Introduction
COVID-19 is a world public health problem due to its morbidity and mortality, especially in at-risk groups. The dental environment has a high risk of viral transmission; accordingly, this study aimed to identify recommendations based on the best available evidence for dental care during this pandemic.

Methods
We performed a search for scientific evidence published since 2002 to March 23th 2020 in electronic databases (MEDLINE/PubMed, EMBASE, Cochrane, and Epistemonikos) and the web pages of the American Dental Association, Centers for Disease Control and Prevention Oral Health, the Ministry of Health in Chile and scientific societies.

Results
We included nine published studies. The recommendations were the following: unrestricted use of personal protection elements, use of extraoral radiographic techniques, use of mouth rinses with 1% hydrogen peroxide or 0.2% iodine povidone, a four-hand technique with ongoing aspiration and the use of absorbable sutures. Furthermore, there is a consensus that non-urgent treatments should be postponed during periods of community transmission.

Conclusions
Dental practitioners are exposed to a high risk of cross-infection, meaning they must implement recommendations based on the best available evidence to preserve the health of team members and the population they are caring for.

Authors: Juan Pablo Vargas-Buratovic[1], Francisca Verdugo-Paiva[2,3], Claudia Véliz-Paiva[1], Elizabeth López-Tagle[4], Alexis Ahumada-Salinas[5], Duniel Ortuño-Borroto[1]

Affiliation:
[1] Escuela de Odontología, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Fundación Epistemonikos, Santiago, Chile
[3] Centro Evidencia Universidad Católica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[4] Facultad de Odontología, Universidad Andres Bello, Santiago, Chile
[5] Dirección de Salud, Municipalidad de Recoleta, Santiago, Chile

E-mail: drortuno@uc.cl

Author address:
[1] Avenida Vicuña Mackenna 4860
Macul, Santiago
Chile

Citation: Vargas-Buratovic JP, Verdugo-Paiva F, Véliz-Paiva C, López-Tagle E, Ahumada-Salinas A, Ortuño-Borroto D. Dental recommendations in the COVID-19 pandemic: A narrative review. Medwave 2020;20(5):e7916 doi: 10.5867/medwave.2020.05.7916

Submission date: 24/3/2020

Acceptance date: 8/5/2020

Publication date: 1/6/2020

Origin: Not commissioned.

Type of review: Externally peer-reviewed by four reviewers, double-blind.

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1. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Mar 26;382(13):1199-1207. | CrossRef | PubMed |
2. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020 Mar;579(7798):270-273. | CrossRef | PubMed |
3. Hui DSC, Zumla A. Severe Acute Respiratory Syndrome: Historical, Epidemiologic, and Clinical Features. Infect Dis Clin North Am. 2019 Dec;33(4):869-889. | CrossRef | PubMed |
4. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020 Mar 3;12(1):9. | CrossRef | PubMed |
5. Peiris JS, Yuen KY, Osterhaus AD, Stöhr K. The severe acute respiratory syndrome. N Engl J Med. 2003 Dec 18;349(25):2431-41. | CrossRef | PubMed |
6. Samaranayake LP, Peiris M. Severe acute respiratory syndrome and dentistry: a retrospective view. J Am Dent Assoc. 2004 Sep;135(9):1292-302. | CrossRef | PubMed |
7. Samaranayake LP; FDI Science Commission. Severe acute respiratory syndrome (SARS): an interim information paper for dental health care workers. Int Dent J. 2003 Jun;53(3):117-8. | CrossRef | PubMed |
8. Hui DS, Memish ZA, Zumla A. Severe acute respiratory syndrome vs. the Middle East respiratory syndrome. Curr Opin Pulm Med. 2014 May;20(3):233-41. | CrossRef | PubMed |
9. Seto WH, Conly JM, Pessoa-Silva CL, Malik M, Eremin S. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update. East Mediterr Health J. 2013;19 Suppl 1:S39-47. | PubMed |
10. Al-Sehaibany FS. Middle East respiratory syndrome in children. Dental considerations. Saudi Med J. 2017 Apr;38(4):339-343. | CrossRef | PubMed |
11. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res. 2020 May;99(5):481-487. | CrossRef | PubMed |
12. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061–9. | CrossRef | PubMed |
13. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. | CrossRef | PubMed |
14. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. | CrossRef | PubMed |
15. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus DIsease 2019 (COVID-2019).February 16-24, 2020. [Internet] | Link |
16. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020 Mar 13. | CrossRef | PubMed |
17. KCDC. Updates on COVID-19 in Korea. March 14, 2020. [Internet] | Link |
18. World Health Organization. Questions and answers on coronaviruses. 2020. [Internet] | Link |
19. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004 Apr;135(4):429-37. | CrossRef | PubMed |
20. Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical applications in dental practice. Eur Radiol. 2010 Nov;20(11):2637-55. | CrossRef | PubMed |
21. Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. 2020 Mar 17;368:m1086. | CrossRef | PubMed |
22. World Health Organization. WHO Now Doesn't Recommend Avoiding Ibuprofen For COVID-19 Symptoms. ScienceAlert. 2020. [Internet] | Link |
23. Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews. J Am Dent Assoc. 2018 Apr;149(4):256-265.e3. | CrossRef | PubMed |
24. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA. 2020 Mar 12. | CrossRef | PubMed |
25. Institute of Medicine (US) Committee on Emerging Microbial Threats to Health in the 21st Century. Microbial Threats to Health: Emergence, Detection, and Response. Smolinski MS, Hamburg MA, Lederberg J, editors. Washington (DC): National Academies Press (US); 2003. | PubMed |
26. Xiao Y, Torok ME. Taking the right measures to control COVID-19. Lancet Infect Dis. 2020 May;20(5):523-524. | CrossRef | Link |
27. Holmes KV. SARS-associated coronavirus. N Engl J Med. 2003 May 15;348(20):1948-51. | CrossRef | PubMed |
28. The Lancet. MERS-Cov: a global challenge. Lancet 381, 1960 (2013). | CrossRef |
29. Khan S, Siddique R, Shereen MA, Ali A, Liu J, Bai Q, et al. Emergence of a Novel Coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2: Biology and Therapeutic Options. J Clin Microbiol. 2020 Apr 23;58(5):e00187-20. | CrossRef | PubMed |
30. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000 Spring;26(1):14-22. | CrossRef | PubMed |
31. American Dental Associaton. ADA: Calls Upon Dentists to Postpone Elective Procedures. 2020 Mar 16. [Internet] | Link |
32. MINSAL. Recomendaciones clínicas basadas en evidencia CORONAVIRUS / COVID-19. Ministerio de Salud de Chile. Santiago, Chile.19 de Marzo. [Internet] | Link |
33. National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health and Health Commission on issuing the guidelines for the use of common medical protective products in the prevention and control of pneumonia infected by new coronavirus (trial). Jan 27, 2020. [Internet] | Link |
34. Neumann I, Rada G. Toma de decisiones basada en evidencia: cuándo vale la pena [Evidence-based decision-making: when it is worthwhile]. Medwave. 2014 Jun 11;14(5):e5966. | CrossRef | PubMed |
35. Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2020 Feb 10;41(2):145-151. | CrossRef | PubMed |
36. Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig. 2020 Apr;24(4):1619-1621. | CrossRef | PubMed |
37. Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health. 2004 Apr;94(4):562-4. | CrossRef | PubMed |

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Mar 26;382(13):1199-1207. | CrossRef | PubMed |

Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020 Mar;579(7798):270-273. | CrossRef | PubMed |

Hui DSC, Zumla A. Severe Acute Respiratory Syndrome: Historical, Epidemiologic, and Clinical Features. Infect Dis Clin North Am. 2019 Dec;33(4):869-889. | CrossRef | PubMed |

Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020 Mar 3;12(1):9. | CrossRef | PubMed |

Peiris JS, Yuen KY, Osterhaus AD, Stöhr K. The severe acute respiratory syndrome. N Engl J Med. 2003 Dec 18;349(25):2431-41. | CrossRef | PubMed |

Samaranayake LP, Peiris M. Severe acute respiratory syndrome and dentistry: a retrospective view. J Am Dent Assoc. 2004 Sep;135(9):1292-302. | CrossRef | PubMed |

Samaranayake LP; FDI Science Commission. Severe acute respiratory syndrome (SARS): an interim information paper for dental health care workers. Int Dent J. 2003 Jun;53(3):117-8. | CrossRef | PubMed |

Hui DS, Memish ZA, Zumla A. Severe acute respiratory syndrome vs. the Middle East respiratory syndrome. Curr Opin Pulm Med. 2014 May;20(3):233-41. | CrossRef | PubMed |

Seto WH, Conly JM, Pessoa-Silva CL, Malik M, Eremin S. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update. East Mediterr Health J. 2013;19 Suppl 1:S39-47. | PubMed |

Al-Sehaibany FS. Middle East respiratory syndrome in children. Dental considerations. Saudi Med J. 2017 Apr;38(4):339-343. | CrossRef | PubMed |

Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res. 2020 May;99(5):481-487. | CrossRef | PubMed |

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061–9. | CrossRef | PubMed |

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. | CrossRef | PubMed |

Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. | CrossRef | PubMed |

World Health Organization. Report of the WHO-China Joint Mission on Coronavirus DIsease 2019 (COVID-2019).February 16-24, 2020. [Internet] | Link |

Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020 Mar 13. | CrossRef | PubMed |

KCDC. Updates on COVID-19 in Korea. March 14, 2020. [Internet] | Link |

World Health Organization. Questions and answers on coronaviruses. 2020. [Internet] | Link |

Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004 Apr;135(4):429-37. | CrossRef | PubMed |

Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical applications in dental practice. Eur Radiol. 2010 Nov;20(11):2637-55. | CrossRef | PubMed |

Day M. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. 2020 Mar 17;368:m1086. | CrossRef | PubMed |

World Health Organization. WHO Now Doesn't Recommend Avoiding Ibuprofen For COVID-19 Symptoms. ScienceAlert. 2020. [Internet] | Link |

Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews. J Am Dent Assoc. 2018 Apr;149(4):256-265.e3. | CrossRef | PubMed |

Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA. 2020 Mar 12. | CrossRef | PubMed |

Institute of Medicine (US) Committee on Emerging Microbial Threats to Health in the 21st Century. Microbial Threats to Health: Emergence, Detection, and Response. Smolinski MS, Hamburg MA, Lederberg J, editors. Washington (DC): National Academies Press (US); 2003. | PubMed |

Xiao Y, Torok ME. Taking the right measures to control COVID-19. Lancet Infect Dis. 2020 May;20(5):523-524. | CrossRef | Link |

Holmes KV. SARS-associated coronavirus. N Engl J Med. 2003 May 15;348(20):1948-51. | CrossRef | PubMed |

The Lancet. MERS-Cov: a global challenge. Lancet 381, 1960 (2013). | CrossRef |

Khan S, Siddique R, Shereen MA, Ali A, Liu J, Bai Q, et al. Emergence of a Novel Coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2: Biology and Therapeutic Options. J Clin Microbiol. 2020 Apr 23;58(5):e00187-20. | CrossRef | PubMed |

Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000 Spring;26(1):14-22. | CrossRef | PubMed |

American Dental Associaton. ADA: Calls Upon Dentists to Postpone Elective Procedures. 2020 Mar 16. [Internet] | Link |

MINSAL. Recomendaciones clínicas basadas en evidencia CORONAVIRUS / COVID-19. Ministerio de Salud de Chile. Santiago, Chile.19 de Marzo. [Internet] | Link |

National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health and Health Commission on issuing the guidelines for the use of common medical protective products in the prevention and control of pneumonia infected by new coronavirus (trial). Jan 27, 2020. [Internet] | Link |

Neumann I, Rada G. Toma de decisiones basada en evidencia: cuándo vale la pena [Evidence-based decision-making: when it is worthwhile]. Medwave. 2014 Jun 11;14(5):e5966. | CrossRef | PubMed |

Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2020 Feb 10;41(2):145-151. | CrossRef | PubMed |

Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig. 2020 Apr;24(4):1619-1621. | CrossRef | PubMed |

Chang HJ, Huang N, Lee CH, Hsu YJ, Hsieh CJ, Chou YJ. The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health. 2004 Apr;94(4):562-4. | CrossRef | PubMed |