Clinical orthodontic management during the COVID-19 pandemic

Since the beginning of 2020, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; first named as the 2019-novel coronavirus or 2019-nCoV) has rapidly spread throughout the inhabited world and led to unprecedented major health, humanitarian, and financial crises. Efforts to contain the spread of the disease have led to major disruptions, forcing regional and, in many cases, national emergencies and lockdowns, leaving only essential services to continue. In many such efforts, performing elective tasks, including orthodontic treatment, are required to be suspended on orders of the federal, provincial/state, and local civic and public health or professional regulatory bodies. Since orthodontic treatment is a long and continuous process, there are millions of patients who were already undergoing orthodontic treatment when scheduled care was abruptly suspended. Due to the unprecedented nature of this pandemic and the unknown length of time that mandatory suspension of elective treatment may be in effect in different regions, consolidated information and guidelines for the clinical orthodontic management of patients during the COVID-19 pandemic are lacking. The aim of this review was to provide a comprehensive summary of the implications of SARS-CoV-2 and COVID-19 on orthodontic treatment and to discuss the contingency management and provision of emergency orthodontic care, using currently available data and literature.

To ensure that all relevant information regarding the rapidly evolving COVID-19 pandemic and any orthodontic implications were obtained, a wide selection of sources were searched and summarized. These sources included peer-reviewed literature publications from electronic databases such as PubMed and Google Scholar using the following search terms: “Coronavirus,” or “COVID-19,” or “SARS-CoV-2,” or “2019-nCoV,” separately combined with “structure,” “incubation,” “latency,” “transmission,” “symptoms,” “dentistry,” “infection control,” “treatment,” and “protocol.” Up-to-date reports and communications from major health bodies such as the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), National Institutes of Health, and major national orthodontic associations and health professional regulatory bodies were also referenced.

Due to the rapidly evolving nature of the disease and the need for scientific evidence to be available quickly, most of the studies were descriptive, small investigational studies, narrative reviews, and expert opinions (Table 1). More recent studies and peer-reviewed studies were preferred when available. As the evidence is still new and limited in quality, a narrative synthesis was undertaken to provide a broad review of key aspects relevant to orthodontists during the current pandemic.

COVID-19 was first reported in Wuhan, Hubei province, central China in December 2019, where bats were suspected to be the primary host.^1–3  Although many coronaviruses primarily infect animals, human infection occurs when the animal-human species barrier is crossed⁴  and, in the case of COVID-19, pangolins and snakes have been suspected to be the intermediate host.^1,5,6  COVID-19 spread worldwide due to travel and, on March 11, 2020, the WHO declared COVID-19 as a pandemic. Currently, COVID-19 can be spread within cities through local transmission from an infected person or community transmission, where the source of infection is unknown. As of April 5, 2020, there have been more than 1.2 million confirmed cases of COVID-19 in 183 countries around the world and more than 69,000 people have died due to this disease (current data available at https://coronavirus.jhu.edu).

Coronaviruses (CoVs) are divided into four genera: namely alpha-, beta-, gamma-, and delta-coronavirus. Part of the beta-coronavirus genera, SARS-CoV-2 is a lipid bilayer enveloped non-segmented positive-sense RNA virus (Figure 1).⁷  Coronavirus virions are spherical and their surface appears crown-like (hence the name corona) due to spiked glycoprotein projections.⁸ 

Human coronaviruses have been reported to remain infectious on inanimate surfaces in the range between 2 hours to up to 9 days.⁹  In a recent study performed under experimental conditions, SARS-CoV-2 specifically was detected on copper for up to 4 hours, cardboard for up to 24 hours, and stainless steel and plastic for up to 3 days.¹⁰  More importantly for dentistry and orthodontics, SARS-CoV-2 was detected in aerosols for up to 3 hours when created using a nebulizer.¹⁰  SARS-CoV-2 did experience an exponential decay in all experimental conditions, where the longest viability of the virus was on stainless steel and plastic (estimated median half-life of 5.6 hours on stainless steel and 6.8 hours on plastic).¹⁰ 

Although direct contact with the intermediate host is suspected to be the initial transmission route of SARS-CoV-2, progression of the virus allowed for human-to-human transmission.^1,11  Human transmission is predominantly through the respiratory tract via droplets, respiratory secretions (cough, sneeze), and or direct contact,¹²  where the virus enters the mucous membrane of the mouth, nose, and eyes.^13–15  Although contact with symptomatic patients is the typical route of transmission, asymptomatic individuals or those within the viral incubation period may also be able to transmit COVID-19.^16,17  Recent studies have also found SARS-CoV-2 in blood, saliva, and fecal swabs,^1,18,19  as well as potential transmission through respiration,²⁰  indicating that more transmission routes may be possible.

The incubation period of SARS-CoV-2 reportedly ranges from 1 to 14 days, with an average of 3–7 days (Figure 2).¹  The time from exposure to infectiousness (latent period) is shorter than the incubation period, as COVID-19 can transfer through asymptomatic or mildly symptomatic carriers.²¹  Generally, patients are considered to be in convalescence when they present with the following: (1) a normal temperature for more than 3 days, (2) resolved respiratory symptoms, and (3) two negative oropharyngeal swab reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid (RNA) tests that are taken at least 24 hours apart.^22,23  However, SARS-CoV-2 detection can also occur after this, as seen from RT-PCR test results 5–13 days later,²²  and positive fecal viral RNA tests in a small percentage of patients during convalescence.²³  Currently, there is insufficient evidence to determine if patients can be contagious during convalescence.

COVID-19 manifestations range from a complete lack of symptoms to symptomatic patients with severe complications leading to multiorgan dysfunction, septic shock, and systematic failure. COVID-19 can be classified into mild, moderate, severe, or critical diseases.^24,25  In a retrospective study of 72,000 cases, 81% of symptomatic patients presented with mild symptoms, whereas severe and critical symptoms were seen in 14% and 5% of the cases, respectively.²⁵ 

Most COVID-19 patients experience a dry cough, fatigue, and fever. Shortness of breath and gastrointestinal symptoms (diarrhea, vomiting), as well as atypical symptoms, including sore throat, severe headache, confusion, and muscle pain, may also occur. A small proportion of patients develop severe complications, including respiratory distress syndrome, shock, and arrhythmias, and some complications can lead to death.^26,27  The proportion of severe or fatal infection varies among countries and the estimated case fatality percentage, as of April 5, 2020, varies between 0.33% and 11.03%.²⁸ 

Individuals of all ages are susceptible to being infected with COVID-19. The age distribution of COVID-19 may vary among countries. Based on currently available information, individuals with certain risk factors are at higher risk of developing severe illness from COVID-19. These include advanced age (particularly individuals aged 65 years and older), presence of comorbidities in individuals of any age (eg, chronic lung disease, moderate-to-severe asthma, heart disease with complications, diabetes, hypertension, renal failure, liver disease, immunocompromised), and close contact with individuals diagnosed with COVID-19. Even though the symptoms are generally less severe in children with COVID-19, young children, particularly infants, were shown to be more susceptible and also more likely to manifest as severe or critical cases.²⁴ 

All dental professionals, including orthodontists, may be at risk of acquiring COVID-19 through multiple transmission routes, including the following: (1) respiratory droplets from coughing and sneezing or created during a dental or orthodontic procedure, (2) indirect contact where viral droplets fall onto a surface that the dental professional or orthodontist later contacts, (3) aerosols created during dental or orthodontic procedures, (4) treating patients who may have experienced indirect contact transmission from removing and replacing aligners, appliances, and rubber bands, and (5) being in contact with multiple such persons, including those who accompany the patients.²⁹  As SARS-CoV-2 has also been identified in the saliva of infected individuals,¹⁹  this poses an additional risk for dental professionals and their patients.³⁰  Orthodontists must be especially cognizant of the available evidence to provide a safe environment for themselves, their patients (and patient family members), and the entire orthodontic team.

Strict adherence to the most up-to-date recommendations from federal, state/provincial, and local public health authorities is essential for all orthodontists. In the current stage of the COVID-19 pandemic, most authorities have suggested that all elective and routine dental treatment should be suspended and that only emergency dental treatment can be provided. A true dental emergency is one that deals with swelling, uncontrollable pain, bleeding, infection, and trauma to teeth and or bones. Orthodontic emergencies may include the embedment of an orthodontic appliance into the gingiva or oral mucosa leading to severe pain and or infection, circumstances related to dental trauma, or conditions where a lack of management would be harmful to the patient.³¹ 

In dealing with a pandemic of this nature, orthodontists should have a contingency plan in place for the management of their patients. The following key steps are recommended, based on an accumulation of the recommendations and suggestions of multiple professional regulatory bodies:

1. Provide patients with a broadcast communication describing the changes in access to the orthodontic clinic/office as per recommendations of the local public health and or dental regulatory authority,

2. Provide active patients with recommendations on treatment progression either on an as-needed individual basis or in a communication provided to all patients (eg, when to stop turning an expander, what to do when the patient has reached their final aligner, etc.). Patients should also be reminded to always wash their hands prior to and after placing and removing appliances or elastics, to clean their appliances regularly by wiping with alcohol, and to store appliances in their cases,²⁹ 

3. Provide a means of communication (phone number or email) to patients to allow them to contact the orthodontist or an orthodontic team member with any questions or concerns, and send problem-related intraoral mobile-phone digital images,

4. Use phone calls or, where possible, video-calling or appropriate teledentistry facilities to assist patients in resolving any emergent orthodontic problem that can be managed at home, or to determine which patients need in-person attendance,

5. Provide emergent orthodontic treatment in a safe manner, where necessary, and

6. Exercise evidence-based precautions during the provision of any in-office emergency treatment.

In the case of orthodontic emergencies, orthodontists should first try to manage the emergency over the phone or remotely. A verbal or electronically signed consent should be obtained to provide advice in this manner and orthodontists should record all advice that was given in accordance with normal record keeping. If possible, orthodontists should guide patients on how to manage minor emergencies at home.²⁹ Table 2 lists some orthodontic emergencies that may be encountered and advice that the orthodontist can give to patients for home management. Orthodontists can also provide their patients with links to such information with audiovisual aids, which may be available on professional orthodontic association websites (eg, https://www1.aaoinfo.org/). If appropriate, an over-the-counter analgesic may be prescribed for mild pain.

When telecommunication is made by the orthodontist, the patient's health history should be obtained to elicit symptoms or contact history relevant to COVID-19. The patient should be advised to seek appropriate medical treatment or hospitalization based on the analysis of this history. In the event that the patient has to be seen in person, the medical history will also allow the orthodontist to assess the potential transmission risks and to ensure that the clinical operatory is equipped with the proper personal protective equipment (PPE). In-person orthodontic treatment should be deferred for 2 weeks if the patient has been in contact with someone who has been infected or if the patient has travelled.

For patients with a history of COVID-19, the CDC currently recommends that patients can leave home isolation when the following criteria have been met: (1) At least 72 hours have passed since recovery (resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms, eg, cough, shortness of breath), and at least 7 days have passed since initial symptoms; or (2) The patient has had two negative laboratory tests 24 hours apart, has no fever (without the use of fever-reducing medications), and other symptoms have improved.³²  For orthodontic emergencies, most patients with suspected or confirmed COVID-19 should not be seen unless the patient has cleared the CDC's guidelines. If the patient must be seen due to the nature of the emergency, proper use of PPE is critical, including fit-tested N95 masks, double gloving, over gown, and face/eye protection.^33,34  The PPE should include hair covers and hoods and eyewear with side shields or full-face shields. Fluid-impermeable shoes are preferred. It has also been reported that SARS-CoV-2 may become re-suspended during the removal of contaminated PPE or from the floor with movement of health care professionals.³⁵  Airborne infection isolation rooms (AIIR) with negative suction and air purifiers with high-efficiency particulate air filters may significantly reduce the risk of transmission and, for this reason, emergency orthodontic and/or dental treatment of known cases of COVID-19 may be more appropriately undertaken in hospital settings where such facilities exist.³⁶ 

When a patient needs to be seen in practice, triage over the phone is needed to confirm a negative history for COVID-19 symptoms, no contact with an infected individual, and no recent travel.³⁷  A screening questionnaire should be completed electronically if possible, prior to entering the practice/office. It is recommended that the patient enter the office with a maximum of one accompanying person,²⁹  who should not be at high-risk for COVID-19 infection (eg, not medically compromised).³⁸  Hand hygiene is the single most important practice for control of nosocomial infections. Washing hands for a minimum 20 seconds with soap, as soap breaks down the lipid layer of the virus, or alcohol-based hand rub (ABHR) with at least 60% ethanol is recommended. Both 80% ethanol and 75% 2-propanol have been established to have reliable and equal potency for SARS-CoV-2, while benzalkonium chloride was not found to be as effective.⁹  At the point of entry to the clinic, the patient and accompanying person should use ABHR.²⁹  After recording the temperature of every person entering the registration area²⁹  by a staff member with appropriate PPE, a screening questionnaire should be completed verbally for each entrant while maintaining a distance of 6 feet between people. This questionnaire should reconfirm the triage questions that were asked over the phone. To avoid contact between people, magazines or other materials that cannot be disinfected should be removed from the waiting room and, when more than one patient needs to be seen for an emergency, appointments should be staggered as much as possible.³⁹ 

Where possible, only the patient should be allowed entry into the clinical/operatory area. The orthodontic practice/office must maintain a very high standard of sterilization and infection prevention and control (IPAC) protocol, including effective hand hygiene before and after contact with a patient,³⁸  and following the proper sequence for replacement and removal of PPE.⁴⁰  During the provision of emergency treatment, the practitioner must be careful to only do what is necessary to resolve the emergency and to take the patient to a position of safety. SARS-CoV-2 is vulnerable to oxidation; therefore, preprocedural mouthrinse containing 1% hydrogen peroxide or 0.2% povidone-iodine⁴¹  can be advised, although the level of evidence for its use is low. During the pandemic, practitioners should refrain from performing any procedures that lead to aerosols, avoiding air water syringes, high-speed handpieces, and ultrasonic scalers. This is because long-distance transmission is possible when viral particles become suspended in the air⁴²  and viral particles may remain in aerosols for up to 3 hours.¹⁰  The CDC has recommended that N95 masks, eye protection, a gown, and gloves should be used for any aerosol-producing procedure that must be completed, and that they should ideally take place in an AIIR,³⁸  as asymptomatic individuals can transmit COVID-19.^16,17  Practitioners should check recommendations made by their local regulatory bodies if an aerosol-producing procedure cannot be avoided though, from an orthodontic perspective, this should be rare. If handpiece use is imperative, anti-retraction handpieces are advised to restrict debris and fluid aspiration and later, ejection.⁴³  High-volume suction is critical for all aerosol-producing procedures.

Radiographs should be deferred during the pandemic but, if radiographs are required, extraoral radiography is preferred over intraoral radiography to reduce saliva and aerosol production due to gagging and coughing.^36,44  If local anesthesia is required, a local anesthetic gel is preferable over local anesthetic sprays due to potential virus spread in the air.³⁴ 

Orthodontic practices must follow rigorous disinfection following the completion of any emergency treatment to minimize spread through fomites and environmental surfaces. Any steel wires and appliance parts that were cut or removed should be treated as highly infected medical equipment and disposed of as a medical hazard. All surfaces should be thoroughly disinfected using hospital-grade disinfectants such as sodium hypochlorite.⁹  For coronaviruses, bleach/sodium hypochlorite should be used at a concentration of 0.1%–0.2% for 1 minute, rather than the typical 0.05% concentration.^9,45,46  Ethanol in concentrations of 62%–95% is also recommended to disinfect small surfaces.^9,46  Hydrogen peroxide vaporizer has also been proposed for post-procedure operatory decontamination.³³  Waterlines that have been used should be adequately purged to prevent a backflow of pathogens, which can harbor in the plastic tubing. All instruments should be properly disinfected and sterilized immediately and all used, as well as unused, disposables that were within the exposed portion of the operatory, should be presumed to be infected and disposed of as infected medical waste.³³ 

• During the COVID-19 pandemic, it is imperative that orthodontists think globally and act locally to minimize the risks of transmitting SARS-CoV-2 in the orthodontic setting.

• Elective treatment, including routine orthodontic treatment, should be suspended and resumed only when permitted by federal, state/provincial, and local health regulatory authorities.

• Emergency orthodontic treatment can be provided by following a contingency plan founded on effective communication and triage. Treatment advice should be delivered remotely first whenever possible and, where necessary, in-person treatment can be performed in a well-prepared operatory following the necessary precautions and IPAC protocol.

• Guidelines and practice advisories issued by federal, state/provincial, and local health and regulatory authorities should be followed.