Coming out of lockdown: informing the public and patients
Martin Addy, emeritus professor in dentistry and Liam Addy, consultant in restorative dentistry, look at how dental teams can keep the public informed as the country edges out of lockdown.
As the hope for easing of lockdown across dentistry approaches, dental teams in practices, clinics, hospitals and schools will prepare for a return to a level of normality in dental care.
How long this process will take has been much debated with polar views expressed ranging from soon to never. Upmost in the minds of the dental team must be public health, patients and the team itself.
Experts and government advisors, whilst recommending slow and cautious easing of some restrictions for the UK population, remind that COVID-19 has not gone away and could be within the population for many months – even years.
Dental teams will be mindful of this in their preparations for the return of dentistry. The purpose of this article, aimed at all dental care professionals, and for that matter health care professionals in general, is to further consider the role of oral hygiene in preventing coronavirus. This includes the transfer of knowledge to the population.
Firstly, consideration should be given to the impact of COVID-19 on the practice of dentistry. It must be seen as adverse and, to date, unique.
Like many occupations, dental professionals have suffered a double lockdown: to stay at home and not go to work for social distancing reasons. Social distancing is further compounded in dentistry by the creation of aerosols in many dental procures. Such aerosols in turn readily contaminate personnel and surgery surfaces.
This means dentists can only offer advice, analgesia and antibiotics (the three As) based usually on a ‘telephone diagnosis’. This comes at a time when the use of antibiotics across medicine and dentistry is being discouraged when an alternative treatment for acute infections is possible, such as drainage. Emergency dental treatment is offered at some clinics and hospitals around the UK, via urgent dental centres (UDCs).
If these centres have aerosol generating procedure (AGP) rooms, then more options are available. Extraction of teeth, however, may be the only clinical intervention that can be offered during this pandemic. To this end, the availability of personal protective equipment (PPE) does not appear to have been an issue in some emergency dental clinics.
Dentists in strong position
The risks of easing lockdown and social distancing have been alluded to. The dental team, however, is in a strong position. It has decades of experience and practice in the prevention of infection to and from patients. Thus, dentistry involves ‘operations’ on patients for many hours of the working day. The constant risk of cross infection is not seen in any other branch of medicine or surgery.
Hand washing and donning of protective equipment by nurses, dentists, hygienists and therapists is just the norm of every day professional life. COVID-19 has, however, added a further layer on infection control for the dental team. This will become particularly apparent as lockdown eases and the danger of a second spike arises.
Infection levels has reached pandemic proportions, partly because individuals can carry the virus with minimal or no symptoms. It is therefore worth reviewing how this viral disease is spread and the basis for preventive measures recommended.
Encourage regular brushing
Direct and indirect spread by the hands has been frequently cited as a major issue in COVID-19. This is the basis for regular hand washing with soaps and hand washing products. In particular, detergent-based products exert rapid antimicrobial action against bacteria, fungi and viruses including the COVID-19 coronavirus.
Direct spread, however, mainly takes place by salivary droplets expelled by coughing, sneezing or just talking. This is what lies behind the recommendation to socially distance. These two issues, of detergents and the mode of salivary spread, fuel the request to the profession to reaffirm two minute, twice daily tooth brushing with toothpaste for everyone.
The detergents in toothpaste are the same as found in hand washes and are effective against coronavirus. The figures for tooth brushing frequency suggest 75% of the UK population brush twice or more per day and 25% brush once or less. 1-2% do not brush at all. There is, therefore, room for the dental team to make a difference.
Other oral care products have been strongly recommended for research in the prevention of coronavirus, notably mouth rinses. For toothpaste and rinses there is an important fact to be considered. Coronavirus replicates in salivary glands and places demands on the duration of antimicrobial action of oral care products.
Even if a product exerts an immediate effect on salivary viral load, unless there is persistence of action, the virus will be rapidly replaced via the salivary glands – possibly by an increase in salivary flow produced by the oral care product.
Here is not the place to discuss the persistence of action of active agents in oral hygiene products, as data are limited. For toothpaste, the persistence of antimicrobial action based on bacteria indicates effects lasting 3-5 hours. This supports recommending more frequent daily brushing but with resulting compliance issues.
Lack of oral care
However, in the context of helping to prevent spread the virus, the timing of brushing is important. Brushing just before leaving home or using public transport, for example, should be recommended. Also carrying toothpaste to apply via a finger would increase the exposure of the mouth to toothpaste activity.
Similar recommendations in oral hygiene practices by frontline workers should be made, including for the dental team. Brushing before donning protective equipment would seem eminently sensible as would more frequent application of toothpaste, even if only by the finger.
Certain groups of people are significant in their need for oral hygiene advice and care. Most notably, these are residential or nursing homes where most are elderly and a proportion have cognitive and or physical impairment.
Many of these residents rely on carers for all their hygiene regimens, but oral care may be lacking. This assertion is supported by a study of oral health of residents in 22 nursing homes in the South West. High levels of plaque, gingivitis and root caries were found. Most dentures were rated as unhygienic. Denture stomatitis was present in one third of denture wearers. Almost two thirds had not seen a dentist in five years (Frenkel et al 2000).
Importantly however, and relevant to today’s dental teams, a randomised controlled trial assessing professionally delivered oral care education to caregivers in the same nursing homes resulted in significant reductions in plaque, gingivitis, denture plaque and denture stomatitis (Frenkel et al 2001).
Unfortunately today, concerns have been expressed about the provision of routine and emergency dental treatment, and oral and denture hygiene for residents in nursing homes and self-isolating elderly and infirm at home. (M Doshi, BDA publications: coronavirus and the elderly, 2020).
Struggles among elderly
The problem for the elderly and infirm, whether at home or in residential care, is compounded by the COVID-19 lockdown measures. These largely curtail or prevent visitors, professional or otherwise, to the elderly.
Additionally, carers in residential homes can struggle to provide oral and denture care to their residents for several reasons. For example, the sheer number and frequency of hygiene regimens required; the previous lack of protective equipment and a lack of knowledge of the potential role of oral and denture cleaning in reducing the spread of coronavirus within residential settings.
The final part of this article is to provide the dental team with an informative document on COVID-19 for dissemination. The document is based on the slogan: Wash Your Hands and Brush Your Teeth.
The dental team may wish to use it as it is, modify to meet their specific needs, or rewrite their own. At this time, dental teams need exploit their considerable skills and specialised knowledge to help in the preventive fight against COVID-19.
Martin Addy is an Emeritus Professor in dentistry at the University of Bristol. Liam Addy is a consultant in restorative dentistry at the Dental School and Hospital of Cardiff University.
Frenkel et al. Geriodontology, 17, 33-38, 2000.
Frenkel et al. Community Dentistry and Oral Epidemiology, 29, 289-297, 2001.
Find out more about Dentistry’s Back to Practice campaign.