Curd Bollen, Yasna Najmi and Maher Almasri examine the influence of the coronavirus outbreak on the current and future practice of implant dentistry.
The year 2020 will always be remembered as the year of COVID-19. It influenced almost every facet of our society – and medical and dental services in particular.
The pandemic caused by the SARS-CoV-2 virus led to a near-worldwide lockdown. This has had a disastrous impact on daily dental services. It also completely changed the future approach towards medicine and dentistry.
This article focuses on the impact of the coronavirus on the field of implant dentistry. In particular, discussion of the environmental, clinical and psychological factors, as well as the economic impact, will take place.
There are several recommendations proposed to introduce a safer workplace for both patients and clinicians in times of a viral pandemic.
Introduction
International scientific literatures elaborates on the origin of the problem. COVID-19 is an airborne infection that is spread by airborne particles (aerosols) and through physical contact (Morawska and Milton, 2020; Jayaweera et al 2020).
General dentistry was extremely affected by this problem. The fact that a majority of the treatments use high-speed and ultrasonic devices that generate aerosols in the treatment room, increased the risk of respiratory transmissions (Amato et al 2020).
Social distancing can restrict the spread of the virus, however this approach is impossible in dentistry where practitioners are always in close contact with their patients during treatments (Lewnard and Lo, 2020).
Implant dentistry is a specific and popular field in dentistry that avoids the use of high speed handpieces and therefore the generation of aerosols, allowing the treatments to be performed in a sterile surgical environment. Even the application of water coolant is not a necessity (Flanagan, 2010). This aseptic surgical approach is strictly indicated for the surgical procedure of splitting the periosteum from the underlying bone.
The COVID-19 pandemic made healthcare professionals – and implant dentists in particular – take extra measures to deliver exceptional care in the safest possible environment. Protocols were reassessed, adapted and rewritten to fulfil the requirements to stop the spread of the coronavirus.
Environmental impact and perspectives
Preselection and triaging over the phone as well as emails or online communications are and will continue to be mandatory.
Patients with symptoms of a COVID-19 infection should be prohibited from entering the implant clinic. This can be assessed by the implementation of a strict door policy: a short questionnaire in combination with an infrared temperature check (Li et al, 2020).
Surgical procedures should by all means be performed under maximal aseptic conditions, using disposable protective equipment where possible. Preparation of the surgical room before and after the treatment, along with the handling of instruments should be carried out up to the highest standards.
Disinfection
Even prior to the advent of COVID-19, this aseptic technique has contributed to an increase in the success rates of the dental implants placed (Veitz-Keenan et al, 2018). The general advice here, is to treat all your patients the same way you prefer to be treated.
The surgical theatre can be disinfected by using commercial UV-C (ultraviolet-C) beams. UV-C beams with a wavelength of 254nm have a germicidal effect on bacteria and viruses, producing damaging consequences on the reproductive apparatus of both microorganisms (Hadi et al, 2020). The equipment can reduce both bacteria and viruses in ambient air up to 90% and the airflow capacity can rise to 120m3/h. Both the US Food and Drug Administration (FDA) and the World Health Organization (WHO) advise this approach to be carried out for the sterilisation of the ambient air in treatment rooms.
However, with ozone disinfection it is less feasible to attain this goal (Elvis and Ekta, 2011; Dubuis et al, 2020).
This approach is based on the addition of oxygen and has several disadvantages. It can not only cause hyperoxygenation and premature ageing of certain surfaces (such as rubber), but it also has an impact on health.
To avoid chest pain, coughing, short breath, eye and skin irritation, it is recommended to keep doctors, assistants and patients away during ozone action.
Clinical impact and perspectives
Clinically the focus should be on (1) reducing the number of appointments, (2) avoiding specific treatment options, (3) applying extra tools and (4) implementing new techniques.
Reduce the number of appointments
The more contact there is between staff and patients, the higher the risk of disease transmission. Reducing the number of appointments is not always possible, but with a different approach, a large reduction in the overall contact time can be obtained.
- Non-submerged techniques: when a one-stage non-submerged technique is used to place the dental implant, there is no need for the second surgical appointment to uncover the implant. The use of tissue-level implants offers this advantage and is a well-documented approach. Moreover, Eposito and co-workers proved in 2009 that there is no difference in the final outcome between a one-stage versus a two-stage implant placement
- Avoiding compromised patients: severely immunocompromised patients as well as those patients taking (several) anticoagulants often present more complications and therefore require more attention and postoperative care. This is due to the fact that they are more susceptible to other infectious diseases. In a pandemic, this means extra and unnecessary appointments (Kumar and Dey, 2020). It is therefore advised to reschedule such patients until after a pandemic or alternatively, refer them to a hospital setting
- Full digital workflow: using an intraoral scanner with the concept of a full digital workflow has several advantages. Not only are fewer visits scheduled, but the chance of cross-infection is also strongly reduced. During impression taking, blood remnants are often left around the impression copings, especially if the implants were uncovered right before the final impression. Using a scanner avoids contact with blood and any remnants. (Papi et al, 2020).
Avoid specific treatment options
Just like ultrasonic scalers are not recommended to be used in periodontal treatments, similarly, alternative approaches have been advised in implant dentistry (Ge et al, 2020).
- Radiology: extraoral radiographs have a low risk of infection in comparison to intraoral techniques. Therefore, OPG and CBCT are the preferred imaging techniques during a viral pandemic, since there is no contact with saliva (Ilhan et al, 2020). This idea is of course not in accordance to the ALARA principle, which emphasises trying to avoid patients’ overexposure to dental X-rays (Dykstra, 2011)
- Piezosurgery: since piezosurgery is an ultrasonic procedure that involves the generation of aerosols, using this equipment is not advised. The same is applicable to water-cooled Nd-YAG lasers or titanium brushes for the treatment of peri-implantitis
- Sinus lift: when bone augmentation is indicated in the posterior maxilla, a closed (Summers) technique is preferred (Summers, 1994). However, for the lateral window technique, high speed water coolant or piezosurgical equipment has to be applied, again creating aerosols
- Magnification: the use of loupes or microscopes during treatments ensures a distance is maintained between the practitioner and the patient. This distance is far below the advised six feet of social distancing. However, it still offers some distance, which contributes to a safer workplace (Friedman et al, 1999)
- Rinsing: before every intraoral dental procedure the patient has to rinse thoroughly with a disinfectant. Recent literature has demonstrated that H2O2 (0.5%) and povidone-iodine/idopovidone (0.2%) are both effective against coronavirus particles. Chlorhexidine has no effect on this virus (Peng et al, 2020; Vergara-Buenaventura and Castro-Ruiz, 2020)
- Coatings: recent research reported that copper-alloy coatings reduce the survival of coronavirus to less than four hours. This technique can coat future instruments and surfaces for medical practices (Poggio et al, 2020).
Implement new techniques
Most implant systems use high speed drilling for osteotomy preparations (850-2,000rpm), always in combination with external water cooling.
It was believed that low-speed drilling without adequate cooling overheated the bone and lead to osteoblast degeneration. However, research has proven otherwise (Kim et al, 2010).
- Bicon: the Bicon implant system (short and wide implants) has been on the market for more than 30 years. It is used with a slow speed drilling handpiece (50rpm) in the absence of coolant. Due to this approach a lot of extra bone can be harvested from the osteotomy (Li et al, 2020)
- Nobel Biocare N1: similarly, this implant also requires slow speed drilling (with a specific Osseoshaper burr) with the absence of a cooling mechanism. Unfortunately, there are no scientific studies yet to show the clinical outcomes of this approach.
Psychological impact and perspectives
The psychological impact of COVID-19 appears double sided. It plays a role for the patient as well as for the practitioner.
Due to the coronavirus pandemic and resulting lockdowns, the population were under extreme stress leading to general fear and anxiety. This overall insecurity often results in mental instability (Skoda et al, 2020).
Nevertheless, patients are not the only ones in this situation. Surgeons are confronted with similar problems and additional challenges. To contend with these issues, they must try to maintain a healthy state of mind. Survival stress, quality stress and organisational stress can all impact a dental practitioner’s mental health. Furthermore, dental clinicians face the daily risk of infection due to their job (Mijiritsky et al, 2020).
At the moment, not enough attention is paid to the psychological consequences of this pandemic according to the authors’ opinion. As well as the resulting repeated lockdowns (Vergara-Buenaventura et al, 2020).
Economic impact and perspectives
The economic impact of the pandemic also has two components: impact on the patients and impact on the clinicians.
Both groups face financial insecurities, due to reduced income and rising expenses.
For patients, this often leads to choosing personal care expenses over more expensive treatments (like implant-supported rehabilitations), which are consequently postponed (Dahab et al, 2020).
Dental practitioners on the other hand, are confronted with additional expenses that do not increase their income. Only rarely is the government willing to support those extra costs.
This leads to a lack in return on investment. It can cause huge financial problems for new or recently opened practices, or clinics with an unstable financial basis.
Conclusion
Previous pandemics often lasted several years or even decades. It is possible that we will have to face the coronavirus pandemic for longer time than we would like.
The development of vaccines has occurred. But there is no security that they will be functional against the eventual mutated SARS-CoV-2 variants that may develop.
The only thing we have in our own hands is the ability to protect ourselves as much as possible.
Implant dentistry can contribute to this protection by taking extra measures into account. Using an aseptic surgical approach, employing air decontamination with UV-C, applying a non-submerged surgical approach, using lower speeds (without irrigation) for the osteotomy preparation, using intraoral scanners and introducing a full digital workflow. Patients should always rinse before any intraoral manipulation.
Defeating this pandemic is something we all will have to do together.
For references, contact Guy Hiscott.
Authors
Professor Curd ML Bollen is head of the Department of Implant Dentistry at the College of Medicine & Dentistry at Ulster University.
Yasna Najmi is a PhD student at the College of Medicine & Dentistry, Ulster University.
Professor Maher Almasri is dean of the College of Medicine & Dentistry at Ulster University.
This article first appeared in Implant Dentistry Today magazine. You can read the full issue here.
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