Abstract

The expansion of coronavirus disease 2019 (COVID-19) throughout the world has alarmed all health professionals. Especially in dentistry, there is a growing concern due to it’s high virulence and routes of transmission through saliva aerosols. The virus keeps viable on air for at least 3 hours and on plastic and stainless-steel surfaces up to 72 hours. In this sense, dental offices, both in the public and private sectors, are high-risk settings of cross infection among patients, dentists and health professionals in the clinical environment (including hospital’s intensive dental care facilities). This manuscript aims to compile current available evidence on prevention strategies for dental professionals. Besides, we briefly describe promising treatment strategies recognized until this moment. The purpose is to clarify dental practitioners about the virus history and microbiology, besides guiding on how to proceed during emergency consultations based on international documents. Dentists should consider that a substantial number of individuals (including children) who do not show any signs and symptoms of COVID-19 may be infected and can disseminate the virus. Currently, there is no effective treatment and fast diagnosis is still a challenge. All elective dental treatments and non-essential procedures should be postponed, keeping only urgent and emergency visits to the dental office. The use of teledentistry (phone calls, text messages) is a very promising tool to keep contact with the patient without being at risk of infection.

Coronavirus; Public Health; Practice Management, Dental; Infections; Dentistry

Introduction

Coronavirus is a family of viruses that causes respiratory infections including the new coronavirus (SARS-CoV-2) discovered in December 2019 in China. Coronaviruses represent enveloped, positive stranded RNA virus that contains four genera: Alpha-, Beta-, Gamma-, and Deltacoronavirus.¹1. Corman VM, Muth D, Niemeyer D, Drosten C. Hosts and sources of endemic human coronaviruses. Adv Virus Res. 2018;100:163-88. https://doi.org/10.1016/bs.aivir.2018.01.001
https://doi.org/10.1016/bs.aivir.2018.01... Six different coronavirus have been identified in humans: HCoV-OC43, -229E, HCoV-NL63, HKU1, the Middle East respiratory syndrome (MERS)-CoV and (SARS)-CoV.²2. Marra MA., Jones SJM., Astell CR., Holt RA., Brooks-Wilson A., Butterfield YSN., et al. The genome sequence of the SARS-associated coronavirus. Science. 2003 May;300(5624):1399-404. https://doi.org/10.1126/science.1085953
https://doi.org/10.1126/science.1085953... Although the latter virus became widely discussed recently, the first human coronaviruses were isolated for the first time in 1937.³3. Wolff MH, Sattar SA, Adegbunrin O, Tetro J. Environmental survival and microbicide inactivation of coronaviruses. In: Schmidt A, Wolff MH, Weber O. Coronaviruses with special emphasis on first insights concerning SARS. Base: Birkhäuser; 2005. p. 201-12. The denomination coronavirus was due to its microscopic aspect resembling crown-like spikes on its surface and the main host receptor for humans seems to be the angiotensin-converting enzyme 2 (ACE2).⁴4. Abbag HF, El-Mekki AA, Al Bshabshe AA, Mahfouz AA, Al-Dosry AA, Mirdad RT, et al. Knowledge and attitude towards the Middle East respiratory syndrome coronavirus among healthcare personnel in the southern region of Saudi Arabia. J Infect Public Health. 2018 Sep - Oct;11(5):720-2. https://doi.org/10.1016/j.jiph.2018.02.001
https://doi.org/10.1016/j.jiph.2018.02.0...

This recent COVID-19 turned into a global public health outbreak.⁵5. Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care. 2020 Mar; pii::S0883-9441(20)30390-7. https://doi.org/10.1016/j.jcrc.2020.03.005
https://doi.org/10.1016/j.jcrc.2020.03.0... ,⁶6. Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Mar;NEJMc2004973. https://doi.org/10.1056/NEJMc2004973
https://doi.org/10.1056/NEJMc2004973... It is transmitted after contact with infected surfaces and with infected patient’s fluids, including saliva and aerosol.⁶6. Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Mar;NEJMc2004973. https://doi.org/10.1056/NEJMc2004973
https://doi.org/10.1056/NEJMc2004973... ,⁷7. Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig. 2020 Apr;24(4):1619-21. https://doi.org/10.1007/s00784-020-03248-x
https://doi.org/10.1007/s00784-020-03248... These characteristics place the dental offices as main risk settings of cross infection among patients, dentists and health professionals in the clinical environment, including hospital’s dental intensive care facilities.⁸8. Souza RC, Costa PS, Costa LR. Dental sedation precautions and recommendations during the COVID-19 pandemic. Braz J Dent. 2020 Apr;77(0):1-3. https://doi.org/10.18363/RBO.V77.2020.E1788
https://doi.org/10.18363/RBO.V77.2020.E1... Dental practitioners are exposed to close contact to patients, to saliva aerosol, blood and handle sharp contaminated instruments.⁹9. 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;12(1):9. https://doi.org/10.1038/s41368-020-0075-9
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After the World Health Organization (WHO) pandemic declaration, institutions like the General Coordination of Oral Health from the Brazilian Health Ministry published a Technical Note with the main clarifications regarding dental practice considering the Coronavirus pandemic.¹⁰10. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde (SAPS). . Atendimento odontológico no SUS. Brasília, DF; 2020. [cited 2020 Mar 31]. Available from: http://www.crosp.org.br/uploads/arquivo/ab69d79b87d04780af08a70d8cee9d70.pdf
http://www.crosp.org.br/uploads/arquivo/... Centers for Disease Control and Prevention (CDC) and American Dental Association (ADA) are recommending dentists to postpone elective procedures and concentrating on emergency or urgent dental care in order to reduce COVID-19 infection,¹¹11. Centers of Disease Control and Prevention – CDC. Recommendation: postpone non-urgent dental procedures, surgeries, and visits. centers of disease control and prevention. 2020 [cited 2020 Mar 31]. Available from: https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html
https://www.cdc.gov/oralhealth/infection... ,¹²12. American Dental Association – ADA. ADA recommending dentists postpone elective procedures. American Dental Assocaition. 2020 [cited 2020 Mar 31]. Available from: https://www.ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-elective-procedures
https://www.ada.org/en/publications/ada-... similar to what several cities in China have done.¹³13. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 Mar:22034520914246. https://doi.org/10.1177/0022034520914246
https://doi.org/10.1177/0022034520914246...

As health professionals, it is extremely relevant that dentists be aware of the biological and social characteristics involved in COVID-19 pandemic, contributing to the clarification of the population and adopting finest clinical measures to avoid unnecessary risks to contain the perioperative transmission.⁸8. Souza RC, Costa PS, Costa LR. Dental sedation precautions and recommendations during the COVID-19 pandemic. Braz J Dent. 2020 Apr;77(0):1-3. https://doi.org/10.18363/RBO.V77.2020.E1788
https://doi.org/10.18363/RBO.V77.2020.E1... Based on the current available evidence related to oral health care, the aim of the present critical appraisal is to compile prevention strategies for dental professionals and clarify dental practitioners about the virus history, pathogenesis, current pharmacological clinical trials, and measures to minimize economic and health consequences to the oral health system.

Microbiological aspects

This new health problem emerged from a public market in which animals are kept and traded alive in Wuham – China. It became the focus of global attention after the spread of an unknown cause epidemic pneumonia. At first, these cases of pneumonia were monitored and tested in the laboratory for coronavirus and possible influenza infections. On January 7, 2020, Chinese authorities announced that a new type of Coronavirus was isolated: the new Coronavirus, nCoV.¹⁴14. Sahin A, Erdogan A, Mutlu Agaoglu P, Dineri Y, Cakirci A, Senel M, et al. 2019 Novel Coronavirus (COVID-19) outbreak: a review of the current literature. Eurasian J Med Investig. 2020;4(1):1-7. https://doi.org/10.14744/ejmo.2020.12220
https://doi.org/10.14744/ejmo.2020.12220...

This new viral agent, which until that moment has not been identified in humans before, was called SARS-CoV-2 and is able to cause respiratory infectious disease that is called COVID-19. Previous occurrence of coronavirus such as the Severe Acute Respiratory Syndrome (SARS) (SARS-CoV) and Middle East Respiratory Syndrome (MERS) (MERS-CoV) left 774 and 850 dead, respectively, reflecting the severity of the threat and the urgency to control this new outbreak as soon as possible.¹⁵15. Iqbal HM, Romero-Castillo KD, Bilal M, Parra-Saldivar R. The emergence of novel-coronavirus and its replication cycle: an overview. J Pure Appl Microbiol. 2020;14(March):6146.

The genomic sequence of the new viral Coronavirus was immediately defined by public health support and online community resources “virological.org” on January 10^th (Wuhan-Hu-1, GenBank accession number MN908947)¹⁶16. Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. A new coronavirus associated with human respiratory disease in China. Nature. 2020 Mar;579(7798):265-9. https://doi.org/10.1038/s41586-020-2008-3
https://doi.org/10.1038/s41586-020-2008-... followed by four other deposited genomes on January 12^th in the database of viral genomic sequences maintained by the Global Initiative on Sharing All Influenza Data (GISAID).¹⁷17. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DK, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020 Jan;25(3). https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045
https://doi.org/10.2807/1560-7917.ES.202... The clinical signs and symptoms in the beginning suggested the presence of a virus closely related to SARS outbreak in 2002/2003. This species also comprised a large number of viruses detected in rhinolophid bats in Asia and Europe. ¹⁷17. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DK, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020 Jan;25(3). https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045
https://doi.org/10.2807/1560-7917.ES.202... After sequencing, the SARS-CoV-2 genome was found to be 96.2% identical to the Bat RaTG13 coV, while sharing 79.5% identity with the SARS-CoV. In this way, the similarity between the genomes of the viruses shows that the bat is the natural host of the virus and SARSCoV-2 may have been transmitted to humans, in an unknown way, through intermediate hosts. Several studies suggest that the bat is the potential reservoir of SARS-CoV-2. However, there is evidence that the origin of SARS-CoV-2 was the seafood market in Wuhan, China.¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... Coronaviruses (CoV) α- and β-CoV are capable of infecting mammals, while γ- and δ-CoV tend to infect birds. Although the six CoVs identified as human-susceptible viruses, presented low pathogenicity, causing mild respiratory symptoms similar to a common cold; SARS-CoV and MERS-CoV may lead to severe and potentially fatal respiratory tract infections.¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... ,¹⁹19. Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol. 2019 Mar;17(3):181-92. https://doi.org/10.1038/s41579-018-0118-9
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Viruses are complex pathogens with a high capacity to infect multiple host species, causing a variety of diseases with numerous symptoms. CoVs are pleomorphic RNA-viruses (subgenus sarbecovirus, subfamily Orthocoronavirinae) characterized by high speed of gene recombination due to constant errors in their RNA polymerase-dependent replication process (RdRP).¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... ,²⁰20. Su S, Wong G, Shi W, Liu J, Lai AC, Zhou J, et al. Epidemiology, genetic recombination, and pathogenesis of coronaviruses. Trends Microbiol. 2016 Jun;24(6):490-502. https://doi.org/10.1016/j.tim.2016.03.003
https://doi.org/10.1016/j.tim.2016.03.00... The main steps involved in the replication cycle of SARS-CoV-2 are: recognition and binding to the host cell via membrane fusion or endocytosis mechanism. After the invasion, the viral genome is released; then occurs translation of the viral polymerase protein; RNA replication; sub-genomic transcription; translation of viral structural proteins; viral structural proteins combination with the nucleocapsid; formation of mature virions and finally the release of mature virions by exocytosis. At the end of the cycle, newly mature virions are released and may infect new targets and the cycle repeats itself continuously.¹⁵15. Iqbal HM, Romero-Castillo KD, Bilal M, Parra-Saldivar R. The emergence of novel-coronavirus and its replication cycle: an overview. J Pure Appl Microbiol. 2020;14(March):6146. During their replication cycle, two-thirds of the viral RNA encode 16 non-structural proteins (NSPs). The other one-third of the virus genome encodes four essential structural proteins, including: spike glycoprotein (S), small envelope protein (E), matrix protein (M) and nucleocapsid protein (N), and also other accessory proteins.¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... ,²¹21. Hussain S, Pan J, Chen Y, Yang Y, Xu J, Peng Y, et al. Identification of novel subgenomic RNAs and noncanonical transcription initiation signals of severe acute respiratory syndrome coronavirus. J Virol. 2005 May;79(9):5288-95. https://doi.org/10.1128/JVI.79.9.5288-5295.2005
https://doi.org/10.1128/JVI.79.9.5288-52...

Host factors can also influence susceptibility to infection and disease progression. Research shows that SARS-CoV-2 use angiotensin-converting enzyme 2 (ACE2). The S-glycoprotein located on the surface of the coronavirus can bind to the ACE2 receptor on the surface of human cells. After binding to the host cell membrane, the RNA of the viral genome is released into the cytoplasm and translates two polyproteins, pp1a and pp1ab that encode non-structural proteins and form the replication and transcription complex (RTC) and the replication cycle continues as stated above ¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... . Host antiviral defense plays an important role in the course of SARS-CoV-2 infection. As the first line of defense against viruses, type I interferon (IFN) plays a critical role in initiating host antiviral responses. Following virus infection, the host innate immune system is activated by the recognition of viral-specific components such as ssRNA, dsRNA or glycoproteins.²²22. Kato H, Takeuchi O, Sato S, Yoneyama M, Yamamoto M, Matsui K, et al. Differential roles of MDA5 and RIG-I helicases in the recognition of RNA viruses. Nature. 2006 May;441(7089):101-5. https://doi.org/10.1038/nature04734
https://doi.org/10.1038/nature04734... The Toll-like and RIG-I-like receptors are the most common host pattern recognition receptors (PRRs) that respond to RNA viruses.²³23. Chan YK, Gack MU. Viral evasion of intracellular DNA and RNA sensing. Nat Rev Microbiol. 2016 Jun;14(6):360-73. https://doi.org/10.1038/nrmicro.2016.45
https://doi.org/10.1038/nrmicro.2016.45... The domains then initiate an antiviral signaling cascade by leading the phosphorylation and activation of IRF3 and NF-κB, leading to the production of type I IFN. IFN-β secretion induces IFN-stimulated genes, which will induce the expression of host antiviral effector factors.²⁴24. Schneider WM, Chevillotte MD, Rice CM. Interferon-stimulated genes: a complex web of host defenses. Annu Rev Immunol. 2014;32(1):513-45. https://doi.org/10.1146/annurev-immunol-032713-120231
https://doi.org/10.1146/annurev-immunol-...

Viruses have developed the capacity to escape host immune detection and to suppress the host IFN system.²⁵25. Kindler E, Thiel V, Weber F. Interaction of SARS and MERS Coronaviruses with the Antiviral Interferon Response. Adv Virus Res. 2016;96:219-43. https://doi.org/10.1016/bs.aivir.2016.08.006
https://doi.org/10.1016/bs.aivir.2016.08... Viruses encode viral proteins that interfere with PRRs signaling pathways to increase an early benefit against host defense. For example, the SARS-CoV N proteins inhibit RIG-I ubiquitination and thus suppress the release of type I IFN,²⁶26. Hu Y, Li W, Gao T, Cui Y, Jin Y, Li P, et al. The severe acute respiratory syndrome coronavirus nucleocapsid inhibits type i interferon production by interfering with TRIM25-Mediated RIG-I Ubiquitination. J Virol. 2017 Mar;91(8):e02143-16. https://doi.org/10.1128/JVI.02143-16
https://doi.org/10.1128/JVI.02143-16... SARS-CoV M proteins prevents the TRAF3/TBK1 complex formation and inhibits TBK1/IKKε-dependent activation of IRF3/IRF7 transcription factors.²⁷27. Siu KL, Kok KH, Ng MH, Poon VK, Yuen KY, Zheng BJ, et al. Severe acute respiratory syndrome coronavirus M protein inhibits type I interferon production by impeding the formation of TRAF3.TANK.TBK1/IKKepsilon complex. J Biol Chem. 2009 Jun;284(24):16202-9. https://doi.org/10.1074/jbc.M109.008227
https://doi.org/10.1074/jbc.M109.008227... Lastly, the repressive modifications that are induced by the nonstructural SARS-CoV nsp1 protein blocks host mRNA translation²⁸28. Tanaka T, Kamitani W, DeDiego ML, Enjuanes L, Matsuura Y. Severe acute respiratory syndrome coronavirus nsp1 facilitates efficient propagation in cells through a specific translational shutoff of host mRNA. J Virol. 2012 Oct;86(20):11128-37. https://doi.org/10.1128/JVI.01700-12
https://doi.org/10.1128/JVI.01700-12... and mediates host mRNA degradation.²⁹29. Huang C, Lokugamage KG, Rozovics JM, Narayanan K, Semler BL, Makino S. SARS coronavirus nsp1 protein induces template-dependent endonucleolytic cleavage of mRNAs: viral mRNAs are resistant to nsp1-induced RNA cleavage. PLoS Pathog. 2011 Dec;7(12):e1002433. https://doi.org/10.1371/journal.ppat.1002433
https://doi.org/10.1371/journal.ppat.100...

Human-to-human transmission of SARS-CoV-2 occurs primarily between family members, including relatives and friends who have more intimate contact with infected or asymptomatic patients or carriers. As an emerging acute respiratory infectious disease, COVID-19 spreads mainly through the respiratory tract pathways through droplets, respiratory secretions and direct contact even at a low infectious dose. Likewise, the presence of SARS-CoV-2 in swabs from fecal and blood samples has been identified, indicating the possibility of multiple routes of infection.¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681...

Based on the current epidemiological investigation, the incubation period is from 1 to 14 days, mainly from 3 to 7 days, being contagious in its latency period. It is highly transmissible in humans, especially in the elderly and people with underlying diseases. Patients with COVID-19 have symptoms such as fever, malaise and cough. Most adults or children infected with SARS-CoV-2 have mild flu-like symptoms. However, a few patients also progress to a critical condition and rapidly develop acute respiratory distress syndrome, respiratory failure, multiple organ failure and even die.¹⁸18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23. https://doi.org/10.1002/jmv.25681
https://doi.org/10.1002/jmv.25681... ,³⁰30. Sun J, He WT, Wang L, Lai A, Ji X, Zhai X, et al. COVID-19: Epidemiology, Evolution, and Cross-Disciplinary Perspectives. Trends Mol Med. 2020 Mar 21.https://doi.org/10.1016/j.molmed.2020.02.008
https://doi.org/10.1016/j.molmed.2020.02... There are still many gaps in knowledge about the epidemiology and clinical overview of COVID-19, including the exact incubation period, the possibility of transmission from asymptomatic carriers and the rate of transmissibility. However, human-human transmission has been rapidly proven and remains responsible for the continued spread of the disease.

Reliable laboratory diagnosis is among the priorities to facilitate public health interventions. In acute respiratory infections, RT-PCR is routinely used to detect viruses caused by respiratory secretions. During international health emergencies, the viability of real-time detection of the virus by real-time RT-PCR has been demonstrated through coordination between public laboratories and universities. ¹⁷17. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DK, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020 Jan;25(3). https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045
https://doi.org/10.2807/1560-7917.ES.202...

SARS-CoV-2 Drug Therapy

Drugs tested effective for SARS-CoV and/or MERS have been included in the WHO mega clinical trial – SOLIDARITY.³¹31. World Health Organization – WHO. “Solidarity” clinical trial for COVID-19 treatments. 2020 [cited 2020 Apr 10]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments
https://www.who.int/emergencies/diseases... For its study, WHO chose a nucleotide analogue Remdesivir; the malaria medication chloroquine (and its analog hydroxychloroquine); a combination of the anti-HIV drugs lopinavir and ritonavir; and that combination plus interferon-b.

Remdesivir is an antiviral prodrug of remdesivirtriphosphate with in vitro activity against coronaviruses.³²32. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-71. https://doi.org/10.1038/s41422-020-0282-0
https://doi.org/10.1038/s41422-020-0282-... ,³³33. Agostini ML, Andres EL, Sims AC, Graham RL, Sheahan TP, Lu X, et al. Coronavirus susceptibility to the antiviral remdesivir (GS-5734) is mediated by the viral polymerase and the proofreading exoribonuclease. MBio. 2018 Mar;9(2):e00221-18. https://doi.org/10.1128/mBio.00221-18
https://doi.org/10.1128/mBio.00221-18... Remdesivir-TP acts as an inhibitor of RNA-dependent RNA polymerases and competes with adenosine-TP for incorporation into emerging viral RNA chains.³⁴34. Brown AJ, Won JJ, Graham RL, Dinnon KH 3rd, Sims AC, Feng JY, et al. Broad spectrum antiviral remdesivir inhibits human endemic and zoonotic deltacoronaviruses with a highly divergent RNA dependent RNA polymerase. Antiviral Res. 2019 Sep;169:104541. https://doi.org/10.1016/j.antiviral.2019.104541
https://doi.org/10.1016/j.antiviral.2019... Hydroxyhloroquine and chloroquine have in vitro activity against SARS-CoV-2 ³²32. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-71. https://doi.org/10.1038/s41422-020-0282-0
https://doi.org/10.1038/s41422-020-0282-... ,³⁵35. Gao J, Tian Z, Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends. 2020 Mar;14(1):72-3. https://doi.org/10.5582/bst.2020.01047
https://doi.org/10.5582/bst.2020.01047... and the mechanism of action includes inhibition of viral enzymes (RNA polymerase), viral protein glycosylation, virus assembly, new virus particle transport, and virus release. Other mechanisms may also involve ACE2 receptor inhibition, decrease acidity in endosomes, and immunomodulation of cytokine release.⁵5. Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care. 2020 Mar; pii::S0883-9441(20)30390-7. https://doi.org/10.1016/j.jcrc.2020.03.005
https://doi.org/10.1016/j.jcrc.2020.03.0... ,³²32. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-71. https://doi.org/10.1038/s41422-020-0282-0
https://doi.org/10.1038/s41422-020-0282-... ,³⁶36. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, et al. In Vitro antiviral activity and projection of optimized dosing design of Hydroxychloroquine for the treatment of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020 Mar:ciaa237. https://doi.org/10.1093/cid/ciaa237
https://doi.org/10.1093/cid/ciaa237...

The third arm of SOLIDARITY combines two HIV protease inhibitor drugs, lopinavir-ritonavir. The combination shown in vitro and in vivo potential activity for SARS-CoV and MERS-CoV ³⁸38. Chen F, Chan KH, Jiang Y, Kao RY, Lu HT, Fan KW, et al. In vitro susceptibility of 10 clinical isolates of SARS coronavirus to selected antiviral compounds. J Clin Virol. 2004 Sep;31(1):69-75. https://doi.org/10.1016/j.jcv.2004.03.003
https://doi.org/10.1016/j.jcv.2004.03.00... ,³⁹39. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus: a possible reference for coronavirus disease-19 treatment option. J Med Virol. 2020 Feb:jmv.25729. https://doi.org/10.1002/jmv.25729
https://doi.org/10.1002/jmv.25729... and the mechanism of action involves the inhibition of M^pro, an essential enzyme for coronavirus replication ⁴⁰40. Liu X, Wang XJ. Potential inhibitors against 2019-nCoV coronavirus M protease from clinically approved medicines. J Genet Genomics. 2020 Feb;47(2):119-21. https://doi.org/10.1016/j.jgg.2020.02.001
https://doi.org/10.1016/j.jgg.2020.02.00... . Recent report published in The New England Journal of Medicine⁴¹41. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with Severe Covid-19. N Engl J Med. 2020 Mar:NEJMoa2001282. https://doi.org/10.1056/NEJMoa2001282
https://doi.org/10.1056/NEJMoa2001282... was not encouraging and the combination of lopinavir-ritonavir did not differ significantly from “standard care” group.

The fourth arm of SOLIDARITY combines lopinavir-ritonavir with interferon-b. The activation of innate antiviral response by interferon should have beneficial effects at least in the initial stage of infection. However, cautions should still be observed and the possibility that interferon might exacerbate inflammation during the late phase of SARS-CoV-2 infection cannot be excluded.⁴²42. Kupferschmidt K., Cohen J. Race to find COVID-19 treatments accelerates. Science. 2020 Mar;367(6485):1412-3. https://doi.org/10.1126/science.367.6485.1412
https://doi.org/10.1126/science.367.6485...

Lastly, clinical trials are being conducted to evaluate the use of SARS-CoV-2 convalescent plasma from persons who have recovered from COVID-19 that potentially contain antibodies to treat patients with life-threatening viral infections.⁴³43. FDA. Recommendations for investigational COVID-19 Convalescent Plasma. 2020 [cited 2020 Apr 6]. Available from: https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/investigational-covid-19-convalescent-plasma-emergency-inds
https://www.fda.gov/vaccines-blood-biolo... A group led by Lei Liu⁴⁴44. Shen C, Wang Z, Zhao F, Yang Y, Li J, Yuan J, et al. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA. 2020 Mar. https://doi.org/10.1001/jama.2020.4783
https://doi.org/10.1001/jama.2020.4783... gave convalescent plasma (total dose: 400 mL with a SARS-CoV-2-specific antibody-IgG titer greater than 1:1,000) to five critically ill patients and the symptoms diminished in all of them within ten days. Even though these cases reported by Shen et al ⁴⁴44. Shen C, Wang Z, Zhao F, Yang Y, Li J, Yuan J, et al. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA. 2020 Mar. https://doi.org/10.1001/jama.2020.4783
https://doi.org/10.1001/jama.2020.4783... are compelling, this investigation has some limitations. The intervention was not evaluated in a randomized clinical trial, and the outcomes in the treatment group were not compared with outcomes in a control group - patients who did not receive the intervention. Moreover, patients received numerous other therapies (antiviral and steroids), and the convalescent plasma was administered up to 21 days, and it is not clear whether this timing is optimal or if earlier administration potentially have been associated with different outcomes. Despite these limitations, the study does provide important evidence to support the possibility of evaluating this therapy in more rigorous studies.

Dental practice in the Covid-19 scenario

Risk scenario

Dentists are among the professionals with the greatest exposure to COVID-19. The oral cavity and the work environment represent a high potential source for transmissibility and susceptibility to this and other etiological agents.⁷7. Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig. 2020 Apr;24(4):1619-21. https://doi.org/10.1007/s00784-020-03248-x
https://doi.org/10.1007/s00784-020-03248... ,⁴⁵45. 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. https://doi.org/10.14219/jada.archive.2004.0207
https://doi.org/10.14219/jada.archive.20... ,⁴⁶46. Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et al. High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci. 2020 Feb;12(1):8. https://doi.org/10.1038/s41368-020-0074-x
https://doi.org/10.1038/s41368-020-0074-... The context of undocumented infections is significant, which facilitates the rapid spread of SARS-CoV-2. A substantial number of individuals do not show any signs and symptoms or have mild symptoms. These individuals serve as the primary source for the majority of reported cases and, therefore, for health teams that can become multipliers.⁴⁷47. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020 Mar;eabb3221. https://doi.org/10.1126/science.abb3221
https://doi.org/10.1126/science.abb3221... ,⁴⁸48. 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;323(11):1061. https://doi.org/10.1001/jama.2020.1585
https://doi.org/10.1001/jama.2020.1585...

The rapid identification of COVID-19 cases is crucial for the containment of the pandemic. However, it is still challenging due to the lack of pathognomonic symptoms, coupled with the limited capacity to perform specialized polymerase chain reaction (PCR) tests⁴⁹49. Sun Y, Koh V, Marimuthu K, Ng OT, Young B, Vasoo S, et al. Epidemiological and clinical predictors of COVID-19. Clin Infect Dis. 2020 Mar:ciaa322. https://doi.org/10.1093/cid/ciaa322
https://doi.org/10.1093/cid/ciaa322... - which also have limitations. The need to develop fast accurate molecular diagnostics is mandatory to identify a large number of infected patients and asymptomatic carriers, in order to prevent the transmission of the virus and ensure proper conduct.⁵⁰50. Lee Y, Kang BH, Kang M, Chung DR, Yi GS, Lee LP, et al. Nanoplasmonic on-chip PCR for rapid precision molecular diagnostics. ACS Appl Mater Interfaces. 2020 Mar;12(11):12533-40. https://doi.org/10.1021/acsami.9b23591
https://doi.org/10.1021/acsami.9b23591... ,⁵¹51. Li Z, Yi Y, Luo X, Xiong N, Liu Y, Li S, et al. Development and clinical application of a rapid IgM-IgG combined antibody test for SARS-CoV-2 infection diagnosis. J Med Virol. 2020 Feb:jmv.25727. https://doi.org/10.1002/jmv.25727
https://doi.org/10.1002/jmv.25727... Rapid tests can facilitate elective care in the future since the risk of contamination by SARS-CoV-2 would be ruled out. However, the dentist can never neglect the existence of other diseases transmitted by saliva and aerosol, such as hepatitis B, measles and tuberculosis.⁵²52. Centers of Disease Control and Prevention – CDC. How TB Spreads. 2020 [Cited 2020 Apr 6]. Available from: https://www.cdc.gov/tb/topic/basics/howtbspreads.htm.evention.
https://www.cdc.gov/tb/topic/basics/howt... ,⁵³53. Centers of Disease Control and Prevention – CDC. Transmission of measles. 2020 [cited 2020 Apr 6]. Available from: https://www.cdc.gov/measles/transmission.html
https://www.cdc.gov/measles/transmission... ,⁵⁴54. Centers of Disease Control and Prevention – CDC. Hepatitis B questions and answers for health professionals. 2020 [cited 2020 Apr 6]. Available from: https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#treatmenthttps://www.cdc.gov/measles/transmission.html
https://www.cdc.gov/hepatitis/hbv/hbvfaq...

Dentists should receive and make great efforts regarding preventive care and testing, as they can seriously affect the flattening of the epidemic curve, avoiding the collapse of the health system. Several modeling studies and scenario comparisons - both related to the current pandemic situation and those already experienced especially in China and Italy - have shown that combined interventions must be implemented, both for the population and for health professionals. General measures for all health professionals including dentists comprise daily monitoring of the temperature and testing the health care provider team; use of N95 masks; distance from the workplace (when possible) with the implementation of network communication technologies with patients; social distance; mobility restriction measures; avoid crowd places; diagnostic tests and isolation of infected individuals as well as their families.⁵⁵55. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J, Bania J, et al. The positive impact of lockdown in Wuhan on containing the COVID-19 outbreak in China. J Travel Med. 2020 Mar:taaa037. https://doi.org/10.1093/jtm/taaa037
https://doi.org/10.1093/jtm/taaa037... Especially for dentists it is necessary to follow guidance protocols and new tools/technologies for dental practice aimed at safeguarding oral health professionals, as well as the population under their care.⁵⁹59. Tan CC. SARS in Singapore: key lessons from an epidemic. Ann Acad Med Singapore. 2006 May;35(5):345-9.,⁶¹61. Kharma MY, Alalwani MS, Amer MF, Tarakji B, Aws G. Assessment of the awareness level of dental students toward Middle East Respiratory Syndrome-coronavirus. J Int Soc Prev Community Dent. 2015 May-Jun;5(3):163-9. https://doi.org/10.4103/2231-0762.159951
https://doi.org/10.4103/2231-0762.159951...

Dental treatment during the Covid-19 Pandemic

Due to the nature of the dental treatment, several procedures, as the use of high-speed handpiece or ultrasonic scalers generates aerosol (very small particles or droplets) that can be inhaled, absorbed by the skin or set in nearby surfaces.⁶²62. Centers of Disease Control and Prevention – CDC. Aerosols | NIOSH | CDC. 2020 [cited 2020 Apr 6]. Available from: https://www.cdc.gov/niosh/topics/aerosols/
https://www.cdc.gov/niosh/topics/aerosol... According to the last Scientific Brief published by the World Health Organization,⁶³63. World Health Organization – WHO. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. 2020 [cited 2020 Apr 6]. Available from: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
https://www.who.int/news-room/commentari... the transmission of the SARS-CoV-2 can occur by respiratory droplets from direct contact with an infected person (distance less than 1m), indirect contact with contaminated surfaces or objects and by aerosol produced during procedures performed on infected patients. Based on that, dental and health organizations have issued recommendations to postpone all elective dental treatments and non-essential procedures and limit services only to urgent and emergency visits.¹⁰10. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde (SAPS). . Atendimento odontológico no SUS. Brasília, DF; 2020. [cited 2020 Mar 31]. Available from: http://www.crosp.org.br/uploads/arquivo/ab69d79b87d04780af08a70d8cee9d70.pdf
http://www.crosp.org.br/uploads/arquivo/... ,¹¹11. Centers of Disease Control and Prevention – CDC. Recommendation: postpone non-urgent dental procedures, surgeries, and visits. centers of disease control and prevention. 2020 [cited 2020 Mar 31]. Available from: https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html
https://www.cdc.gov/oralhealth/infection... ,¹²12. American Dental Association – ADA. ADA recommending dentists postpone elective procedures. American Dental Assocaition. 2020 [cited 2020 Mar 31]. Available from: https://www.ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-elective-procedures
https://www.ada.org/en/publications/ada-... Dental health care personnel (DHCP) should be aware of the mechanisms of transmission, the expanded infection control procedures, be able to identify patients with signs / symptoms of COVID-19 and have a clear understanding of what characterizes a dental emergency, urgent dental care and non-emergency dental treatment.

During the COVID-19 pandemic, DCHP should use telecommunication or teledentistry prior the dental treatment to evaluate the needs of the patient and to minimize the risk of infection, asking if patient has fever, cough or shortness of breath (ADA)⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... and have traveled national or internationally (CDC).⁶⁵65. Centers of Disease Control and Prevention – CDC. Coronavirus and travel in the United States. 2020 [cited 2020 Apr 6]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-in-the-us.html
https://www.cdc.gov/coronavirus/2019-nco... ,⁶⁶66. Centers of Disease Control and Prevention – CDC. Travelers returning from international travel. 2020 [cited 2020 Apr 6]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html
https://www.cdc.gov/coronavirus/2019-nco... When possible, dentist should offer advice, prescribe medication for analgesia and/or antimicrobial (when appropriate) and postpone the visit of the patient to the office, but keep direct contact with the patient by phone or text message.⁶⁷67. NHS. NHS England and NHS Improvement. Issue 3, Preparedness letter for primary dental care. 2020 Mar 25 [cited 2020 Apr 2]. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/issue-3-preparedness-letter-for-primary-dental-care-25-march-2020.pdf
https://www.england.nhs.uk/coronavirus/w... If patient presents a dental emergency (potentially life threatening), as an uncontrolled bleeding, or an urgent dental need that requires relieve of severe pain and/or risk of infection,⁶⁸68. American Dentistry Association – ADA. What constitutes a dental emergency? 2020 [cited 2020 Apr 6]. Available from: https://success.ada.org/~/media/CPS/Files/OpenFiles/ADA_COVID19_Dental_Emergency_DDS.pdf?utm_source=adaorg&utm_medium=covid-resources-lp&utm_content=cv-pm-emerg-def&utm_campaign=covid-19&_ga=2.171390569.899008890.1586126066-1720481024.1573059269
https://success.ada.org/~/media/CPS/File... and present sign/symptom of respiratory infection, this patient should not be seen in a dental office and should be referred for an emergency care facility where Transmission-Based Precautions (N95 masks, Airborne Infection Isolation Room for example) are available (ADA).⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO...

In the United Kingdom, the National Health Service (NHS) is working with dental practices and community dental services to establish Local Dental Urgent Care System in every region. These dental offices will accommodate visits of all types of patients, including those with suspected or confirmed COVID-19, patients that are shielded, vulnerable or patients without any of those specific conditions. In those places dental public health practitioners will be available and will have access to the FFP3 respirator to perform the treatment.⁶⁷67. NHS. NHS England and NHS Improvement. Issue 3, Preparedness letter for primary dental care. 2020 Mar 25 [cited 2020 Apr 2]. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/issue-3-preparedness-letter-for-primary-dental-care-25-march-2020.pdf
https://www.england.nhs.uk/coronavirus/w...

In most countries, cases of dental emergency or urgent dental care on patients without any signs and symptoms of COVID-19 can be treated at the dental office. However, since there is a large number of asymptomatic cases of Covid-19,⁴⁷47. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020 Mar;eabb3221. https://doi.org/10.1126/science.abb3221
https://doi.org/10.1126/science.abb3221... the dentist should take extra precautions when seeing the patient and not assume he/she is COVID-19 free. Besides the asymptomatic patients, dental practitioners should be aware that children represent a significant transmission risk to the virus since they present milder symptoms than adults.⁶⁹69. Mallineni SK, Innes NP, Raggio DP, Araujo MP, Robertson MD, Jayaraman J. Coronavirus disease (COVID-19): characteristics in children and considerations for Dentists providing their care. Int J Paediatr Dent. 2020 Apr. https://doi.org/10.1111/ipd.12653
https://doi.org/10.1111/ipd.12653... It is important to maintain patient isolation (have only one patient in the waiting room), adhere to the infection control protocol: standard procedure of putting on and removing all Personal Protective Equipment (PPE), including gown, goggles, N95 mask with face full shield and gloves.⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... Before every treatment, patient should use a mouth rinse with 1% or 1.5% hydrogen peroxide or 0.2% povidone ⁹9. 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;12(1):9. https://doi.org/10.1038/s41368-020-0075-9
https://doi.org/10.1038/s41368-020-0075-... ,⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... and should wear goggles and bib during the whole procedure. To minimize the aerosol production, dentists should use hand instrumentation, high-volume saliva ejector and dental dam during the treatment and refrain to use 3-in-1 syringe.⁶¹61. Kharma MY, Alalwani MS, Amer MF, Tarakji B, Aws G. Assessment of the awareness level of dental students toward Middle East Respiratory Syndrome-coronavirus. J Int Soc Prev Community Dent. 2015 May-Jun;5(3):163-9. https://doi.org/10.4103/2231-0762.159951
https://doi.org/10.4103/2231-0762.159951...

Intraoral radiographs should be avoided since it can induce coughing; the office space should be limited to the patient and to the operator and dental assistant. After the treatment, the DCHP should wear appropriate PPE to proceed with the cleaning and disinfection of the room and equipment using the recommended disinfecting products.⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... Besides, dentists should reconsider the use of sedation (inhalation and pharmacological) to manage severe anxiety or phobia in the dental settings and focus on non-pharmacological techniques to minimize the potential risk of needing life support measures that involve the manipulation of airways and aerosolization (inhalation sedation).⁸8. Souza RC, Costa PS, Costa LR. Dental sedation precautions and recommendations during the COVID-19 pandemic. Braz J Dent. 2020 Apr;77(0):1-3. https://doi.org/10.18363/RBO.V77.2020.E1788
https://doi.org/10.18363/RBO.V77.2020.E1...

In a specific situation where the patient has an unavoidable emergency and no signs and symptoms of COVID-19 and the dentist does not have a N95 mask or higher level, he/she must wear surgical mask in a single use, goggles and face shield to treat a patient, but be aware that the risk of contamination will be moderate.⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... There is a limitation in following this procedure since there is current community spread of COVID-19 with asymptomatic cases in the population. Current research shows that the prognosis of patients with COVID-19 is worst for those older than 60 years of age or presenting underlying diseases (diabetes, hypertension or cardiovascular disease, for example).⁷⁰70. Cheng H, Wang Y, Wang GQ. Organ-protective effect of angiotensin-converting enzyme 2 and its effect on the prognosis of COVID-19. J Med Virol. 2020 Mar. https://doi.org/10.1002/jmv.25785
https://doi.org/10.1002/jmv.25785... In this sense, members of the health team must use clinical judgment and take all precautions to prevent transmission.

In this unprecedented situation, it is advisable to look for and apply the most recent protocols and guidance from your local dental organizations in your country that are based in the current literature and be aware that the COVID-19 pandemic brings challenges to the dental health care providers not only on their practices but on their financial situation as well. A general flowchart (Figure) was constructed based on the ADA’s Interim guidance on minimizing COVID-19 transmission risk when treating dental emergencies.⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... As also stated in this ADA’s document,⁶⁴64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1]. Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
https://www.ada.org/~/media/CPS/Files/CO... Figure 1 does not constitute legal advice or legal guidance. It only helps clinicians for their own judgment about the risks of infection while working in dental offices.

Perspectives

Health professionals are facing new challenges in providing care to their patients. Remote treatment via chat, video conversation, telemedicine, teledentistry and other technologies have given rise to a new look at the professional-patient relationship, opening doors to an untapped universe, since most dentists do not use them as part of their daily work.⁷¹71. Wright JH, Caudill R. Remote treatment delivery in response to the COVID-19 Pandemic. Psychother Psychosom. 2020 Mar;1-3:1-3. https://doi.org/10.1159/000507376
https://doi.org/10.1159/000507376... It is estimated that by 2025 over 60% of the population will be using mobile internet.⁷²72. GSMA. The mobile economy 2020. London: GSMA, 2020 [cited 2020 Apr 10]. Available from: https://www.gsma.com/mobileeconomy/wp-content/uploads/2020/03/GSMA_MobileEconomy2020_Global.pdf
https://www.gsma.com/mobileeconomy/wp-co... Therefore, mobile technologies, including phones, are great allies to community health even in low and middle-income population.⁷³73. Ryan-Pettes SR, Lange LL, Magnuson KI. Mobile phone access and preference for technology-assisted aftercare among low-income caregivers of teens enrolled in outpatient substance use treatment: questionnaire study. JMIR Mhealth Uhealth. 2019 Sep;7(9):e12407. https://doi.org/10.2196/12407
https://doi.org/10.2196/12407... Individuals that still do not have access to mobile services would also benefit due to diminishing waiting lines in local health assistance, at the nearest Primary Health Units.

In private offices, the limitation on dental and medical activities to only urgent and emergency procedures presents a strong impact on the economy of these sectors.⁷⁶76. Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 outbreak: an overview on dentistry. Int J Environ Res Public Health. 2020 Mar;17(6):E2094. https://doi.org/10.3390/ijerph17062094
https://doi.org/10.3390/ijerph17062094... This economic crises have raised reflections and concerns that go beyond clinical security and social detachment and have highlighted the importance of social security and financial education. Such factors must also be taken into account by the entities that guide dental practice, in order to generate discussions to support the dentists on those occasions where they will have to keep distance from their routine clinical tasks during COVID-19.

The dental class, which comprises in its vast majority, autonomous professionals, should recover the issues of financial education, frequently so distant from the contents of the academic curriculum. There is an evident scarcity of articles related to financial education for dental offices. Emergency financial reserve, funds to deposit this reserve and long-term investments, public or private pension, should be part of the incisive recommendations to this group. Other professional classes are raising these issues concerning this urgent moment to guarantee social security for all and to go beyond the packages proposed by governments.⁷⁷77. European Federation of Journalists – EFJ. COVID-19: It is time to guarantee social security for all. 2020 [cited 2020 Apr 6]. Available from: https://europeanjournalists.org/blog/2020/03/23/covid-19-it-is-time-to-guarantee-social-security-for-all/
https://europeanjournalists.org/blog/202... Such strategies must be sustainable, long-term, with a view to protecting the self-employed and avoiding an unprecedented economic crisis.

Conclusions

This recent COVID-19 turned into a global public health outbreak. It is transmitted after contact with infected surfaces and with infected patient’s fluids, including saliva and aerosol. A substantial number of individuals do not show any signs and symptoms and may disseminate the virus. These characteristics put the dental offices as main risk settings of cross infection among patients and dentists. Currently there is no effective treatment and fast diagnosis is still a challenge. All elective dental treatments and non-essential procedures should be postponed, keeping only urgent and emergency visits to the dental office. Unexpected situations like this pandemic, brings financial issues to the dental team; in this way, financial education become very important subject to be discussed during the professional school. The use of telecommunication (phone calls, text messages) and teledentistry are very promising tools to keep contact with the patient without put them in high risk of infection.

Acknowledgments

National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico and Tecnológico - CNPq), and the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Nível Superior - CAPES).

References

Publication Dates

History