The Dentist Will See You Now. But Should You Go?

Add dental visits to the list of services you can book now or shortly, as cities, counties and states continue to modify their months-long stay at home orders aimed at reducing COVID-19 infections and hospitalizations.

Dental offices were largely shuttered across the United States after being advised in March by the American Dental Association and the Centers for Disease Control and Prevention to close their practices to all but emergency care. Many closed entirely.

The hope was that by allowing dentists to continue to treat serious cases — such as intense tooth pain and infections — those patients would stay out of hospital ERs, where medical workers were busy with severely ill coronavirus patients. And because the personal protective gear dentists and other health care providers need was in especially short supply, routine dental check-ups and cleanings were deemed nonessential, at least initially.

More recently though, the restrictions against routine care have been loosened in many places. So, is it really safe to go to the dentist now?

Can't completely eliminate the coronavirus transmission risk

Dr. Gregory Poland, an infectious disease specialist at the Mayo Clinic and a spokesman for the Infectious Diseases Society of America says he thinks some infections in dental settings are likely to be inevitable.

"But the hope is that recommendations for their practices that all dentists should be following will mitigate that risk," says Poland.

The concern about the risk of transmission of COVID-19 during a visit to the dentist is understandable. Dental settings have "unique characteristics that warrant specific infection control considerations," says Michele Neuburger, a dental officer for CDC's Division of Oral Health, and a member of CDC's COVID-19 Response Infection Prevention Control Team.

"Dental health care personnel use instruments such as dental [drills], ultrasonic scalers and air-water syringes that create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms and other debris," says Neuburger.

Large droplets can land directly on others in the exam room and can contaminate frequently touched surfaces. The spray could also include small "aerosolized" droplets of COVID-19 if a patient has the virus. And those droplets can remain in the air for up to three hours, according to some estimates, potentially spread the virus to dental staff or the next patient unless stringent precautions — such as PPE for staff and disinfection of the treatment room, instruments and surfaces between patients — aren't taken.

No cases of COVID-19 traced to dental offices, so far

Despite these potential risks, the good news is that both the World Health Organization and the CDC say there have been no confirmed cases of COVID-19 transmitted in a dental office, so far. And that includes follow-up by the CDC of news reports suggesting such infections, Neuburger says.

In mid-May, in sync with the American Dental Association, the CDC issued more guidance for dental practices — guidance that continues to be periodically updated.

Ron Greenberg, 62, a computer science professor at Loyola University in Chicago, returned to his dentist in early June. "I have been nervous about going anywhere since mid-March," he says. But when he finally screwed up the courage for his delayed checkup, the dental office had "lots of procedures in place" that made him feel better. A member of the staff called with a list of questions about his health a few days before the appointment, then again on the day of his checkup.

Greenberg was told to call the receptionist from his car when he arrived, and then wait to let a staffer open the office's front door — so he didn't even need to touch a doorknob.

"They led me straight to the hand sanitizer," he says. "Next was a temperature check. ... Everybody wore masks, until I had to take mine off for them to work on me. And the hygienist and dentist had full face shields for when they were working close in."

Greenberg says he was confident enough after experiencing all those extra precautions to schedule a follow-up appointment for several days later to repair a chipped tooth.

CDC guidelines: Avoid powered tools where possible

Greenberg's visit included many of the precautions recommended by the CDC. These, edited for clarity, include:

Screen patients before each appointment, and when they arrive, for symptoms of COVID-19 — such as cough and fever — and postpone if they have symptoms that could indicate they have the virus.

Use each patient's car or a spot outside the office as the waiting room.

Remove items such as toys, magazines, and coffee stations [which can be infection sources] from waiting rooms.

Require masks for patients and anyone with them while in the office area and immediately after procedures and checkups.

Place a plastic or glass barrier between patient and reception staff.

Avoid using powered tools when possible — some practices no longer use a polisher for teeth cleanings, for example.

Leave out only the tools needed for each individual patient so other tools cannot potentially become contaminated.

Use rubber dams over a patient's mouth for procedures when possible in order to limit spray of secretions.

Use multiple dental workers when doing aerosol-generating procedures when possible, to speed up the visit and minimize exposure.

Install HEPA filters to improve room filtration which might, research suggests, reduce transmission of airborne particles of the virus.

Although a weekly survey by the ADA of dental practices nationwide found that their volume of patients had reached 65% of pre-COVID-19 levels as of June 22, dentists know at least some patients continue to be worried enough to stay away, even if they're in pain or overdue for important procedures such as gum surgery.

Delaying checkups or care for dental pain can potentially turn a small cavity into a root canal or tooth extraction and add to treatment time, higher costs and even more pain, says Howard Golan, a dentist in Williston Park, N.Y., who recently reopened his practice, after seeing patients only for emergency care since mid-March. In very rare cases, he says, missing out on dental care can result in serious infections and even death.

Dentists have a vested interest in taking all possible precautions.

"Dentists are typically 12 to 18 inches away from their patients," notes Louis G. DePaola, the associate dean of clinical affairs at the University of Maryland School of Dentistry in Baltimore. "To do their work dentists have to lean close-in to what currently is the most infectious part of a person if they have COVID-19 — their mouth."

Protecting the health of others working in the office is paramount, too.

What about the orthodontist?

Daniella Smith, of Silver Spring, Md., saw her dentist for a cleaning in late May, and that's when she also resumed orthodontist visits for her two children, ages 12 and 15.

"I was pretty impressed by all the new measures," says Smith, including staff opening all doors, and no use of the high-powered polisher during her cleaning. The kids were advised to brush their teeth just before coming to the office, to cut down on saliva being sprayed during an appointment.

"With all the time and money spent on the kids' braces, we really didn't want their teeth to move back," says Smith, "which is why we made appointments when the office opened back up."

Ideally, dentists would test their patients for COVID-19 ahead of their appointments and reschedule anyone who test positive. But the "point of care" tests that can give results in about 15 minutes can produce false results, says Marko Vujicic, chief economist, and vice president at the ADA's Health Policy Institute.

"We're keeping our eyes on testing to see if there will be an effective way we can truly determine the COVID status of patients before treatment," says Vujicic. "Until then, we are advising dentists to take an abundance of caution according to the guidelines when it comes to treating patients."

"I think everyone is looking for the best science as we go forward," says Connie White, the president of the Academy of General Dentistry and interim dean for clinical programs at the University of Missouri-Kansas City School of Dentistry. The National Institute of Dental and Craniofacial Research is soliciting coronavirus-related research proposals on, among other things, ways to improve disinfection and prevent disease transmission.

Meanwhile, White and other dental leaders also say they realize continued upticks in coronavirus cases across the U.S. could result in dental offices being told to shut again in certain regions.

"I hope that's not the case, of course," says White. But with openings and closures in flux, it's a good idea to make sure any dental procedure begun during one appointment can be concluded soon thereafter. "Patients should discuss with their dentist what is necessary to do right now and what can wait," White advises.

Remember, infectious disease specialists note, that we all have important responsibilities as patients, too, to let the dentist know before or on the day of the appointment if we're feeling sick in any way. We're all in this together — if you're sick, stay home. [Copyright 2020 NPR]