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Breaking News: COVID-19 and Dentistry
Mitigation of Aerosol Generating Procedures in Dentistry – A Rapid Review by the Scottish Dental Clinical Effectiveness Programme (SDCEP): An Appraisal
It had the makings of a perfect storm! A vicious virus infecting through aerosol transmission, and a livelihood necessitating aerosol generating procedures (AGPs). This epitomizes the predicament of returning to dental practice in the Coronavirus Disease 2019 (COVID-19) pandemic era. Eight months into the pandemic, various bodies have issued multiple recommendations on how best to mitigate AGPs in routine dentistry,1 but most are not evidence-based and are unsubstantiated, probably due to the dearth of data on SARS-CoV-2 and its spread.
Hence, it is gratifying to note the arrival of a brand new document from the Scottish Dental Clinical Effectiveness Programme (SDCEP) entitled Mitigation of Aerosol Generating Procedures in Dentistry – A Rapid Review,2 sponsored by NHS Education, Scotland. Chaired by Professor Jeremy Bagg, and an erudite group of academics, clinicians and a member of the public have produced this timely document (46 pages) identifying and appraising the extant evidence on a number of key questions related to AGPs in dentistry, and recommending mitigation measures.
In the preamble, the authors categorically state that the review and the conclusions do not have the status of guidance, and should primarily be used to inform policy-making, and developing clinical guidance relevant to dental care delivery during the COVID-19 pandemic. This is a sensible stance as the data on SARS CoV-2 and the spread of infection are constantly emerging.
The document focuses on three main areas, ie AGPs, procedural mitigation and environmental mitigation. These are then subdivided as, categorization of AGPs, high volume suction, rubber dam isolation, preprocedural mouthrinses, antimicrobial coolants, ventilation and air-cleaners. Then, each of the sub-sections are further discussed in terms of: i) evidence summary and appraisal; ii) considered judgement and agreed position; and iii) agreed position statement. Thus, in total there are well argued and articulated, six position statements for the foregoing subcategories. The document ends with a succinct section on implications for clinical practice, and research considerations.
On the whole, the clarity of the document must be commended. Some of the traditionally recommended infection control measures, such as the preprocedural antiseptic mouthwashes, are discouraged, and I fully concur with this view of a ritualistic practice that has a flimsy evidence base, in terms of combating infection transmission in the clinical environment. I also believe the categorization of AGPs into three groups, according to the uses of high (a) and low (b) powered instrumentation, and (c) no powered instrumentation, is sensible, simple and practical, as dentists can formulate the mitigation measures accordingly. One statement that I personally do not concur with is the division of fallow periods into five different time periods of 5 min intervals, as dictated by the use of AGPs. I wonder whether this is a practical proposition.
The latter, however, is a minor blemish in an otherwise insightful and instructive review on AGPs in dental practice. Professor Bagg and his team should be applauded for producing such an important, comprehensive and a timely commentary when the pandemic is waning in most countries, and return to routine clinical dentistry is a feasible proposition. I have no hesitation in commending this freely available review as essential reading to all practitioners.
Note: Any further discussion of the review will appear in the November 2020 issue of Dental Update.