Estimating COVID-19 prevalence and infection control practices among US dentists

BackgroundUnderstanding the risks associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during oral health care delivery and assessing mitigation strategies for dental offices are critical to improving patient safety and access to oral health care.MethodsThe authors invited licensed US dentists practicing primarily in private practice or public health to participate in a web-based survey in June 2020. Dentists from every US state (n = 2,195) answered questions about COVID-19–associated symptoms, SARS-CoV-2 infection, mental and physical health conditions, and infection control procedures used in their primary dental practices.ResultsMost of the dentists (82.2%) were asymptomatic for 1 month before administration of the survey; 16.6% reported being tested for SARS-CoV-2; and 3.7%, 2.7%, and 0% tested positive via respiratory, blood, and salivary samples, respectively. Among those not tested, 0.3% received a probable COVID-19 diagnosis from a physician. In all, 20 of the 2,195 respondents had been infected with SARS-CoV-2; weighted according to age and location to approximate all US dentists, 0.9% (95% confidence interval, 0.5 to 1.5) had confirmed or probable COVID-19. Dentists reported symptoms of depression (8.6%) and anxiety (19.5%). Enhanced infection control procedures were implemented in 99.7% of dentists’ primary practices, most commonly disinfection, COVID-19 screening, social distancing, and wearing face masks. Most practicing dentists (72.8%) used personal protective equipment according to interim guidance from the Centers for Disease Control and Prevention.ConclusionsCOVID-19 prevalence and testing positivity rates were low among practicing US dentists. This indicates that the current infection control recommendations may be sufficient to prevent infection in dental settings.Practical ImplicationsDentists have enhanced their infection control practices in response to COVID-19 and may benefit from greater availability of personal protective equipment. ClinicalTrials.gov: NCT04423770.     

Impact of SARS-CoV-2 on saliva: TNF-⍺, IL-6, IL-10, lactoferrin,lysozyme, IgG,IgA, and IgM

ObjectivesUnderstanding the role of certain salivary components, such as TNF-?, IL-6, IL-10, lactoferrin, lysozyme, IgG, IgA, and IgM, in airway defense during the ongoing SARS-CoV-2 pandemic is essential. The salivary immune barrier of patients with COVID-19 may play a role in their prognosis. The present study aims to evaluate the impact of SARS-CoV-2 on saliva composition.MethodsA longitudinal study was carried out with male and female firefighters aged 24–48 years. The study sample (n = 34) was divided into 3 groups: asymptomatic volunteers with a negative polymerase chain reaction (PCR) test for SARS-CoV-2 (group 1, Control, n = 21); patients with symptoms of COVID-19 of less than 7 days’ duration and a diagnosis of SARS-CoV-2 infection by PCR (group 2, COVID-19, n = 13); and recovered patients from group 2 who were free of COVID-19 symptoms for at least 2 months (group 3, post-COVID-19 recovery, n = 13). All groups underwent real-time PCR to detect the presence of SARS-CoV-2, as well as analysis of the salivary concentrations of TNF-?, IL-6, IL-10, lactoferrin, lysozyme, IgG, IgA, and IgM by the ELISA method.ResultsLactoferrin concentrations were significantly decreased in the infected group (COVID-19) when compared to those not infected by SARS-CoV-2 (control) (p = 0.032). IgA concentrations were decreased in the COVID-19 and post-COVID-19 groups compared to the control group (p = 0.005 and p = 0.016, respectively). Comparison of the COVID-19 and post-COVID-19 groups also revealed an increase in IgM concentrations during acute SARS-CoV-2 infection (p = 0.010).ConclusionSARS-CoV-2 alters the composition of the salivary immune barrier.     

What is the rate of COVID-19 infection in a population seeking oral health care?

BackgroundAlthough rates of COVID-19 have remained low among US dentists, the authors aimed to determine the risk of there being COVID-19 in patients seeking oral health care.MethodsThe authors performed a retrospective chart review of all emergency department consultations from June 1, 2020, through December 31, 2020. They used Pearson correlation coefficients to compare rates with citywide prevalence (P < .05).ResultsThe authors located 203 encounters with 149 tests and 10 cases of COVID-19. Cases were strongly correlated with the citywide positivity rate (r = 0.9147; P = .0039). All patients who tested positive were asymptomatic and afebrile, and one-half (50%) visited a dentist within a week of consultation.ConclusionsThe rate of COVID-19 in a population seeking oral health care reflects the community positivity rate. Asymptomatic or presymptomatic patients pose risks to providers, staff members, and other patients.Practical ImplicationsDentists should remain vigilant during the ongoing COVID-19 pandemic, even with vaccination rollout. The Centers for Disease Control and Prevention maintains an accessible website with easy access to each state’s positivity rate and caseload.     

Insurance claim data trends in pulpal therapy for pediatric patients

BackgroundThe purpose of this study was to identify differences in usage trends for 2 specific pulpal therapy treatments in pediatric patients during an 11-year period from January 1, 2010, through December 31, 2020.MethodsInsurance data claims for children aged 2 through 12 years undergoing a pulpotomy or a pulpectomy performed by a general dentist (GD) or pediatric dentist (PD) from 2010 through 2020 were extracted from a dental data warehouse. The state where the provider was located was included in the extracted claim.ResultsRates of undergoing a pulpotomy or pulpectomy declined from 2010 through 2020 (odds ratio [OR], 0.978 or 0.946, respectively; P < .001). PDs were more likely to perform pulpotomies than GDs (OR, 1.393; P < .001), but PDs were less likely to perform pulpectomies than GDs (OR, 0.225; P < .001). Younger patient age was a significant predictor for undergoing pulpotomy treatment for both GDs and PDs (ORs, 0.850 and 0.892, respectively; P < .001). With increasing patient age, PDs had increased odds of performing a pulpectomy (OR, 1.030; P < .001) and GDs had decreased odds of performing a pulpectomy (OR, 0.995; P = .04). When examining effects according to American Academy of Pediatric Dentistry national membership districts, the trends remained consistent with those above.ConclusionsThe percentage of children undergoing pulpotomy and pulpectomy therapy declined from 2010 through 2020 among both GDs and PDs.Practical ImplicationsThese changes in pulpal therapy practice might indicate a teaching change in pulpal therapy guidelines, suggesting that less invasive pulpal therapy can be used rather than pulpotomies or pulpectomies.     

COVID-2019 fundamentals

BackgroundA novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified at the end of 2019. The disease caused by SARS-CoV-2 was named COVID-19. The main purpose of this review was to provide an overview of SARS-CoV-2.MethodsThe authors searched the MEDLINE database for clinical studies related to virus characteristics, pathogenesis, diagnosis, transmission mechanisms, and treatment options.ResultsAs of January 27, 2021, the number of infected people and deaths associated with COVID-19 worldwide were approximately 100 million and 2 million, respectively. The manifestations of COVID-19 are variable, and the severity is affected by age and preexisting medical conditions. Children and adolescents are usually asymptomatic or have mild symptoms. Older adults, in comparison, may experience severe illness and have disproportionally elevated mortality. Among those who survive, some may experience enduring deficits. The viral load is particularly elevated in saliva and oropharynx, which constitute potential sources of infection. The diagnosis of the disease may be confounded by factors related to the replicating cycle of the virus, viral load, and sensitivity of the diagnostic method used. As of January 2021, COVID-19 has no cure but can be prevented. Its treatment is based on supportive care along with antiviral medications and monoclonal antibodies. In severe cases with multiorgan involvement, mechanical ventilation, dialysis, and hemodynamic support may be necessary.ConclusionsCOVID-19 is a transmittable disease with a variable course. A substantial number of patients, particularly children, remain asymptomatic. Important advances have been made in the development of new treatments. However, the mortality in vulnerable populations remains elevated.Practical ImplicationsThe elevated viral load in the oral cavity and pharynx suggests that oral health care professionals could get infected through occupational exposure. Providers should understand the variables that influence the yield of diagnostic studies because false-negative results can occur.     

The effect of mouthrinses on severe acute respiratory syndrome coronavirus 2 viral load: A systematic review

BackgroundConsidering that the oral cavity is a major entryway and reservoir for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the aim of the authors was to perform a systematic review of in vivo and in vitro studies to assess the effectiveness of mouthrinses on SARS-CoV-2 viral load.Types of Studies ReviewedThe authors searched PubMed, Web of Science, Scopus, MedRxiv, and bioRxiv databases, including in vitro and in vivo studies assessing the virucidal effect of mouthrinses on SARS-CoV-2 or surrogates. From a total of 1,622 articles retrieved, the authors included 39 in this systematic review.ResultsPovidone-iodine was the most studied mouthrinse (14 in vitro and 9 in vivo studies), frequently showing significant reductions in viral load in in vitro assays. Similarly, cetylpyridinium chloride also showed good results, although it was evaluated in fewer studies. Chlorhexidine gluconate and hydrogen peroxide showed conflicting results on SARS-CoV-2 load reduction in both in vitro and in vivo studies.Practical ImplicationsPovidone-iodine–based mouthrinses appear to be the best option as an oral prerinse in the dental context for SARS-CoV-2 viral load reduction. Although the results of primary studies are relevant, there is a need for more in vivo studies on mouthrinses, in particular, randomized controlled clinical trials, to better understand their effect on SARS-CoV-2 viral load and infection prevention.     

Oral manifestations of COVID-2019–related multisystem inflammatory syndrome in children: a review of 47 pediatric patients

BackgroundAlthough much is still unknown about the full effects of COVID-19, literature from the early stages of the COVID-19 pandemic (spring and summer 2020) supports a postviral immunologic reaction resulting in a multisystem inflammatory syndrome in children (MIS-C). The purpose of this study was to report the rates of documented oral and oropharyngeal manifestations among these patients and to determine the association of these findings with other MIS-C symptoms.MethodsThe authors conducted a retrospective review of pediatric patients with COVID-19 who were admitted to the Morgan Stanley Children’s Hospital of NewYork-Presbyterian. Patients fulfilling the Centers for Disease Control and Prevention criteria for MIS-C were included in this study. The documented signs, symptoms, and laboratory values were collected and compared with the presence of oral or oropharyngeal findings.ResultsThe mean (standard deviation) age of MIS-C patients was 9.0 (5.0) years (range, 1.3-20.0 years), and there was no obvious sex difference (51.1% male, 48.9% female). With respect to oral findings, 23 patients (48.9%) had red or swollen lips, whereas only 5 (10.6%) had a strawberry tongue. Oral or oropharyngeal findings were associated significantly with the presence of systemic rash (P = .04) and conjunctivitis (P = .02).ConclusionsThe presence of oral or oropharyngeal changes may be an early indicator of MIS-C and should be considered suggestive of MIS-C in the setting of COVID-19 infection.Practical ImplicationsDental care providers may play an integral role both in the early detection of oral manifestations of MIS-C and in the identification of oral lesions in hospitalized patients with confirmed MIS-C.     

COVID-19 among dentists in the United States: A 6-month longitudinal report of accumulative prevalence and incidence

BackgroundIn 2020, the Centers for Disease Control and Prevention and the American Dental Association released COVID-19 infection control interim guidance for US dentists, advising the use of optimal personal protection equipment during aerosol-generating procedures. The aim of this longitudinal study was to determine the cumulative prevalence and incidence rates of COVID-19 among dentists and to assess their level of engagement in specific infection control practices.MethodsUS dentists were invited to participate in a monthly web-based survey from June through November 2020. Approximately one-third of initial respondents (n = 785) participated in all 6 surveys, and they were asked about COVID-19 testing received, symptoms experienced, and infection prevention procedures followed in their primary practice.ResultsOver a 6-month period, the cumulative COVID-19 infection prevalence rate was 2.6%, representing 57 dentists who ever received a diagnosis of COVID-19. The incidence rates ranged from 0.2% through 1.1% each month. The proportion of dentists tested for COVID-19 increased over time, as did the rate of dentists performing aerosol-generating procedures. Enhanced infection prevention and control strategies in the dental practice were reported by nearly every participant monthly, and rates of personal protection equipment optimization, such as changing masks after each patient, dropped over time.ConclusionsUS dentists continue to show a high level of adherence to enhanced infection control procedures in response to the ongoing pandemic, resulting in low rates of cumulative prevalence of COVID-19. Dentists are showing adherence to a strict protocol for enhanced infection control, which should help protect their patients, their dental team members, and themselves.Practical ImplicationsCOVID-19 infections among practicing dentists will likely remain low if dentists continue to adhere to guidance.     

The pediatric dental workforce in 2016 and beyond

BackgroundChildhood caries is a major oral and general health problem, particularly in certain populations. In this study, the authors aimed to evaluate the adequacy of the supply of pediatric dentists.MethodsThe authors collected baseline practice information from 2,546 pediatric dentists through an online survey (39.1% response rate) in 2017. The authors used a workforce simulation model by using data from the survey and other sources to produce estimates under several scenarios to anticipate future supply and demand for pediatric dentists.ResultsIf production of new pediatric dentists and use and delivery of oral health care continue at current rates, the pediatric dentist supply will increase by 4,030 full-time equivalent (FTE) dentists by 2030, whereas demand will increase by 140 FTE dentists by 2030. Supply growth was higher under hypothetical scenarios with an increased number of graduates (4,690 FTEs) and delayed retirement (4,320 FTEs). If children who are underserved experience greater access to care or if pediatric dentists provide a larger portion of services for children, demand could grow by 2,100 FTE dentists or by 10,470 FTE dentists, respectively.ConclusionsThe study results suggest that the supply of pediatric dentists is growing more rapidly than is the demand. Growth in demand could increase if pediatric dentists captured a larger share of pediatric dental services or if children who are underserved had oral health care use patterns similar to those of the population with fewer access barriers.Practical ImplicationsIt is important to encourage policy changes to reduce barriers to accessing oral health care, to continue pediatric dentists’ participation with Medicaid programs, and to urge early dental services for children.     

Is hydrogen peroxide an effective mouthwash for reducing the viral load of SARS-CoV-2 in dental clinics?

BackgroundPrevious studies have demonstrated that SARS-CoV-2 is mainly transmitted by inhalation of aerosols and can remain viable in the air for hours. Viruses can spread in dental settings and put professionals and patients at high risk of infection due to proximity and aerosol-generating procedures, and poor air ventilation.ObjectivesThe aim of this study was to investigate the effects of a 1% hydrogen peroxide (H₂O₂) mouth rinse on reducing the intraoral SARS-CoV-2 load.MethodsPortable air cleaners with HEPA filters exposed for 3 months were analysed to test for virus presence in a waiting room (where patients wore a face mask but did not undergo mouth rinsing) and three treatment rooms (where patients wore no mask but carried out mouth rinsing). As CO₂ is co-exhaled with aerosols containing SARS-CoV-2 by COVID-19 infected people, we also measured CO₂ as a proxy of infection risk indoors. Specific primer and probe RT-PCR were applied to detect viral genomes of the SARS-CoV-2 virus in the filters. Specifically, we amplified the nucleocapsid gene (Nuclv) of SARS-CoV-2.ResultsCO₂ levels ranged from 860 to 907 ppm, thus indicating low ventilation and the risk of COVID-19 transmission. However, we only found viral load in filters from the waiting room and not from the treatment rooms. The results revealed the efficiency of 1-minute mouth rinsing with 1% H₂O₂ since patients rinsed their mouths immediately after removing their mask in the treatment rooms.ConclusionsOur findings suggest that dental clinics would be safer and more COVID-19 free by implementing mouth rinsing 1 min with 1% H₂O₂ immediately after the patients arrive at the clinic.     

Frequency and pattern of outpatient dental visits during the COVID-19 pandemic at hospital and community clinics

BackgroundThe authors aimed to measure the frequency of dental visits before and during the COVID-19 pandemic and to evaluate whether dental visits can be predicted from demographic characteristics, socioeconomic status, oral problem diagnoses, and dental service providers.MethodsParticipants for this retrospective study were patients visiting dental care providers at hospital- and community-based outpatient clinics in Alberta, Canada. Data were retrieved from electronic databases from March 12, 2020, through September 30, 2020, and from the same period for 2018 and 2019. The COVID-19 lockdown was declared for March 12 through May 14, 2020. Data were analyzed using analysis of variance test and multiple logistic regression at α = 0.05.ResultsFrom a total of 14,319 dental visits, 5,671, 5,036, and 3,612 visits occurred in 2018, 2019, and 2020, respectively. The mean (standard deviation) frequency of daily visits was 36.69 (15.64), 32.09 (15.51), and 24.24 (14.78), respectively. Despite the overall decrease, the frequency of visits for infections, salivary problems, and temporomandibular disorders increased during the COVID-19 pandemic in 2020. Dental visits during the pandemic were associated with more complicated oral diagnoses and dental services as well as higher economic status.ConclusionsDuring the COVID-19 pandemic, the frequency of dental visits decreased specifically during lockdown. Patients with complicated problems requiring urgent treatments mainly visited dental clinics. Reduced access to care was observed primarily among socially disadvantaged groups.Practical ImplicationsAlthough guidelines and related recommendations have been effective in restoring the compromised dental system during the COVID-19 pandemic, additional modifications are needed to promote in-person visits to improve the oral health status of patients.     

A retrospective,single-center cohort study on complications after dental extractions in patients taking biologic agents

BackgroundAlthough biologic agents represent a growing class of therapeutics, little is known about how these agents affect the provision of dental treatment.MethodsThis retrospective case-control study analyzed patients undergoing dental extraction treated with biologic agents from 2017 through 2020. Complications within 30 days postextraction were recorded.ResultsOne-hundred twenty-one patients were treated during 147 encounters. Fifteen patients experienced complications during 16 encounters. Notable or excessive pain was most common (14/16; 88%). Patients who experienced complications were treated with 7 biologic agents: dulaglutide, belimumab, adalimumab, aflibercept, tofacitinib, ranibizumab, and ixekizumab. Complication after extraction—specifically, pain—was elevated for patients receiving aflibercept and ranibizumab. When grouped by class, complications were more common with vascular endothelial growth factor antagonism.ConclusionsThe impact of biologics on the provision of and recovery after dental treatment remains unknown. Pain was most commonly reported. Patients treated with vascular endothelial growth factor antagonists experienced an elevated rate of complications.Practical ImplicationsThis study provides preliminary data on how patients taking biologic agents heal after dental extraction. It is limited by small sample sizes. Further work will build on this data to determine appropriate management of patients taking biologics in the dental setting.     

US dental health care workers’ mental health during the COVID-19 pandemic

BackgroundThis study was designed to assess the prevalence of anxiety and depression symptoms and understand factors influencing mental health among dental health care workers (DHCWs) during the COVID-19 pandemic.MethodsBeginning in June 2020, 8,902 DHCWs participated monthly in an anonymous longitudinal, web-based survey (response rate, 6.7%). The Patient Health Questionnaire-4 was used to estimate rates of anxiety and depression symptoms. Changes in mental health over time and differences by demographic and practice characteristics, COVID-19 community transmission level, and COVID-19 vaccination status were tested using χ² tests and multilevel multivariable logistic regression.ResultsAnxiety symptom rates peaked in November 2020 (28% of dental hygienists, 17% of dentists) and declined to 12% for both professions in May 2021. Depression symptom rates were highest in December 2020 (17% of dental hygienists, 10% of dentists) and declined to 8% in May 2021. Controlling for gender, age, race or ethnicity, and COVID-19 community transmission level, the authors found that dentists had significantly lower odds of anxiety symptoms (adjusted odds ratio [aOR], 0.82; 95% CI, 0.70 to 0.95) and depression symptoms (aOR, 0.79; 95% CI, 0.67 to 0.93) than dental hygienists. Compared with vaccinated respondents, those who were unvaccinated but planning on getting vaccinated had significantly higher rates of anxiety (aOR, 1.71; 95% CI, 1.20 to 2.44) and depression (aOR, 1.57; 95% CI, 1.07 to 2.29) symptoms.ConclusionsDHCWs’ mental health fluctuated during the pandemic. Anxiety and depression in DHCWs were associated with demographic and professional characteristics as well as perceived risk of COVID-19.Practical ImplicationsMental health support should be made available for DHCWs.This clinical trial was registered at ClinicalTrials.gov. The registration numbers are NCT04423770 and NCT04542915.     

Saliva diagnostics: Salivaomics,saliva exosomics,and saliva liquid biopsy

BackgroundEach day, humans produce approximately 0.5 through 1.5 liters of saliva, a biofluid that is rich in biological omic constituents. Our lack of understanding how omic biomarkers migrate from diseased tissue to the saliva has impeded the clinical translation of saliva testing. Although such biomarkers must be conveyed via the vascular and lymphatic systems to the salivary glands, the molecular mechanisms that underlie this transport remain unclear. Although COVID-19 highlighted the need for rapid and reliable testing for infectious diseases, it represents only one of the many health conditions that potentially can be diagnosed using a saliva sample.Types of Studies ReviewedThe authors discuss salivaomics, saliva exosomics, and the mechanisms on which saliva diagnostics are based and introduce a novel electrochemical sensing technology that may be exploited for saliva liquid biopsy.ResultsThe utility of saliva for screening for lung cancer is under investigation. Saliva testing may be used to stratify patients, monitor treatment response, and detect disease recurrence. The authors also highlight the landscapes of saliva-based SARS-CoV-2 testing and ultrashort cell-free DNA and outline how these fields are likely to evolve in the near future.Practical ImplicationsBreakthroughs in the study of saliva research, therefore, will facilitate clinical deployment of saliva-based testing.     

The incidence of COVID-19 among dentists practicing in the community in Canada: A prospective cohort study over a 6-month period

BackgroundOral health care settings carry a potentially high risk of causing cross-infection between dentists and patients and among dental staff members due to close contact and use of aerosol-generating procedures. The authors aimed to estimate COVID-19 incidence rates among Canadian dentists over a 6-month period.MethodsThe authors conducted a prospective cohort study of 644 licensed dentists across Canada from July 29, 2020, through February 12, 2021. An online questionnaire, adapted from the World Health Organization’s Unity Studies protocols for assessment of COVID-19 risk among health care workers, was used to collect data on self-reported severe acute respiratory syndrome coronavirus 2 infections every 4 weeks. A bayesian Poisson model was used to estimate the incidence rate and corresponding 95% credible intervals (CIs).ResultsMedian age of participants was 47 years; most participants were women (56.4%) and general practitioners (90.8%). Median follow-up time was 188 days. Six participants reported COVID-19 infections during the study period, giving an incidence rate of 5.10 per 100,000 person-days (95% CI, 1.86 to 9.91 per 100,000 person-days). The incidence proportion was estimated to be 1,084 per 100,000 dentists (95% CI, 438 to 2,011 per 100,000 dentists) and 1,864 per 100,000 people (95% CI, 1,859 to 1,868 per 100,000 people) in the Canadian population during the same period.ConclusionsThe low infection rate observed among Canadian dentists from July 29, 2020, through February 12, 2021, should be reassuring to the dental and general community.Practical ImplicationsAlthough the infection rates were low among Canadian dentists, it is important to continue to collect disease surveillance data.     

How can child life specialists help address dental fear and anxiety in children?: A review

BackgroundPainful pokes, buzzing drills, uncomfortable pressure, foreign tastes, and disturbing noises are all events that a child can experience in a single dental appointment. Each event has the potential to trigger dental fear and anxiety in pediatric patients. Dental fear and anxiety are common for children and can lead to the neglect of dental care into adulthood. Many behavioral interventions currently in practice focus on immediate behavior changes rather than long-term psychosocial well-being of children.ObjectiveThe purpose of this paper was to review the literature of pediatric dental fear and anxiety and provide reasoning for child life specialist intervention in the pediatric dental clinic.ResultsRooted in developmental theory, child life specialists advocate for the psychosocial care of children in various healthcare environments, including dental clinics. Child life specialists work to minimize pediatric fear and anxiety using various strategies, including psychological preparation. Psychological preparation is accomplished by the provision of developmentally appropriate education, therapeutic or medical play, and preparation books.ConclusionsFurther research is needed to establish the effectiveness of child life specialist intervention, such as psychological preparation, in pediatric dentistry at reducing pediatric dental fear and anxiety.