July 2020 Orthodontics 117

Enhanced CPD DO C

Sally Zahran Natasha Wright

A Review of COVID-19
and the Implications for
Orthodontic Provision in
England
Abstract: COVID-19 is an unprecedented virus that is destroying the lives of many people worldwide. Dentistry as a profession falls into a
high-risk group due to our close proximity to patients and the aerosols generated in routine dental procedures. The UK dental community
has frantically searched for answers to questions about the new virus and guidance on provision of dental care. This article will review
the most up-to-date recommendations for infection control procedures and use of personal protective equipment (PPE) in England.
PubMed, Embase and Google Scholar databases were searched up until 9 June. This is a review of the current information, guidelines and
recommendations about the COVID-19 virus and use of PPE for dentists and orthodontists.
As of 9 June, the dental profession has received mixed guidance on how best to manage our patients whilst national lockdown
is eased and we enter a recovery phase, but uncertainty remains for the long-term provision of Orthodontics.
CPD/Clinical Relevance: This article gives an overview of guidance and recommendations for dentists and orthodontists in the UK during
the COVID-19 pandemic, especially with regards to infection control and use of PPE.
Ortho Update 2020; 13: 117–124

The World Health Organization (WHO)
declared, on 30 January 2020, that
the COVID-19 outbreak had become a
public health emergency of international
concern.1,2 The risk of cross-infection in
dental settings can be high between
patients and dental health care
professionals (DHCP). Countries with
COVID-19 needed to impose strict infection
prevention and control measures in
hospitals and dental practices.3
As COVID-19 was spreading
rapidly in the United Kingdom (UK), Public
Health England and the National Health
Service (NHS) were revising guidelines for
personal protective equipment (PPE) for
the health care professionals. This guidance
was based on the recommendations of the
WHO and available scientific evidence.4
As an orthodontist in the UK
in the initial stage of the pandemic, it was
difficult to obtain consistent information
relevant to our profession. DHCPs routinely
adopt ‘universal precautions’ for cross-
infection control for all patients, however,
it became apparent early on that this was
not enough to protect us from COVID-19.
There is understandably a lot of anxiety and
concern, amongst the dental profession
in the UK, as to how we deal with the
current situation, and what the future will
hold. This review aims to answer some
of the questions that dental health care
professionals have, as the death toll in UK
from COVID-19 passes 51,000.
The objectives of this article are
to:
 Provide an overview of the COVID-19
virus and modes of transmission;
 Provide an overview of Personal
Protective Equipment (PPE) currently
available in the United Kingdom;
 To summarize the current guidance
and recommendations for dentists and
orthodontists following a review of the
current literature.
Methods
The main keywords used for the search
were ‘COVID-19’, ‘Personal Protective
Equipment’, ‘Dentistry’, ‘Guidance’,
‘Orthodontics’.
The review is limited to official

Sally Zahran, BDS, MSc, MOrth RCS(Ed), Senior Registrar in Orthodontics and Natasha Wright, BDS, MFDS RCS, MSc, MOrth RCS(Eng), FDS
RCS(Eng), Consultant Orthodontist, Addenbrooke’s Hospital and Guy’s and St Thomas NHS Foundation Trust, UK.

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118 Orthodontics
guidance in Dentistry and Orthodontics in
relation to COVID-19.
Following a search of PubMed,
Google Scholar and Embase databases, 10
articles with general dental guidance were
found, however, no articles with specific
guidance to orthodontics. In addition,
official websites were searched for updated
guidance to Dentists and Orthodontists
during the COVID-19 pandemic including
the World Health Organization (WHO),
Public Health England, NHS England,
British Dental Association, General Dental
Council, the Centers for Disease Control
and Prevention (CDC), the Royal College
of Surgeons of Edinburgh (RCSEd), British
Orthodontic Association (BOS), Faculty
of General Dental Practice (FGDP) and
British Association of Oral and Maxillofacial
Surgeons (BAOMS).
Results
What is COVID-19?
COVID-19 is a highly contagious disease
of the respiratory tract caused by a new
coronavirus SARS-CoV-2. It was first
reported in China in December 2019 and,
ever since then, it has continued to spread
all over the world.5 The WHO Director
General declared COVID-19 a global
pandemic on 11 March 2020.6
Clinical features
Clinical presentations of COVID-19 range
from no symptoms to severe pneumonia.
The majority of patients (80%) suffer from
mild respiratory infections. Severe illness
and death are more common among the
elderly and in people with underlying
chronic conditions.7 Symptoms include
fever, a continuous dry cough, shortness
of breath and fatigue. Atypical symptoms
include muscle pain, confusion, headache,
sore throat, diarrhoea, loss of smell and
vomiting. Bilateral pneumonia was shown
when computed tomography (CT) of the
chest was done for COVID-19 patients,
resulting in ‘ground-glass’ appearance and
patchy shadows bilaterally.3,8
Based on data from the
European Centre for Disease Prevention
and Control (ECDC) in March 2020, 32%
of diagnosed cases in the EU/EEA and UK
required hospitalization, with 2.4% having
severe respiratory problems requiring
support and/or ventilation. The death rate
at this time was 1.5% among diagnosed
cases.9
Mode of transmission of COVID-19
According to the WHO, the predominant
mode of transmission of COVID-19 is
believed to be via respiratory droplets
July 2020
resulting from sneezing or coughing, and via DHCPs are at an increased risk
contact with affected surfaces.10,11 As droplets of exposure to the COVID-19 virus during
travel short distances through the air; it is certain procedures, in particular aerosol
recommended we adopt a minimum distance generating procedures (AGP) and the
of 2 metres between individuals to prevent existing standard protective procedures in
droplet transmissions.12 dentistry are not enough to stop COVID-19
The virus has been shown to from spreading.3
survive in aerosols for hours and on surfaces
for days. There are also signs that patients What is Personal Protective Equipment (PPE)?
may be able to spread the virus while Personal Protective Equipment (PPE) is
asymptomatic and that during the incubation normally worn to protect the health care
period they might be carriers.3,13 workers and patients from cross-infection.
The choice of PPE worn depends on the
Why is COVID-19 more serious than the risk of exposure to blood and body fluids,
Influenza Virus? and the risk of infection to patients. PPE
Both COVID-19 and influenza viruses have includes use of gloves; disposable plastic
similar clinical presentation and mode of aprons or full body gowns; protective face
transmission. However, the reproductive (R) wear including full-face shields, visors and
number for COVID-19 is between 2 and 2.5, masks and protective glasses, hairnets, and
which means that each coronavirus patient appropriate footwear.19
might potentially infect 2 to 2.5 other people, Masks routinely used in
compared to influenza where the average orthodontics as part of PPE are fluid-
patient spreads the virus to around 1.3 other resistant (Type IIR) surgical face masks
people. Data suggests that 15% of patients (FRSMs) that cover the face and mouth
with COVID-19 suffer from severe infection, and come with or without a face shield.
with 5% experiencing critical infections They help block large-particle droplets,
requiring ventilation. This is higher than that splashes or sprays that may contain viruses
observed for influenza infection.14 and bacteria, preventing them from
The mortality rate for COVID-19 reaching the wearer’s mouth and nose.
in Italy was over 12% and this was attributed They also protect patients from the wearer’s
to an elderly population.15 Amongst Chinese respiratory emissions. They don’t, however,
patients, it was 3.6%, and outside of China it filter very small particles in the air that
was reported to be 1.5%.14 These mortality may be transmitted by coughs or sneezes.
rates are based on the number of deaths Surgical masks do not provide complete
divided by the number of confirmed cases protection from contaminants because of
of COVID-19, which is not representative the loose fit between the surface of the
of the actual death rate as there are many face mask and the skin. Surgical masks,
unconfirmed asymptomatic patients and therefore, do not provide the wearer with
people who only suffer from very mild a reliable level of protection from inhaling
symptoms.16 smaller airborne particles and are not
As of 9 June 2020, there have considered respiratory protection.19,20,21
been 29,673 deaths related to COVID-19 in Filtering face piece respirators
England.17 Public Health England estimates (FFPs) are disposable respiratory protective
that, on average, 17,000 people have died equipment designed to achieve a very
from the flu in England annually between close facial fit and very efficient filtration
2014/15 and 2018/19. However, the yearly of airborne particles. FFPs are classified
deaths vary widely from as high as 28,330 in by the European Standard (EN 149:2001)
2014/15 to a low of 1,692 in 2018/2019.18 into FFP1, FFP2, and FFP3, which have
The stark overriding difference filtration capacities of at least 80%, 94%,
between COVID-19 and influenza to date and 99%, respectively. The FFP2 respirators
is that there is no reliable vaccine and are almost equal to N95 respirators, which
treatment for COVID-19. There is no pre- are recommended to be used in the
existing immunity in the population for the case of airborne infections in the United
new virus and, accordingly, everyone in the States (US) and other countries. FFP3
population is assumed to be susceptible.10,14 respirators, on the other hand, provide the
best level of protection, and they are the
Transmission of COVID-19 in a dental setting ideal respirators in the UK for protection
As dentistry involves the use of rotary against infectious diseases in health care
dental instruments, it can result in excessive settings.22,23
generation of aerosols and droplets. Surgical
masks may protect the wearer from droplet Infection prevention and control in a dental
spatter, but they do not provide complete setting during COVID-19
protection against inhalation of airborne The most important measure to reduce
infectious agents.5 the risk of spreading infectious diseases
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July 2020 Orthodontics 119

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120 Orthodontics July 2020

Setting Context Disposable Disposable Disposable Surgical Mask Fluid- Filtering

Gloves Plastic Apron Fluid- resistant Face Piece
repellent (Type IIR) Respirator-
Coverall/ Surgical Mask FFP3
Gown
Any setting Performing Single use* X Single use* X X Single use*
an aerosol
generating
procedure on
a possible or
confirmed case
Primary care Direct patient Single use* Single use* X X Single* or X
and other non- care − possible sessional use**
emergency or confirmed
outpatient and case(s) (within
other clinical 2 metres)
settings, eg Working in X X X X single* or X
optometry, reception/ sessional use**
dental, communal
maternity, area with
mental health possible or
confirmed
case(s) and
unable to
maintain 2
metres social
distance***
 *Single use refers to disposal of PPE or decontamination of reusable items, eg eye protection, after each patient and/or following
completion of a procedure, task, or session; dispose or decontaminate reusable items after each patient contact as per Standard
Infection Control Precautions (SICPs).
 ** A single session refers to a period of time where a health care worker is undertaking duties in a specific care setting/exposure
environment, eg on a ward round; providing ongoing care for inpatients. A session ends when the health care worker leaves the care
setting/exposure environment. Sessional use should always be risk assessed and considered where there are high rates of hospital cases.
PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable.
 ***Non clinical staff should maintain 2 m social distancing, through marking out a controlled distance; sessional use should always be
risk assessed.
Table 1. Recommended PPE for primary and outpatient setting in England.11

to patients is hand hygiene.11 The virus
can survive on surfaces for hours or
even days, depending on the type of
surface, the temperature and humidity, so
comprehensive and meticulous disinfection
of every surface in the dental clinic is
crucial.3
When seeing known or
suspected COVID-19 patients, it is essential
to employ both standard infection control
precautions (SICPs) and transmission-based
precautions (TBPs). SICPs are the essential
infection control precautions necessary to
decrease the risk of spread of contagious
micro-organisms from blood and body
fluids. These precautions should be used
by all staff at all times for all patients. TBPs
are additional infection control measures
that must be employed when managing
patients who are suspected or confirmed to
have contagious diseases.
TBPs are divided into:
 Contact precautions, which prevent
spread of infection through direct
contact or indirectly from the nearby
environment.
 Droplet precautions which prevent
spread of infection from the respiratory
tract of one person to another, through
short distances by droplets (>5 µm).
Usually a distance of approximately 2
metres around the infected individual is
considered the ‘zone of risk’ of infection.
 Airborne precautions which prevent
spread of infection from the respiratory
tract of one person to another by
aerosols (= 5 µm). For non-aerosol
generating procedures, it is essential
to employ both droplet and contact
precautions to prevent and control
the spread of COVID-19. For all aerosol
generating procedures (AGPs) airborne
precautions are essential
(Table 1).11
Guidance for UK dentists
during the COVID-19 pandemic
The COVID-19 pandemic has been a rapidly
changing situation. Many dentists in the
UK found that the guidance in the initial
stage of the pandemic was unclear and
variable. Until very recently, government
and professional advice for the DHCP was
insufficient.24 The NHS’s initial instruction
was that DHCP should continue to provide
routine dental care for asymptomatic
patients with no close contact history with
COVID-19 patients, and only to stop seeing
patients who had symptoms. There was,
however, general fear and anxiety amongst
the dental community on whether our
routine infection control procedures and
PPE were adequate. Moreover, much of the
dental profession are worried about the
personal financial consequences.25
On 25 March the Chief Dental

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July 2020
Officer (CDO) in England issued a guidance
letter for DHCP in Primary Dental Care during
COVID-19. The guidance letter advised that
all routine dental care should be stopped and
all practices to establish remote urgent care
services (UDC), providing telephone triage
for their emergency patients and, whenever
possible, treating with advice, analgesia and,
when indicated, antimicrobials (AAA). For
patients deemed to have a life-threatening
emergency, trauma, severe facial/dental
pain, bleeding, or any dental conditions that
may result in a severe systemic illness or
exacerbate an underlying medical condition,
the advice was to refer them to a local Urgent
Dental Centre (UDC).26
The guidance by the CDO was
updated on 15 April27 but, more importantly,
a document for standard operating
procedures (SOPs) for dental care was
published by NHS England. This document
explained in specific detail principles for the
operation of UDC systems in the UK, infection
control measures and the PPE needed during
the period of transmission of COVID-19 (Table
2). For infection control, the document gave
specific recommendations for DHCP on hand
hygiene practices, as well as respiratory
hygiene using the phrase ‘Catch it, bin it, kill
it’, and advised that DHCPs should receive
training for donning and doffing PPE. Urgent
Dental Centres were instructed to triage
patients and provide a remote service with
advice, and face-to-face treatment was for
those patients with acute dental problems
that required immediate management.28
Finally, on 28 May, the CDO
announced that, from 8 June, primary care
dental services can recommence face-to-
face dental treatment, whether routine or
urgent.29 Accordingly, on the 4 June, the
guidance for SOP in England was updated.
UDC sites and primary care dental services
should continue to have 2 stages for patient
management, the remote stage first, followed
by face-to-face if deemed essential. Dental
treatment for suspected/confirmed COVID-
19 patients and their households would
continue to be provided at local UDCs. The
document emphasized the importance of
prioritizing patients with pressing dental care
needs and that AGPs should continue to be
avoided whenever possible.30
The CDO guidelines categorized
procedures into AGPs and non-AGPs.
It included specific and clear clinical
guidelines for periodontal treatment,
paediatric dentistry, restorative dentistry
and endodontics. Unfortunately, there were
no clear orthodontic guidelines, instead all
orthodontic procedures were categorized as
non-AGPs.30
A challenge facing the resumption
Orthodontics 121
Waiting Room/ Dental Surgery Dental Surgery
Reception Non-AGP treatment Treatments
No clinical involving AGPs
treatment
Good hand hygiene Yes Yes Yes
Disposable gloves No Yes Yes
Disposable plastic No Yes No
apron
Disposable gown* No No Yes*
Fluid-resistant Yes Yes No
surgical mask
Filtering face piece No No Yes
(FFP3) respirator**
Eye protection*** No Yes Yes
 * Fluid-resistant gowns (or long-sleeved, waterproof apron) must be worn during
aerosol generating procedures (AGPs). If non-fluid-resistant gowns are used, a disposable
plastic apron should be worn underneath.
 **If wearing an FFP3 that is not fluid-resistant, a full-face shield/visor must be worn.
 ***Eye protection ideally should be disposable. If polycarbonate safety glasses/goggles
or equivalent are used, they should be disinfected in line with manufacturers’ guidance.
Table 2. Personal protective equipment (PPE) for COVID-19 urgent dental care settings.28
of dental treatment is the need for ‘down and the British Orthodontic Society
time’ following treatment. Following an AGP, (BOS)33 recommended that orthodontic
the CDO guidelines recommends the room emergencies should be triaged by
is left vacant for one hour (neutral pressure telephone and advice provided to relieve
room) before cleaning. The room should be pain. The BOS produced a series of
ventilated by opening windows or using excellent videos (https://www.bos.org.uk/
extractor fans which vent to the exterior. COVID19-BOS-Advice/Patients-Advice/
Surgical masks, FFP2/FFP3/N95 respirators Patients-Home-Videos-Repairs) that one
and eye protection can be used for a session could refer patients to, on how best to
of work. A full-face visor is single use and manage appliance component breakages.34
should be changed between patients to There was an emphasis to maintain optimal
protect the respirator from contamination by oral hygiene, adopt a low sugar diet and
droplets or splatter.30 avoid hard and sticky foods that can break
Aerosols are also produced the appliance. Only those patients that
naturally through breathing, speaking, suffered severe pain or intra-oral trauma
sneezing and coughing, as such, the from component failure, not relieved by the
Faculty of General Dental Practice (FGDP) application of wax, or where there is a risk
recommended that the term Aerosol of inhalation of part of the appliance, were
Generated Exposure (AGE) should also seen in person.33
be considered alongside AGP. For each There has been considerable
procedure the clinician should take into debate as to what orthodontic procedures
account the duration of a procedure, are deemed aerosol generating. On the
patient factors, mitigation factors such as 4 June the CDO published the much-
using high-volume suction, and natural anticipated standard operating procedure,
exposures caused by coughing, sneezing and ‘Transition to recovery’ in which it
breathing.31 categorized all orthodontic treatment as
non-AGP but accepted prolonged use of a 3
Guidance for UK Orthodontists in 1 air/water syringe is an AGP.30
during the COVID-19 pandemic The BOS followed up with a
Due to the cessation of all elective treatment statement that there remained a lack of
in primary and secondary care and the clarity regarding the position of Public
current shortage of PPE in the UK, routine Health England on slow speed handpieces
orthodontic treatment stopped on the 25 and 3:1 syringes with regards to aerosol
March. production and that this may have adverse
During this period, the Royal effects on both staff and patients.35
College of Surgeons of Edinburgh32 On 9 June, the BOS went on to
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122 Orthodontics
state that, although a slow handpiece creates
an aerosol, until the present time, there is
no evidence linking the AGP with COVID-19
transmission. The BOS therefore concluded
that, if orthodontists decide to use a slow
speed handpiece, the orthodontic procedure
can be carried out with PPE appropriate for
non-AGP as long as a fluid-resistant surgical
mask is worn in conjunction with high
volume evacuation (HVE) as close as possible
to the treatment area.36
One can conclude from the
guidance that the only orthodontic
procedures that would indicate the need to
don an FFP3 mask would be the use of a high
speed handpiece for removal of aesthetic
brackets or following a risk assessment where
the clinician perceives that the removal or
placement of an appliance will result in a
prolonged exposure time and use of a 3:1
syringe.
When do DHCP see patients who
had COVID-19 and completed
home isolation?
It is important, where possible, that
patients known to have, or who may have
been exposed to COVID-19, isolate for a
minimum time frame before they are seen for
assessment and management as an urgent
orthodontic emergency.
The Centers for Disease Control and
Prevention (CDC) is the leading national
public health institute of the United States
and they recommend the following time
frames based on two strategies:
A non-test-based-strategy
requires a minimum of 3 days (72 hours) to
have passed since recovery (resolution of
fever without the use of medications and
improvement in respiratory symptoms) and
at least 7 days since symptoms first started.
A test-based-strategy requires
patients to have a resolution of symptoms
and negative results for COVID-19 from
at least two consecutive nasopharyngeal
swabs collected ≥24 hours apart (total of two
negative specimens).
People with laboratory-confirmed
COVID-19 but who had no symptoms need to
isolate for at least 7 days since the date of the
first positive COVID-19 diagnostic test.5
Potential exposure and crisis
planning guidance by the
Centers for Disease Control and
Prevention (CDC)
Orthodontic emergency patients can
be potential COVID-19 carriers. CDC
recommends that DHCPs contact patients
48 hours after the provision of emergency
dental care to ask them if they have any
subsequent signs or symptoms of COVID-19.
If a patient reports any signs or symptoms
of infection, they should be referred to
their medical provider for evaluation and
the DHCP should follow the CDC guidance
for health care professionals with potential
exposure risk.5
In stark contrast, NHS England
recommends that, in health care settings,
staff who are exposed to a patient who
develops COVID-19 symptoms should
only self-isolate at home if they develop
symptoms, even if they were not using
appropriate PPE. If they develop COVID-19
symptoms whilst at work, they must stop
work instantly and go home, which should
be followed by decontamination of the unit
as for a patient with COVID-19 symptoms. If
a member of staff tests positive for COVID-
19, other members of staff need to follow
no additional precautions unless they
develop COVID-19 symptoms.30
The CDC recommend those
DHCP who are at higher risk from COVID-
19, such as pregnant females and those
of older age, should avoid carrying out
emergency dental care.5
Is pre-operative mouthrinse
recommended?
It has been suggested that a pre-operative
rinse with 0.2% povidone-iodine or 0.1%
hydrogen peroxide mouthrinses may
decrease the microbial load in saliva with
non-specific virucidal effect on SARS-
CoV-2.37,38,39 However, the FGDP guidance
recommends that there is no evidence of
this virucidal effect.31
Recommending analgesia
for orthodontic pain relief:
Ibuprofen or Paracetamol?
On 14 April, the Commission on Human
Medicines expert group concluded that,
until the present time, there isn’t enough
evidence to conclude that there is a
relationship between taking Ibuprofen and
predisposition to infection by COVID-19
or even the aggravation of its symptoms.40
NHS England, however, recommends that
any COVID-19 patients, or those suspected
to have it, as well as their families,
should take Paracetamol in preference to
Ibuprofen.28
Conclusions and final
observation
The surgical masks Orthodontists routinely
wore prior to the COVID-19 pandemic do
not offer sufficient protection during AGPs;
Recommendations from Public Health
England are that, during high risk AGPs,
such as the use of a high speed handpiece,
the health care professional should wear
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July 2020
gloves, a long-sleeved, disposable, fluid-
repellent gown, an FFP3 respirator, a full-
face shield or visor and hairnet.
The CDO stated that
orthodontic treatment is a non-AGP and,
due to the ever changing climate, this
has brought some uncertainty amongst
clinicians.
The British Orthodontic
Society has confirmed that, although a
slow handpiece creates an aerosol, at
this time there is no evidence linking the
AGP with COVID-19 transmission. Routine
orthodontic treatment can be undertaken
with PPE appropriate for non-AGPs, as long
as a fluid resistant surgical mask is worn in
conjunction with high volume evacuation
(HVE).
This is an uncertain time for
dental health care professionals and,
until there is a vaccine or treatment for
COVID-19, the manner in which we deliver
orthodontic treatment is facing some
radical changes.
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