Restorative dental treatment in times of COVID-19

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Restorative dental treatment in times of COVID-19

Tratamento dentário restaurador em tempos de COVID-19

Robson de Lima GOMES1 https://orcid.org/0000-0001-8189-1885

Marlus da Silva PEDROSA2 https://orcid.org/0000-0002-4052-7208

Claudio Heliomar Vicente da SILVA3 https://orcid.org/0000-0002-5649-8683

ABSTRACT

Since the outbreak of the Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus
2 (SARS-CoV-2), numerous restrictive measures have been adopted by governments of different countries. The return to elective
dental care in Brazil is a reality even during the COVID-19 pandemic. During restorative dental procedures, the dental professional
requires close contact with the patient, being exposed to contaminated saliva and fluids. In addition, transmission of COVID-19 by the
generation of aerosol produced by dental handipieces may be possible. Thus, the dental staff must know how to act during restorative
dental procedures, putting into practice the correct clinical protocols to avoid cross-contamination and COVID-19 spread. The purpose
of this article is to review the literature on the biosafety practices especially in the context of restorative dental procedures in times of
COVID-19.
Indexing terms: Betacoronavirus. Coronavirus infections. Dental offices. Dentistry.

RESUMO
Desde o surgimento da COVID-19, causada pelo coronavírus da Síndrome Respiratória Aguda Grave 2 (SARS-CoV-2), inúmeras medidas
restritivas foram adotadas pelos governos de diferentes países. O retorno ao atendimento odontológico eletivo no Brasil uma realidade
mesmo durante a pandemia do COVID-19. Durante procedimentos odontológicos restauradores, o profissional de odontologia requer
contato próximo com o paciente, sendo exposto a saliva e outros contaminantes. Além disso, a transmissão de COVID-19 pela
geração de aerossol produzido por peças de mão odontológicas pode ser possível. Assim, a equipe odontológica deve saber agir em
durante o procedimento restaurador, colocando em prática os protocolos clínicos corretos para evitar a contaminação cruzada e a
disseminação do COVID-19. O objetivo deste artigo é revisar a literatura sobre as práticas de biossegurança, especialmente no contexto
de procedimentos odontológicos restauradores em tempo de COVID-19.
Termos de indexação: Betacoronavirus; Infecções por coronavirus. Consultórios odontológicos. Odontologia.

INTRODUCTION Syndrome Coronavirus 2 (SARS-CoV-2), has spread from

Wuhan city, in China, to other provinces and countries in
The outbreak of the Coronavirus Disease 2019 late December 2019 [1,2]. The World Health Organization
(COVID-19), caused by the Severe Acute Respiratory (WHO) declared the COVID-19 as international health

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1
Universidade Federal de Pernambuco, Curso de Odontologia. Recife, PE, Brasil.
2
Universidade de São Paulo, Faculdade de Odontologia, Departamento de Biomateriais e Biologia Oral. São Paulo, SP, Brasil.
3
Universidade Federal de Pernambuco, Curso de Odontologia, Departamento de Prótese e Cirurgia Buco-Facial. Av. Prof. Moraes Rego, s/n.,
50670-901, Recife, PE, Brasil. Correspondence to: CHV SILVA. E-mail: <[email protected]>.
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How to cite this article

Gomes RL, Pedrosa MS, Silva CHV. Restorative dental treatment in times of COVID-19. RGO, Rev Gaúch Odontol. 2020;68:e20200019.
http://dx.doi.org/10.1590/1981-863720200001920200075

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BY RGO, Rev Gaúch Odontol. 2020;68:e20200019 1
RL GOMES et al.

emergency on 30 January 2020 [1-3]. COVID-19 affected Patient reception and waiting room
the economy and health systems of several countries
[4,5]. According to the most recent data from the Johns A telephone triage should be considered to assess
Hopkins Coronavirus Resource Center (coronavirus.jhu.edu/), the patient’s current signs and symptoms. In suspected
the global number of confirmed cases of COVID-19 was cases, it is recommended that the patient do not attend
dental services. In cases where patient attendance is
9.129.793 with 472.793 deaths on June 23.
indicated, it is important that the professionals are able
The incubation period of COVID-19 was estimated to identify suspected cases of COVID-19. The body
to be 5 to 14 days [2,3]. COVID-19 positive patients may temperature must be the evaluated using a digital forehead
experience fever, dry cough, dyspnea, fatigue, muscle thermometer as it does not require physical contact. Then,
pain, headache, sore throat, diarrhea, vomiting, ageusia, a clinical pre-treatment questionnaire must be applied to
anosmia and mucocutaneous manifestations [2,3,6,7]. patient [9,16]. The questionnaire should address questions
According to the symptoms and their intensity, the cases regarding fever, respiratory problems, travel to endemic
can be classified as mild (26%), moderate (65%) or areas, and contact with confirmed or suspected cases of
severe (9%). The severe cases are often associated with COVID-19 [9].
later ages and the existence of comorbidities (diabetes, It is important that the patient respect the
hypertension, cardiovascular diseases; respiratory scheduled appointment time and the dentists pay attention
problems, obesity, immunosuppression) [8]. to the time between each patient. The time to carry out
The contact with symptomatic or asymptomatic all recommendations for disinfection of the dental office
should also be respected [4,9,14-16].
patients, without adequate individual protection, brings
to health professionals a high risk of infection, especially In the waiting room, clear instructions in order
physicians, physiotherapists, nurses and dentists [1-3,9]. to not disseminate infections should be given. Sink with
The last, due to the physical proximity to the patients (face soap and water for hand washing and hand sanitizer
to face), frequent exposure to saliva, blood and other (70% alcohol gel) should be easily available. It must be
ensured that all patients receive surgical masks. A distance
fluids, production of aerosols, in addition to contaminated
of at least 1m between the patients should be respected
manual cutting instruments, presents high chances of
[4,9,16].
contamination and cross-infection during dental care
[1,9-12].
To reduce the spread of SARS-Cov-2, the Brazilian Use of Personal Protection Equipment (PPE)
Federal Council of Dentistry and the Brazilian Health
Personal protective equipment (masks, surgical
Regulatory Agency recommended dental care to be
caps, gloves, lab coats, waterproof disponible gowns,
performed only in cases of urgencies and emergencies
goggles and face shields) must be available daily as they
following strict infection control guidelines [13-15]. The promote an effective barrier against most generated
return to elective dental care in Brazil is a reality. The aerosols [4,9,10,14,16,18-20].
professional must observe that the risk of cross-infection
may increase according to the procedure. The purpose
of this article is to review the literature on the biosafety Masks
practices especially in the context of restorative dental
Surgical mask should be used in procedures at
procedures in times of COVID-19.
least 1m from the patient and changed constantly. They
The dental practice may predispose the COVID-19 must not be touched or placed on the neck and pockets.
dissemination due to the procedures, which involve face- When performing aerosol generation procedures, a N95
to-face communication and frequent exposure to saliva, blood respirator must be chosen. The N95 respirator with an
and other body fluids. In addition, during the procedures, exhalation valve are not recommended dentistry as it
concerns remains on contaminated saliva droplets and provide low resistance during exhalation. In addition, it is
produced aerosols [1,4,9-12,14-18]. a vulnerable component of a respirator and under actual

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 Restorative dental treatment in times of COVID-19

working conditions may become dirty or damaged to the Mouthwashes with hydrogen peroxide
point of causing significant leakage [21]. The exhaled air
may contaminate patients and the environment if the Mouthwashes prior to dental treatment are
professional is infected. The N95 or PFF2 mask must be recommended to reduce the amount of microorganisms
changed if dirty. on the oral surfaces. In addition, before the procedures,
the patients can be asked to brush their teeth without
denfrice in appropriate room. Mouthwash with 0.12%
Gloves chlorhexidine, usually used in dentistry, did not prove to
be the most effective in preventing the transmission of
Gloves should be used when there is a risk of Coronavirus. The use of Hydrogen Peroxide 1% or 1.5%
contact with blood, body fluids, secretions, mucous (9ml for 30 seconds) is seen as the most effective agent
membranes and skin as well as contaminated dental to be used prior to treatment. This procedure should be
instruments or equipment. performed after a consistent reduction of residual saliva,
by continuous aspiration. This procedure should be
performed before the subsequent use of 0.12% or 0.2%
Lab coats and disposable gowns chlorhexidine [4,9,15,22].

Lab coats or disposable gowns with long sleeves,

thumb-loop/knitted cuff wrists and open back/closure Recommendations regarding dental restorative
back design must be used. They must be non-allergenic, procedures
resistant and provide an effective antimicrobial barrier.

Dental handpieces
Goggles and face shields
Handpieces are frequently used in cavity
The COVID-19 may also be transmitted through preparation during restorative dental procedures. In view
contact with the mucous membranes of the eyes, so it is of the current situation, anti-retraction dental handpieces
essential to wear goggles. Eyeglasses are not considered with specially designed anti-retractive valves or other
personal protective equipment as they do not have side anti-reflux designs are strongly recommended in order
shields. Face shields should be used to provide broader to avoid cross-contamination as they reduce the reflux of
protection, reducing contact between droplets/aerosols with oral bacteria in the tubes of the handpiece and dental unit
the professional’s face and the surgical mask or respirator. and the production of aerosols [9,16,22]. In addition, they
The dental healthcare personnel must learn the should be sterilized after each appointment [9,22].
proper care, maintenance, useful life, and disposal of the
personal protective equipment. The professional must
Water spray
remove all the personal protective equipment before
leaving the dental office. Between each appointment, To avoid the high production of aerosols, the use of
disinfection of goggles and face shield should be performed the high speed handipiece without abundant water spray
by washing with soap and water and 70% alcohol [9,16]. is the most recommended. It is not recommended to use
the triple syringe. In addition, the frequent use of spitpan,
aspirators or cotton to dry the area is not recommend as
Hand washing the contamination of air and water tubes can occur inside
the dental unit [10,15,16].
There is a growing awareness of the importance
of hand washing. Epidemiological studies show that hand
washing with soap and water and disinfection with 70% Rubber dam isolation
alcohol gel are effective in controlling the transmission of
COVID-19. The 70% alcohol gel is effective only if your Rubber dam isolation of the operative field during
hands are not visibly dirty [4,9,10]. cavity preparation whenever the procedure permits should

RGO, Rev Gaúch Odontol. 2020;68:e20200019 3

RL GOMES et al.

be used. This significantly minimizes the production of Urgencies and emergencies in Dentistry
contaminated aerosol or prevents spills of contaminated
saliva and blood, particularly in cases where use high-speed In view of the recommendations of the Brazilian
handpieces are required [4,9,10,16,22]. Federal Council of Dentistry, during the COVID-19
pandemic, only emergency and urgent care is recommended
[14,15]. Dental emergencies are procedures that do not
Suction pumps present a risk of death but that require intervention to
relieve discomfort such as pain [7,14,15]. The restorative
High-powered suction systems are necessary procedures that are considered dental emergencies are
during restorative procedure to eliminate infectious droplets dental trauma, extensive caries or defective restorations
as soon as they are emitted, and thereby minimizing their that cause pain and fabrication of provisional restorations
dispersion in the air. It is also important to clean the suction if the restoration is lost, broken or is causing gingival
device filters at the end of each appointment with irritation.
chlorine-based disinfectant (2.5 - 5% sodium hypochlorite
[10,15].
Surfaces disinfection

All contaminated surfaces need to be cleaned

Cavity preparation
and disinfected correctly at the end of each patient
In cases where rubber dam isolation is not possible appointment, which include the dental office, common
areas, equipment, door handles, chairs, tables, floor and
as well as in elective cases, one should opt for manual
walls [9,22]. 62-71% ethanol, 0.1% sodium hypochlorite
removal of carious tissue by using dentine excavators
and 50% quaternary ammonia can be used for cleaning
[4,9,15,16]. The use of chemical caries removal techniques
and disinfection. Other biocidal agents, such as 0.05-
should also be considered [4]. 0.2% benzalkonium chloride or 0.02% chlorhexidine
digluconate are also agents of choice, but are less effective.
Protective barriers must be changed each appointment
Dental X-rays
as the SARS-Cov-2 survives for approximately 2 to 9 days
on surfaces [9,16,22].
Preferences should be given to panoramic
radiographs or cone beam computed tomography. Intra-
oral radiographs stimulate salivation and coughing during Waste management in dental office
image acquisition [15,17]. Minimal sedation might also
be considered to control the vomiting reflex in some Waste produced after performing procedures
procedures [10]. in patients with suspected or confirmed coronavirus
infection is considered infectious medical waste. Disposal
of contaminated materials such as gloves and masks must
Adhesive dental materials be done after each visit and packed in closed plastic bags
identified as infectious [10,16]. The dental instruments and
A minimum time permanence in the dental office dental high and low speed handpiece must be sterilized.
can minimize the chances of cross-infection. Materials Care must be taken in the handling of dental materials to
that guarantee a reduced clinical time are recommended. not promote cross-infection [16].
Universal adhesive systems are products easy to use since
the same product has several technical possibilities [23,24]. CONCLUSION
To reduce the clinical time, preferences should be given to
Bulk-Fill composite resins as it permits increments of up to In order to minimize COVID-19 spread,
4mm in thickness [25,26]. It is clear the benefits that these recommendations for safe dental care are necessary.
materials provide in a matter of reduced clinical time for Dental professionals must be aware of the signs
the professional during dental restorative care in times of and symptoms of COVID-19, and the control measures in
COVID-19. avoid the spread of the disease.

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