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Managing Dental Caries Against the Backdrop of COVID-19: Approaches to Reduce Aerosol Generation

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Managing Dental Caries Against the Backdrop of COVID-19: Approaches to Reduce Aerosol Generation 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. BRITISH DENTAL JOURNAL | VOLUME 229 NO. 7 | OctobER 9 2020 411 © The Author(s), under exclusive licence to british Dental Association 2020 CLINICAL 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
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