©

or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

© 2020 EDIZIONI MINERVA MEDICA Minerva Stomatologica 2020 October;69(5):324-7

Online version at http://www.minervamedica.it DOI: 10.23736/S0026-4970.20.04372-1

SPECIAL ARTICLE

COVID-19: how to decrease the risk

of infection in dental practice?
Pedro H. da HORA SALES 1 *, Priscila LOPES de GUSMÃO SALES 2,
Maria L. da HORA SALES 3

1Mario Jucá University Center, Federal University of Pernambuco, Maceió, Brazil; 2Alagoas State University of
Health Sciences, Maceió, Brazil; 3Health Science Alagoas State University, Maceió, Brazil
*Correspondent author: Pedro H. da Hora Sales, Mario Jucá University Center, Federal University of Pernambuco, Avenida Presi-
dente Roosevelt 1200, Barro Duro, Maceió (AL), 57040-600, Brazil. E-mail: salespedro@gmail.com

A B S TRACT
A new pandemic classified by the World Health Organization and called COVID-19, is causing widespread respiratory
infections and deaths in several countries on the five continents. Although it does not have a high lethality rate, this new
virus can present rates of complications and hospitalizations in the intensive care unit in up to 20% of patients, especially
the elderly and those with compromised health, which can cause a collapse in the health system national public health.
Dentistry is one of the most vulnerable professions due to work in the oral cavity, one of the areas with the highest con-
centration of the virus, therefore having an important role in controlling the disease. The objective of this work is through
a review of the current literature, to establish conducts that can reduce the contamination by COVID-19 between the
population and the dental team during the service in the public and private health system.
(Cite this article as: da Hora Sales PH, Lopes de Gusmão Sales P, da Hora Sales ML. COVID-19: how to decrease the risk of
infection in dental practice? Minerva Stomatol 2020;69:324-7. DOI: 10.23736/S0026-4970.20.04372-1)
Key words: COVID-19; Coronavirus; Dentistry; Public health; Pandemics.

C oronavirus is a class of viruses that cause

respiratory diseases in animals and hu-
mans, being generally seasonal and associated
with periods of influenza. The new coronavirus
discovered in January 2020, is associated with
a new pathology to COVID-19, presenting a
structure similar to that of other coronaviruses,
such as that of severe acute respiratory syndrome
(SARG) and that of the Middle East respiratory
syndrome (MERS).1
The main clinical characteristics of CO-
VID-19 are not very different from SARG
and MERS, with symptoms including cough,
high fever, muscle pain, sneezing, respiratory
tract infection, with about 7% to 10% of cases
showing more serious complications evolving
for pneumonia, and the reported lethality rate
ranging from 1-2% to 3.4%, being significantly
lower than that of SARS around 10% and that of
MERS, around 30%.1, 2
The main form of contagion is through close
contact with infected patients, especially through
droplets that can infect mucous membranes such
as those of the mouth, nose and eyes,3, 4 with the
infected patient being able to remain in the in-
cubation period of 1 to 14 days, being the Most
patients have symptoms around 12 days, so a 14-
day average observation and quarantine period
should be performed in suspected cases.2
Most patients are in the age group between
49 and 59 years, with no predilection for sex.
Patients with systemic comorbidities such as
diabetes, hypertension or immunocompromised
patients and elderly patients have a higher rate

324 Minerva Stomatologica October 2020

 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
COVID-19 PREVENTION IN DENTAL PRACTICE
of complications with several cases progressing
to death.2
Therefore, biosafety control measures must be
carried out during dental practice in order to min-
imize the risk of contamination by the team and
other patients. The mucosa of the oral cavity has
a high expression of the angiotensin-converting
enzyme receptor 2 (ECA2), this receptor being
responsible for the entry of the virus into the cell
and consequently its infection.4 The dental ac-
tivity requires close contact with the patient and
with body fluids such as saliva and blood, and
the professionals may also be exposed to indirect
contacts such as contamination of the surfaces of
the dental office caused by suspended particles
from high-speed instruments, and by the very na-
ture of the profession it is impossible to maintain
a distance of less than 1 meter from the patient,
which makes the category potentially exposed to
the risks of contamination.5, 6
The objective of this work is through a lit-
erature review, to seek measures that reduce the
exposure of patients and dental surgeons to con-
tamination by COVID-19 during dental practice.
Performing dental anamnesis
Anamnesis is an essential part of dental practice.
Through it, initial data are collected that allow to
determine the patient’s general health status and
thereby determine the risk of care, estimate the
prognosis and in some cases define the diagno-
sis. With the new pandemic of COVID-19, it is
extremely important that new items are added in
the traditional anamnesis in order to determine
the risk of contamination during care.6 The pro-
fessional should ask the patient some questions,
such as: Did you have contact with any person
diagnosed or suspected of having COVID-19?
Did you have a fever, sore throat and or any
breathing difficulties in the last 14 days? Did
you travel abroad in the last 14 days? Did you
have contact with someone who has returned
from abroad in the last 14 days? These questions
will help to define the priority of dental treat-
ment. The patient’s temperature should always
be checked as well and in case of fever the pa-
tient should be referred for medical evaluation
immediately.
Vol. 69 - No. 5 Minerva Stomatologica
DA HORA SALES
Hand hygiene
Hand hygiene is essential to reduce contamina-
tion by COVID-19, as hands are often brought to
the mouth, nose and eyes that are the gateway to
the virus. Hand washing should always occur be-
fore and after clinical care, and the use of gloves
is not a substitute for proper hand washing.3
Hand hygiene always requires the use of running
water and detergent substances. Hygiene with
70% alcohol is also a good alternative, causing
virus inactivation3. Outside the work environ-
ment, moisturizers should be used to recover the
skin surface damaged by the use of soaps and
other alkaline detergents.3
Urgent care
It is prudent that during the pandemic season,
elective procedures are avoided or minimized.
Therefore, emergency care should be prioritized.
Urgent care is common in dentistry, and a wide
variety of clinical conditions can be included,
such as: pulpitis, dental or facial trauma, odonto-
genic infection, among others, which can generate
aerosols and increase the risk of contamination.5, 6
Use of personal protective equipment
The use of personal protective equipment (PPE)
is essential for dental practice and should be used
regardless of the COVID-19 pandemic. The pro-
fessional must always wear goggles, gloves, hat,
closed coat and masks. During care that gener-
ates aerosols, the following must always be used:
Hair hat, FFP2 or N95 masks, face shields, and
disposable long sleeve aprons.7
Decreasing the amount of virus
through mouthwash
It is already known that the ACE2 receptor, re-
sponsible for the entry of COVID-19 in human
cells, has a great expression in the epithelium of
the oral mucosa, especially the tongue,4 therefore
it is essential to perform antisepsis before dental
care in order to reduce viral load. Mouthwashes
with antiseptic mouthwashes are already well
known and widely used in dentistry, with emphasis
on 0.12% chlorhexidine. However, this substance
325
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
DA HORA SALES
is not highly effective for COVID-19.6 The virus
is sensitive to oxidation, being effective the use
of mouthwashes with 0.2% polvidine and for pa-
tients allergic to iodine, 1% hydrogen peroxide.6
Use of high and low speed instruments
High and low rotation instruments are used in
dentistry associated with drills to perform vari-
ous procedures such as: Cavity preparations,
endodontic accesses, prophylaxis, oral surgery,
among others. Due to the speed of rotation, these
instruments are used with abundant use of wa-
ter or saline generating aerosols, becoming a
means of contamination by COVID-19.8 Pro-
cedures that require high and low speed instru-
ments should be avoided. If it is necessary to use
as in urgent cases, it is recommended to associ-
ate the procedure with the installation of dykes
or rubber sheets, which minimize the amount of
virus coming from the oral cavity as they leave
the tooth isolated. In such cases, it is essential
that the Dental Surgeon perform the procedure
“with four hands,” with the help of an assistant
so that the liquid generated during the use of the
drills is better aspirated. Attention should also be
given to the sucker, preferably with high power
and making use of surgical and detachable tips.6
Disinfection of surfaces before
and after dental care
After dental care, a thorough cleaning of all
possibly contaminated surfaces, including door
handles, must be carried out, thereby reducing
the possibility of contagion from another patient
or the dental team. The virus can remain on in-
animate surfaces such as metal, plastic or glass
for up to 9 days, however it is easily inactivated
with specific substances. The use of 70% alco-
hol, 0.5% hydrogen peroxide or 0.1% sodium
hypochlorite used for 1 minute was effective in
inactivating the virus. Chlorhexidine 0.2% and
benzalkonic chloride 0.2% were less effective.9
Additional care
The pathogenesis of COVID-19 occurs through
infection of host cells through the ACE recep-
tor24. The expression of ACE2 is especially in-
326 Minerva Stomatologica October 2020
COVID-19 PREVENTION IN DENTAL PRACTICE
creased in patients with type I and II diabetes and
in patients using medications based on angioten-
sin-converting enzyme inhibitors like many hy-
pertensive patients. Patients who are in this situ-
ation can potentially be more likely to develop
COVID-19 because they have a greater amount
of ECA2, which facilitates the action of the vi-
rus, with the severity and lethality of COVID-19
greater in hypertensive and diabetic patients.9 It
is interesting that clinicians who especially treat
elderly patients with ACE inhibitors, substitute
medications in order to reduce the risk of infec-
tion. ACE can also be increased after ibuprofen
administration, so this medication should be
avoided by dental surgeons for pain control.10
Conclusions
In the face of the COVID-19 pandemic, new bio-
safety measures are needed to reduce contagion.
Dentistry is a profession that works directly with
the oral cavity and therefore very exposed to the
virus. Because of this, some measures need to be
taken to minimize contagion, such as: strict hand
hygiene with running water and soap and 70%
alcohol gel, use of appropriate PPE, disinfection
of surfaces with 70% alcohol or sodium hypo-
chlorite, use of mouthwash by the patient with
1% hydrogen peroxide or 0.2% polvidine.
References
1. Lana RM, Coelho FC, Gomes MF, Cruz OG, Bastos LS,
Villela DA, et al. The novel coronavirus (SARS-CoV-2)
emergency and the role of timely and effective national health
surveillance. Cad Saude Publica 2020;36:e00019620.
2. He F, Deng Y, Li W. Coronavirus Disease 2019 (COVID-19):
what we Know? J Med Virol 2020. [Epub ahead of print]
3. Yan Y, Chen H, Chen L, Cheng B, Diao P, Dong L, et
al. Consensus of Chinese experts on protection of skin and
mucous membrane barrier for health-care workers fighting
against coronavirus disease 2019. Dermatol Ther (Heidelb)
2020;e13310.
4. 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;12:8.
5. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (CO-
VID-19): emerging and future challenges for dental and Oral
Medicine. J Dent Res 2020;99:481–7.
6. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmis-
sion routes of 2019-nCoV and controls in dental practice. Int
J Oral Sci 2020;12:9.
7. Sorbello M, El-Boghdadly K, Di Giancinto I, Cataldo R,
Esposito C, Falcetta S, et al. The Italian Covid-19 outbreak:
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.

Vol. 69 - No. 5
2020;56:E008. Chinese.

discussed in the manuscript.

thesia 2020. [Epub ahead of print]
©

COVID-19 PREVENTION IN DENTAL PRACTICE

al. [Consideration and prevention for the aerosol transmis-

8. Yu YX, Sun L, Yao K, Lou XT, Liang X, Zhao BW, et
experiences and recomendations from clinical pratice. Anaes-

sion of 2019 novel coronavirus]. Zhonghua Yan Ke Za Zhi

Minerva Stomatologica
COPYRIGHT 2020 EDIZIONI MINERVA MEDICA

infection? Lancet Respir Med 2020;8:e21.

with biocidal agents. J Hosp Infect 2020;104:246–51.

327
History.—Article first published online: May 14, 2020. - Manuscript accepted: May 7, 2020. - Manuscript received: March 31, 2020.
Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
10. Fang L, Karakiulakis G, Roth M. Are patients with hyper-
DA HORA SALES

tension and diabetes mellitus at increased risk for COVID-19

of coronaviruses on inanimate surfaces and their inactivation
9. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence