Dental Care Implications in Coronavirus Disease-19 Scenario: Perspectives.

AIM: The aim of this review is to discuss the implications of COVID-19 on various aspects of dental care. BACKGROUND: The COVID-19 pandemic had suspended dental practice globally for over 3 months. While dental practice is being resumed cautiously, standard infection control protocols that were traditionally overlooked are now being strictly implemented. Post-COVID-19, dental care is expected to see a drastic change in the way it is practiced. REVIEW RESULTS: With a view on the natural history and disease dynamics of COVID-19, this review reports various aspects of dental care, viz., patient triaging, engineering and work practice controls, and administrative, financial, and ethical aspects of dental care during and after COVID-19 pandemic. Current evidence-based recommendations with regard to infection-control practices are discussed. A call for universal oral health care with suggestions regarding integration of medical and health care is also proposed. CONCLUSION: COVID-19 is expected to be a watershed moment in the field of dentistry. While we expect to see positive changes in safe delivery of dental care, an increase in cost of availing care is imminent. CLINICAL SIGNIFICANCE: The practice of dentistry and dental infection control has undergone dimensional changes due to bloodborne infectious diseases such as hepatitis B virus infections and human immunodeficiency virus epidemic. Due to these pandemics, many regulatory organizations have provided safety recommendations and guidelines that impact the dental practice. Currently, we are faced with a highly infective disease with a high mortality rate among people with comorbidities and of predominantly droplet transmission and no concrete safety recommendations and guidelines. This manuscript addresses multiple issues, gaps, and pragmatic solutions in controlling transmission of SARS-CoV-2 in dental settings, during and after the pandemic.

Dental infection control and occupational safety in the Russian Federation.

BACKGROUND: In the recent past, the Russian Federation has seen a considerable increase in HIV caseload. A high level committee was formed to assess the status of dental infection control and safety (IC&S) in Russia. This article is one of the outcomes to assess the status of IC&S and is the research of a doctoral student (PhD) in public health. PURPOSE: To assess needs in Dental Infection Control and Occupational Safety in the Moscow Metropolitan Region of the Russian Federation. MATERIALS AND METHODS: A survey with variables assessing knowledge, attitude and practice of IC&S was administered to dentists practicing and or teaching in Moscow city and suburban areas on a convenience sample of dental practitioners. RESULTS: The total number of completed questionnaires were 303. Over 67% had up to three significant exposures to blood and potentially infectious materials (OPIM), but less than 30% got tested for HIV in the previous 3 months. Use of personal protective equipment was not based on anticipated exposure. Less than 10% had an understanding of Spaulding's classification with respect to sanitization, disinfection and sterilization. Only about 34% stated that there was a potential for infectious disease transmission through a percutaneous route and about 61% double gloved while treating patients with infectious diseases. Only about 61% disinfected impressions and most (83%) used alcohol for disinfection purposes. While 34% still used glass-bead sterilizers, about 13% did not sterilize handpieces between patients. CONCLUSION: Results from this study indicated a disparity in the practice of infection control and safety procedures requiring formulation of nationwide dental safety standards. Further, there is a need in implementation of a standardized dental safety curriculum for dental schools and continuing dental education requirements in dental safety for practicing dentists in the Russian Federation.

Evaluation of an automated dental unit water system's contamination control protocol.

BACKGROUND: This study addresses the efficacy of an automated decontamination protocol using the germicide 'tetra acetyl ethylene diamine (TAED) perborate' (Farmec SpA, Italy). The germicide TAED perborate protocol is used in the Castellini Dental Units fitted with an Autosteril unit (an automated device that can cycle 0.26% TAED perborate solution and sterile water for cleaning the water system between patients and overnight). Prior to testing the Autosteril and the 0.26% TAED perborate protocol on the Logos Jr Dental Unit (Castellini SpA, Italy), TAED perborate was used on a dental unit water system simulation device. METHODS: A dental unit water system simulation device equipped with four dental unit water systems and with naturally grown and mature biofilm contamination was used in this study (three treatment units and one control). One treatment group used a simulated 5 minutes contact with TAED perborate and sterile water for irrigation; the second used a simulated 5 minutes contact with TAED perborate and 2 ppm ClO2 for irrigation; the third used a simulated 5 minutes contact with TAED perborate and municipal water for irrigation. The control group used municipal water for irrigation with no cleaning/disinfection protocols. This protocol was repeated for 30 cycles. Laser scanning confocal microscopy (LSCM) was used to study the effects on natural and mature biofilms, and R2A agar used to quantify heterotrophic plate counts in the effluent irrigant. Antimicrobial efficacy was evaluated by challenging TAED perborate with microbes and spores (M. smegmatis and B. subtilis). Deleterious effects of the germicide were evaluated on metal and nonmetal parts of dental unit water systems. Heterotrophic plate counts using R2A agar and LSCM of the lines were conducted to assess biofilm and microbial control. RESULTS: Baseline water samples showed mean contamination >5.6 log10 cfu/ml. After initial cleaning, all three groups maintained mean contamination levels of less than 1.1 (SD <0.3) log10 cfu/ml. LSCM of baseline samples was positive for live biofilm in all groups. At the end of the study, viable biofilm was only present in the control. In the microbial challenge test, all vegetative organisms were killed within 30 seconds of contact, while spores were killed within 5 minutes. Corrosion was seen in metals used in US-manufactured dental unit materials, while not observed in those used in the Castellini Logos Jr dental unit. CONCLUSION: In this study, the TAED perborate protocol was effective in biofilm control and control of dental treatment water contamination. Use of sterile water or 2 ppm ClO2 along with TAED treatment also controlled planktonic contamination effectively. CLINICAL SIGNIFICANCE: Environmental biofilms contaminate dental unit water systems over time and affect the quality of dental treatment water. Contaminants include environmental biofilms, microbes, including gram-negative rods and endotoxins in high doses that are not of acceptable quality for treating patients. There are many germicidal protocols for treating this contamination and one such is the prescribed use of TAED perborate used in conjunction with sterile water for irrigation in the autosteril device, an integral component of the Castellini dental units for between patient decontamination of dental unit water systems. This study was conducted on an automated simulation dental unit water system to test the TAED perborate protocol's efficacy on naturally grown, mature environmental biofilms, it's efficacy on microbes and spores and it's effects on materials used in dental unit water systems. This translational research addresses both microbial control and material effects of TAED perborate in studying efficacy and possible deleterious effects and simulated use in dentistry. Currently, this antimicrobial use protocol is followed worldwide in the Castellini dental units that are used in day-to-day dental patient care.

Comparison of knowledge, attitudes and practice of dental safety from eight countries at the turn of the century.

OBJECTIVE: To compare infection control (IC) knowledge, attitudes and practice of dentists across eight countries. METHODS: Self-administered infection control surveys were completed by 1,874 clinicians in eight countries. Practitioner's knowledge, attitudes, and practice of infection control were examined using over 100 variables. Chi-squared statistics (α = 0.05) were used to compare respondents from different national groups. RESULTS: Immunizations rates varied significantly across the eight countries (p < 0.01) with Asian countries having a lower rate of immunization against HBV than the United States practitioners. Perceived risk of acquiring HIV varied significantly across the study groups (p < 0.01); China had the lowest portion (75%). Dentists in the US reported 92% surface barrier use; only 15% in China reported use. Only 58% of practitioners in Pakistan reportedly used disposable exam gloves; 97% of US practitioners regularly use these gloves. For all groups assessed, including the United States, little over 50% of practitioners understood and practiced Universal/Standard (UP/SP) precautions effectively. CONCLUSION: Analyses from this study suggest that the dental IC knowledge and practice varied widely across the eight countries of interest. Many of the countries were found to have barriers to access IC materials. Results indicate that all eight countries could use improved education standards for universal precautions. CLINICAL SIGNIFICANCE: Knowledge, attitudes and practice of dental safety vary in different parts of the world. This study compares the compliance rates in dental safety among countries and pegs them to the level of practice in the United States. This study also provides evidence-based data on the needs in the regions surveyed and could be used to implement remedial educational measures in improving safe practices.

Evaluation of two methods in controlling dental treatment water contamination.

UNLABELLED: Dental unit water systems are contaminated with biofilms that amplify bacterial counts in dental treatment water in excess of a million colony forming units per milliliter (cfu/ml). The Centers for Disease Control and Prevention and the American Dental Association have agreed that the maximum allowable contamination of dental treatment water not exceed 500 cfu/ml. This study was conducted to evaluate two protocols in controlling contamination of dental unit water systems and dental treatment water. Both methods used an antimicrobial self-dissolving chlorine dioxide (ClO2) tablet at a high concentration (50 ppm) to shock the dental unit water system biofilms initially followed by periodic exposure. To treat dental treatment source water for patient care, 3 parts per million (ppm) ClO2 in municipal/tap water was compared to use of a citrus botanical extract dissolved in municipal water. Heterotrophic microbial counts of effluent water and laser scanning confocal microscopy were performed to evaluate effects of the two treatments. Results from this study indicated that both treatments were effective in controlling biofilm contamination and reducing heterotrophic plate counts <500 cfu/ml. A comprehensive study addressing compatibility of 50 ppm ClO2 on the metals and nonmetal components of the dental water system and effects of low-grade chemicals used on composite bonding to dentin and enamel is warranted before translation from efficacy studies to common clinical use. CLINICAL SIGNIFICANCE: This study provides evidence-based information of using two methods of controlling dental treatment water contamination. The study was conducted in a clinical practice setting in an active dental clinic and the results are meaningful to a clinician who is interested in providing safe dental treatment water for patient care. KEYWORDS: Dental waterline biofilms, Dental treatment water contamination control, Chlorine dioxide, Emulsifiers, Heterotrophic plate counts, Laser scanning confocal microscopy. How to cite this article: Bansal R, Puttaiah R, Harris R, Reddy A. Evaluation of Two Methods in Controlling Dental Treatment Water Contamination. J Contemp Dent Pract 2011;12(2):73-83. Source of support: Nil Conflict of interest: None declared.

Effects of iodine in microbial control of dental treatment water.

OBJECTIVE: To determine the effects of low levels of iodine constantly present in the dental unit water system on microbial control of dental treatment water and biofilm control. MATERIALS AND METHODS: This study used a dental unit water system simulator with eight dental unit waterline systems built to scale and function, each controlled via computer. Each of the eight units was operated independently, four units supplied with self-contained water reservoirs and four units supplied with municipal water. Four units were precleaned to remove biofilm buildup. The study had a well-balanced design with equal representation (variables) of presence/absence of biofilms, selfcontained reservoirs for introduction of treatment water, source water directly connected to municipal water source and iodinated cartridges within the self-contained reservoirs and between municipal water and dental unit. Point-of-use iodinated resin cartridges (IRC) were retrofitted proximal to handpiece and air/ water syringe tip lines in four units, and iodinated resin water cartridges (IRSWC) were fitted to the other four units at the source water output. Heterotrophic plate counts were performed at baseline and twice weekly for a period of 6 weeks. One representative waterline sample was taken from each group at baseline and end-of-study to analyze changes in biofilm status using scanning electron microscopy. RESULTS: Waterlines not previously contaminated with biofilms did not show organization of biofilm matrix in units equipped with IRSWC. Constantly present low levels of iodine, demonstrated some disruption of biofilms in waterlines already contaminated with mature biofilms. All groups showed contamination levels < 500 cfu/ml (colony forming units per milliliter) consistent with the CDC and ADA guidelines. CONCLUSION: In this 6 weeks study, IRSWC equipped waterlines showed disruption of established biofilms, controlled formation of new biofilms in clean lines and rendered the dental treatment water < 500 cfu/ml. Point-of-use iodinated resin cartridges were also effective in controlling contamination in the dental treatment water. CLINICAL SIGNIFICANCE: Dental unit water systems that are in use get contaminated with microbes and biofilms in weeks of being put into use. These biofilms contaminate the treatment water thereby putting patients and staff at risk of infection by predominantly gram-negative microbes. Biofilms in the water systems must be cleaned periodically with a strong decontaminant and the dental treatment source water needs to be modified with a low-grade antimicrobial that can preserve the water quality yet safe to humans. In this translational research study, we evaluate the effects of elemental iodine dissolved in water flowing through an iodine containing cartridge in controlling biofilm and dental treatment water contamination using a dental unit water system simulator, prior to clinical utilization.

Effects of hydrogen peroxide on dental unit biofilms and treatment water contamination.

OBJECTIVES: To study effects of various concentrations of hydrogen peroxide on mature waterline biofilms and in controlling planktonic (free-floating) organisms in simulated dental treatment water systems; and to study in vitro the effects of 2%, 3%, and 7% hydrogen peroxide on the removal of mature biofilms and inorganic compounds in dental waterlines. METHODS: Four units of an automated dental unit water system simulation device was used for 12 weeks. All units were initially cleaned to control biofilms and inorganic deposits. H2O(2) at concentrations of 1%, 2%, 3% was used weekly for periodic cleaning in three treatment group units (units 1, 2 & 3), with 0.05%, 0.15% and 0.25% H(2)O(2) in municipal water used as irrigant respectively. The control unit (unit 4) did not have weekly cleanings and used municipal water as irrigant. Laser Scanning Confocal Microscopy and Scanning Electron Microscopy were used to study deposits on lines, and weekly heterotrophic plate counts done to study effluent water contamination. A 24 hour in vitro challenge test with 7%, 3% and 2% H(2)O(2) on mature biofilms was conducted using harvested waterlines to study biofilm and inorganic deposit removal. RESULTS: Heterotrophic plate counts of effluent water showed that the control unit reached contamination levels in excess of 400,000 CFU/mL while all treatment units showed contamination levels <500 CFU/mL through most of the 12 weeks. All treatment units showed varying levels of biofilm and inorganic deposit control in this short 12 week study. The in vitro challenge test showed although there was biofilm control, there was no eradication even when 7% H(2)O(2) was used for 24 hours. CONCLUSIONS: 2% H(2)O(2) used as a periodic cleaner, and diluted to 0.05% in municipal water for irrigation was beneficial in controlling biofilm and planktonic contamination in dental unit water systems. However, to remove well established biofilms, it may take more than 2 months when initial and multiple periodic cleanings are performed using H(2)O(2).

Sample infection control needs assessment survey data from eight countries.

OBJECTIVES: To compare knowledge, attitudes and practice of standard methods in infection control by dentists in eight countries using a standardised questionnaire. METHODS: Self-administered questionnaires on dental infection control and safety (IC&S) knowledge, attitudes and practice were distributed to a convenience sample of dentists in India, Pakistan, Thailand, Philippines, Taiwan, China, South Korea and the United States of America. RESULTS: Knowledge and practice of infection control among the Asian dentists lagged behind the levels of US dentists. Availability and affordability of equipment and materials were some of the reasons for the practice of infection control and safety. Attitude towards universal/standard precautions in controlling bloodborne pathogens was comparable between groups surveyed. Tested knowledge and practice of infection control was acceptable but the attitude and understanding of universal/standard precautions was ambiguous among both Asian and USA dental practitioners. Education in dental infection control should focus on improving the attitudes of practitioners towards universal precautions. CONCLUSIONS: Knowledge and practice of dental IC&S was high among the USA respondents. Immunisation and IC & S should be stressed in Asia. Information obtained through this study could be used to plan and implement policies in improving dental infection control and occupational safety in individual countries.

A pragmatic approach towards single-use-disposable devices in dentistry.

Disinfection and decontamination including sterilization of devices take a lot of time. For the sake of convenience and hygiene, there are many non-sterile and sterile single-use-disposable supplies available for safe provision of dental care. Some reusable devices cannot be adequately cleaned and therefore sterility may not be assured, therefore, single-use-disposable devices play an important role in replacing such reusable devices. Single-use-disposable devices are commonly used in dentistry as they are easy to use and can be discarded after one use. All devices/instruments/supplies that enter the oral cavity should be sterile reusable items or sterile or non-sterilie single-use-disposable items. In this paper we address comprehensively the rationale for use of such devices and also the pragmatic use of such devices in dentistry.

Failure of anti-retraction valves and the procedure for between patient flushing: a rationale for chemical control of dental unit waterline contamination.

PURPOSE: To evaluate the efficacy of anti-retraction valves; and to compare between-patient flushing with water and with using a chemical treatment to control patient-to-patient contamination through dental unit waterlines (DUWL). METHODS: For the first aim, nine new antiretraction valves from three different manufacturers were utilized. Each valve was installed along the water line connecting the high-speed handpiece to the dental unit. The handpieces were made to run and stop in a container filled with a solution of about 7 log10/mL of Bacillus subtilis spores (used as a marker) and retraction of spores was measured. Subsequently, all nine valves were installed in dental units in use in private offices, and all tests repeated after 15, 30 and 60 working days. For the second aim, the efficacy of mechanical flushing (30 seconds for each instrument) was compared with that of mechanical flushing in combination with pressurized air and of a between-patient disinfecting procedure (2 minutes contact with TAED and persalt utilizing an "autosteril" system). Before each test (10 tests for each procedure), known concentrations of Pseudomonas aeruginosa (ATCC 27853) suspension (4 to 7 log10cfu/mL) was loaded in the DUWL and let sit for 20 minutes. RESULTS: In the anti-retraction valve experiment, at baseline only one anti-retraction valve showed a failure in opposing fluid retraction. After 15 days, three valves, after 30 days, six valves, and after 60 days, eight valves showed failure. In the flushing experiment, a highly significant linear correlation (r =.9178) was found between values before and after mechanical flushing. Post flush log10cfu/mL values showed the removal of about only 1 log10cfu/mL of the microorganisms (only about 10% in absolute counts). On the other hand, no cfu/mL was detected in waterlines after the "autosteril" disinfecting cycles.