-based treatments that remove or reduce the generation of aerosols during the management of carious lesions. It maps aerosol generating procedures (AGPs), where possible, to alternative non-AGPs or low AGPs. This risk reduction approach overcomes the less favourable outcomes associated with temporary solutions or extraction-only approaches. Even if this risk reduction approach for aerosol generation becomes unnecessary in the future, these procedures are not only suitable but desirable for use as part of general dental care post-COVID-19.

Background provision.4,5,6 Tis acute phase of the pandemic seems to be little supporting evidence for mass is subsiding, although further acute phases transmission of respiratory pathogens through Te novel coronavirus, severe acute respiratory are being seen in diferent countries. Tere provision of dental care in the past, evidence is syndrome coronavirus 2 (SARS-CoV-2), has is increasing dental need across populations still emerging around transmission of this novel precipitated the COVID-19 pandemic. Te and dental practices are sufering fnancially, virus, where there is no innate immunity in the World Health Organisation (WHO)1 has so practices are opening and commencing care. global population. recommended a society-wide quarantine However, the WHO has taken a cautious and In general, management of dental caries has approach (during acute or peak phases of the risk assessment approach and recommended traditionally involved using instruments that disease), social distancing and handwashing that situations where aerosol generating have potential to generate bio-aerosols containing followed by contact tracing. Alongside this, procedures (AGPs) are carried out should saliva, blood and tooth debris; the high-speed air most countries have suspended elective be reduced to a minimum, with additional rotor,17,18,19,20,21 slow-speed handpiece22,23,24 and and non-urgent dental care,2,3 closing many precautions in place. use of the air-water syringe to complete steps for practices with only emergency treatment It is still controversial but there is growing most dental materials.16,17,25,26 concern over possible airborne transmission Until uncertainty around the level of risk 4,5,6,7 1Ege University, School of Dentistry, Department of of SARS-CoV-2. Although there has associated with SARS-CoV-2 transmission Paediatric Dentistry, Bornova, Izmir, 35100, Turkey; been much written about possible spread of between dental staf and patients is resolved 2Radboud University, Department of Oral Function and Prosthetic Dentistry, College of Dental Sciences, Radboud COVID-19 through aerosols generated in the or an acceptable level of risk is agreed, and University Medical Centre, Nimegen, 6525 GA, The dental surgery, reviews of the evidence show because many aspects of dental treatment Netherlands; 3Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, there is little directly relating to respiratory generate aerosols, a precautionary position is Hong Kong; 4Director of Clinical Innovation, DentaQuest, viruses, despite over 70 years of research into to keep aerosol generation as low as possible. 5 Boston, MA 02129 USA; University of Washington, 8,9,10,11 Department of Oral Health Sciences, Seattle, 98195, USA; bio-aerosols in dental settings. Studies 6Professor and Honorary Consultant, Paediatric Dentistry, of microbial content of aerosols and splatter Aim School of Dentistry, College of Biomedical & Life Sciences, Cardif University, Heath Park, Cardif, CF14 4XY, UK. generated during dental procedures have mostly *Correspondence to: Ece Eden involved aerobic bacteria.9,10,11,12,13,14,15 Viral This paper presents evidence-based Email address: [email protected] studies are sparse, focusing on blood-borne management for dental caries that removes Refereed Paper. HIV and hepatitis B.8,16 Tis limits confdence in or reduces the generation of aerosols and aids Accepted 7 August 2020 the assumptions around transmission of SARS- personalised care planning based around AGP https://doi.org/10.1038/s41415-020-2153-y CoV-2 during dental treatment. Although there reduction.

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Table 1 Direct restorative procedures (ie not involving a laboratory stage) for managing coronal and root surface carious lesions for permanent and primary teeth with high, low and non-AGP alternatives

Lesion location High AGP* Low AGP* Non-AGP

Carious lesions limited to enamel Maximise fuoride during tooth brushing Smooth surface N/A Resin infltration Topical fuoride therapy (Other remineralisation agents**) ART/HVGIC sealant Occlusal surface N/A Resin fssure sealant GIC sealant Fluoride Approximal surface N/A Resin infltration (Other remineralisation agents**) Carious lesion extending into dentine or on root surface ART restoration Carious tissue removal (high-speed air rotor) Smooth or root surface N/A NRCC and composite resin restoration SDF ART restoration Carious tissue removal (high-speed air rotor) Resin fssure sealant (minimal Occlusal surface NRCC† and composite resin restoration enamel breakdown) SDF Carious tissue removal (high-speed air rotor) ART restoration† and composite resin restoration Resin infltration (outer 1/3 Hall Technique Approximal/multi-surface Stainless steel crown (conventional placement) dentine) NRCC† Zirconia crown SDF†

Key: * = use rubber dam with sealant around tooth/dam interface and high-volume aspiration ** = CPP-ACP could be used as an additional measure but should not replace fuoride. Peptides may be considered, though there is limited evidence to support them. SDF is not recommended for anterior teeth † = only for primary teeth ART = atraumatic restorative treatment CMCR = chemo-mechanical caries removal GIC = glass-ionomer cement HVGIC = high-viscosity glass-ionomer cement NRCC = non-restorative cavity control SDF = silver diamine fuoride

Caries management strategies with or procedures that can be modifed to be carried disease, dental caries, in a biological manner; reduced aerosol generation out in a way that does not generate aerosols and treating the cause and not just its symptoms compromise the quality of the procedure. Low (the carious lesions).27 Although they are changing frequently, in AGPs are those that also contain steps that might Te non-AGPs and low AGPs for managing response to evidence, we have set this paper generate a lower amount of aerosol, such as the carious lesions can be grouped into: against a background of local, national and air-water syringe where the air and water are used 1. Control the disease – prevention, early international standards and recommendations. independently of one another. Non-AGPs still detection and managing the carious lesion These include use of patient flow and have potential for salivary contamination and low (whether confned to enamel or cavitated) environment cleaning processes, and standard AGPs may need the air-water syringe in some through controlling the bioflm, by making and enhanced PPE use, as well as other instances. However, there is less aerosol produced the lesion cleansable with non-restorative measures put in place to practice safely practice if the water is used to wash without combining cavity control (NRCC) or by removing while COVID-19 is still a health threat. Dental it with air to give a spray.16,26 Use of rubber dam the plaque and using chemicals to stop its professionals are familiar with infection control with sealing around tooth holes and high-volume progress and promote remineralisation strategies, but afer an outbreak of a highly evacuation help minimise risk. Because of the (commonly silver diamine fuoride [SDF]; infective, potentially airborne-transmitted possibility of viral load in the blood of COVID- topical fuoride) virus, extra protective measures have to be 19-positive patients, it is preferable to avoid pulpal 2. Cover and seal the biofilm and carious adopted. In this time of emerging evidence exposures. The non-invasive and minimally lesion – involves no caries removal and resulting in constant change, these measures invasive procedures, such as selectively removing creates a seal to deprive the carious bioflm should continue to be in line with national and carious tissues during atraumatic restorative of nutrients, oxygen etc, causing the carious local regulations, with vigilance to changes and treatment (ART) and the Hall Technique (HT), lesion to arrest, such as fssure sealing and by reference to Public Health England. are discussed below and make pulp exposures resin infltration for non-cavitated lesions The paper will consider the alignment of less likely. However, if a pulp exposure did look and the HT traditional AGPs for caries management with likely during caries removal, an indirect pulp cap 3. Carious tissue removal – only decomposed, ‘non-AGPs’ and ‘low AGPs’ (see Tables 1 and should be considered. infected dentine and unsupported 2). Non-AGPs are those that generally do not Te procedures discussed here are based demineralised enamel should be removed include steps that generate aerosols, such as the around minimal intervention dentistry selectively using hand instruments (eg ART use of rotary instruments and air-water syringes approaches, aiming to maintain the dentition and/or chemo-mechanical caries removal where air and water are used together in a spray, throughout the course of life by handling the [CMCR]).

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Table 2 Non-aerosol caries management options

Occlusal Multi-surface Depth of carious lesion Primary teeth Permanent teeth Primary teeth Permanent teeth

APP APP APP APP Limited to enamel TF TF TF TF SDF ART/HVGIC FS SDF

NRCC NRCC SDF Extending no more than the outer 1/3 to 1/2 of SDF ART* ART* ART dentine ART +/- CMCR +/- CMCR +/- CMCR +/- CMCR HT

ART** ART** ART** ART** +/- CMCR Over halfway through dentine +/- CMCR +/- CMCR +/- CMCR HT +/- SDF +/- SDF +/- SDF +/- SDF

Key: * = because the lesion is shallow, it is likely that complete carious tissue removal will be necessary to give adequate depth to the restorative material ** = because the lesion is deeper, selective carious tissue removal can be carried out APP = active primary prevention ART = atraumatic restorative treatment ART/HVGIC FS = atraumatic restorative treatment fssure sealant using high-viscosity glass-ionomer cement CMCR = chemo-mechanical caries removal HT = Hall Technique NRCC = non-restorative cavity control SDF = silver diamine fuoride TF = topical fuoride +/- = with or without

The online supplementary information with hand instruments. A Cochrane review restorations.33 Tooth survival afer 3.5 years fle details further sources and some video found no diference in the preventive efect of was 89% and not signifcantly diferent from tutorials of these techniques. resin, LVGIC or HVGIC sealants.30 either amalgam (91%) or ART restorations (90%), and in a randomised control trial of Methods to control carious lesions Early detection occluso-proximal cavitated lesions, survival (of Te purpose of treating dental caries is primarily pulp and tooth) was 92% at 2.5 years compared Prevention to stop its progression within the tooth as well to 98% for teeth treated with the HT.34 NRCC Primary preventive approaches (also as restoring the lost dental hard tissues when has a less robust evidence base than the other known as non-invasive strategies for the needed. Early detection of carious lesions treatment options discussed in this paper, with management of caries) can reduce the risk of will reduce the need for aerosol-producing most of the reports of success being related to progressive dental tissue loss and avoid the restorative care required for advanced lesions. particular situations and carried out by dentists need for treatments using rotary instruments. In addition, patients with active dental caries who support this technique. Te choice to use Te main preventive approaches have to be need to have their disease risks addressed as part NRCC is less dependent on the shape or type through the community and home, with of the long-term disease management.31,32 of lesion than it is on the attitude of the patient behavioural components such as sugar towards prevention and the skill of the dentist restriction, plaque removal and oral health Non-restorative cavity control for in behaviour change.35 education. Clinicians hold a pivotal role in dentinal lesions supporting oral health behaviours. What it is and when to use it Non-AGP use For remineralisation, fuoride-based agents NRCC is a method of using ‘cleaning’ to NRCC consists of three concurrent stages: are accepted as the primary medicament. prevent biofilm maturation and carious 1. Working with the patient to make plaque Although there is less supporting evidence, lesions progression. It can be used for dentinal control more successful (improving oral other remineralisation agents such as carious lesions in the primary and permanent hygiene procedure/habits). Te patient has self-assembling peptide P11-428 might be dentition, root carious lesions and cavitated to be ready to change behaviours that led to considered. coronal smooth surface lesions. development of the disease in the frst place. Preventive sealants cover plaque-retentive Success depends on the clinician’s ability to areas, occlusal fssures and pits, which are How it works and clinical efectiveness change the patient’s (or in the case of a child, most vulnerable to caries.29,30 However, By making the carious surface accessible and the parent’s) behaviour towards taking resin-based sealants involve a washing step to having plaque frequently and thoroughly responsibility. So, ‘prevention’ becomes remove the acid etch thoroughly, generating removed, the carious process will arrest. very much more than simply providing some aerosol. Nevertheless, this risk can In primary teeth, the efectiveness of NRCC instruction of what to do (knowledge) and be avoided by using low-viscosity or high- in medium and large cavities together with how to do it (skills), but has to involve an viscosity glass-ionomer cement (LVGICS/ ART restorations in small cavities has been aspect of refocusing the patient to feeling HVGIC) and excess material can be removed tested in comparison to amalgam and ART empowered to make a diference to their

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own oral health (attitude). Daily removal or How it works and clinical efectiveness there is less weakening of the tooth structure disruption of the bioflm by brushing with SDF penetrates infected dentine,43 making (that is, less extensive lesions) and the tooth a fuoridated toothpaste will slow down the the lesion twice as hard as healthy dentine.44 structure can support them. In cases where the carious process and can even halt it It produces a dense superfcial layer and flls lesion is extensive, the sealant may not be able 2. Creating a cavity shape where the carious in micro-cavities with solid metallic silver.45 to withstand breakdown of the lesion surface bioflm/dentine is accessible to a toothbrush It also acts directly on the plaque bioflm,46,47 if the forces are high. (lesion exposure). In some cases, inhibiting bacterial growth.48,49 Removing Although they have a lower retention rate overhanging enamel has to be removed. carious tissue before SDF application is not than resin sealants, the therapeutic efect of To avoid use of rotary instruments, hand necessary as it does not improve caries arrest.50 GIC on the tooth seems to balance the bulk instruments can be used to gain access to SDF has been shown to have some efect in material loss. Tere is good evidence to support the lesion (see ART) preventing carious lesions in primary teeth, a high caries-preventive effect from high- 3. Treatment with 38% SDF and/or a 5% NaF with one review showing that, by applying viscosity glass-ionomer sealants.30 However, varnish therapy to reduce carious activity it at least once per year, 61% of new caries there is little directly comparable evidence, and promote remineralisation.33 These lesions might be prevented.51 SDF is clinically as yet, on their relative performances sealing additional measures can support success of efective as well as cost-efective, and has the dentinal carious lesions. the NRCC approach if the carious lesion is advantage of combined use with all other caries active or there is increased risk that carious management techniques.51,52 Non-AGP use lesion activity will recur. Resin fssure sealant application involves use Non-AGP use of the air-water syringe, creating an aerosol. In the primary dentition, the goal is Carious tissue is not removed at all. To minimise Clinicians could consider using GIC or to avoid the lesion causing pain and/or droplet and aerosol production, the surface is HVGIC ART sealants instead, as these do not infection until the tooth exfoliates. For the dried with cotton instead of compressed air, then require rinsing or desiccation for placement, permanent dentition, with grossly broken SDF is applied using a micro brush. Arresting to prevent further progression of lesions. More down teeth, root carious lesions or coronal lesions using SDF can provide a solid foundation long-term treatment may be required later, but smooth surface lesions, the main goal is for restorations53,54 and can be combined with there may be sufcient success from the sealant to avoid the lesions leading to pain and/or ART in primary or permanent teeth or the HT. to allow it to be managed by re-sealing rather infection while also avoiding or delaying the Tere are currently no clinical trials of efcacy, than replacing with a restoration. need for restoration. so combinations may be thought of as a ‘belt and braces’ approach to synergise the benefts Resin infltration SDF for dentine lesions of both treatments. What it is and when to use it What it is and when to use it Resin infltration (RI) is a technique that SDF is a clear, colourless liquid that Methods for sealing the carious arrests non-cavitated carious lesions.61,62 It arrests active cavitated carious lesions and lesion can treat non-cavitated lesions on smooth remineralises demineralised enamel and and approximal surfaces in both dentitions dentine.36 Some products have a blue tint, but Fissure sealing over non-cavitated effectively. Lesions have to be limited to these are not available in the UK. Although carious lesion enamel and the outer third of dentine.61,62,63,64,65 licensed to treat dentine sensitivity in the UK What it is and when to use it It can also camoufage the whitish appearance and some other countries, it is more usually Sealant materials can control non-cavitated of hypomineralised enamel on smooth used ‘of-label’ to arrest carious lesions. It turns lesions on occlusal surfaces where there is no surfaces.62,64 Similar to sealants, this is also active carious lesions black; therefore, consent signifcant breach in the surface integrity of the known as a micro-invasive treatment. to treatment must be obtained and it must be tooth, even if the lesion can be seen clinically handled with care as it will temporarily stain (through shadowing), or radiographically, to How it works and clinical efectiveness skin, mucosa and most surfaces on contact. extend into dentine.55,56,57,58,59,60 Tese are also A very low-viscosity resin infiltrate is SDF is an efective way of treating active known as micro-invasive treatments. introduced into the micro-porosities of carious lesions for primary and permanent teeth lesions to fll them through capillary action and (coronal dentine and root).37,38 It can be How it works and clinical efectiveness arrest their progress.65 Systematic reviews show used opportunistically while the patient is in As well as being highly efective for prevention RI to be an efective micro-invasive treatment the dental chair by applying to other high- of dental caries,30 placing a well-sealed fssure at timespans up to 36 months.61,65 risk surfaces. SDF is efective in arresting sealant over a carious lesion will arrest it and early childhood caries39 and exposed root stop it from progressing.57,58,59,60 Low AGP use surfaces.40 It is more successful when used While shallow or moderately deep lesions are Te difusion of the RI results from surface and in cleansable lesions and accessible areas of likely to be successfully managed, there is not sub-surface dehydration conditions created by the mouth.41 When caries is more severe or enough evidence to make recommendations hydrochloric acid followed by ethanol. Te air- afects multiple teeth, repeated applications for deeper lesions for long-term management. water syringe has to be used to rinse and dry of SDF controls the disease (for example, Although they may provide a good seal, they which may produce aerosols. Rubber dam, applied afer two weeks and six weeks, then will not add much to the strength of the tooth. sealing material and high-volume evacuators six months as required).42 Teir application is limited to teeth where should be used.5,66

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Hall Technique Methods for carious dentine lesion Chemo-mechanical methods for carious What it is and when to use it management tissue removal Te HT is a method for treating asymptomatic Currently, there are sodium hypochlorite-based carious primary molar teeth where the lesion Atraumatic restorative treatment and enzyme-based CMCR agents in the market. has extended into dentine (cavitated or non- What it is and when to use it A recent systematic review found CMCR time- cavitated). Te correct size of preformed metal ART involves using hand instruments to access consuming, but efective, for caries removal.74 crown is chosen and then pushed over the carious lesions through enamel and to remove Te manufacturer’s recommendations are that tooth to seal the carious lesion.67 a selected amount of demineralised dental the caries removal agents are washed out, but Te HT has been used in some secondary tissues. Tis is also known as a minimally could well be removed with spoon instruments care settings for temporary management of invasive treatment. and cleaned with wet cotton pellets. partially erupted permanent molars afected by molar incisor hypomineralisation. However, How it works and clinical efectiveness Limitations of non-AGP and low AGP there are currently no clinical trials to support ART restorations with HVGIC have shown in management of carious lesions this use. If practitioners are considering using high success in long-term follow-up studies for the HT as a temporary non-AGP measure single surfaces, in the primary and permanent Te majority of carious lesions in children for permanent molar teeth, there are a dentitions, with meta-analyses showing and young adults can be treated with non- few points, besides the lack of supporting weighted mean annual failure percentages of AGP measures because they are usually the evidence, that they should consider. Firstly, 5% in primary molars over the frst three years, frst lesion on a tooth. One of the difculties the crowns should only be placed on teeth and 4.1% over the frst fve years in permanent with applying non-AGPs in adults is that most that are not yet in occlusion. Secondly, the posterior teeth.29 However, there are not lesions occur in relation to a failing restoration HT in this cas , unlike primary teeth HT use, enough studies on multi-surface restorations (previously known as secondary caries) and it provides only a temporary solution until more in the permanent dentition to recommend it does not seem possible to remove restorative defnitive restorative treatment and this will as a long-term strategy yet. A recent systematic materials without using rotary instruments and necessitate an AGP to remove the crown. review reported no significant differences creating aerosols. However, repairing existing Finally, permanent tooth preformed crowns in survival percentages between ART and restorations rather than replacing them should are less easy to ft than those for primary teeth traditionally produced multiple-surface be considered where possible. and almost always need to be trimmed with restorations in primary molars,72,73 and for scissors, crimped and polished. single-surface restorations in primary molars Conclusion and posterior permanent teeth.73 Large-sized How it works and clinical efectiveness multi-surface ART/HVGIC restorations in Treatments that remove or reduce the It provides full coronal coverage and the risk of primary molars were less successful because of generation of aerosols during the management future carious lesion development on another poor restorative material performance rather of carious lesions can allow a successful risk surface of the tooth is avoided.67 than the caries removal technique. However, reduction approach and are still efective. Te HT is technically simple to carry out and ART may be a good short-term strategy for is well accepted by children, their parents and large multi-surface cavities or for stabilising Confict of interest dentists.68,69 It has a strong evidence base showing the dentitions before other restorative None. high long-term success rates in randomised interventions. control trials (>90%) compared to conventional References restorations (50–80%) and comparable to Non-AGP use 1. World Health Organisation. COVID-19 strategy update. 68,69,70 2020. Available at https://www.who.int/docs/ conventional crowns. The high rate of ART involves no rotary, aerosol-producing default-source/coronaviruse/covid-strategy-update- success, its durability and cost-efectiveness have instruments during opening of the cavity and 14april2020.pdf (accessed July 2020). meant use of the HT has increased, with a recent selective removal of the carious tissue. ART’s 2. American Dental Association. COVID-19 Frequently Asked Questions. 2020. Available online at https:// survey including 709 paediatric dentists from six success is determined not only by the shape success.ada.org/en/practice-management/patients/ continents showed that 92% had heard about it and the sharpness of the hand instruments, coronavirus-frequently-asked-questions (accessed July 2020). 71 and 51% were using it. but also the technique used as well as the 3. Centers for Disease Control and Prevention. Dental knowledge of the afected dental tissues and Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Non-AGP use experience of the dental practitioner. Disease 2019 (COVID-19) Pandemic. 2020. 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416 BRITISH DENTAL JOURNAL | VOLUME 229 NO. 7 | October 9 2020 © The Author(s), under exclusive licence to British Dental Association 2020