News

The big question at the moment in the dental industry in Australia is whether or not dentists should continue seeing patients for treatment during the precautionary times of the Coronavirus pandemic.

As of Wednesday evening here in Australia society is being warned to practice self-isolation as much as possible as a precautionary measure and to maintain a 1.5 metre safe distance away from fellow humans where possible.

We are told that shaking hands and hugging as means of greeting are now inappropriate, and must cease.

These practices allow the easy spread of Covid-19, and must stop.

In these times.

Some dental associations and state authorities in the USA are recommending for dental practices to cease regular appointments.

The reasons for caution and possible change of routine:

As far as I can see there are two reasons for change.

Firstly, as a profession we need to be seen to be helping to reduce the spread of the Coronavirus throughout society.

Information to hand at the moment is that the Covid-19 virus can remain active away from the human body for time frames of several hours. [See the research attached below on BBC news quoting research published in the New England Journal of Medicine.].

Putting it simply, the use of ultrasonic scalers and high speed drills on dental patients who may not know they are infected with Covid-19 will create an aerosol spray that could propagate their infection onto dental office surfaces, clothing, and dental office employees.

As such, from the research, in my opinion, by carrying on the usual practice of dentistry in rooms not set up with the correct airflow, we could be putting our dental staff at risk of infection.

And unwittingly, their families and friends that they come in contact with could easily also become infected.

However, in my opinion, the use of public places, and touching common surfaces in public places, also contains added risk of infection.

But, if we as dentists are practicing safe procedures that do not, and has not resulted over the years in the spread of Hepatitis B, one could easily suggest that those measures in place are therefore sufficient to not spread Covid-19.

Only time will tell….

But, what would happen to any business or industry that an outbreak of Coronavirus was traced to?

Would there be a public shaming of that industry?

Especially at times when other industries are practicing less populous practices that are significantly more socially responsible?

What would happen if an outbreak of Coronavirus in a retirement village was traced back to someone from that community visiting a dental practice for treatment?

The news this week:

An email on Wednesday April 18 from the Australian Dental Association, is suggesting for dentists to proceed with a “business as usual” approach.

The email read:

Since the last time I was in contact, the situation regarding COVID-19 has changed considerably.  

Over the last 24 hours, we’ve seen mixed messages from international dental regulators and associations about the potential disruption of dental services, deferral of all non-essential treatment and forced closures.  

Understandably, this has caused confusion and distress about what this means for us as business owners, employees, contractors, academics, researchers and students, and as an entire profession.  

Last night, we called a meeting with ADA Branch Presidents and CEOs from every state and territory. The following was taken into consideration:

1. The environments in the UK and US, while sharing some similarities, are not identical to the one in Australia.
   
2. It’s vital that information and resources are prepared with consideration of the Australian context.
   
3. We have some of the most rigorous infection prevention and control standards in the world.
   
4. The Federal Health Minister’s office has confirmed that essential health services including dental will continue to operate as normal. There is no current advice or mandate from the Federal Government, AHPRA, or the Dental Board that suggests dental services should be limited or ceased.
   
5. The ADA must continue to dedicate our resources to managing both the wider implications of COVID-19 on dental practices through resources and information, and to ensuring the availability of emergency masks. 
6. While at this time there is no requirement that dental services reduce or cease, we will be developing contingency plans to assist practices in the event the advice of the Health Department changes.  

For now, provided you’re keeping across the advice available on the ADA website (www.ada.org.au/COVID-19) and from the Department of Health, you can continue to practice to our usual high standards.   

The ADA team from around the country are collaborating to support the huge number of support requests we’re receiving, while rapidly developing resources and information based on expert advice across infection control, human resources, and finance. 

This is approach in Australia is in distinct contrast to the Ohio Dental Association website posting on Monday March 16:

Gov. DeWine recommends COVID-19 actions for dental offices

by ODA Staff
3/16/2020

Governor Mike DeWine contacted the Ohio Dental Association and Ohio State Dental Board and asked for our help in addressing the spread of COVID-19.

These recommendations to the dental profession are intended to reduce the risk of patients’ exposure to COVID-19 (coronavirus) to preserve Personal Protective Equipment and supplies, while still allowing access to necessary and emergency dental services that will maintain the oral health of the citizens of Ohio and keep them out of hospital Emergency Rooms.

Governor DeWine has requested the following: 

A review of inventories and identification of any surplus personal protective equipment and supplies. Once identified, contact your local Emergency Management Agency about sharing these goods with local hospitals and medical clinics for COVID-19 patients and clinicians. EMA contact list can be found here: https://webeoctraining.dps.ohio.gov/ohiocountyEMADirectorList/countyemalist_web.aspx

Please reschedule elective procedures including but not limited to: 

• Any cosmetic or aesthetic procedures, such as veneers, teeth bleaching, or cosmetic bonding
• All routine hygiene appointments
• Any orthodontic procedures not including those that relieve pain and infection or restore oral function or are trauma-related
• Initiation of any crowns, bridges, or dentures that do not address or prevent pain or restore normal oral functioning
• Any periodontal plastic surgery
• Extraction of asymptomatic non-carious teeth
• Recall visits for periodontally healthy patients
• Delay all appointments for high risk patients, including ASA 2 and 3 patients, unless it is an emergency

By sharing supplies we are directly supporting our fellow clinicians as they undertake the greatest viral threat in modern history. By rescheduling elective procedures we are doing our part to prevent community spread.

We urge you to undertake the two above strategies and consider the following additional measures: 

• Use cell phone triage – use the cell phone to take a picture of the area and text to the dentist
• Have a detailed questionnaire/conversation before scheduling appointments and prior to any procedure about flu like symptoms, travel abroad for self and family/friends/co-workers etc. to permit a thorough evaluation of the patient
• Consider taking the temperature of the patient at the outset
• Reconsider scheduling high risk patients unless they need emergency treatment
• Careful evaluation of the need for scheduling of ASA 2 & 3 patients
• Use of 1% hydrogen peroxide rinse prior to examination of the oral cavity by the patient to reduce microbial load
• Use of rubber dam isolation & high volume suction to limit aerosol in treatment procedures
• Proper disinfection protocol between patients with a possible repeat of the protocol for a 2nd time.

To prevent over-crowding of waiting areas or the possible spread of infection:

• Consider having patients wait in their cars instead of the waiting areas to prevent inadvertent spread of the virus (call patient when surgical area is ready for treatment)
• Consider staggering appointment times to reduce waiting room exposure
• Consider rescheduling elective procedures on ASA 2 & 3 patients (https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system)
• Have front desk staff take measures to prevent exposure
• Have sterilization staff, lab technicians and auxiliary staff take adequate measures to prevent exposure
• Limit access to waiting room use to only patients. Accompanying individuals have to wait in their respective transportation.
• Remove all magazines/toys etc from waiting area to prevent contamination.

Thank you for your understanding and cooperation during these difficult times. We will continue to provide resources and updates for dental offices as they become available.

Coronavirus Resources:

• Info from the ADA specific to dentists: https://success.ada.org/…/infectious-diseases-2019-novel-co…
• Info from the Ohio Department of Health: https://coronavirus.ohio.gov/wps/portal/gov/covid-19/
• Info from the CDC: https://www.cdc.gov/coronavirus/2019-ncov/summary.html

Check back here for more details as they become available. 

This information is being provided as a public service during the coronavirus outbreak.

This BBC article [published at https://www.bbc.com/future/article/20200317-covid-19-how-long-does-the-coronavirus-last-on-surfaces ] on March 17 2020 by Richard Gray was edited on 18 March 2020 to add the fact that the research paper by Neeltje van Doremalen and colleagues has now been published in the New England Journal of Medicine.

Like many respiratory viruses, including flu, Covid-19 can be spread in tiny droplets released from the nose and mouth of an infected person as they cough. A single cough can produce up to 3,000 droplets. These particles can land on other people, clothing and surfaces around them, but some of the smaller particles can remain in the air. There is also some evidence that the virus is also shed for longer in faecal matter, so anyone not washing their hands thoroughly after visiting the toilet could contaminate anything they touch.

It is worth noting that, according to the Centres for Disease Control and Prevention, touching a surface or object with the virus and then touching one’s own face “is not thought to be the main way the virus spreads”. Even so, the CDC, the World Health Organization and others health authorities, have emphasised that both washing one’s hands and cleaning and disinfecting frequently touched surfaces daily are key in preventing Covid-19’s spread. So although we still don’t know exactly how many cases are being caused directly by contaminated surfaces, experts advise exercising caution.

One aspect that has been unclear is exactly how long SARS-CoV-2, the name of the virus that causes the disease Covid-19, can survive outside the human body. Some studies on other coronaviruses, including Sars and Mers, found they can survive on metal, glass and plastic for as long as nine days, unless they are properly disinfected. Some can even hang around for up to 28 days in low temperatures.

Coronaviruses are well known to be particularly resilient in terms of where they can survive. And researchers are now beginning to understand more about how this affects the spread of the new coronavirus. (Read more about the global fight against Covid-19.)

Neeltje van Doremalen, a virologist at the US National Institutes of Health (NIH), and her colleagues at the Rocky Mountain Laboratories in Hamilton, Montana, have done some of the first tests of how long SARS-CoV-2 can last for on different surfaces. Their study, which has been published in the New England Journal of Medicine, shows that the virus could survive in droplets for up to three hours after being coughed out into the air. Fine droplets between 1-5 micrometres in size – about 30 times small than the width of a human hair – can remain airborne for several hours in still air.

It means that the virus circulating in unfiltered air conditioning systems will only persist for a couple of hours at the most, especially as aerosol droplets tend to settle on surfaces faster in disturbed air.

But the NIH study found that the SARS-CoV-2 virus survives for longer on cardboard – up to 24 hours – and up to 2-3 days on plastic and stainless-steel surfaces. (Learn how to clean your mobile phone properly.)

The findings suggest the virus might last this long on door handles, plastic-coated or laminated worktops and other hard surfaces. The researchers did find, however, that copper surfaces tended to kill the virus in about four hours.

But there is a speedier option: research has shown that coronaviruses can be inactivated within a minute by disinfecting surfaces with 62-71% alcohol, or 0.5% hydrogen peroxide bleach or household bleach containing 0.1% sodium hypochlorite. Higher temperatures and humidity also tend to result in other coronaviruses dying quicker, although research has shown that a related coronavirus that causes Sars could be killed by temperatures above 56°C or 132°F (hotter than even a bath scalding enough to cause injury) at a rate of about 10,000 viral particles every 15 minutes.

Although there is no data on how many virus particles will be in a single droplet coughed up by an infected person, research on the flu virus suggests smaller droplets can contain many tens of thousands of copies of the influenza virus. However, this can vary depending on the virus itself, where in the respiratory tract it is found and at what stage in the infection the person is.

The researchers did find, however, that copper surfaces tended to kill the virus in about four hours

On clothing and other surfaces harder to disinfect, it is not yet clear how long the virus can survive. The absorbent natural fibres in cardboard, however, may cause the virus to dry up more quickly than on plastic and metal, suggests Vincent Munster, head of the virus ecology section at Rocky Mountain Laboratories and one of those who led the NIH study.

“We speculate due to the porous material, it desiccates rapidly and might be stuck to the fibres,” he says. Changes in temperature and humidity may also affect how long it can survive, and so may explain why it was less stable in suspended droplets in the air, as they are more exposed. “[We’re] currently running follow-up experiments to investigate the effect of temperature and humidity in more detail.”

The ability of the virus to linger for so long only underlines the importance of hand hygiene and cleaning of surfaces, according to Munster.

“There is a potential for this virus to be transmitted via a variety of routes,” he says.

* This article was edited on 18 March 2020 to add the fact that the research paper by Neeltje van Doremalen and colleagues has now been published in the New England Journal of Medicine. It has also been clarified that the virus’s survival on natural fibres has only been tested on cardboard.

Just for the record…

The hepatitis B virus can survive outside the body for at least 7 days.

According to the World Health Organisation, the hepatitis B virus can survive outside the body for at least 7 days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine. The incubation period of the hepatitis B virus is 75 days on average, but can vary from 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B.

https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

The HIV virus cannot survive very well outside the body.

Even if HIV can survive outside the body, does that necessarily mean that a person who touches or comes into casual contact with infected blood or semen runs the risk of infection? The answer to that question is almost universally “no.”

https://www.verywellhealth.com/how-long-can-hiv-live-outside-of-the-body-48891

https://www.cdc.gov/hiv/basics/transmission.html

HIV isn’t spread through saliva, and there is no risk of transmission from scratching because no body fluids are transferred between people.

HIV does not survive long outside the human body (such as on surfaces), and it cannot reproduce outside a human host. It is not spread by

• Mosquitoes, ticks, or other insects.

• Saliva, tears, or sweat that is not mixed with the blood of an HIV-positive person.

• Hugging, shaking hands, sharing toilets, sharing dishes, or closed-mouth or “social” kissing with someone who is HIV-positive.

All suggestions of socially responsible isolation practices by authorities are being put into place to reduce the anticipated EXCESSIVE demand on our medical resources so that everybody who does get infected can be treated appropriately and effectively.

Countries with high mortality rates associated with the Coronavirus are where they are because they failed to implement socially responsible isolation practices.

Although these practices may seem brutal for businesses and society, they are essential for lowering the impact of this pandemic.

We live in interesting times.

Stay tuned….

There are so many other smart things you should be doing during these uncertain times, to sure up your dental practice and to prevent patients from bleeding out of your office [figuratively speaking].