COVID EXPERIENCE SHOWS DENTAL CLINICS ARE SAFE
Hygiene protocol already in place has proven effective at containment, writes Dr. Ben Balevi.
On March 16, the B.C. College of Dental Surgeons — at the gentle recommendation of government — directed its members to no longer perform any elective or non-essential procedures, at least until further notice. A day earlier, The New York Times published an online infographic that placed dentists, dental hygienists and dental assistants at most risk of being exposed to the virus responsible for COVID-19.
To someone who spends his day working closely inside the mouths of his patients, this made perfect sense. All dentists are aware that even the simplest dental surgery generates airborne droplets (aerosols), but what we don’t know — at least not with scientific certainty — is to what extent they can spread COVID-19.
Dental clinics have been abiding by comprehensive universal infection control methodology, including donning personal protective equipment, since instances of Hepatitis B in the late 1970s and then concern about HIV transmission in dental offices dating back to the 1980s. Notwithstanding these concerns, there has been no reported case of these infections associated with a dental clinic interaction since.
However, the question was if these already universal infection control protocols were sufficient to prevent the spread of COVID-19 in a busy dental clinic environment?
The immediate and understandable response of many provincial health officers and dental regulatory bodies across the country was to impose the strictest guidelines upon the reopening of dental clinics. Specifically, the compulsory use of the already limited supplies of N95 masks and the requirement that procedures, which may generate airborne droplets, are done in a closed room, and that these rooms remain empty for three hours between patients so as to allow the airborne droplets to settle. This begged the question if these added regulations would make patients better off.
As a clinician, my decisions are grounded in precautionary and evidence-based principles. The precautionary principle dictates that in the absence of scientific evidence, my clinical decisions must err on the side of caution. Furthermore, in my practice we make decisions that balance empirical data and clinical contexts with patient values and/or societal benefits.
The novel coronavirus gives us an opportunity to examine this necessary balancing act up close. It’s possible that as we strive for the ultimate infection control so as to avoid one bad outcome, we could be unintentionally causing another.
We should first be asking some important questions, then look for the evidence. Does the even stricter recommended protocol really protect patients from COVID? What harm is done from the consequential rise in cost and decline in efficiency of oral care? And then ask how this will affect patients. Will it prevent some patients, and therefore the public at large, from seeking treatment? On which side should we err: The risk and spread of infection or the consequential rise in cost and decline of efficient delivery of dental care?
To answer the first question, I searched the current medical literature and research resources available online. Also, I consulted dental associations and colleagues regarding any dental-related cases or clusters of the COVID-19’s virus transmission.
Although there were a few cases reported in the mainstream media of oral health-care professionals dying from COVID-19, none were directly traced to patient care, but rather from a non-clinical social interaction with a family member or from a three-day international dental conference held in Vancouver in early March.
Furthermore, despite the fact that the first case of COVID-19 was reported in Toronto on Jan. 25 and in British Columbia on Jan. 28, and that dentists and other dental-care workers attending Vancouver’s Pacific Dental Conference on March 5-7 continued to treat patients in their clinics for more than a week before they were ordered to shut down, no cases of COVID-19 transmission occurred in a dental-care appointment in B.C. or Canada. Furthermore, in countries such as China, Singapore, Taiwan, Korea, Japan and Sweden, dental office were never ordered to shut down, per se, but continued to offer non-urgent care throughout the pandemic, with no documented cases of dental-appointment transmission.
One would assume that since dental care is such a highly utilized health-care service with reportedly the highest risk of viral exposure, as reported by the New York Times, there would likely have been some, if not many, clusters of COVID-19 traced back to dental care. Yet there were none.
I would argue this is not a coincidence but a case of when the “absence of evidence is evidence of absence.” In other words, the absence of dental clusters is evidence that the universal inflection control protocol that dental clinics have followed for more than 40 years was already protective of a contagious virus, long before the appearance of COVID-19. This is consistent with a recently published scientific paper that concluded that essential services from dental offices offer the most favourable risk-benefit outcome amid the COVID-19 pandemic.
When it came time to reopen dental offices in mid-May, Provincial Health Officer Dr. Bonnie Henry, provincial Health Minister Adrian Dix and the B.C. College of Dental Surgeons of B.C. must have taken this evidence into account. They tabled returnto-work dental guidelines that were consistent with infection control guidelines that were in place before the COVID outbreak. Also included were how to serve patients through the dental clinic so as not to violate social distance requirements, as well as screening patients and workers for COVID-19 before they entered the clinic premises. These additions to protocol were relatively simple to implement at minimal cost and inefficiency in patient care.
Dental offices have been open for more than two months in B.C. and, so far, the province continues to report no cases or outbreaks of COVID-19 traced back to the any dental clinic. Accordingly, I think the provincial government should be commended for rationally balancing the precautionary principle against an evidence-based approach, and achieving the best result in public health policy.
As a clinician, my decisions are grounded in precautionary and evidence-based principles.