Is dental treatment safe during the pandemic?
Covid-19 prompted national and regional dental associations to advise dentists to close their practices and/or postpone elective and non-emergency treatment during lockdown periods.
This advice has not been followed consistently, because the dental profession in most countries is dominated by private practices with little regulation. Some dentists have chosen to stay open and offer standard services even in hot spots of high community transmission.
Through the first half of 2020 there’s been a wide range of responses from most dentists closing up shop completely to some dentists urging their patients to continue with non-essential treatments as usual. As restrictions ease in many regions with continued community transmission, there’s ongoing conflicts within the profession about how to practice safely.
These inconsistencies have contributed to public uncertainty about how to manage our oral health during the pandemic, and what to expect from dentistry in the long-term.
The pressures of Covid-19 on the current dental model has been (sometimes literally) painful for individual patients and dental professionals. However, it’s possible that the pandemic could be a catalyst for transformation.
I hope that we emerge from the pandemic with a more holistic, humane, equitable and prevention-focused version of dentistry.
In this article I’ll explore some immediate and long term questions from a patient’s perspective:
- the risks of attending the dentist during the pandemic
- keeping your mouth safe when the dentist isn’t safe
- what does the future hold for dentistry
Risks at the Dentist
Dentists are an intrinsically high risk environment for Covid-19 exposure, in addition to all the usual risks of public spaces where there is community transmission of Covid-19 (such as sharing an enclosed space and close physical contact).
The crucial problem is that there are many common dental procedures, including hygienist’s cleanings and drilling cavities, that create an aerosol spray of saliva particles into the air (Aerosol Generating Procedures – AGPs). There are also procedures (including x-rays) in the dental chair that cause patients to cough, which release a spray of saliva droplets.
If a patient has Covid-19, their saliva contains microscopic virus particles. Droplets of their saliva from coughing can travel up to 2 metres (6 feet) before falling almost immediately to the surface below. Aerosol saliva particles generated by AGPs may travel much further (up to 8 metres or 27 feet) and may linger in the air for 2-3 hours before settling on surfaces below [link].
The greatest, and most immediate risk from a patient with Covid-19 are dental workers, especially hygienists whose main task of cleaning generates aerosol saliva spray. However, anyone who enters the dental office within 2-3 hours could be potentially at risk of inhaling virus-contaminated droplets inhaled in the air. Further exposure could come from exposure to surfaces that were cleaned immediately after the treatment but continued to collect virus contamination from suspended saliva spray for up to three hours.
Dental safety standards
Dental practices already had very high standards for sterilization and PPE, however Covid-19 and it’s airborne risks requires even greater vigilance.
When you book your next dental appointment, ask what extra measures they are taking to address the serious, life-threatening risks of Covid-19. Are their social distancing, screening, cleaning, PPE and AGP reduction practices good enough?
It’s become fairly standard for dental practices to ask patients to wait in their cars, wear masks and use hand sanitiser. Empty waiting rooms and contactless payments help to reduce the risk of virus spreading.
Most dental practices are attempting to screen out patients (and staff) with Covid-19 with questions and temperature tests. These measures are both unreliable, but may catch someone who is symptomatic, has tested positive, or who knows they have been exposed to the contagin. However, the real risk of transmission lies with asympotomatic or presympotomatic patients.
Asymptomatic individuals (who have Covid but never develop symptoms) and presymtomatic individuals (who have contracted the disease up to 14 days ago but not yet developed symptoms) are both highly contagious to anyone who is exposed to their saliva droplets.
A few dental practices are require everyone to take a Covid-19 test immediately before their appointment. However Covid-19 tests are of limited use because results are not available instantly and are not 100% reliable.
Dental practices should allow a sufficient break between an AGP and entering the room to clean it (a ‘fallow period’), to allow droplets to fall to surfaces so they can be cleaned. The recommended fallow period is one hour, however arguably may take 2-3 hours for aerosol particles to fall out of the air. [link]
This fallow period is reduced for negative pressure rooms with powerful extractor fans, vacuum units or filtration units. These types of air cleaning systems are necessesary for the safe removal of amalgam fillings, so biological and holistic dentists are more likely to already have them in place.
Dental workers have been using personal protective equipment (PPE) such as gloves and surgical masks since the AIDS epidemic. In the early weeks of the pandemic, many dental practices donated their stocks of PPE to frontline staff working with Covid-19 patients due to global shortages.
The Covid-19 epidemic brings a new safety standard that layers a face shield over an N95type respirator masks covered by a disposable mask, ie three layers of face protection. Washable or disposable caps and knee length gowns complete the dental PPE needed for safer (but not completely safe) work with AGPs [link].
Ideally, dental workers should change their PPE gear between every new patient they treat, especially after AGPs.
However, due to the cost and sometimes ongoing difficulties of aquiring PPE, not every practice is supplying adequate PPE to meet recommended safety standards.
Dental workers in large practices such as dental schools and hospitals have voiced their complaints about inadequate PPE publically. It seems likely that it is even more a problem in small, private practices where staff feel unable to speak out.
Reducing aerosols (AGPs)
Some dental practices are working with alternative techniques and tools that reduce the saliva spray from aerosol generating procedures (AGPs).
Hygienists can clean teeth manually instead of with an ultra-sonic scaler, but hand cleaning is much slower, and more uncomfortable for both patients and hygienists [link].
Low speed drills produce less aerosol than high speed drill but take longer and are more uncomfortable for most patients. Using dental dams, high tech suction devices or intra-oral negative vacuum can all reduce the spread of saliva.
Immunity and your gums
In addition to these risks in the dental office, there is another risk which you may want to consider when deciding whether its safe to go back to your dentist yet.
Any procedure that cuts into the gum might lower your body’s immunity. This includes standard hygienist cleanings, periodontal deep cleanings and tooth extractions. If you go ahead with one of these procedures, take extra precautions to build up immune resistance and avoid exposure to Covid-19.
If you are in severe or ongoing pain, or have swelling in your mouth, you should seek emergency treatment even where there is a risk of Covid-19 transmission.
At home oral health
If you weigh up your personal risks vs benefits and decide that going to the dentist isn’t worth it for you right now, there is actually quite a lot you can do at home to prevent teeth and gum problems from developing or getting worse.
Nourish your teeth and gums with the best quality fresh vegetables and protein you can access.
Good oral health comes with a nutrient dense diet that is rich in minerals and fat-soluble Vitamins A, D and K2 consumed as fresh, local, inseason, minimally processed food rather than in capsules or powders.
You probably know that sugar is not good for teeth. If you are craving sweets, try to avoid sticky, chewy candies and soda drinks of any kind.
Even kombucha may be harmful for teeth because the phosphorus in the bubbles can draw out calcium from your enamel making them vulnerable to harmful bacteria.
Avoid popcorn as well, because it can break weak teeth, knock out fillings and cut your gums.
The mouth plays an important role in the body’s immune system. Poor oral hygiene can increase your risk of Covid-19 infection [link].
Brush your teeth twice a day, floss at least once a day, and rinse your mouth out after eating to help maintain a clean healthy oral cavity.
Brush and floss gently to avoid damaging your gums. Bleeding gums can potentially compromise your immunity.
Rather than brushing straight after you eat, when your enamel is soft and vulnerable, try rinsing with a salt water solution after every meal or snack.
These simple habits can help prevent or stabilize decay or gingivitis until it’s safe to visit the dentist.
For more oral health habits for prevention and healing, watch Holistic Oral Health at Home, my free online workshop.
What can we anticipate for dental services going forward?
Like pretty much everything else right now, it’s difficult to predict what the future holds for dentistry.
My speculations below are based on current information from the industry, which assumes a 1-2 year minimum before returning to ‘normal,’ along with my own analysis of opportunities for long overdue changes to the way we think about oral health.
Regular services limited
Almost everywhere that’s been locked down, dentists were closed to all but emergency treatments.
In regions where a second wave of Covid-19 is emerging regular dental services may be restricted even further.
Dental hygienist cleanings are likely to be the last services to return to normal because of the greater risk involved.
However, because dentistry is privatised and minimally regulated in most regions, decisions about who returns to work and when are left up to individual practice owners, who may prioritise financial concerns over the safety of their staff, their patients or even themselves.
This is leading to high levels of stress and anxiety among dental professionals [link].
Switzerland was one of the first European countries to ease restrictions. Swiss dentists experienced a rush of patients seeking urgent dental treatment after six weeks in lockdown. The backlog of emergency and urgent dental treatment had severe consequences for some people, who have lost teeth that might have been saved under normal circumstances.
Wherever dental services are available, people will go for emergency and urgent treatment. However, it’s likely that widespread economic hardship and unemployment will lead many to postpone elective and non-urgent dental treatments for at least the next couple of years.
More people may start seeking out alternatives for the first time, searching for self-help approaches to manage non-urgent issues and to prevent urgent issues from becoming emergencies.
We can expect to see increasing demand for home remedies and oral health coaches, so it’s important that effective products and services become available for every market, and in every language.
Fewer dental practices
Many dental practices are in such a financially precarious position that they may not be able to reopen after lockdown restrictions are lifted [link] [link].
This is likely to lead to increasingly widespread dental apartheid aka dental deserts ie areas where few, if any, dentists practice, such as in rural and tribal areas of the United States.
Without access to conventional dental services, it’s a matter of social justice to make effective preventative care and home remedies widely available in unconventional ways.
Online coaching, mobile and pop up clinics, community and peer educators are some of the possibilities worth exploring.
We can expect to see increased charges for professional dental services; primarily to cover the costs of extra PPE, and in some practices Covid-19 diagnostic testing and updated sterilisation equipment.
Rising prices will widen the gap between those who can afford regular dental care and an increasing proportion of people who will go into hardship or debt for urgent or emergency treatment.
Now is the time for communities to invest in preventative systems of food and housing security and grassroots health care to help prevent oral health problems becoming emergencies as well as bolstering our immune systems and increasing resilience to many other illnesses.
Dentists are already experimenting with video and phone consultation services, and some may continue to offer tele-dentistry into the future [link].
Because dental hygienists are being forced to adapt to so many challenges, I am offering a short course to help dental hygienists get started offering oral health coaching online.
Dental hygienists already have preventative knowledge and skills that they haven’t always gotten to a chance to share with patients in their chair, due to time pressure.
Now is a wonderful opportunity for hygienists to either add online coaching to their in person services or pivot to be able to work from home in the future.
I also want to see more online health practitioners integrate effective oral health support into their practices (and I’ll be looking at adding a course for natural health practitioners eventually).
There are genuine opportunities for radical transformation!
Almost every type of industry and organisation is going through a crucible of change this year.
There are intense pressures causing great harm at the same time as creating opportunities for radical change in every aspect of our lives.
It will be fascinating to see how it all unfolds and what the future of dentistry and oral health becomes.
In the meantime, please take good care of your teeth and gums at home with the tools you have available to you.
Has a dentist told you that your cavities or receding gums are your fault because you are drinking too much Coke, you don’t floss enough or you need to stop breastfeeding your baby? And you know that isn’t true!
I’m not going to blame you or shame you.
The underlying causes of your oral health issues are not your fault!
Nature or nurture, ancestry or environment, free will or systemic oppression, unconscious emotions or the degraded food system
These are the factors that make your teeth and gums vulnerable to disease.
Even though your tooth decay and gum disease is not your fault, it is within your power to change.
You can turn your oral health around with natural strategies and healthy habits.