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 fluoride, the less favourable outcomes associated
procedures that generate aerosols. the Hall Technique and resin infiltration, 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 This acute phase of the pandemic seems to be little supporting evidence for mass
is subsiding, although further acute phases transmission of respiratory pathogens through
The novel coronavirus, severe acute respiratory are being seen in different countries. There 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. The and dental practices are suffering financially, 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
1
Ege University, School of Dentistry, Department of of SARS-CoV-2.4,5,6,7 Although there has associated with SARS-CoV-2 transmission
Paediatric Dentistry, Bornova, Izmir, 35100, Turkey; been much written about possible spread of between dental staff and patients is resolved
2
Radboud 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, Nijmegen, 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.
Boston, MA 02129 USA; 5University of Washington,
Department of Oral Health Sciences, Seattle, 98195, USA;
bio-aerosols in dental settings.8,9,10,11 Studies
6
Professor and Honorary Consultant, Paediatric Dentistry, of microbial content of aerosols and splatter Aim
School of Dentistry, College of Biomedical & Life Sciences,
Cardiff University, Heath Park, Cardiff, 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 This limits confidence 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 fluoride during tooth brushing
Smooth surface N/A Resin infiltration Topical fluoride therapy
(Other remineralisation agents**)
ART/HVGIC sealant
Occlusal surface N/A Resin fissure sealant
GIC sealant
Fluoride
Approximal surface N/A Resin infiltration
(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 fissure 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 infiltration (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 fluoride. 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 fluoride

Caries management strategies with or procedures that can be modified 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 The 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 confined to enamel or cavitated)
environment cleaning processes, and standard AGPs may need the air-water syringe in some through controlling the biofilm, 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 after an outbreak of a highly evacuation help minimise risk. Because of the (commonly silver diamine fluoride [SDF];
infective, potentially airborne-transmitted possibility of viral load in the blood of COVID- topical fluoride)
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 biofilm
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 fissure sealing and
by reference to Public Health England. are discussed below and make pulp exposures resin infiltration 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 The 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 fissure sealant using high-viscosity glass-ionomer cement
CMCR = chemo-mechanical caries removal
HT = Hall Technique
NRCC = non-restorative cavity control
SDF = silver diamine fluoride
TF = topical fluoride
+/- = with or without

The online supplementary information with hand instruments. A Cochrane review restorations.33 Tooth survival after 3.5  years
file details further sources and some video found no difference in the preventive effect of was 89% and not significantly different 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
The 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. The choice to use
The 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, fluoride-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). The patient has
self-assembling peptide  P11-4 28 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 first place.
Preventive sealants cover plaque-retentive Success depends on the clinician’s ability to
areas, occlusal fissures and pits, which are How it works and clinical effectiveness 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 effectiveness 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 difference to their

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own oral health (attitude). Daily removal or How it works and clinical effectiveness there is less weakening of the tooth structure
disruption of the biofilm by brushing with SDF penetrates infected dentine,43 making (that is, less extensive lesions) and the tooth
a fluoridated 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 superficial layer and fills 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
biofilm/dentine is accessible to a toothbrush It also acts directly on the plaque biofilm,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 effect 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 effect in material loss. There 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 effective as well as cost-effective, 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 fissure 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 sufficient 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 There are currently no clinical trials of efficacy, than replacing with a restoration.
need for restoration. so combinations may be thought of as a ‘belt
and braces’ approach to synergise the benefits Resin infiltration
SDF for dentine lesions of both treatments. What it is and when to use it
What it is and when to use it Resin infiltration (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 camouflage the whitish appearance
and some other countries, it is more usually Sealant materials can control non-cavitated of hypomineralised enamel on smooth
used ‘off-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 significant 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 effectiveness
skin, mucosa and most surfaces on contact. extend into dentine.55,56,57,58,59,60 These are also A very low-viscosity resin infiltrate is
SDF is an effective way of treating active known as micro-invasive treatments. introduced into the micro-porosities of carious
lesions for primary and permanent teeth lesions to fill them through capillary action and
(coronal dentine and root). 37,38 It can be How it works and clinical effectiveness arrest their progress.65 Systematic reviews show
used opportunistically while the patient is in As well as being highly effective for prevention RI to be an effective micro-invasive treatment
the dental chair by applying to other high- of dental caries,30 placing a well-sealed fissure at timespans up to 36 months.61,65
risk surfaces. SDF is effective 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 The diffusion 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. The air-
affects 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 after 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 Their 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
The 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). The correct size of preformed metal ART involves using hand instruments to access consuming, but effective, for caries removal.74
crown is chosen and then pushed over the carious lesions through enamel and to remove The 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
The HT has been used in some secondary tissues. This 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 affected
by molar incisor hypomineralisation. However, How it works and clinical effectiveness 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 The 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 first three years, first lesion on a tooth. One of the difficulties
the crowns should only be placed on teeth and 4.1% over the first five 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
definitive 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 fit 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 effectiveness 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 effective.
The 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 Conflict 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
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