Odontol.

Sanmarquina 2020; 23(2): 139-146 ODONTOLOGÍA SANMARQUINA

http://dx.doi.org/10.15381/os.v23i2.17758
ISSN-L 1560-9111; eISSN: 1609-8617

Artículo de Revisión
Enfermedad por coronavirus Mariela Ramírez-Velásquez 1,a, Priscilla Medina-Sotomayor 1,b,

2019 (COVID-19) y su Ángel Aurelio Morocho Macas 1,c

1
Universidad Católica de Cuenca sede Azogues, Azogues,
repercusión en la consulta Ecuador.
a
Doctora en Ciencias Odontológicas.

odontológica: una revisión Doctora en Odontología.

b

c
Magíster en Administración de Tecnologías de Información.

Correspondencia:
Mariela Ramírez Velásquez: mramirezv@ucacue.edu.ec
Universidad Católica de Cuenca, Av. 16 de abril y Ernesto
Che Guevara, Azogues, Ecuador, 030102.
ORCID: 0000-0001-7041-4346

Coautores:
Priscilla Medina Sotomayor: ipemedinas@ucacue.edu.ec
Coronavirus disease 2019 (COVID -19) ORCID: 0000-0002-8117-8550
Ángel Aurelio Morocho Macas: amorocho@ucacue.edu.ec
and its impact on dental practice: a review ORCID: 0000-0003-2946-1284

Editor invitado:
Donald Ramos-Perfecto
Universidad Nacional Mayor de San Marcos, Perú.

Conflicto de intereses: los autores declaran no

tener conflictos de interés.

Fuente de financiamiento: autofinanciado.

Resumen
La presencia de la nueva pandemia COVID-19 o SARS-CoV-2 evidencia la necesidad Recibido: 16/04/20
de adoptar medidas que minimicen, prevengan y controlen el riesgo de infección y la Aceptado: 20/04/20
Publicado: 09/05/20
propagación del virus en la práctica odontológica. Por lo cual, el objetivo de este artí-
culo es establecer las repercusiones en los distintos ámbitos de la atención odontológica
ante la presencia del virus, en relación con la práctica de control de infecciones denta-
les, las características de contagio de este (en los diferentes escenarios estomatológicos),
los procedimientos odontológicos y las posibles consideraciones durante la pandemia.
Concluyendo que en la práctica odontológica se debe priorizar los procedimientos de
emergencia a aquellos pacientes sin síntomas respiratorios además de la evaluación previa
para descartar cualquier sintomatología relacionada con el virus, precautelando la salud
de profesionales y pacientes que interactúan durante la consulta odontológica.
Palabras clave: Coronavirus; Pandemias; Control de infecciones; Síndrome respiratorio
agudo severo; Cuidado dental (fuente: DeCS BIREME).

Abstract
The presence of the new pandemic COVID-19 or SARS-CoV-2 shows the need to adopt
measures that minimize, prevent, and control the risk of infection and the spread of the
virus in dental practice. Therefore, the objective of this article is to establish the repercus-
sions in different areas of dental care facing the presence of the virus, in relation to the
practice of dental infection control, its contagion characteristics (in different stomato-
logical scenarios), dental procedures and possible considerations during the pandemic.
Concluding that in dental practice, emergency procedures should be prioritized to those
patients without respiratory symptoms in addition to the prior evaluation to rule out any
symptomatology related to the virus, protecting the health of professionals and patients
who interact during the dental consultation.
Keywords: Coronavirus; Pandemics; Infection Control; Severe acute respiratory syn-
drome; Dental care (source: MeSH NLM).

© Los autores. Este artículo es publicado por la revista Odontología Sanmarquina de la Facultad de Odontología, Universidad Nacional Mayor de San Marcos. Este es un
artículo de acceso abierto, distribuido bajo los términos de la licencia Creative Commons Atribucion - No Comercia_Compartir Igual 4.0 Internacional. (http://creativecom-
mons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial, distribución y reproducción en cualquier medio, siempre que la obra original sea debidamente citada.

139
Ramírez-Velásquez et al.

Introducción la OMS continúa aumentando y la situación de preven-

En un periodo de corto tiempo, el brote de neumonía
causada por un nuevo coronavirus llamado nueva neu-
monía por coronavirus (NNC) se presentó por primera
vez en China, extendiéndose rápidamente a 24 países
y regiones del mundo. El número de casos confirma-
dos y muertes continúa aumentando. La Organización
Mundial de la Salud (OMS) anunció que los brotes del
nuevo coronavirus han constituido una emergencia de
salud pública de preocupación internacional. El control
eficaz de la infección puede evitar que el virus se propa-
gue aún más 1.
Debido a la especialidad de los entornos de atención
médica bucal, el riesgo de infección cruzada es grave en-
tre los pacientes y los profesionales de la salud bucal, por
lo cual es urgente implementar protocolos de control de
infecciones estrictos y eficientes.
A continuación se comunica, una revisión de las pautas
existentes y las investigaciones publicadas pertinentes a
los principios y prácticas de control de infecciones den-
tales, discutiendo principalmente las características de la
infección en los entornos de la atención estomatológica
y recomendaciones sobre la evaluación de protocolos de
control de infecciones en las circunstancias actuales.
Revisión de la literatura
Antecedentes
Desde el descubrimiento del nuevo coronavirus, en di-
ciembre del 2019, la neumonía causada por él, conoci-
da como NNC es altamente contagiosa y la población
es generalmente susceptible. Recientemente este virus
se denominó oficialmente coronavirus 2 del síndrome
respiratorio agudo severo (SARS-CoV-2), el número de
casos confirmados, sospechosos y fatales reportados por
ción y control de la epidemia es sombría.
El virus surgió en Wuhan, provincia de Hubei, China
y se expandió rápidamente al resto del mundo, trans-
mitido principalmente por inhalación o contacto con
superficies contaminadas, cuenta con un período de in-
cubación de 2 a 14 días con una media de 5 días 2,3.
Los coronavirus son virus con genoma ARN, que po-
seen una envoltura lipoproteica, y cuyo diámetro varía
de 60 a 140 nm. En la superficie existen proyecciones
en forma de espigas que al microscopio electrónico tie-
nen la apariencia de corona. (Figura 1)
El virus ha sido identificado como un coronavirus que
presenta similitud en un 95% con el coronavirus de
murciélago y un 70% de similitud con el SARS-CoV 2.
Todas las personas sin distinción de edad son suscepti-
bles de infección, debido a que las gotas que se generan
durante el estornudo o la tos de pacientes asintomáti-
cos llevan gran cantidad de carga viral 4. Los pacientes
pueden estar infectados durante todo el tiempo que los
síntomas duren, incluso en el período de recuperación.
Las gotas contaminadas pueden alcanzar 1-2 m y depo-
sitarse en las superficies durante un período de tiempo,
siendo susceptibles a la desinfección con hipoclorito de
sodio y peróxido de hidrógeno 5.
En vista de la naturaleza especial de las operaciones de
diagnóstico y tratamiento bucal, además del alto riesgo
de infección cruzada se ha visto la necesidad de tomar
medidas de protección correctas durante el diagnóstico
y el tratamiento bucal para prevenir infecciones.
Manifestaciones clínicas
Las manifestaciones clínicas son variadas, desde un estado
asintomático hasta el síndrome de dificultad respiratoria

Figura 1. Partícula del coronavirus 2 del síndrome respiratorio agudo severo (SARS-CoV-2) bajo
microscopio electrónico. Fuente: Tomado de Creative Commons (https://www.flickr.com/photos/
yusamoilov/49679288857/in/photolist-2iFZkM4-2iCBt7X-2iHUFdT-2iLYhir-2iHxBMr-2iFZcRv-
2iKxrbU-2iGhjYY-2iDnLMP-2iDRP1p-2iJveA5-2iGWUaM-2iGGzNJ-2iHatBh-2iG5Bik-2iDtnpd-2iE-
8cWF-2iHvsLH-2iDVEkh-2iKWEGv-2iL4ECe-2iLm4qR-2iG47oH-2iHA83R-2iLm4wN-2iHHPBU-
2iERn99-2iCtzbC-2iQCZ7h-2iGYJoM-2iHKtKP-2iGeCcS-2iBtQz8-2iJmxif-2iF8SQY-2iGLDHy-2iEcY-
jF-2iMVMei-2iRRYae-2iFFbzh-2ipTdX5-2iL78yp-2iPbvmk-2iRRYnZ-2iQXffo-2iAtWAh-2iKdmov-
2iFLoMn-2iRoLvN-2iJe3jK/)

140 Odontol. Sanmarquina 2020; 23(2)

 Enfermedad por coronavirus 2019 (COVID-19) y su repercusión en la consulta odontológica: una revisión
aguda y disfunción multiorgánica. Las características clíni-
cas más comunes incluyen: fiebre (no en todos los pacien-
tes), tos, dolor de garganta, fatiga, dolor de cabeza, mialgia
y disnea. La conjuntivitis también se ha descrito como una
manifestación clínica 6. Se han reconocido cuatro tipos de
coronavirus llamados HKU1, NL63, 229E y OC43, todos
ellos circulando en humanos y generalmente causando en-
fermedad respiratoria leve 2.
La característica común de la enfermedad es el progreso a
neumonía al final de la primera semana, fallo respiratorio
y muerte, esta progresión está asociada a un aumento ex-
tremo de las citosinas inflamatorias, incluidas IL-2, IL-7,
IL-10, GCSF, IP10, MCP1, MIP1A y TNF-α 6.
La media del tiempo de inicio de los síntomas hasta la
disnea se describe de 5 días, la hospitalización de 7 días
y el síndrome de dificultad respiratoria 8 días. La necesi-
dad de ingreso en cuidados intensivos está en el 20-30%
de los pacientes infectados. Las complicaciones incluyen
lesión pulmonar aguda, síndrome agudo respiratorio
(SAR), shock y lesión renal aguda. La recuperación co-
mienza en la segunda o tercera semana, la media de hos-
pitalización de los pacientes recuperados es de 10 días.
Los ancianos y aquellos con comorbilidades subyacentes
(50-75% de los casos fatales) son los más propensos a
la muerte. La tasa de mortalidad en pacientes adultos
hospitalizados oscila entre los 4 – 11%. La severidad en
los casos de neonatos, lactantes y niños son significativa-
mente más suaves que en los adultos 7. Sin embargo, en
pacientes con enfermedades preexistentes como enfer-
medades cardiovasculares, hipertensión, enfermedades
respiratorias, cáncer, obesidad, fumadores, se asocia el
mayor riesgo de complicaciones y muerte 8,9.
Vías de transmisión
Las principales vías de transmisión son directas y por
contacto 10 :
El virus del COVID-19 ha sido recientemente identifi-
cado en la saliva de paciente infectados, por la tanto la
propagación a través de las gotas del tracto respiratorio
cuando el paciente tose, estornuda o habla en voz alta
son vías de transmisión durante la consulta odontoló-
gica 11,12. El contacto personal cercano con una persona
infectada es la razón por la que la OMS recomienda el
aislamiento social.
Otra forma de contagio se produce al extenderse, en las
manos, patógenos al contacto con superficies inanima-
das 13 y luego entrar en contacto con la cavidad bucal,
nasal, ojos y otras membranas mucosas. Los patógenos
en la sangre o los fluidos corporales con sangre también
pueden ingresar al cuerpo humano a través de la mucosa
o piel dañada por los aerosoles usados en los procesos
odontológicos y causar infección 1,3,10.
Protocolos clínicos de atención
odontológica
El contacto cercano y frecuente con los pacientes en la
consulta dental, expone al personal médico bucal a ries-
go de exposición al nuevo coronavirus, debido a que el
Odontol. Sanmarquina 2020; 23(2)
diagnóstico y tratamiento bucal tiene una particulari-
dad, que durante el examen bucal el odontólogo y el
paciente se encuentran cara a cara. El paciente tose o
estornuda y el profesional corta tejidos duros de las pie-
zas dentales o usa instrumentos ultrasónicos durante los
tratamientos de la boca, lo que puede provocar que las
secreciones, saliva o sangre del paciente salpiquen, y sin
haber las medidas de protección adecuadas, las partícu-
las grandes o pequeñas de gotas suspendidas en el aire,
podrían llegar a la conjuntiva, mucosa bucal o nasal del
profesional, causando infección. Además, también exis-
te el riesgo de una infección cruzada entre los pacientes
debido a los instrumentos odontológicos utilizados para
los tratamientos dentales como la turbina, pudiendo
quedar restos de microorganismos patógenos luego de
su uso. Cuando las manos del personal odontológico o
los pacientes entran en contacto con estos instrumentos
contaminados, puede haber el riesgo de infección 14.
Es necesario debido a las particularidades propias de las
consultas odontológicas con un riesgo de infección cru-
zada alto entre odontólogos y pacientes, en países y/o
regiones afectadas o en riesgo de COVID-19, ciertas
consideraciones para el control y/o prevención del vi-
rus. Este artículo basado en investigaciones relevantes,
presenta consideraciones esenciales sobre COVID-19 y
la infección nosocomial en los consultorios odontoló-
gicos y proporciona recomendaciones para profesiona-
les odontólogos y estudiantes en áreas (potencialmen-
te) afectadas durante y después de superar la pandemia
COVID-19.
En la sala de espera
Las clínicas odontológicas deben establecer una clasi-
ficación previa al examen para evaluar a los pacientes
con fiebre. La oficina de preinspección o triaje debe
mantener una buena ventilación y el personal debe es-
tar equipado con instalaciones de monitoreo rápido de
temperatura, desinfectantes de piel y equipo de protec-
ción personal. Si se encuentra un paciente con fiebre
durante el triaje se le debe proveer inmediatamente una
mascarilla e indicarle el hospital más cercano, solo se
debe realizar el tratamiento bucal después de resolver los
síntomas, incluso se ha informado que después de que
un paciente con infección por SARS-CoV se cura, el
diagnóstico y tratamiento bucal debe posponerse hasta
un mes después del alta 15.
Protección del personal
Durante el período de prevención y control de la epi-
demia, los odontólogos deben aprender activamente a
controlar el coronavirus en la consulta diaria, con un
buen manejo del paciente para prevenir infecciones cru-
zadas y con la correcta protección al personal durante el
diagnóstico y tratamiento, así se previene la propagación
de la epidemia y se garantiza la calidad odontológica y la
seguridad del paciente.
Las medidas estrictas de higiene de manos son para preve-
nir cualquier fuente de infección14,15 además, en compara-
ción con otros coronavirus, el COVID-19 sobrevive más
141
Ramírez-Velásquez et al.
tiempo in vitro 1 reforzando la necesidad de una buena hi-
giene de manos y la importancia de desinfectar completa-
mente la superficie de los objetos. La higiene de manos se
debe realizar antes de contactar con el paciente para una
operación aséptica, después de contactar al paciente, des-
pués de la exposición a los fluidos corporales y después de
contactar al entorno circundante del paciente, equipados
con agentes de limpieza calificados, antisépticos de ma-
nos entre otras. La luz ultravioleta de 254 nm también ha
sido descrita como un inactivador del coronavirus cuando
se encuentra en suspensión, el proceso debe realizarse a
puerta cerrada durante quince minutos 16.
Es importante recordar que el uso de guantes no es un
sustituto para lavarse las manos, y debe hacerse este pro-
cedimiento después de quitárselos 1.
El equipo de protección del personal debe incluir guan-
tes, gorras, mascarillas, gafas, máscaras protectoras, trajes
de aislamiento y ropa protectora, diseñados para preve-
nir la piel, las membranas mucosas de los ojos, la boca,
la nariz, etc. Además, el personal debe poder ponerse y
quitarse el equipo de protección de manera correcta y
hábil. La transmisión de gotas es una de las principa-
les rutas de transmisión del nuevo coronavirus, por lo
tanto, las mascarillas médicas pueden proporcionar una
protección adecuada para el diagnóstico y tratamiento
bucal diario. De acuerdo con la OMS, los pacientes
que entran en contacto con el COVID-19, deben usar
mascarillas N95 17, ajustarse perfectamente a la cara y
limitando su uso a cinco veces siguiendo las recomenda-
ciones del fabricante18. Si el equipo de protección llega-
ra a contaminarse durante el diagnóstico o tratamiento,
debe remplazarse o desinfectarse de inmediato. Después
del uso, las gafas protectoras deben limpiarse y desin-
fectarse con etanol al 75% o colocarse en 500- 1000
mg/L de desinfectante que contenga cloro durante 30
minutos, luego enjuagarse con agua corriente y secarse
para su uso 1.
Atención del paciente
Ante la situación epidemiológica de la enfermedad pro-
vocada por el nuevo coronavirus registrada en América
y el mundo, quedó limitada la atención odontológica de
emergencia a aquellas personas sin síntomas respiratorios.
El manejo temprano de las emergencias dentales agudas
es importante para evitar que los pacientes por acciden-
tes y emergencias culminen en ingresos hospitalarios y
además preocupa que con la suspensión de la atención
dental diaria o de rutina, más pacientes de lo habitual
podrían necesitar admisión para el tratamiento de in-
fecciones dentales agudas que amenazan las vías respira-
torias y/o requieran cuidados intensivos. Los pacientes
con graves inflamaciones pueden progresar a emergen-
cias potencialmente mortales, lo que puede aumentar
los riesgos en el contexto de la disminuida disponibili-
dad de atención médica. Para tales pacientes, las extrac-
ciones dentales deben priorizarse sobre un tratamiento
restaurador. Debe considerarse además la administra-
ción de antimicrobianos, lo cual es una desviación de la
odontología de rutina que debe discutirse a fondo con
142
los pacientes. Las decisiones sobre la realización del tra-
tamiento deben tomarse con el consentimiento apropia-
do del paciente 19.
De igual manera será necesaria ante la aparición de este
virus la reorganización oportuna de los servicios en la
consulta odontológica diaria en cualquier consultorio
público, o privado como una estrategia de control de
infecciones para prevenir la propagación de la CO-
VID-19. La figura 2 representa las divisiones en el área
de atención de emergencia en la Escuela y Hospital de
Estomatología, Universidad de Wuhan, durante el brote
de la enfermedad por coronavirus 2019 donde las dis-
tintas áreas están separadas dependiendo del grado de
probabilidad de contagio 20.
Entre las recomendaciones según la experiencia vivida
en dicho hospital, todo el personal de triaje que labo-
re en el área amarilla debe usar mascarilla quirúrgica
desechable, gorro y ropa de trabajo. En el área naranja,
el personal odontológico debe contar con el equipo de
protección personal, que incluye mascarilla desechable
N95, guantes, batas, gorro, cubierta de zapatos y gafas
o careta, además de ropa protectora. La clínica de aisla-
miento (área roja) destinada para pacientes con sospecha
de COVID-19, quienes se están recuperando de CO-
VID-19 (pero menos de un mes después de ser dados
de alta), o para pacientes que necesitan procedimientos
dentales que producen gotas y / o aerosoles. El área
debe ser desinfectada una vez cada medio día. Además,
toda el área de aislamiento se desinfecta inmediatamente
después de que finaliza el tratamiento y el paciente se ha
ido. El área de la cuadrícula detrás de la línea roja es solo
para el personal. El personal puede descansar en la habi-
tación (área verde). Se recomienda entrar a la habitación
por turnos y seguir usando máscaras médicas a menos
que estén comiendo o bebiendo 20.
Según la OMS 21 es recomendable una orientación sobre
prevención y el control de infecciones durante la aten-
ción del paciente cuando se sospecha una infección por
COVID-19. Además, es necesario el triaje previo a la
atención para medir y registrar la temperatura de todos
los miembros del personal y paciente como un procedi-
miento rutinario.
Los pacientes con fiebre serán derivados a los centros
hospitalarios designados para la atención de pacientes
con COVID-19 luego de su registro 10. Y de ser el caso,
donde el paciente haya estado en alguna región epidé-
mica en los últimos 14 días, inmediatamente se sugiere
la cuarentena durante al menos 14 días, criterios estable-
cidos por la OMS 20 (Tabla 1).
Las orientaciones sobre prevención a esta pandemia, de-
ben mantenerse permanentemente en las salas de espera
por parte del personal la cual además debe disminuir
su capacidad en un 50% evitando las aglomeraciones
y manteniendo la distancia entre personas de 1 a 2 m,
por lo tanto, es preferible que asistan solos a la consulta,
excepto si acompañan a un niño, o adultos mayores que
requieran asistencia estrictamente de emergencia y cum-
pliendo con las medidas de protección adecuada.
Odontol. Sanmarquina 2020; 23(2)
 Enfermedad por coronavirus 2019 (COVID-19) y su repercusión en la consulta odontológica: una revisión

Figura 2. Divisiones del área odontológica para el tratamiento de pacientes ante la Pandemia de COVID-19:
Zona amarilla: destinada para el Triaje y zona de espera o recepción. Zona Naranja: Clínica odontológica.
Zona Roja: Clínica de aislamiento. Zona Verde: área de descanso solo para el personal. Se proporcionan
entradas separadas para pacientes (flecha roja) y personal (flecha azul). Fuente: Elaborado a partir de Meng
et al, 2020.

Tabla 1. Distribución de la anamnesis dirigida con preguntas realizadas durante el triaje odontológico
Preguntas de control Conducta Clínica
Si / No Temperatura >37 °C Temperatura < 37 °C

¿Ha tenido fiebre en los últimos 14 días? SI SI

¿Ha tenido problemas respiratorios en los
últimos 14 días
¿Ha viajado a países con elevado número de
casos de COVID-19 en los últimos 14 días?
¿Ha estado en contacto con alguna persona
confirmada de COVID-19?
¿Ha estado en contacto con personas que
presenten cuadro respiratorio agudo en los
últimos 14 días?
A Cualquier Pregunta A Cualquier Pregunta
Advertir al paciente sobre posible contagio Paciente debe regresar en 14 días, a excep-
y remitir a una unidad de salud. ción de presentar alguna urgencia dental.
NO NO
A Todas Las Preguntas A Todas Las Preguntas
Paciente debe regresar en 14 días, a excep- Tratar al paciente con los cuidados y reco-
ción de presentar alguna urgencia dental. mendaciones

Fuente: Elaborado a partir de Tuñas IT de C. et al.

Procedimientos odontológicos durante la
pandemia COVID-19
Antes de cualquier procedimiento odontológico se re-
comienda disminuir la flora microbiana de la cavidad
bucal con un enjuague bucal antimicrobiano en el pa-
ciente 21,22. Además, por recomendación de la OMS se
debe evitar procedimientos que puedan causar tos por la
emisión de gotas o caso contrario tomar las medidas de
precaución necesarias; de igual manera, se debe evitar el
uso de la jeringa triple o de tres vías durante el proceso
de diagnóstico o tratamiento, el uso de dispositivos de
alta succión para succionar la saliva a tiempo, puede re-
ducir la generación de gotas y aerosoles 14.
Antes del examen bucal, los pacientes pueden usar peróxi-
do de hidrógeno al 0,5% o povidona yodada al 1%, clo-
ruro de cetilpiridinio al 0,05- 0,10% o enjuagues bucales
que reduzcan el número de microrganismos en gotas de
saliva 10,14,21. Los estudios in vitro han demostrado que los
enjuagues de povidona yodada y el cloruro de cetilpiri-
dinio pueden inhibir la actividad del coronavirus SARS-
CoV 16,23,24. La clorhexidina al 0,12% no es eficaz 10.
Debido a que la radiografía intraoral es el examen com-
plementario más utilizado, se debe considerar que po-
dría haber reflejos faríngeos que pueden causar náuseas,
tos y vómito, por lo tanto, se puede considerar técnicas
de imágenes extraorales 25.

Odontol. Sanmarquina 2020; 23(2) 143

Ramírez-Velásquez et al.

En relación a los dispositivos y artículos de uso odon-
tológico, se debe tratar de elegir los desechables y elimi-
narlos inmediatamente en un recipiente que contenga
desinfectante de cloro de 1000 mg/L durante 30 mi-
nutos. En caso de ser esterilizables, utilizar el vapor a
presión (autoclave). Las telas deben sumergirse en un
desinfectante que contenga cloro de 500 mg/L durante
30 minutos 14.
Los diques de goma y los eyectores de saliva de alta
succión pueden ayudar a minimizar el aerosol o las sal-
picaduras durante los procedimientos en la consulta
odontológica.
A continuación, algunas recomendaciones tras la expe-
riencia vivida en el hospital de Wuhan por la crisis cau-
sada por la aparición del COVID-19, en los casos que
las patologías requieran asistencia 20:
–– Se debe proceder al diagnóstico de COVID-19.
–– Antes de la atención del paciente usar enjuague bucal
antimicrobiano.
–– A los pacientes se les debe evaluar signos y síntomas
para determinar en que entorno clínico deben atenderse.
–– Contactar con el paciente 1 a 2 días antes de cual-
quier sesión programada para corroborar si la visita en
persona es necesaria o el problema puede resolverse sin
una visita al consultorio.
–– En el caso de pulpitis sintomática irreversible la ex-
posición pulpar puede procederse con la remoción quí-
mica-mecánica de la caries bajo aislamiento con dique
de goma y un eyector de saliva de alta succión después
de la anestesia local; posteriormente, se puede realizar la
desvitalización pulpar para reducir el dolor.
–– En el caso de necesitarse una extracción dental y su-
tura, se prefiere la sutura absorbible.
–– En traumatismo facial de tejidos blandos, se debe
realizar desbridamiento y sutura. Se recomienda enjua-
gar la herida lentamente y usar el eyector de saliva para
evitar la pulverización.
–– Los casos potencialmente mortales con lesiones
complejas bucales y maxilofaciales deben ingresarse de
inmediato a un hospital designado para pacientes con
COVID-19 y se recomienda tomografía computariza-
da de tórax para apoyar el diagnóstico de la infección
viral, en busca de resultados positivos por imágenes
como recurso más rápido, aunque se debe sospechar
y estar atentos de varios aspectos en la valoración
del paciente como son la combinación de informa-
ción epidemiológica, por ejemplo, el historial de viaje
o residencia en la región afectada 14 días antes de la
aparición de los síntomas. Las pruebas de laboratorio
específicas para el diagnóstico del COVID-19 son otra
alternativa como la prueba de reacción en cadena de la
polimerasa con la transcriptasa inversa (RT-PCR), en
muestras de tracto respiratorio. Cabe mencionar que
un solo resultado negativo de la prueba de RT-PCR
de pacientes sospechosos no excluye la infección. En
conclusión, se debe estar atento de los síntomas de los
pacientes sospechosos, antecedentes epidemiológicos
y los resultados positivos de imágenes de tomografía
computarizada de tórax en un primer momento.
–– En el caso de dolor espontáneo debido a una fractura
dental sin caries, se debe utilizar la pieza de mano de
alta velocidad para la preparación cavitaria, en este caso
se debe programar como el último paciente del día para
disminuir el riesgo de infección nosocomial. Después
del tratamiento, deben seguirse los procedimientos de
limpieza y desinfección ambiental de rutina.
–– Alternativamente, los pacientes podrían ser tratados
en una habitación aislada y bien ventilada o habitacio-
nes aisladas para casos sospechosos con COVID-19.
Consideraciones para las emergencias
odontológicas
Con la finalidad de minimizar la transmisión del CO-
VID-19 entre los pacientes y el equipo de profesionales
en la consulta odontológica, así como proporcionar la
mejor atención en las consultas se presenta las situacio-
nes que son consideradas emergencias para la atención
en el consultorio dental (Tabla 2); se presenta además
el riesgo de trasmisión para el personal y paciente en la
Tabla 3 basado en la ADA Interim Guidance for Mana-
gement of Emergency and Urgent Dental Care 26.

Tabla 2. Situaciones consideradas emergencias en pacientes sin síntomas respiratorios

a. Dolor dental severo por inflamación pulpar.

b. Pericoronitis o dolor en el tercer molar.
c. Osteítis postoperatoria quirúrgica, cambios de apósito seco.
d. Absceso o infección bacteriana localizada que produce dolor e hinchazón localizados.
Emergencias sin
e. Fractura de dientes que causa dolor o causa trauma en los tejidos blandos.
síntomas
f. Trauma dental con avulsión / luxación.
respiratorios
g. Cementación final de la corona / puente si la restauración temporal se pierde, se rompe o causa irritación gingival.
h. Reemplazar la obturación temporal en endodoncia por acceso, en pacientes que experimentan dolor.
i. Corte o adaptación de un alambre de ortodoncia o aparatos que perforan o ulceran la mucosa oral.
j. Reprogramar cita y/o orientar sino es emergencia. 

Fuente: Elaborado a partir de ADA 2020 26

144 Odontol. Sanmarquina 2020; 23(2)

 Enfermedad por coronavirus 2019 (COVID-19) y su repercusión en la consulta odontológica: una revisión

Tabla 3. Riesgo de trasmisión para personal de salud y paciente según lo expuesto en la tabla 1
Plan de tratamiento recomendado
Riesgos Recomendaciones
para el paciente
Bajo a. No requiere cuarentena de 14 días

b. Usar el juicio clínico y tomar todas las precauciones para evitar la transmisión.
c. Sugerir que el paciente sea examinado para Infección por COVID-19 después del
Moderado Remitir al paciente al departamento
tratamiento dental
d. Si es positivo, debe poner en cuarentena por 14 días de emergencias o al centro dental
que cumpla con los criterios estable-
e. Utilice el juicio clínico y tome todas las precauciones. para prevenir la transmisión. cidos, de no ser factible su asistencia.
f. Si se implementa el tratamiento, exija que el paciente se realice la prueba para
Alto
detectar la infección por COVID-19 inmediatamente después del tratamiento; si es
positivo cuarentena durante 14 días todos los profesionales
Fuente: Elaborado a partir de ADA 2020 26

Determinar el riesgo de contagio del paciente juega
un papel importante en la seguridad de la atención
odontológica 27. Las urgencias dentales deben ser prio-
rizadas tomando todas las consideraciones necesarias
28
, incluidos los protocolos de atención determinados
en el área médica que pueden servir para un correc-
to triaje del paciente y así minimizar los riesgos en la
consulta odontológica 29,30.  9. Zhou M, Zhang X, Qu J. Coronavirus disease 2019
Conclusiones
Durante el control de la pandemia del COVID-19, la
atención odontológica de urgencia debe priorizarse a los
tratamientos de rutina, es imprescindible evaluar la con-
dición clínica del paciente para determinar la presencia
de cualquier síntoma relacionado con la infección vi-
ral y trabajar acorde al nivel de riesgo del mismo. Son
muchos los desafíos que aún quedan por enfrentar para
regresar a los tratamientos odontológicos de manera
convencional, por consiguiente, los profesionales deben
cumplir estrictamente las normas de bioseguridad, ética
y actualización continua para responder apropiadamen-
te a este nuevo reto.
7. Farooq I, Ali S. COVID-19 outbreak and its monetary
implications for dental practices, hospitals and healthca-
re workers. Postgrad Med J. 2020 DOI: 10.1136 / post-
gradmedj-2020-137781
8. Jordan RE, Adab P, Cheng KK. Covid-19: Risk Factors
for Severe Disease and Death. BMJ. 2020;368. DOI:
10.1136/bmj.m1198.
(COVID-19): a clinical update. Front Med. 2020. DOI:
10.1007/s11684-020-0767-8.
10. Tuñas IT de C, Silva ET da, Santiago SBS, Maia KD,
Silva-Júnior GO. Doença pelo Coronavírus 2019 (CO-
VID-19): Uma abordagem preventiva para Odontologia.
Rev Bras Odontol. 2020;77:e1766. DOI: http://dx.doi.
org/10.18363/rbo.v77.2020.e1766.
11. Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus
COVID-19 impacts to dentistry and potential salivary
diagnosis. Clin Oral Investig. 2020;;24(4):1619–21.
12. To KK-W, Tsang OT-Y, Yip CC-Y, Chan K-H, Wu
T-C, Chan JM-C, et al. Consistent Detection of 2019
Novel Coronavirus in Saliva. Clin Infect Dis. 2020
DOI: 10.1093 / cid / ciaa149

Referencias bibliográficas 13. Doerrbecker J, Friesland M, Ciesek S, Erichsen TJ, Ma-

1. Li ZY, Meng LY. [The prevention and control of a new
coronavirus infection in department of stomatology].
Zhonghua Kou Qiang Yi Xue Za Zhi. 2020;55(0):E001.
2. Singhal T. A Review of Coronavirus Disease-2019
(COVID-19). Indian J Pediatric. 2020;87(4):281–6.
3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al.
Clinical Characteristics of 138 Hospitalized Patients
With 2019 Novel Coronavirus–Infected Pneumonia in
Wuhan, China. JAMA. 2020;323(11):1061-9.
4. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmis-
sion routes of 2019-nCoV and controls in dental prac-
tice. Int J Oral Sci. 2020;12(1):9.
5. Kampf G, Todt D, Pfaender S, Steinmann E. Per-
sistence of coronaviruses on inanimate surfaces and
their inactivation with biocidal agents. J Hosp Infect.
2020;104(3):246–51.
6. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al.
Epidemiological and clinical characteristics of 99 cases of
2019 novel coronavirus pneumonia in Wuhan, China: a
descriptive study. Lancet. 2020;395(10223):507–13.
teu-Gelabert P, Steinmann J, et al. Inactivation and sur-
vival of hepatitis C virus on inanimate surfaces. J Infect
Dis. 2011;204(12):1830–8.
14. Center For Disease Control and Prevention. Guideli-
nes For Infection Control in Dental Health-Care Set-
tings-2003. MMWR. 2003;52(RR-17):1-68.
15. Samaranayake LP, Peiris M. Severe acute respiratory sy-
ndrome and dentistry: A retrospective view. J Am Dent
Assoc. 2004;135(9):1292–302.
16. Kariwa H, Fujii N, Takashima I. Inactivation of SARS
Coronavirus by Means of Povidone-Iodine, Physical
Conditions and Chemical Reagents. Dermatology.
2006;212(Suppl 1):119–23.
17. Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M.
Medical Masks vs N95 Respirators for Preventing CO-
VID-19 in Health Care Workers A Systematic Review
and Meta-Analysis of Randomized Trials. Influenza
Other Respi Viruses. 2020 DOI: 10.1111/irv.12745.
18. Fisher EM, Shaffer RE. Considerations for Recom-
mending Extended Use and Limited Reuse of Filte-
ring Facepiece Respirators in Healthcare Settings.  J

Odontol. Sanmarquina 2020; 23(2) 145

Ramírez-Velásquez et al.

Occup Environ Hyg. 2014; 11(8):D115-28. DOI: 25. Vandenberghe B, Jacobs R, Bosmans H. Modern den-
10.1080/15459624.2014.902954. tal imaging: a review of the current technology and
clinical applications in dental practice. Eur Radiol.
19. Dave M, Seoudi N, Coulthard P. Urgent dental care
2010;20(11):2637–55.
for patients during the COVID-19 pandemic. Lan-
cet. 2020;395(10232):1257. DOI:  10.1016/S0140- 26. American Dental Association. ADA Interim Guidance
6736(20)30806-0 for Management of Emergency and Urgent Dental Care.
[Consultado el 7 de abril 2020]. Accesible en: https://
20. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (CO-
www.ada.org/~/media/CPS/Files/COVID/ADA_Int_
VID-19): Emerging and Future Challenges for Dental and
Guidance_Mgmt_Emerg-Urg_Dental_COVID19.pdf.
Oral Medicine. J Dent Res. 2020:002203452091424.
DOI: 10.1177/0022034520914246. 27. Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et
al. High expression of ACE2 receptor of 2019-nCoV
21. World Health Organization. Q&A on coronaviruses
on the epithelial cells of oral mucosa. Int J Oral Sci.
(COVID-19)  [consultado el 26 de febrero 2020].  Ac-
2020;12(1):8. DOI: 10.1038/s41368-020-0074-x.
cesible en: https://www.who.int/news-room/q-a-detail/
q-a-coronaviruses. 28. Sepúlveda VC, Secchi AA, Donoso-Hofer F. Urgency
Dental Care Considerations in the Context of Corona-
22. Marui VC, Souto MLS, Rovai ES, Romito GA,
virus COVID-19 (SARS-CoV-2). Int J Odontostomat.
Chambrone L, Pannuti CM. Efficacy of preprocedur-
2020;14(3):279-84.
al mouthrinses in the reduction of microorganisms
in aerosol: A Systematic Review. J Am Dent Assoc. 29. Sociedad Mexicana de Medicina de Emergencias, A.C.
2019;150(12):1015-26. Protocolo de atención para COVID-19 (SARS-CoV-2)
de la Sociedad Mexicana de Medicina de Emergencias.
23. Eggers M, Eickmann M, Zorn J. Rapid and Effec-
[Consultado el 18 de abril 2020]. Accesible en: https://
tive Virucidal Activity of Povidone-Iodine Products
www.flasog.org/static/COVID-19/GuiaCOVID19S-
Against Middle East Respiratory Syndrome Coronavi-
MME.pdf
rus (MERS-CoV) and Modified Vaccinia Virus Ankara
(MVA). Infect Dis Ther. 2015;4(4):491–501. 30. Suarez SS, Campuzano R, Vidale MD, Garrido CE,
Gimenez MT. Recomendaciones para prevención y con-
24. Shen L, Niu J, Wang C, Huang B, Wang W, Zhu N, et
trol de infecciones por SARS-CoV-2 en odontología.
al. High-Throughput Screening and Identification of Po-
Odontología. 2020;22(2):5-32.
tent Broad-Spectrum Inhibitors of Coronaviruses. J Virol.
2019;93(12):e00023-19. DOI: 10.1128/JVI.00023-19.

146 Odontol. Sanmarquina 2020; 23(2)

Odontol. Sanmarquina 2020; 23(3): 1-10 ODONTOLOGÍA SANMARQUINA
http://dx.doi.org/10.15381/os.v23i3.18130
ISSN-L 1560-9111; eISSN: 1609-8617

Artículo de Revisión
COVID-19 y su trascendencia Jorge Luis Mija Gómez 1, a

en la atención dental: revisión 1

Universidad Nacional Mayor de San Marcos. Lima,
Perú.
y actualización de la literatura a
Maestro en Estomatología.

Correspondencia:
Jorge Luis Mija Gómez: jlmijagomez@gmail.com
Jr. Pasco 3353 2do piso. San Martin de Porres, Lima,
Perú.
ORCID: 0000-0001-7728-9402

Editor:
Juan Carlos Cuevas-González
Universidad Autónoma de Ciudad Juárez, México.

Conflicto de intereses: el autor declara no tener

COVID-19 and its significance in dental conflictos de interés.

care: review and update of the literature Fuente de financiamiento: autofinanciado.

Recibido: 02/06/20
Aceptado: 20/06/20
Publicado: 09/07/20

Resumen
A fines del 2019 se presentaron 27 casos de neumonía atípica de etiología desconocida
en la ciudad de Wuhan, China. Los síntomas de los pacientes que padecían la nueva
neumonía viral fueron fiebre, tos seca, disnea y fatiga. El virus causante fue nombrado
coronavirus de tipo 2 causante del síndrome respiratorio agudo severo (SARS-CoV-2)
y la enfermedad fue nombrada en febrero de 2020 por la Organización Mundial de la
Salud como enfermedad por coronavirus COVID-19. Las rutas de contagio de persona
a persona incluyen transmisión directa por inhalación de gotitas de tos, estornudos, y
transmisión indirecta, por medio de fómites que hagan contacto con las membranas
mucosas orales, nasales u oculares. Los odontólogos debido a la naturaleza única de los
procedimientos que realizan, tienen un alto riesgo de infección cruzada del COVID-19,
ya que al trabajar en la boca del paciente está expuestos a una gran cantidad de gotas de
saliva y aerosoles producidos durante la atención dental. La pandemia del COVID-19
requiere que el odontólogo tenga una preparación especial para la prevención del conta-
gio en la consulta dental. El odontólogo también debe actualizarse sobre cómo el CO-
VID-19 se relaciona con la profesión para estar bien preparado y ser miembro activo en
las medidas sanitarias para controlar la pandemia. El objetivo de esta revisión es presentar
información actualizada sobre el COVID-19, y dar soporte científico para el uso de las
diferentes estrategias para minimizar el riesgo de contaminación cruzada en la práctica
dental durante la pandemia de COVID-19.
Palabras clave: COVID-19; SARS-CoV-2; Atención dental; Bioseguridad (fuente:
DeCS BIREME).

Abstract
By the end of 2019, 27 atypical pneumonia cases of unknown etiology were presented in
Wuhan, China. The symptoms of the patients suffering from the new viral pneumonia
were fever, dry cough, dyspnea, and fatigue. The virus was named coronavirus type 2
causing severe acute respiratory syndrome (SARS-CoV-2) and the disease was named in
February 2020 by the World Health Organization as coronavirus disease COVID-19.

© Los autores. Este artículo es publicado por la revista Odontología Sanmarquina de la Facultad de Odontología, Universidad Nacional Mayor de San Marcos. Este es un
artículo de acceso abierto, distribuido bajo los términos de la licencia Creative Commons Atribucion - No Comercia_Compartir Igual 4.0 Internacional. (http://creativecom-
mons.org/licenses/by-nc-sa/4.0/) que permite el uso no comercial, distribución y reproducción en cualquier medio, siempre que la obra original sea debidamente citada.

1
Mija Gómez

The routes of transmission from person to person include direct transmission by inhala-
tion of cough droplets, sneezing, and indirect transmission, through fomites that contact
the oral, nasal, or ocular mucous membranes. Dentists, due to the unique nature of the
procedures they perform, have a high risk of COVID-19 cross-infection, since when
working in the patient's mouth they are exposed to a large number of saliva drops and
aerosols that are produced during dental treatments. The COVID-19 pandemic requires
dentists with special preparation for the prevention of contagion in the dental office. The
dentist should also be updated on how COVID-19 relates to the profession to be well
prepared and to be an active member in sanitary measures to control the pandemic. This
review aims to present updated information on COVID-19 and to provide scientific
support for the use of different strategies to minimize the risk of cross-contamination in
dental practice during the COVID-19 pandemic.
Keywords: COVID-19; SARS-CoV-2; Dental care; Biosecurity (source: MeSH NLM).

Introducción en la boca del paciente están expuestos a una gran can-

A fines de diciembre de 2019 se identificaron 27 ca-
sos de neumonía atípica de etiología desconocida en la
ciudad de Wuhan, provincia de Hubei en China 1. Los
síntomas clínicos típicos de los pacientes que padecían
la nueva neumonía viral fueron fiebre, tos y mialgia o fa-
tiga con tomografía computarizada (TC) torácica anor-
mal, y los síntomas menos comunes fueron producción
de esputo, dolor de cabeza, hemoptisis y diarrea. Inves-
tigadores chinos mediante exámenes virales, obtenidos
de hisopado de garganta, aislaron rápidamente un nue-
vo virus y secuenciaron su genoma (29 903 nucleóti-
dos), lo que descartó la presencia de virus comunes que
causan neumonía, como los virus de la influenza, los
adenovirus y los coronavirus asociados con el síndrome
respiratorio del Medio Oriente (MERS) y el síndrome
respiratorio agudo severo (SARS). Este nuevo patógeno
fue nombrado inicialmente como “nuevo coronavirus
2019” (2019-nCoV) 2 y oficialmente nombrado por el
Comité Internacional de Taxonomía de Virus (ICTV)
como coronavirus de tipo 2 causante del síndrome res-
piratorio agudo severo (SARS-CoV-2) debido al análisis
filogenético y taxonómico de este novedoso coronavirus,
y la enfermedad fue nombrada el 11 de febrero de 2020,
por la Organización Mundial de la Salud (OMS), como
enfermedad por coronavirus COVID-19 3.
Debido a la rápida diseminación por diferentes países,
la epidemia de COVID-19 fue declarada el 30 de enero
de 2020 por la OMS una emergencia de salud pública
de preocupación internacional 4, y el 11 de marzo preo-
cupados por el nivel de propagación del COVID-19 la
OMS lo declara como una pandemia de amenaza para
la salud pública 5.
Al 01 de junio de 2020, la OMS ha notificado 6 057
853 casos confirmados de COVID-19 a nivel mundial,
incluidas 371 166 muertes 6. En el Perú, el primer caso
de COVID-19 se confirmó el 06 de marzo de 2020, y
para el 27 de mayo, según datos oficiales, se habían re-
portado ya 135 905 resultados positivos los cuales cau-
saron la muerte de 3 983 personas 7.
Los odontólogos debido a la naturaleza única de los
procedimientos que realizan, tienen un alto riesgo de
infección cruzada del COVID-19, ya que al trabajar
tidad de gotas de saliva (Flügge) 8 y producción de ae-
rosoles con gran potencial de transmitir el virus 9. Pa-
cientes asintomáticos pueden transmitir el COVID-19
10
lo que presenta un desafío aún mayor en el control
y la prevención de la enfermedad. Por tanto, mientras
dure la pandemia por COVID-19, solo se debe rea-
lizar tratamientos dentales de urgencia, para prevenir
la transmisión del COVID-19 entre odontólogo, pa-
cientes y personal del consultorio. Esta revisión tiene
el objetivo de presentar aspectos importantes del CO-
VID-19 y su relación con la práctica odontológica, ha-
ciendo énfasis en las medidas preventivas para evitar la
infección cruzada durante los tratamientos de urgencia
en el consultorio dental.
COVID-19
La enfermedad conocida como COVID-19 es causada
por el virus SARS-CoV-2, este es un virus zoonótico,
que, al identificar y comparar su secuencia de nucleó-
tidos se encontró una homología del 96,2% entre su
ARN y la del coronavirus Bat-CoV-RaTG13 presente
en el murciélago de herradura chino (Rhinolophus sini-
cus), por lo que se considera a este murciélago como el
huésped natural del virus y al pangolín como el probable
huésped intermedio en la ruta de transmisión de animal
a humano, seguido de contagio masivo de humano a
humano 11,12. El SARS-CoV-2 tiene una homología del
80% con el SARS-CoV, de ahí que fue nombrado ini-
cialmente como nuevo coronavirus 2019-nCoV 3.
Los coronavirus pertenecen a la familia Coronaviridae,
tienen un material genético de ARN de cadena sencilla
(monocatenario) de polaridad positiva [(+) ssARN], con
un tamaño de 27-32 kilobases, y cuatro proteínas estruc-
turales, de las cuales la proteína Spike (S) representan las
estructuras más grandes del virus y son esenciales para
la entrada en las células huésped 3,13 (Figura 1). Los co-
ronavirus se pueden diferenciar en cuatro géneros: alfa,
beta, delta y gamma, de los cuales los coronavirus de
tipo alfa y beta infectan a los humanos, principalmente
los sistema respiratorio, gastrointestinal y sistema ner-
vioso central. Estudios filogenéticos demuestran que los
betacoronavirus incluye al SARS-CoV, el MERS-CoV y
el agente causal COVID-19 14.

2 Odontol. Sanmarquina 2020; 23(3)

 COVID-19 y su trascendencia en la atención dental: revisión y actualización de la literatura

Figura 1. Partícula de coronavirus, (material genético de ARN de cadena sencilla de polaridad positiva), constituido
por una nucleocápside y esta a su vez compuesta por (+) ssARN y la Nucleoproteína. ( tomado de: Palacios M, Santos
E, Velázquez M, León M. COVID-19, una emergencia de salud pública mundial. [published online ahead of print, 2020
Mar 20]. Rev Clin Esp. 2020; S0014-2565(20)30092-8.)

Rutas de contagio desafío para el personal de salud en la lucha por con-

El COVID-19 se transmite directamente de persona a
persona a través de las gotitas de Flügge (de 0,5 a 10
μm) originadas al hablar, toser o estornudar por la per-
sona infectada 11, 15, 16. Estas gotitas pueden permanecer
suspendidas en el aire hasta por 30 minutos y a una dis-
tancia máxima de 1 metro, luego se depositan rápida-
mente, por tanto, para ser vehículo de transmisión debe
haber un contacto cercano con la persona infectada 8, 17.
También es probable el contagio indirecto por contacto
con fómites en el entorno de un infectado 15, y luego
de este contacto se lleve material infectado a la mucosa
oral, nasal y también esta reportado el contagio a través
de la conjuntiva del ojo 18. Respecto a la transmisión in-
trauterina del SARS-CoV-2, la evidencia actual sugiere
que la transmisión vertical es poco probable 19.
La enzima convertidora de angiotensina 2 (ACE2) es
el principal receptor de las células huésped del SARS-
CoV-2 y desempeña un papel crucial en la entrada del
virus en la célula para causar la infección final 20. La pro-
teína S del SARS-CoV-2 es la responsable de unirse al
receptor ACE2, este receptor se encuentra altamente ex-
presado en las células epiteliales de todo el tracto respi-
ratorio, lengua y de las glándulas salivales, lo que explica
el riesgo potencialmente alto de infección a través de la
cavidad oral 3,15.
Periodo de incubación
El período de incubación del COVID-19 es de 5 a 6
días en promedio, llegando en algunos casos a los 14
días 21,22, que son los días recomendados para la obser-
vación médica y cuarentena de potenciales infectados.
Este periodo de incubación relativamente largo, con
ausencia de cualquier sintomatología, representa un
trolar la propagación del COVID-19.
Características clínicas
Los síntomas iniciales son presencia de fiebre, tos seca,
congestión nasal, fatiga y otros signos de infección del
tracto respiratorio alto. La mayoría de los pacientes con
COVID-19 presentan sintomatología relativamente
leve, pero en aproximadamente la cuarta parte de los
casos, la infección puede progresar a enfermedad grave
con disnea y congestión pulmonar severa. La insuficien-
cia multiorgánica puede dar lugar a insuficiencia respi-
ratoria, shock, síndrome de dificultad respiratoria agu-
da, arritmia, lesión aguda del miocardio, lesión hepática
aguda y sepsis, incluso la muerte 11. Esta progresión está
asociada a un aumento extremo de citosinas pro-infla-
matorias, incluidas interleuquinas (IL-1B, IL-2, IL-6,
IL-7, IL-10, IL-12), interferones (IFNα, IFNγ), factor
de necrosis tumoral alfa (TNF-α), factor de crecimiento
transformante beta (TGF-β) y quimioquinas (CCL2,
CCL3, CCL5, CXCL8, CXCL10). Este aumento lla-
mado tormenta de citoquinas, conlleva a la muerte por
una respuesta inflamatoria sistémica no controlada 23-25.
En pacientes de edad avanzada y pacientes con existen-
cia de comorbilidades, principalmente hipertensión,
diabetes y cardiopatía isquémica, el riesgo de complica-
ciones graves aumenta 26,27.
Está reportado que aproximadamente el 80% de los
pacientes con COVID-19 son asintomáticos o con sin-
tomatología muy leve, sobretodo en pacientes niños y
jóvenes. Los portadores asintomáticos pueden provocar
una transmisión de persona a persona y deben conside-
rarse una fuente de infección del COVID-19 28-30.

Odontol. Sanmarquina 2020; 23(3) 3

Mija Gómez
Las manifestaciones cutáneas son menos frecuentes,
pero en casos agudos de COVID-19 se puede presen-
tar erupción eritematosa, urticaria localizada o genera-
lizada, sin embargo, puede ser difícil distinguir la causa
subyacente (infección viral o la medicación prescrita) 31.
En niños con COVID-19 se ha reportado casos raros de
eritema multiforme, síndrome hiperinflamatorio multi-
sistémico similar a la enfermedad de Kawasaki 32,33.
Manifestaciones bucales de COVID-19
El genoma del SARS-CoV-2 se ha detectado en la sa-
liva de la mayoría de los pacientes con COVID-19, lo
que indica la posible infección de las glándulas salivales.
En algunos pacientes el SARS-CoV-2 se detectó solo en
la saliva, pero no en el aspirado nasofaríngeo. La saliva
también se ha utilizado para detectar al virus en pacien-
tes hospitalizados sin fiebre o síntomas respiratorios 34,35.
La pérdida del gusto y el olfato se ha reportado como
uno de los síntomas de COVID – 19. La mayoría de los
pacientes con estos síntomas (91%) informaron la apari-
ción de alteraciones del gusto aun antes de los síntomas
respiratorios. El trastorno del gusto podría explicarse
por la alta expresión de ACE2 en el dorso de la lengua,
rica en papilas gustativas 27.
Se ha reportado presencia de gingivitis descamativa, úl-
ceras y ampollas compatibles con estomatitis herpética
recurrente en la mucosa palatina, aparentemente asocia-
do a COVID-19, así como sensación de quemazón y
dolor de la orofaringe 36 (Figura 2).
Pacientes con periodontitis moderada o grave no tra-
tada puede empeorar en casos severos de COVID-19,
en los que un estado inflamatorio persistente parece
actuar como un desencadenante de la cascada de coa-
gulación y se asocia con mayores niveles de productos
de degradación de fibrinógeno (por ejemplo, dímero
D) 37. También se reportó un aumento espontáneo en
la prevalencia de enfermedad periodontal necrotizante
Figura 2. A. Múltiples úlceras de color naranja con halo eritematoso y distribución simétrica en el paladar duro derecho del
paciente. B. Múltiples úlceras amarillentas con un halo eritematoso en el paladar duro izquierdo del paciente.
(tomado de: Carreras-Presas M, et al.)
4 Odontol. Sanmarquina 2020; 23(3)
(EPN), en relación al aumento de casos confirmados de
COVID-19. La etiología de la EPN puede estar asocia-
da con coinfecciones bacterianas que ocurren intraoral-
mente en pacientes con COVID-19. Los análisis me-
tagenómicos de los infectados con frecuencia detectan
lecturas bacterianas anormalmente altas de Prevotella
intermedia, además de géneros patógenos comunes im-
plicados en la aparición y progresión de enfermedades
orales como: estreptococos, Fusobacterium, Treponema
y Veillonella. P. intermedia se considera una especie bac-
teriana etiológica importante para varias lesiones perio-
dontales agudas, que junto con las especies de Fusobac-
terium y Treponema, constituyen una gran proporción
de la microbiota presente en las lesiones EPN 38.
Atención odontológica en tiempos de COVID-19
Los odontólogos son los profesionales de mayor riesgo
de transmisión de COVID-19, ya que por la naturaleza
de la atención dental, desde el diagnóstico al tratamien-
to el odontólogo y el paciente se encuentran cara a cara,
además que la producción de aerosoles durante proce-
dimientos dentales debido al uso de piezas de mano de
alta y baja velocidad, raspadores ultrasónicos, jeringa
triple, coloca al odontólogo, personal que trabaja en el
consultorio y pacientes en un alto riesgo de infección
cruzada (Figura 3). La transmisión de COVID-19 en la
consulta dental se puede dar por cuatro rutas principa-
les: (1) exposición directa a secreciones respiratorias del
paciente; (2) contacto indirecto con superficies o instru-
mentos contaminados; (3) inhalación de suspensión de
virus en el aire; y (4) contacto de la mucosa (nasal, oral y
conjuntival) con gotitas y aerosoles que contienen infec-
ción que se impulsan al toser y hablar sin mascarilla 15.
Los pacientes con COVID-19 no deben ser tratados en
un entorno de atención dental regular, sino en un am-
biente hospitalario en una sala de aislamiento de presión
negativa. Los pacientes asintomáticos (portadores) pueden
 COVID-19 y su trascendencia en la atención dental: revisión y actualización de la literatura
Figura 3. Dinámica de la infección cruzada en el consultorio dental. (Adaptado de Fallahi H, et al. 2020)
presentarse para recibir tratamiento dental y por la difi-
cultad de identificarlos son de gran riesgo para la trans-
misión de COVID-19. Esta característica epidemiológi-
ca de COVID-19 ha hecho su control extremadamente
difícil, por lo que los tratamientos electivos deben pos-
ponerse y solo realizar tratamientos de urgencia en el
consultorio dental, siguiendo protocolos de control de
infección estrictos. La decisión sobre la realización del
tratamiento debe tomarse con el consentimiento apro-
piado del paciente, quien firmara el consentimiento in-
formado en el que se debe explicar los riesgos de la aten-
ción dental en tiempos de la pandemia COVID-19 39.
El odontólogo y todo el personal que trabaje en la con-
sulta dental deben realizarse la prueba diagnóstica de
COVID-19 para descartar algún positivo que pueda
contagiar a los pacientes, sin embargo, un resultado ne-
gativo no quita la posibilidad de infección posterior a
la toma de la muestra, por tanto un resultado negativo
no debe descuidar la implementación de las medidas de
prevención y control del COVID-19.
Evaluación del paciente (triaje)
Con el propósito de controlar la infección por CO-
VID-19, la medida preventiva fundamental radica en el
triaje de pacientes que requieran atención dental de ur-
gencia en el consultorio. El examen inicial por teléfono
para identificar pacientes con sospecha o posible infec-
ción con COVID-19 se puede realizar de forma remota
al momento de programar las citas (Figura 4). Las tres
Odontol. Sanmarquina 2020; 23(3)
preguntas más relevantes para el triaje inicial deben
incluir cualquier exposición a una persona con diag-
nóstico conocido o sospecha de COVID-19, cualquier
historial de viaje reciente a un área con alta inciden-
cia de COVID-19 o presencia de cualquier síntoma
de enfermedad respiratoria y/o fiebre. Una respuesta
positiva a cualquiera de las tres preguntas debe gene-
rar preocupación inicial, y el cuidado dental electivo
debe diferirse por al menos 2 semanas. Se debe alen-
tar a estos pacientes a que realicen la cuarentena y se
comuniquen con su médico de atención primaria por
teléfono 40.
Debido a que solo se debe de realizar tratamientos de
urgencia, una videollamada o un mensaje con foto es
una herramienta muy útil para determinar la necesidad
de tratamiento del paciente, y así evitar el traslado del
paciente al consultorio encaso no sea una verdadera
urgencia. Aunque su impacto en el entorno clínico ha
sido poco investigado, la aplicación WhatsApp Mes-
senger (Facebook Inc., Mountain View, California) se
encuentra entre las herramientas de comunicación más
utilizadas por personas de toda edad 41. El primer paso
siempre debe ser la asistencia virtual, y WhatsApp pue-
de considerarse una buena herramienta para hacerlo. La
asistencia virtual se puede realizar mediante el uso de
fotos y videos. Se recomienda hacer un triaje a través
de WhatsApp para analizar las urgencias reales que se
puedan presentar y evaluar la necesidad de una cita pre-
sencial o la posible atención de forma remota 42,43.
5
Mija Gómez
Figura 4. Flujograma de atención a pacientes durante la pandemia COVID-19. (Adaptado de: Ather A et al.)
Al llegar el paciente a la consulta dental, se debe hacer
la desinfección del calzado y colocarse botas descarta-
bles. Se debe medir la temperatura corporal del pacien-
te utilizando un termómetro infrarrojo a distancia, los
pacientes que presentan fiebre (38 °C) y / o síntomas
de enfermedad respiratoria deben recibir indicaciones
para que cumplan cuarentena de 2 semanas y se debe
posponer todo tratamiento electivo, y en caso de tener
una urgencia que no se pueda controlar con medidas
farmacológicas, se debe derivar al paciente a un am-
biente hospitalario donde pueda atenderse en una sala
con presión negativa. En caso el paciente no presente
ninguna sintomatología que nos indique posible con-
tagio de COVID-19, antes de recibir atención dental,
debe completar un formulario de historial médico de-
tallado, un cuestionario de detección COVID-19 y la
firma del consentimiento informado detallando los po-
sibles riesgos de atención dental y COVID-19 40,44. Es
de suma importancia que los pacientes se programen
con cita previa, con un espacio de tiempo de seguridad
entre consultas dentales, evitando el contacto o incluso
la proximidad con otros pacientes.
Uso de equipo de protección personal (EPP)
El EPP consiste en prendas para proteger a todo el per-
sonal, incluido limpieza y seguridad que este poten-
cialmente expuesto a contagio. El EPP estándar con-
siste en guantes, mascarilla y mandilón. Sin embargo,
en caso de infecciones transmitidas por el aire como el
COVID-19, se debe usar equipo adicional que incluya
guantes, gorro, mascarillas o respiradores, gafas, másca-
ras protectoras, trajes de aislamiento y ropa protectora,
diseñados para proteger la piel y las membranas mucosas
de los ojos, la boca y nariz 27. Si bien es cierto que el uso
de EPP en la consulta es lo que más resalta para el pa-
ciente, no es más que una de las medidas para prevenir
infecciones cruzadas y no se debe considerar como la
medida principal de prevención; si no está acompañado
6 Odontol. Sanmarquina 2020; 23(3)
de medidas administrativas y técnicas eficaces, como por
ejemplo el triaje a distancia, lavado de manos, la utilidad
de los EPP es limitada 45.
El uso de guantes no sustituye el lavado de manos y de-
bido a la baja resistencia del SARS-CoV-2 a los deter-
gentes, es la medida más importante en el control de la
infección. El lavado de manos debe cumplir con la regla
del "dos antes y tres después" que incluye antes de tocar
a un paciente, antes de realizar cualquier procedimiento
aséptico, después de exposición a fluidos corporales del
paciente, después de tocar a un paciente y después de to-
car los alrededores del paciente o elementos que puedan
estar contaminados 46.
El uso de mascarillas como protección respiratoria ha de-
mostrado efectividad en el control de infección del CO-
VID-19. Un concepto importante sobre la protección
respiratoria a bioaerosoles es que los microorganismos
son partículas que poseen forma, tamaño y peso, por
lo que pueden ser filtrados. Las gotas son consideradas
mayores a 5 μm y los aerosoles menores a 5 μm. Dentro
de la protección respiratoria para el manejo de microor-
ganismos tenemos las mascarillas quirúrgicas o cubrebo-
cas y los respiradores. Aunque las mascarillas quirúrgicas
tienen cierta capacidad de filtración, no deben usarse
cuando se atienden pacientes con enfermedades causa-
das por aerosoles (menor a 5 μm). Estas mascarillas no
están diseñadas para brindar un sello facial; por tanto,
no filtran alrededor del borde de la mascarilla cuando el
usuario inhala, por lo que la transmisión ocurre por la
diseminación de material infeccioso de tamaño tal que
es respirable. Los respiradores son equipos que filtran
todo el aire que respira el usuario, aunque con mayor o
menor eficiencia según el modelo y especificaciones. En
Estados Unidos los respiradores certificados por el Ins-
tituto Nacional para la Seguridad y Salud Ocupacional
(NIOSH) son los N95 y tienen un mínimo de filtración
del 95% para las partículas más penetrantes (0,1 a 0,3
 COVID-19 y su trascendencia en la atención dental: revisión y actualización de la literatura
μm). El respirador N95 tiene que ajustar bien sobre la
cara para prevenir la filtración de aire contaminado. Es-
tos respiradores vienen en diferentes tamaños, se debe
usar el que se ajuste mejor al rostro 47-49. Es importante
destacar que los aerosoles pueden permanecer suspendi-
dos en el aire hasta por 30 minutos, por lo tanto, quitar
la máscara antes de 30 minutos en este entorno puede
aumentar el riesgo de contacto con partículas contami-
nadas 50. Se debe evitar que el respirador haga contacto
con el labio al momento de retirarlo.
La pandemia de COVID-19 ha provocado una gran es-
casez de respiradores N95, lo que ha llevado a realizar
estudios que demuestren la efectividad de su desinfec-
ción para reusarlos, se encontró que el calor seco inacti-
va el virus del COVID-19 luego de 5 minutos a 70 ° C
y es uno de los métodos más seguros y que no produce
deterioro del respirador, pudiendo realizarse hasta por
5 veces, siempre que el respirador no haya sido conta-
minado con fluidos del paciente. La irradiación ultra-
violeta (UV) fue una opción secundaria, sin embargo,
la luz UV puede afectar la resistencia del material y el
posterior sellado de los respiradores. Finalmente, los tra-
tamientos que involucran líquidos y vapores requieren
precaución, ya que el vapor, el alcohol y el hipoclori-
to pueden conducir a la degradación de la eficiencia de
filtración, dejando al usuario vulnerable a los aerosoles
virales 51,52.
Uso de colutorios
Debido a que el SARS-CoV-2 es bastante sensible a la
oxidación, se debe proporcionar un enjuague bucal con
agentes oxidantes al paciente antes de comenzar el pro-
cedimiento dental, para disminuir la carga viral en la
saliva de un paciente infectado. Se recomienda peróxido
de hidrógeno al 1%, para obtener 15 mL de este coluto-
rio, se mezcla 5 mL de peróxido de hidrógeno a 10 Vol.
adicionando 10 mL de agua destilada. También puede
usarse yodopovidona al 0.2%. La clorhexidina parece
no tener efecto sobre el SARS-CoV-2, por lo que no es
aconsejable su uso 53,54.
Reducción de producción de aerosoles.
El riesgo más grande de transmisión de COVID-19
durante la atención dental, es a través de la generación
de aerosoles, ya que el virus puede permanecer viable
e infectar ya sea por inhalación o por contacto con la
mucosa oral, nasal o la conjuntiva del ojo. El uso de
instrumental rotatorio y jeringa triple debe evitarse en lo
posible, ya que crea un spray visible o aerosol que con-
tiene principalmente gotas de agua, saliva, sangre, mi-
croorganismos, y otros desechos, que se van a precipitar
por la gravedad contaminando las superficies expuestas
del consultorio 55,56. En caso no se pueda evitar el uso
de la pieza de mano, esta debe tener una válvula antirre-
tracción que evite la aspiración y expulsión de desechos
y fluidos durante los procedimientos dentales, ya que se
ha determinado que microorganismos pueden contami-
nar los tubos de agua y aire de la unidad dental si es que
no se cuenta con válvula antirretracción 57.
Odontol. Sanmarquina 2020; 23(3)
Se debe evitar la toma de radiografías intraorales, para
prevenir tos o reflejo nauseoso en el paciente, lo que
generaría aerosoles. Las radiografías extraorales y la TC
son alternativas a tomar en cuenta 50.
Aislamiento absoluto con dique de goma
El aislamiento absoluto con dique de goma, debido a la
creación de una barrera en la cavidad oral reduce efec-
tivamente la generación de gotas y aerosoles mezclados
con saliva y/o sangre del paciente en un 70%. Después
de la colocación del dique, se requiere adicionalmente
de una succión de alto volumen para evitar al máximo la
propagación de aerosoles y salpicaduras. El aislamiento
absoluto debe ser de rutina en todos los procedimientos
dentales que lo permitan 15,42.
Desinfección de superficies del consultorio
La investigación ha demostrado que los coronavirus
pueden permanecer en superficies de metal, vidrio y
plástico de manera activa a temperatura ambiente de
2 horas hasta 9 días. Por lo tanto, como las superficies
en las clínicas dentales sirven como lugares de depósi-
to para gotas y aerosoles mezclados con la saliva y / o
sangre de los pacientes, pueden ayudar efectivamente a
propagar la infección. Pruebas recientes indican que el
SARS-CoV-2 puede ser vulnerable a biocidas como el
hipoclorito de sodio al 0,1%, el peróxido de hidrógeno
al 0,5%, al etanol de 60 a 75%, glutaraldehído al 2,5%,
formaldehído 1% y compuestos de amonio fenólico
y cuaternario si se utilizan de acuerdo con las instruc-
ciones del fabricante. El digluconato de clorhexidina al
0,02% es ineficaz 15,59.
El uso de luz ultravioleta (UV) para la desinfección del
consultorio no ha sido probada para inactivar al SARS-
CoV-2, pero si hay evidencia de la inactivación por luz
UV (especialmente la UV-C) de los coronavirus MERS
y SARS, genéticamente muy parecidos al SARS-CoV-2.
En caso se cuente con luz UV-C para la desinfección
de las superficies del consultorio, se debe usar como un
complemento y no debe remplazar de ninguna manera
la desinfección con agentes biocidas 60-62.
Conclusiones
La declaración de pandemia de COVID-19 por la
OMS nos pone en un escenario pocas veces imagina-
do, y el odontólogo debe conocer las características del
SARS-CoV-2, las rutas de transmisión, manifestacio-
nes clínicas iniciales que lleven a identificar a los pa-
cientes infectados y lo más importante, las medidas a
tomar para interrumpir la cadena de transmisión. El
odontólogo desde su consulta privada debe participar
activamente en las políticas de salud pública, identifi-
cando posibles contagiados, orientándolos en las medi-
das para no propagar la infección y derivándolos para
la atención especializada. La atención dental debe res-
tringirse exclusivamente a tratamientos de emergencia
y urgencia, siguiendo estrictamente los protocolos de
bioseguridad y medidas específicas para el control de
COVID-19.
7
Mija Gómez
Referencias bibliográficas
1. Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A,
Al-Jabir A, et al. World Health Organization declares
global emergency: A review of the 2019 novel corona-
virus (COVID-19). Int J Surg. 2020; 76:71-76. DOI:
10.1016/j.ijsu.2020.02.034.
2. Jung S, Kinoshita R, Thompson R, Linton N, Yang Y,
Akhmetzhanov A, et al. Epidemiological Identification
of A Novel Pathogen in Real Time: Analysis of the Atypi-
cal Pneumonia Outbreak in Wuhan, China, 2019–2020.
J Clin Med. 2020;9(3):637. DOI:10.3390/jcm9030637
3. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmis-
sion routes of 2019-nCoV and controls in dental prac-
tice. Int J Oral Sci. 2020;12:9. DOI: 10.1038/s41368-
020-0075-9.
4. World Health Organization (WHO) Declaración del
Director General de la OMS sobre la reunión del Comi-
té de Emergencia del Reglamento Sanitario Internacional
acerca del nuevo coronavirus (2019-nCoV). [Consultado
el 10 de abril de 2020]. Accesible en: https://www.who.
int/es/dg/speeches/detail/who-director-general-s-state-
ment-on-ihr-emergency-committee-on-novel-coronavi-
rus-(2019-ncov).
5. World Health Organization (WHO) Director-General's
opening remarks at the media briefing on COVID-19
- 11 March 2020. [Consultado el 15 de abril de 2020].
Accesible en: https://www.who.int/dg/speeches/detail/
who-director-general-s-opening-remarks-at-the-media-
briefing-on-covid-19---11-march-2020.
6. World Health Organization (WHO). Coronavirus disease
(COVID-19) Situation Report – 133. [Consultado el 02 de
junio de 2020]. Accesible en: https://www.who.int/docs/de-
fault-source/coronaviruse/situation-reports/20200601-co-
vid-19-sitrep 133.pdf?sfvrsn=9a56f2ac_4.
7. Ministerio de Salud. (MINSA). Comunicado N°113. Ca-
sos confirmados por Coronavirus COVID-19 ascienden a
135 905 en el Perú. [Consultado el 01 de junio de 2020].
Accesible en: https://www.gob.pe/institucion/minsa/no-
ticias/165852-minsa-casos-confirmados-por-coronavi-
rus-covid-19-ascienden-a-135-905-en-el-peru-comuni-
cado-n-113.
8. Murillo G. Las gotitas de Flügge. Rev Med Inst Mex Se-
guro Soc. 2009;47(3):290.
9. Watanabe A, Tamaki N, Yokota K, Matsuyama M,
Kokeguchi S. Use of ATP bioluminescence to survey the
spread of aerosol and splatter during dental treatments.
J Hosp Infect. 2018;99(3):303‐305. DOI: 10.1016/j.
jhin.2018.03.002
10. Jiang X, Zhang X, Zhao X, Li C, Lei J, Kou Z. Transmis-
sion Potential of Asymptomatic and Paucisymptomatic
SARS-CoV-2 Infections: A Three-Family Cluster Study
in China. J Infect Dis. 2020;221(12):1948-52. DOI:
10.1093/infdis/jiaa206.
11. 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(5):481‐487.
DOI: 10.1177/0022034520914246.
12. Reina J. El SARS-CoV-2, una nueva zoonosis pandémica
que amenaza al mundo. Vacun. 2020;21(1):17-22. DOI:
10.1016/j.vacun.2020.03.001
8 Odontol. Sanmarquina 2020; 23(3)
13. Palacios M, Santos E, Velázquez M, León M. CO-
VID-19, una emergencia de salud pública mundial. [pu-
blished online ahead of print, 2020 Mar 20]. Rev Clin
Esp. 2020;S0014-2565(20)30092-8. DOI: 10.1016/j.
rce.2020.03.001.
14. Baghizadeh M. What dentists need to know about
COVID-19. Ora.l Oncol. 2020;105:104741. DOI:
10.1016/j.oraloncology.2020.104741.
15. Fallahi H, Keyhan S, Zandian D, Kim S, Cheshmi B.
Being a front-line dentist during the Covid-19 pande-
mic: a literature review. Maxillofac Plast Reconstr Surg.
2020;42(1):12. DOI: 10.1186/s40902-020-00256-5.
16. Sigua E, Bernal J, Lanata A, Sánchez C, Rodríguez
J, Haidar Z, et al. COVID-19 y la Odontología: una
Revisión de las Recomendaciones y Perspectivas para
Latinoamérica. Int. J. Odontostomat. 2020;14(3):299-
309.
17. Aranaz J, Gea M, Requena J. Mitos y miedos: las pre-
cauciones frente a la gripe aviar las justifica el mecanis-
mo de transmisión. Gac Sanit. 2006;20(5):410-3. DOI:
10.1157/13093212.
18. Lu C, Liu X, Jia Z. 2019-nCoV transmission throu-
gh the ocular surface must not be ignored. Lancet.
2020; Feb 22;395(10224):e39. DOI: 10.1016/S0140-
6736(20)30313-5.
19. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al.
Clinical characteristics and intrauterine vertical transmis-
sion potential of COVID-19 infection in nine pregnant
women: a retrospective review of medical records. Lan-
cet. 2020; Mar 7;395(10226):809-815. DOI: 10.1016/
S0140-6736(20)30360-3.
20. 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(1):8. DOI: 10.1038/s41368-020-0074-x
21. Backer J, Klinkenberg D, Wallinga J. Incubation pe-
riod of 2019 novel coronavirus (2019-nCoV) infections
among travellers from Wuhan, China, 20-28 January
2020. Euro Surveill. 2020;25(5):2000062. DOI:
10.2807/1560-7917.ES.2020.25.5.2000062.
22. Khader Y, Al Nsour M, Al-Batayneh O, Saadeh R, Bas-
hier H, Alfaqih M, et al. Dentists' Awareness, Perception,
and Attitude Regarding COVID-19 and Infection Con-
trol: Cross-Sectional Study Among Jordanian Dentists.
JMIR Public Health Surveill. 2020;6(2):e18798. DOI:
10.2196/preprints.18798.
23. Channappanavar R, Perlman S. Pathogenic human
coronavirus infections: causes and consequences of
cytokine storm and immunopathology. Semin Immu-
nopathol. 2017;39(5):529-539. DOI:10.1007/s00281-
017-0629-x.
24. Ramírez M, Medina P, Morocho A. Enfermedad por co-
ronavirus 2019 (COVID-19) y su repercusión en la con-
sulta odontológica: una revisión. Odontol Sanmarquina.
2020;23(2):139-146. DOI: 10.15381/os.v23i2.17758.
25. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Cli-
nical features of patients infected with 2019 novel coro-
navirus in Wuhan, China. Lancet. 2020; 395:497-506.
DOI:10.1016/S0140-6736(20)30183-5.
 COVID-19 y su trascendencia en la atención dental: revisión y actualización de la literatura
26. Tarazona-Santabalbina F, Martínez-Velilla N, Vidán
M, García-Navarro J. COVID-19, adulto mayor y eda-
dismo: errores que nunca han de volver a ocurrir. Rev
Esp Geriatr Gerontol. 2020; S0211 139X(20)30059-7.
DOI: 10.1016/j.regg.2020.04.001.
27. Odeh N, Babkair H, Abu-Hammad S, Borzangy S,
Abu-Hammad A, Abu-Hammad O. COVID-19: Pre-
sent and Future Challenges for Dental Practice. Int J
Environ Res Public Health. 2020;17(9):E3151. DOI:
10.3390/ijerph17093151.
28. Jiang X, Zhang X, Zhao X, Li C, Lei J, Kou Z, et al.
Transmission potential of asymptomatic and paucisymp-
tomatic SARS-CoV-2 infections: a three-family cluster
study in China. J Infect Dis. 2020;221(12):1948-52.
DOI: 10.1093/infdis/jiaa206.
29. Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, et al. Cli-
nical characteristics of 24 asymptomatic infections with
COVID-19 screened among close contacts in Nanjing,
China. Sci China Life Sci. 2020;63(5):706‐711. DOI:
10.1007/s11427-020-1661-4.
30. Bai Y, Yao L, Wei T, Tian F, Jin D, Chen L, et al. Pre-
sumed Asymptomatic Carrier Transmission of CO-
VID-19 [published online ahead of print, 2020 Feb
21]. JAMA. 2020;323(14):1406‐1407. DOI:10.1001/
jama.2020.2565.
31. Estébanez A, Pérez-Santiago L, Silva E, Guillen-Climent
S, García-Vázquez A, Ramón M. Cutaneous manifes-
tations in COVID-19: a new contribution [published
online ahead of print, 2020 Apr 15]. J Eur Acad Derma-
tol Venereol. 2020;10.1111/jdv.16474. DOI: 10.1111/
jdv.16474.
32. Labé P, Ly A, Sin C, Nasser M, Chapelon-Fromont E,
Ben P, et al. Erythema multiforme and Kawasaki disease
associated with COVID-19 infection in children [publi-
shed online ahead of print, 2020 May 26]. J Eur Acad
Dermatol Venereol. 2020;10.1111/jdv.16666. DOI:
10.1111/JDV.16666.
33. Licciardi F, Pruccoli G, Denina M, Parodi E, Taglietto
M, Rosati S, et al. SARS-CoV-2-Induced Kawasaki-Like
Hyperinflammatory Syndrome: A Novel COVID Phe-
notype in Children [published online ahead of print,
2020 May 21]. Pediatrics. 2020; e20201711. DOI:
10.1542/peds.2020-1711.
34. To K, Tsang O, Chik-Yan Yip C, Chan K, Wu T, Chan
J, et al. Consistent detection of 2019 novel coronavirus
in saliva [published online ahead of print, 2020 Feb
12]. Clin Infect Dis. 2020; ciaa149. DOI: 10.1093/cid/
ciaa149.
35. Sabino-Silva R, Jardim A, Siqueira W. Coronavirus CO-
VID-19 impacts to dentistry and potential salivary diag-
nosis. Clin Oral Investig. 2020;24(4):1619‐1621. DOI:
10.1007/s00784-020-03248-x
36. Carreras-Presas M, Sánchez A, López-Sánchez A, Sa-
las J, Pérez S. Oral vesiculobullous lesions associated
with SARS-CoV-2 infection. Oral Dis. 2020;10.1111/
odi.13382. DOI: 10.1111/ODI.13382.
37. Vieira A. Oral Manifestations in Coronavirus Disease
2019 (COVID-19) [published online ahead of print,
2020 Jun 7]. Oral Dis. 2020;10.1111/odi.13463.
doi:10.1111/odi.13463.
Odontol. Sanmarquina 2020; 23(3)
38. Patel J, Woolley J. Necrotizing periodontal disease: oral
manifestation of COVID-19 [published online ahead of
print, 2020 Jun 7]. Oral Dis. 2020;10.1111/odi.13462.
DOI: 10.1111/odi.13462.
39. Dave M, Seoudi N, Coulthard P. Urgent dental care
for patients during the COVID-19 pandemic. Lan-
cet. 2020;395(10232):1257. DOI: 10.1016/S0140-
6736(20)30806-0.
40. Ather A, Patel B, Ruparel N, Diogenes A, Hargreaves
K. Coronavirus Disease 19 (COVID-19): Implications
for Clinical Dental Care. J Endod. 2020;46(5):584‐595.
DOI:10.1016/j.joen.2020.03.008.
41. Caprioglio A, Pizzetti G, Zecca P, Fastuca R, Maino G,
Nanda R. Management of orthodontic emergencies du-
ring 2019-NCOV. Prog Orthod. 2020; Apr 7;21(1):10.
DOI: 10.1186/s40510-020-00310-y.
42. Krynskia L, Goldfarba G, Maglioc I. La comunicación
con los pacientes mediada por tecnología: WhatsApp,
e-mail, portales. El desafío del pediatra en la era digi-
tal. Arch Argent Pediatr 2018;116(4):554-559. DOI:
10.5546/aap.2018.e554.
43. Mars M, Scott R. WhatsApp in Clinical Practice:
A Literature Review. Stud Health Technol Inform.
2016;231:82‐90. DOI: 10.3233/978-1-61499-712-2-82.
44. Guiñez M. Impacto del COVID-19 (SARS-CoV-2) a
Nivel Mundial, Implicancias y Medidas Preventivas en la
Práctica Dental y sus Consecuencias Psicológicas en los
Pacientes. Int. J. Odontostomat. 2020;14(3):271-278.
45. Huh S. How to train the health personnel for protec-
ting themselves from novel coronavirus (COVID-19)
infection during their patient or suspected case care. J
Educ Eval Health Prof. 2020;17:10. DOI: 10.3352/jee-
hp.2020.17.10.
46. 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 [published on-
line ahead of print, 2020 Mar 13]. Dermatol Ther. 2020;
e13310. DOI: 10.1111/dth.13310.
47. Wang X, Pan Z, Cheng Z. Association between 2019-
nCoV transmission and N95 respirator use. J Hosp
Infect. 2020;105(1):104‐105. DOI: 10.1016/j.
jhin.2020.02.021.
48. Castañeda J, Hernández H. Mascarilla N95: una medida
útil en la prevención de la tuberculosis pulmonar. Acta
Pediatr Mex. 2017 mar;38(2):128-133.
49. Torres K, Sevilla E. Conceptos para la selección y uso de
mascarillas y respiradores, como medidas de protección
durante los brotes de influenza. Rev Inst Nal Enf Resp
Mex. 2009;22(3):230-237.
50. Martins-Filho P, de Gois-Santos V, Tavares C, de Melo E,
do Nascimento-Júnior E, Santos V. Recommendations
for a safety dental care management during SARS-CoV-2
pandemic. Rev Panam Salud Publica. 2020;44:e51.
DOI: 10.26633/RPSP.2020.51.
51. Liao L, Xiao W, Zhao M, Yu X, Wang H, Wang Q, et
al. Can N95 Respirators Be Reused after Disinfection?
How Many Times?. ACS Nano. 2020;14(5):6348‐6356.
DOI: 10.1021/acsnano.0c03597.
9
Mija Gómez
52. Cadnum J, Li D, Redmond S, John A, Pearlmutter B,
Donskey C. Effectiveness of Ultraviolet-C Light and a
High-Level Disinfection Cabinet for Decontamination
of N95 Respirators. Pathog Immun. 2020;5(1):52‐67.
DOI: 10.20411/pai.v5i1.372.
53. Araya S. Consideraciones para la atención de urgencia
odontológica y medidas preventivas para COVID-19
(SARSCoV2). Int. J. Odontostomat. 2020;14(3):268-
270.
54. Ali S, Zeb U, Muhammad A. Transmission Routes and
Infection Control of Novel Coronavirus-2019 in Den-
tal Clinics – A Review. J Islamabad Med Dental Coll.
2020;9(1):63-70. DOI: 10.35787/jimdc.v9i1.517.
55. Van Doremalen N, Bushmaker T, Morris D, Holbrook
M, Gamble A, Williamson B, et al. Aerosol and Surfa-
ce Stability of SARS-CoV-2 as Compared with SARS-
CoV-1. N Engl J Med. 2020;382(16):1564‐1567. DOI:
10.1056/NEJMc2004973.
56. Bustamante M, Herrera M, Ferreira. R, Riquelme
D. Contaminación bacteriana generada por aeroso-
les en ambiente odontológico. Int. J. Odontostomat.
2014;8(1):99-105.
57. Badillo B, Morales G, Martínez C, Castillo U, Gasca N,
Hernández G, et al. Análisis bacteriológico de piezas de
mano de alta velocidad utilizadas en la práctica clínica.
Rev ADM. 2019;76(5):261-266.
10
58. Li Y, Ren B, Peng X, Hu T, Li J, Gong T, et al. Saliva is
a non-negligible factor in the spread of COVID-19 [pu-
blished online ahead of print, 2020 May 4]. Mol Oral
Microbiol. 2020;10.1111/omi.12289. DOI: 10.1111/
omi.12289.
59. Kampf G, Todt D, Pfaender S, Steinmann E. Per-
sistence of coronaviruses on inanimate surfaces and
their inactivation with biocidal agents. J Hosp In-
fect. 2020;104(3):246‐251. DOI: 10.1016/j.
jhin.2020.01.022.
60. Bedell K, Buchaklian AH, Perlman S. Efficacy of an
Automated Multiple Emitter Whole-Room Ultravio-
let-C Disinfection System Against Coronaviruses MHV
and MERS-CoV. Infect Control Hosp Epidemiol.
2016;37(5):598‐599. DOI: 10.1017/ice.2015.348
61. Kariwa H, Fujii N, Takashima I. Inactivation of SARS
coronavirus by means of povidone-iodine, physical con-
ditions and chemical reagents. Dermatology. 2006;212
Suppl 1(Suppl 1):119‐123. DOI: 10.1159/000089211.
62. Darnell ME, Subbarao K, Feinstone SM, Taylor DR.
Inactivation of the coronavirus that induces severe
acute respiratory syndrome, SARS-CoV. J Virol Me-
thods. 2004;121(1):85‐91. DOI: 10.1016/j.jviro-
met.2004.06.006.
Odontol. Sanmarquina 2020; 23(3)
Article

COVID-19 Outbreak in North Italy: An Overview

on Dentistry. A Questionnaire Survey
Maria Grazia Cagetti 1, Jean Louis Cairoli 2, Andrea Senna 1 and Guglielmo Campus 3,4,*
1 Department of Biomedical, Surgical and Dental Science, University of Milan, Via Beldiletto 1,
I-20142 Milan, Italy; maria.cagetti@unimi.it (M.G.C.); andreasenna75@hotmail.com (A.S.)
2 Private Practitioner, President of the Lombardy Chamber of Dentists, Varese, Italy; jlcairo@gmail.com

3 Department of Surgery, Microsurgery and Medicine Sciences, School of Dentistry, University of Sassari,

Viale San Pietro, I-07100 Sassari, Italy

4 Department of Restorative, Preventive and Pediatric Dentistry, University of Bern, Freiburgstrasse 7,

CH-3010 Bern, Switzerland

* Correspondence: Guglielmo.campus@zmk.unibe.ch; Tel.: +41-31-664098

Received: 28 April 2020; Accepted: 25 May 2020; Published: 28 May 2020

Abstract: This survey assessed the symptoms/signs, protective measures, awareness, and
perception levels regarding COVID-19 among dentists in Lombardy, Italy. Moreover, an analysis of
the answers gathered in areas with different prevalence of the disease was carried out. All
Lombardy’s dentists were sent an online ad hoc questionnaire. The questionnaire was divided into
four domains: personal data, precautionary measures (before patient arrival; in the waiting room;
in the operating room), awareness, and perception. Three thousand five hundred ninety-nine
questionnaires were analyzed. Five hundred two (14.43%) participants had suffered one or more
symptoms referable to COVID-19. Thirty-one subjects were positive to the virus SARS-CoV-2 and
16 subjects developed the disease. Only a small number of dentists (n = 72, 2.00%) were confident of
avoiding infection; dentists working in low COVID-19 prevalence areas were more confident than
those working in the Milan area and high prevalence area (61.24%, 61.23%, and 64.29%, p < 0.01
respectively). The level of awareness was statistically significantly higher (p < 0.01) in the Milan area
(71.82%) than in the other areas. This survey demonstrated that dentists in the COVID-19 highest
prevalence area, albeit reported to have more symptoms/signs than the rest of the sample, were the
ones who adopted several precautionary measures less frequently and were the more confident of
avoiding infection.

Keywords: COVID-19; infection; dentist; protective measures; awareness; infection control

1. Introduction
The coronavirus pandemic has deeply affected the world. Up to 12 May, 2020, the total number
of confirmed cases has exceeded four million and a half, with more than two hundred eighty
thousand deaths. The SARS-CoV-2 human-to-human transmission has been described through
airborne droplets or direct contact with cases or with contaminated surfaces [1]. Avoiding close
contact (less than 1 m) with people, especially those with respiratory symptoms, is the most important
preventive measure to be taken to prevent the spreading of the infection.
In May 2020, Italy is still among European countries with the highest number of Covid-19 cases,
now in third place after Spain and the United Kingdom. The majority of cases are concentrated in the
Northern part of the country (Lombardy) and held the sad European deaths record [2]. Another dark
Italian record is the number of health care workers who were infected or who died as a result of the
infection. The official number of infected health workers up to 12 May, 2020, according to the Italian
Superior Health Institute, amounted to 21.981 workers [3]. According to the Italian National
Int. J. Environ. Res. Public Health 2020, 17, 3835; doi:10.3390/ijerph17113835 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 3835 2 of 11

Federation of the Order of Physicians, Surgeons, and Dentists, instead, the number of deceased
physicians up to the 10 May, 2020 amounted to 160 deaths [4], of whom sixteen were dentists.
Although patients affected by COVID-19 are not supposed to receive dental treatments, undiagnosed
infected subjects without or with very mild symptoms could be eligible for dental treatment in
emergency cases. Dental care in Italy is largely provided by private practitioners and mainly financed
by patients’ direct payment, or, to a lesser extent, by private insurance schemes.
The risk of cross-infection in dentistry has been described considerably high [5] since splatters and
aerosols produced during routine dental treatments contribute to increased risk [6]. This issue might be
a relevant professional hazard when infective agents, such as coronaviruses, are widespread in the
population [7]. Dentists and health care professionals working in wards with pneumonia patients are at
higher risk of developing infective diseases during their regular activities [8]. Data on the real risk of virus
diffusion by dental procedures are urgent since none is available in the literature [8,9]. In a recent paper,
the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces was investigated in
experimental conditions, showing that the airborne transmission of SARS-CoV-2 is plausible since
the virus can remain viable and infectious in aerosols for hours [9]. Without data on airborne SARS-
Cov-2 gained in real dental care situations, operational envelopes and disinfection procedures to face
the viral infection are hypothetical.
Well-designed questionnaires are a useful method to easily collect data from participants in
studies [10]. Questionnaires to investigate dentists’ knowledge, attitudes, and perceptions regarding
viral infection control in the dental environment found in the literature [11–14] show that awareness
and precautionary measures carried out by dentists on patients with a viral infection are not always
completely satisfactory. The main aim of this survey was to assess the symptoms/signs, the protective
measures, the level of awareness, and perception regarding the COVID-19 outbreak among dentists
working in North Italy. The ancillary aim was also to appraise if the answers provided bear
resemblance in areas with different prevalence of the disease.

2. Materials and Methods

2.1. Development and Building-Up of the Questionnaire

The first bunch of items related to the health situation, risk, and knowledge of an infectious
disease was derived from the questionnaire developed for the SARS risk [15]. The authors followed
the Stehr-Green scale to build up the questionnaire [16]. The questionnaire was structured into four
domains, the first regarded personal data (age, gender, area of living, and working status), the second
the health conditions (symptoms/signs relative to the COVID-19 flu), the third the working condition
and personal protective equipment (PPE) adopted after the outbreak of the infection, and the fourth
the knowledge and the self-perceived risk of infection (Table 1). Among the PPE included in the
questionnaire, some, such as the use of sterile gloves, do not have a scientific justification but were
deliberately inserted to check whether the answers were selected with the sole logic of demonstrating
that any contrast measures regarding the virus had been implemented or whether the equipment
adopted was the result of a thoughtful choice.

Table 1. Questionnaire items.

Items
male
Gender
female
Age
Zip Code (living)
Zip Code (working)
Private dentist
Working status Private/NHS
NSH
No symptoms/signs
From the start of the COVID-19 you had You resulted COVID-19 positive
You were hospitalized for COVID
Int. J. Environ. Res. Public Health 2020, 17, 3835 3 of 11

I had one/more symptoms/signs

Fever
Cough
Fatigue
Short Breath
Nasal congestion
Headache
Rhinorrhea
Sore throat
Diffuse pain
Diarrhea
Anosmia
Ageusia
Conjunctivitis
Only if you work in the NHS, are you currently Yes
working? No
You kept working as usual
From the 21st February You limited your activity to emergencies
You have stopped all activities
Between 21–23 February
Between 24 February and 1 March
If you have limited your professional activity to
Between 2–6 March
emergencies, when did you start limiting?
Between 7–14 March
After 14th March
Between 21–23 February
Between 24 February and 1 March
If you have stopped your professional activity, when did
Between 2–6 March
this happen?
Between 7–14 March
After 14th March
None
Phone Triage
Spaced appointments so to not saturate the waiting room
Deferring therapies in elderly patients, or patients with
systemic diseases
Handle disinfection several times a day
Disinfection of pushbuttons, Point of sale, chairs several
times a day
Verify the patient’s current health status on access
Detecting the patient’s body temperature
Detecting the body temperature of all co-workers and ask to
leave to those with a temperature above 37.5 °C.
Washing the patient’s hands
Space of at least one meter between patients
Mask for the patient
Frequent ventilation of waiting rooms
Removal of magazines and books from the waiting area
If you have continued working after 21st February, Storage of coats, bags, and other items outside the operating
which of the following measures have you adopted? area
Pre-operative rinse with mouthwash containing 1%
hydrogen peroxide
Pre-operative rinse with mouthwash containing
chlorhexidine 0.12–0.2%
Pre-operative rinse with mouthwash containing 0.2–1%
iodopovidone
Pre-operative rinse with mouthwash containing alcohol and
essential oils
Pre-operative rinse with mouthwash containing
Cetylpyridinium chloride at 0.05–0.10%
Rinse with diluted mouthwash
Ventilation of the operating area for at least 10 min after each
patient
Surface disinfection with 70% ethyl alcohol
Surface disinfection with 0.5% sodium hypochlorite
Surface disinfection with usual disinfectants containing other
active ingredients
Int. J. Environ. Res. Public Health 2020, 17, 3835 4 of 11

Washing operators’ hands before and after each procedure

Removal of all disposable protective devices and disinfection
of non-disposable devices
Surgical mask
Filtering facepiece 2 or filtering facepiece 3 masks
Disposable headset
Sterile microfiber disposable gown
Which of the following protective equipment did you Water-repellent, non-wowen fabric TNT disposable gown
wear/use? Disposable gown
Safety glasses or visor
Sterile disposable gloves
Disposable gloves
Rotating instrument with anti-retraction valve
Yes
Did you follow a course on Covid-19?
No
Yes
Do you think that you know enough on COVID-19?
No
Unlikely
Do you believe that the infection by SARS-CoV-2 is a risk Very unlikely
for the dentist? Likely
Very likely
No confident
How sure are you that you can avoid becoming infected Enough confident
with SARS-CoV-2 during work activities? A bit confident
Confident
Less than the risk run in a supermarket
In a health emergency situation such as the current one,
Comparable to the risk run in a supermarket
do you believe that the risk of infection transmission in
Higher than the risk run in a supermarket
the dental practice is:

A preliminary questionnaire was built up and pre-tested on a small group of dentists (n = 12);
Intraclass Correlation Coefficients (ICC) was run for the test-retest and intra-rater reliability for each
item. An ICC value of 0.80 or higher was considered satisfactory. All the items with a value of ICC
below 0.80 were discussed by the authors and modified following the preliminary study.
An anonymous online survey (Survey Monkey™, SVMK Inc. San Mateo, CA, US) has been
prepared. On the 10th of April, all dentists n = 9247 included in the database of the Order of Physicians,
Surgeons, and Dentists of Lombardy, 89.79% of all dentists registered in Lombardy, received an email
asking their consent to participation in the questionnaire in accordance with applicable privacy laws.
All the participants were asked to declare that they have read the privacy policy and voluntarily
approve data collection and processing. If they answered No, the questionnaire was automatically
closed, and no data were collected. A second reminder was emailed to the non-responders after four
days and the last one on the 16th of April. The survey was stopped one week after its beginning.

2.2. Data Analysis

Answers to the questionnaire were inserted in Excel™ 2019 for Mac. The data were cleaned and
then transferred to STATA16™ (StataCorp LLC, College Station, Texas, USA) for their statistical
analysis. The 12 Lombardy provinces were grouped as follows: Milan province, with a COVID-19
prevalence of 0.53%, was considered alone, and provinces where the prevalence of COVID-19 was
higher than 0.90% (Cremona, Lodi, Brescia, Bergamo) were grouped together. Provinces with lower
prevalence (Varese, Como, Monza, Sondrio, Lecco, Pavia, Mantua) with a mean of 0.44 (data
evaluated 24th April) were also grouped together [5]. Absolute and relative frequencies were
calculated for each item. Difference in proportion was evaluated with χ2 test or Fisher exact test if one
cell had a value of less than five. Multiple testing for post hoc estimation was calculated, such as the
number of observed frequencies, expected frequencies, percentage, and contribution to the chi-
square. The symptoms most frequently reported in the literature (fever, cough, fatigue) were used
for a comparison between areas with different COVID-19 prevalence [17]. A p-value less than 0.05 was
considered statistically significant. The row data are available as Supplementary Materials (Table S1).
Int. J. Environ. Res. Public Health 2020, 17, 3835 5 of 11

3. Results
In the pre-test evaluation, only two items showed an ICC below the threshold (i.e., “Which of
the following protective equipment did you wear/use?” ICC = 0.73 and “Do you believe that the
infection by SARS-CoV-2 is a risk for the dentist?” ICC = 0.78) and, after discussion among the
authors, the questions were slightly modified. A total of 9247 invitations were emailed, and 112
(1.21%) were not delivered by the system. After the first dispatch, 65.95% of the emails were opened:
1.32% refused and 41.60% participated in the questionnaire. At the end of the survey, 4308
questionnaires were returned. Three thousand five hundred ninety-nine questionnaires (response
rate 39.40%) were analyzed (69.27% males and 30.73% females). A statically significant (p < 0.01)
predominance of males was observed among dentists who compiled the questionnaire (Table 2).

Table 2. Participants' distribution by age and gender.

Males Females Total

Age Groups
n (%) n (%) n (%)
<30 years 180 (5.02) 181 (5.05) 361 (10.07)
31–40 years 350 (9.76) 271 (7.56) 621 (17.32)
41–50 years 401 (11.18) 270 (7.53) 671 (18.71)
51–60 years 692 (19.30) 242 (6.75) 934 (26.05)
>60 years 861 (24.01) 138 (3.85) 999 (27.86)
Total 2493 (69.27) 1106 (30.73) 3599 (100.00)
χ 2(4) = 285.48 p < 0.01.

Thirty-one subjects (0.86% of the dentists whose questionnaires were analyzed) were positive to
the virus SARS-CoV-2, and 16 subjects developed the disease. The triage of symptoms/signs related
to COVID-19 showed that 474 (13.47%) participants claimed to have suffered one or more
symptoms/signs referable to COVID-19.
Among the symptoms/signs (Table 3), the sense of fatigue and fever were the most common
(7.63 and 7.21%, respectively), while breath difficulties and conjunctivitis were the less frequent (1.98
and 1.98%, respectively). Almost 10% of the dentists working in area with a high prevalence of
COVID-19 reported to suffer or have suffered from three or more symptoms (χ2(6) = 63.64 p < 0.01 post
ad hoc estimation likelihood-ratio χ2(6) = 62.12 p < 0.01).

Table 3. Prevalence of symptoms/signs related to the COVID-19 in the different Lombardy provinces.
Percentages were calculated per column.

Milan Area High Prevalence Area Low Prevalence Area

OF EF % Cχ2 OF EF % Cχ2 OF EF % Cχ2
No symptoms
1072 1067.47 86.80 0.02 721 784.83 79.41 5.19 1221 1161.69 90.86 3.03
One symptom
38 34.35 3.08 0.39 39 25.26 4.29 7.47 20 25.26 1.50 8.09
Two symptoms
59 57.73 4.78 0.03 61 42.45 6.72 8.11 43 42.45 3.20 6.26
Three or more symptoms
66 75.44 5.34 0.14 87 55.46 9.58 17.93 60 55.46 4.46 5.95
χ = 63.64 p < 0.01 Post ad hoc estimation Likelihood-ratio χ = 62.12 p < 0.01. OF, observed
2(6) 2(6)

frequency; EF, expected frequency; %, percentage; Cχ2, contribution to chi-square.

The three main common symptoms from the literature (fever, cough, and fatigue) were
statistically highly (χ2(6) = 59.20 p < 0.01 Post ad hoc estimation Likelihood-ratio χ 2(6) = 52.31 p < 0.01)
reported from dentists working in Milan and the high prevalence area (Table 4).
Int. J. Environ. Res. Public Health 2020, 17, 3835 6 of 11

Table 4. Prevalence of the most associated symptoms/signs related to the COVID-19 in the different
Lombardy provinces. Percentages were calculated per column.

Milan Area High Prevalence Area Low Prevalence Area

Symptoms/Signs
OF EF % OF EF % OF EF % OF EF %
Fever 17 16.29 11.97 0.03 21 11.98 13.38 6.80 8 17.73 7.84 5.34
Cough 15 19.50 10.57 1.03 26 14.32 16.56 9.52 14 21.20 13.73 2.45
Fatigue 25 21.61 17.60 0.53 23 18.88 16.65 3.19 13 23.51 12.74 4.70
Fever + Cough 11 10.98 7.75 0.00 10 8.07 6.37 0.46 10 11.95 9.80 0.32
Fever + Fatigue 25 26.56 17.60 0.09 31 19.53 19.74 6.74 19 28.91 18.63 3.40
Cough + Fatigue 11 11.33 7.75 0.01 9 8.33 5.73 0.05 12 12.33 11.77 0.01
Fever + Cough + Fatigue 38 35.77 26.76 0.14 37 26.30 23.57 4.35 26 38.93 25.49 4.30
χ2(6) = 59.20 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(6) = 52.31 p < 0.01.

More than 90% of the responders worked as private dentists and only 242 (6.82%) worked
partially or full-time in the National Health System (NHS). Almost half of the dentists continued to
work after the outbreak of the disease (21st February).
Several precautionary measures were adopted by dentists who continued to work after SARS-CoV-
2 outbreak; in Table 5, the measures were grouped in (1) measures adopted before the patient’s arrival, (2)
measures adopted in the waiting room, and (3) measures adopted in the operating room. Among
measures taken before the patient’s arrival, the delay of the appointments to not saturate the waiting room
was the most adopted (86.07%). Frequent ventilation of the waiting room (88.98%) and the washing of the
operators’ hands before and after each procedure (91.64%) were the most taken measures.

Table 5. Precautionary measures taken by dentists that continued to work after the outbreak of
COVID-19.

Item n (%)
Phone Triage 2542 (82.37)
Spaced appointments as not saturate the waiting room 2656 (86.07)
Before patient
Deferring therapies in elderly patients, or with systemic diseases 1912 (61.96)
arrival
Detecting body temperature of all co-workers and leave those with a
656 (21.26)
temperature above 37.5 °C.
Disinfection of pushbuttons, POS, chairs, several times a day 2525 (81.82)
Verify the patient’s current health status on access 2568 (83.21)
Detecting the patient’s body temperature 725 (23.49)
Washing the patient’s hands 2413 (78.19)
In the waiting
Space of at least one meter between patients 2312 (74.92)
room
Mask for the patient 1011 (32.76)
Frequent ventilation of waiting rooms 2746 (88.98)
Removal of magazines and books from the waiting area 2418 (78.35)
Storage of coats, bags, and other items outside the operating area 2103 (68.15)
Pre-operative rinse with mouthwash containing 1% hydrogen peroxide 813 (26.34)
Pre-operative rinse with mouthwash containing chlorhexidine 0.12–0.2% 1658 (53.73)
Pre-operative rinse with mouthwash containing 0.2–1% iodopovidone 251 (8.13)
Pre-operative rinse with mouthwash containing alcohol and essential oils 190 (6.16)
Pre-operative rinse with mouthwash with Cetylpyridinium chloride at
86 (2.79)
0.05–0.10%
In the operating Rinse with diluted mouthwash 112 (3.63)
room Ventilation of the operating area for at least 10 min after each patient 2379 (77.09)
Disinfection of surfaces with 70% ethyl alcohol 1264 (40.96)
Disinfection of surfaces with 0.5% sodium hypochlorite 611 (19.80)
Disinfection of surfaces with usual disinfectant with other active
1875 (60.76)
ingredients
Washing operators’ hands before and after each procedure 2828 (91.64)
Removal of all disposable protective devices and disinfection of devices 2484 (80.49)
Int. J. Environ. Res. Public Health 2020, 17, 3835 7 of 11

Table 5 reports precautionary measures with more than 80% positive replies, among those of
Table 4, stratified by areas with a different prevalence of COVID-19. Statistically significant
differences were found for all considered items. The delay of the appointments in order to not
saturate the waiting room, the frequent ventilation of the waiting room, and the washing of the
operators’ hands before and after each procedure were the items with the higher differences among
areas (p < 0.01). Surprisingly, dentists from the area with the highest COVID-19 prevalence claimed
to have used some virus containment strategies, such as the disinfection of pushbuttons, point of sale
(POS), and chairs several times a day, the removal of all disposable protective devices, and
disinfection of devices and washing hands, less frequently than dentists who work in the lower
prevalence areas (Table 6).
In addition to the PPE commonly used by dentists, such as the use of disposable gloves (93.22%)
and surgical masks (74.56%), the use of glasses/visors (91.28%), disposable headsets (63.75%), and
facial filters (58.84%) were the equipment most claimed (Table 7).

Table 6. Precautionary measures against COVID-19 stratified by areas with different prevalence of
the disease. The items with 80% or more positive replies were used. Percentages were calculated per
column.

Milan Area High Prevalence Area Low Prevalence Area

Answers
OF EF % Cχ2 OF EF % Cχ2 OF EF % Cχ2
Phone triage
χ2(2) = 11.41 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 11.44 p < 0.01
No 185 344.3 17.57 3.90 126 252.7 15.91 0.04 233 372.9 18.78 4.27
Yes 868 1092.98 82.43 1.51 666 803.58 84.09 0.02 1008 958.1 81.22 1.66
Appointments delayed so to not saturate the waiting room
χ2(2) = 6.78 p = 0.03 Post ad hoc estimation Likelihood-ratio χ2(2) = 6.84 p = 0.03
No 96 305.1 9.12 1.05 123 223.7 15.53 0.92 211 330.2 17.00 3.14
Yes 957 923.9 90.88 0.35 669 677.3 84.47 0.30 1030 998.8 83.00 1.04
Disinfection of pushbuttons, POS, chairs, several times a day
χ2(2) = 8.04 p = 0.02 Post ad hoc estimation Likelihood-ratio χ2(2) = 8.10 p = 0.02
No 107 352.61 10.16 1.55 202 258.79 25.50 0.67 212 381.59 17.08 3.50
Yes 946 876.38 89.24 0.62 590 643.20 74.50 0.27 1029 948.41 82.92 1.41
Verify the patient’s current health status on access
χ2(2 )= 8.79 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 8.56 p = 0.01
No 161 336.28 15.29 1.81 89 246.81 21.60 0.67 268 363.91 16.78 3.75
Yes 892 892.72 84.71 0.69 703 655.19 78.40 0.23 973 966.09 83.22 1.41
Frequent ventilation of waiting rooms
χ2(2) = 5.61 p = 0.06 Post ad hoc estimation Likelihood-ratio χ2(2) = 5.62 p = 0.06
No 299 275.12 24.33 2.07 204 201.92 22.62 0.02 272 297.95 20.44 2.26
Yes 930 953.87 75.67 0.60 698 700.08 77.38 0.01 1059 1033.04 79.56 0.65
Washing operators’ hands before and after each procedure
χ2(2) = 9.21 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 9.32 p < 0.01
No 262 246.15 21.32 1.02 199 180.46 22.09 1.91 232 266.38 17.44 4.44
Yes 967 982.45 78.68 0.26 702 720.54 77.91 0.48 1098 1063.62 82.56 1.11
Removal of all disposable protective devices and disinfection of devices
χ 2(2) = 9.09 p = 0.01 Post ad hoc estimation Likelihood-ratio χ2(2) = 9.17 p = 0.01
No 392 365.86 21.32 1.87 281 267.92 22.09 0.64 357 396.22 17.44 3.88
Yes 837 863.14 78.68 0.79 619 632.08 77.91 0.27 974 934.77 82.56 1.65

Only one-third of the dentists reported to have followed a Continuous Educational Course on
COVID-19, but 70.49% of the sample believed to have enough knowledge on the disease and the
protective measures (data not in tables).
Int. J. Environ. Res. Public Health 2020, 17, 3835 8 of 11

About the risk perception of being infected by SARS-CoV-2 (Table 8), the majority of the dentists
(64.50%) replied that the dentistry is a profession at risk; only 2.13% of the dentists claimed to be
confident in avoiding the infection and 68.50% believed that in the actual health emergency, the risk
of infection transmission during the dental practice is higher than that run in a supermarket.

Table 7. Personal protective equipment (PPE) and devices adopted by the dentists.

Items n (%)
Surgical mask 2386 (74.56)
FFP2 or FFP3 facial filters 1755 (54.84)
Disposable headset 2040 (63.75)
Sterile microfiber disposable gown 675 (21.09)

The same variables mentioned above were stratified by areas with different prevalence of
COVID-19 (Table 8). Unlike what could be assumed, even though only a small number of dentists in
all areas believe to be confident in avoiding the infection, dentists working in areas with a high
COVID-19 prevalence are more confident than those working in a lower prevalence area (61.23% vs
64.29% and 66.41%). Dentists from different areas agree that the risk of infection is higher in the dental
setting than in a supermarket, but a statistically significant difference among areas was noted (63.63%
in high COVID-19 area, 68.25% in low COVID-19 area, and 71.82 in Milan area (Table 9).

Table 8. Perception of risk related to COVID-19.

Items as n (%)
Do you believe that the infection by SARS-CoV-2 is a risk for the dentist?
Very unlikely Unlikely Likely Very likely
107 (3.11) 121 (3.52) 993 (28.91) 2214 (64.50)
How sure are you that you can avoid being infected by SARS-CoV-2 during work?
Not confident A bit confident Enough confident Confident
1275 (37.20) 966 (28.19) 1113 (32.48) 73 (2.13)
In a health emergency situation such as the current one, do you believe that the risk of infection transmission in the dental
practice is:
Comparable to the risk run in a
Higher than the risk run in a supermarket Less than the risk run in a supermarket
supermarket
2349 (68.50) 405 (11.81) 675 (19.69)

Table 9. Risk perception of COVID-19 stratified by areas with different prevalence of COVID-19.
Percentages were calculated per column.

Milan Area High Prevalence Area Low Prevalence Area

Answers
OF EF % OF EF % OF EF % OF EF %
Do you believe that the infection by SARS-CoV-2 is a risk for the dentist?
χ2(6) = 13.54 p = 0.03 Post ad hoc estimation Likelihood-ratio χ2(6) = 13.67 p = 0.03
Very unlikely 48 40.97 3.74 1.21 22 30.40 2.51 2.32 46 44.64 3.57 0.04
Unlikely 38 37.08 2.96 0.02 29 27.51 3.31 0.08 38 40.41 2.95 0.14
Likely 311 344.67 24.26 3.29 289 255.74 32.95 4.33 376 375.59 29.19 0.00
Very likely 785 759.28 61.24 0.87 537 563.36 61.23 1.23 828 827.37 64.29 0.00
How sure are you that you can avoid becoming infected with SARS-CoV-2 during work?
χ2(6) = 17.91 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(6) = 17.99 p < 0.01
Not confident 482 436.53 40.95 4.74 292 325.26 32.30 3.40 464 476.21 36.13 0.31
Enough
321 334.62 27.27 0.56 278 249.33 31.70 3.30 350 365.04 27.25 0.62
confident
A bit confident 349 380.46 29.66 2.60 286 283.49 32.61 0.02 444 415.05 34.60 2.02
Confident 25 25.38 2.12 0.01 21 18.92 2.39 0.23 26 27.70 2.02 0.10
In a health emergency situation such as the current one, do you believe that the risk of infection transmission in the dental
practice, compared to that run in a supermarket, is
χ2(4) = 16.08 p < 0.01 Post ad hoc estimation Likelihood-ratio χ2(42) = 16.04 p < 0.01
Lower 211 232.78 17.91 2.04 200 173.30 22.80 4.11 249 253.92 19.38 0.09
Comparable 121 140.73 10.27 2.77 119 104.77 13.57 1.93 159 153.51 12.37 0.20
Higher 846 804.05 71.82 2.14 558 598.93 63.63 2.80 877 877.57 68.25 0.01
Int. J. Environ. Res. Public Health 2020, 17, 3835 9 of 11

4. Discussion
The present survey was carried out during the period of maximum diffusion of COVID-19 in Europe.
Lombardy, situated in Northern Italy, with about 10 million inhabitants (more than one-sixth of Italy’s
entire population), is the region with the highest number of SARS-CoV-2 infections and deaths.
The sample of dentists to whom the questionnaire was emailed includes almost all Lombardy
dentists. The response rate was quite low; however, given the high number of questionnaires sent,
the sample of responders is high and representative of the Lombardy dentist population.
At the moment in which this paper was written, three papers were available in literature
reporting data collected through a questionnaire administered to a sample of dentists investigating
different aspects of the COVID-19 in the dental setting [13,14,18]. The first two papers investigated
knowledge, attitudes, and practices of dental practitioners regarding COVID-19, one study involving
a sample of dentists from different countries and continents and the second involving a sample of
dentists from Jordan [13,14,18]. The third study, including a sample of dentists from all over the world,
aimed to assess fear and practice modifications related to COVID-19 [18]. None of these studies addressed
the health conditions of dentists related to the disease. In the present survey, among the interviewed
dentists, the percentage of subjects diagnosed with the new coronavirus (0.86%) is similar to that reported
in the population of high COVID-19 prevalence areas. This data could suggest a greater infection diffusion
among dentists. However, this finding could be due to a possibly higher participation rate in the
questionnaire of subjects infected with the virus or with claimed symptoms/signs. They were reported by
a relatively high percentage of dentists (14.43%). Nevertheless, these symptoms/signs may have been
caused by other conditions such as seasonal flu, still present in the period of the widespread of SARS-
CoV-2. However, the highest prevalence reported by dentists working in the provinces where
COVID-19 had spread, such as Bergamo and Cremona, is startling.
Regarding the precautionary measures taken by dentists that continued to work after the outbreak
of COVID-19, it is possible to compare these data with those reported in a worldwide taken sample of
dentists [19]. Patients’ body temperature before dental treatment was taken by less than a quarter of the
Lombardy sample, while this measure was carried out by more than two-thirds of dentists interviewed
all over the world. In the same study, considering the use of PPE, the majority of dentists reported to
believe that the use of facial filters is a useful habit in the current outbreak, but only a minority claimed to
use it. More than half of the Lombardy sample declared to use these PPE. Only a quarter of the
international sample of dentists make their patients do a pre-treatment mouth-rinse, while in Lombardy,
the majority of dentists use this protective measure on patients. Nevertheless, it is important to note that
half of the Lombardy sample reported using chlorhexidine-containing rinse that appears not to be efficient
against SARS-CoV-2, and only one-third reported to use a mouth-rinse containing more active
compounds [19]. Finally, handwashing before and after each treatment was a habit reported by a high
percentage of dentists from both samples. The majority of dentists from both surveys are afraid of getting
infected with SARS-CoV-2 in the dental environment.
The use of sterile gloves and gown as well as other PPE included in the present questionnaire
do not have a scientific justification in this pandemic situation, as reported above. Regarding the use
of gloves, only a small minority of dentists claimed to use sterile gloves, while the use of sterile gowns
was reported by about a fifth of the sample. However, it is possible to hypothesize that dentists
unprepared for the pandemic used PPE that they already had to protect themselves, albeit knowing
that some, such as sterile gloves and gowns, were not necessary to avoid the infection.
Unlike what could be expected, for both preventive measures and self-perceived infection risk
related to COVID-19, dentists from the areas with the highest prevalence of the disease seem to be
generally less preoccupied: they reported a lower implementation of some of the most frequently
adopted preventive measures than their colleagues from areas at low COVID-19 prevalence as well
as a lower perception of being infected. The different perception of the risk reported by dentists who
live and work in areas with a different prevalence of the disease can be explained by the fact that
where many infected people are present, the risk is seen as general, reducing the perception of a
higher infection risk at the dental chair, while dentists who live and work in areas with a lower
prevalence of the disease consider the occupational risk as higher.
Int. J. Environ. Res. Public Health 2020, 17, 3835 10 of 11

Only one-third of the dentists reported to have followed a Continuous Educational Course on
COVID-19, but more than two-thirds believe to have enough knowledge about the new disease. This
discrepancy could represent a weakness. Throughout this international health crisis, a large amount
of information reaches us every day, involving the circulation of many fake news, which can
represent a danger especially in the health context [20].

5. Conclusions
In conclusion, this survey gives an insight into the dental profession in one of the European areas
where COVID-19 has caused the greatest number of deaths in proportion to the number of inhabitants.
A quite high percentage of the sample reported symptoms attributable to the infection, especially those
working in the high prevalence area. However, only 31 of these subjects were diagnosed with COVID-
19. Even though the majority of dentists adopted several precautionary measures, recognized as valid
by the scientific community, those working in the highest prevalence COVID-19 area reported adopting
several measures less frequently than dentists in low prevalence area. The same unexpected finding
was disclosed regarding the COVID-19 risk perception: dentists in the highest prevalence area were
more confident to avoid the infection than others.
Only one-third of the dentists report to have followed a Continuous Educational Course on
COVID-19, but the majority of the sample believes to have enough knowledge on the disease and the
protective measures to avoid infection.
Supplementary Materials: The following are available online at www.mdpi.com/1660-4601/17/11/3835/s1, Table
S1: Row data.

Author Contributions: M.G.C., J.-L.C., A.S., and G.C. designed and planned the study; M.G.C., J.-L.C., and G.C.
created the questionnaire and tested it; J.-L.C. submitted the questionnaire and collected the data; G.C.
performed the statistical analysis; M.G.C. and G.C. wrote the manuscript draft and created the tables. All authors
have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Acknowledgments: All person that had taken part in the study are mentioned as authors.

Conflicts of Interest: The authors declare no conflict of interest.

Abbreviation
MERS-CoV Middle East Respiratory Syndrome MERS-CoV
SARS-CoV Severe Acute Respiratory Syndrome
COVID-19 Coronavirus Disease
POS Point of sale
PPE Personal Protective Equipment
NHS National Health System

References
1. Chen, X.; Ran, L.; Liu, Q.; Hu, Q.; Du, X.; Tan, X. Hand Hygiene, Mask-Wearing Behaviors and Its
Associated Factors during the COVID-19 Epidemic: A Cross-Sectional Study among Primary School
Students in Wuhan, China. Int. J. Environ. Res. Public Health 2020, 17, 2893.
2. European Centre for Disease Prevention and Control. Available online:
https://www.ecdc.europa.eu/en/cases-2019-ncov-eueea (accessed on 12 May 2020).
3. Italian Health Institute. Available online: https://www.iss.it (accessed on 12 May 2020).
4. Italian National Federation of the Order of Physicians, Surgeons and Dentists. Available online:
https://portale.fnomceo.it (accessed on 12 May 2020).
5. Volgenant, C.M.C.; de Soet, J.J. Cross-transmission in the Dental Office: Does This Make You Ill? Curr. Oral
Health Rep. 2018, 5, 221–228.
6. Szymańska, J. Dental bioaerosol as an occupational hazard in a dentist’s workplace. Ann. Agric. Environ.
Med. 2007, 14, 203–207.
Int. J. Environ. Res. Public Health 2020, 17, 3835 11 of 11

7. Peng, X.; Xu, X.; Li, Y.; Cheng, L.; Zhou, X.; Ren, B. Transmission routes of 2019-nCoV and controls in dental
practice. Int. J. Oral Sci. 2020, 12, 9.
8. Zemouri, C.; de Soet, H.; Crielaard, W.; Laheij, A. A scoping review on bio-aerosols in healthcare and the
dental environment. PLoS ONE 2017, 12, e0178007.
9. Holbrook, M.G.; Gamble, A.; Williamson, B.N.; Tamin, A.; Harcourt, J.L.; Thornburg, N.J.; Gerber, S.I.;
Lloyd-Smith, J.O.; de Wit, E.; Munster, V.J. Aerosol and Surface Stability of SARS-CoV-2 as Compared with
SARS-CoV-1. N. Engl. J. Med. 2020, 382, 1564–1567.
10. Song, Y.; Son, Y.J.; Oh, D. Methodological Issues in Questionnaire Design. J. Korean. Acad. Nurs. 2015, 45,
323–328.
11. Khosravanifard, B.; Rakhshan, V.; Najafi-Salehi, L.; Sherafat, S. Tehran dentists’ knowledge and attitudes
towards hepatitis B and their willingness to treat simulated hepatitis B positive patients. East Mediterr.
Health J. 2014, 20, 498–507.
12. Gaffar, B.O.; El Tantawi, M.; Al-Ansari, A.A.; AlAgl, A.S.; Farooqi, F.A.; Almas, K.M. Knowledge and
practices of dentists regarding MERS-CoV. A cross-sectional survey in Saudi Arabia. Saudi Med. J. 2019, 40,
714–720.
13. Khader, Y.; Al Nsour, M.; Al-Batayneh, O.B.; Saadeh, R.; Bashier, H.; Alfaqih, M.; Al-Azzam, S.; Al-
Shurman. B.A. Dentists’ awareness, perception, and attitude regarding COVID-19 and infection control: A
cross-sectional study among Jordanian dentists. JMIR Public Health Surveill. 2020, doi:10.2196/18798.
14. Brug, J.; Aro, A.R.; Oenema, A.; de Zwart, O.; Richardus, J.H.; Bishop, G.D. SARS risk perception,
knowledge, precautions, and information sources, the Netherlands. Emerg. Infect Dis. 2004, 10, 1486–1489.
15. Stehr-Green, P.A.; Stehr-Green, J.K.; Nelson, A. Developing a questionnaire. FOCUS Field Epidemiol. 2003,
2, 1–6.
16. Li, L.Q.; Huang, T.; Wang, Y.Q.; Wang, Z.P.; Liang, Y.; Huang, T.B.; Zhang, H.Y.; Sun, W.; Wang, Y. COVID-
19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J. Med. Virol. 2020,
doi:10.1002/jmv.25757.
17. Kamate, S.K.; Sharma, S.; Thakar, S.; Srivastava, D.; Sengupta, K.; Hadi, A.J.; Chaudhary, A.; Joshi, R.;
Dhanker, K. Assessing Knowledge, Attitudes and Practices of dental practitioners regarding the COVID-
19 pandemic: A multinational study. Dent. Med. Probl. 2020, 57, 11–17.
18. Ahmed, M.A.; Jouhar, R.; Ahmed, N.; Adnan, S.; Aftab, M.; Zafar, M.S.; Khurshid, Z. Fear and Practice
Modifications among Dentists to Combat Novel Coronavirus Disease (COVID-19) Outbreak. Int. J. Environ.
Res. Public Health 2020, 17, 8.
19. Carrouel, F.; Conte, M.P.; Fisher, J.; Gonçalves, L.S.; Dussart, C.; Llodra, J.C.; Bourgeois, D. COVID-19: A
Recommendation to Examine the Effect of Mouthrinses with β-Cyclodextrin Combined with Citrox in
Preventing Infection and Progression. J. Clin. Med. 2020, 9, 1126.
20. O’Connor, C.; Murphy, M. Going viral: Doctors must tackle fake news in the covid-19 pandemic. BMJ 2020,
369, 1587.

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
 JCTXXX10.1177/2380084420924385JDR Clinical & Translational ResearchThe Clouds of COVID-19
research-article2020

Vol. XX • Issue X Dental Care under the Clouds of COVID-19

Special Communication

Dental Care and Oral Health

under the Clouds of COVID-19
Y.F. Ren1 , L. Rasubala1, H. Malmstrom1, and E. Eliav1

C
Abstract: Coronavirus disease 2019 CoV-2 and that oral symptoms, oronavirus disease 2019 (COVID-
(COVID-19), caused by the severe acute including loss of taste/smell and dry 19), caused by the severe acute
respiratory syndrome coronavirus mouth, might be early symptoms of respiratory syndrome coronavirus
2 (SARS-CoV-2), has caused much COVID-19, presenting before fever, dry 2 (SARS-CoV-2), has spread rapidly across
anxiety and confusion in the cough, fatigue, shortness breath, and the globe since it was first reported in
community and affected the delivery other typical symptoms. Oral health China in December 2019. As of April 15,
of vital health care services, including researchers may play a more active role 2020, SARS-CoV-2 has infected >2 mil-
dental care. We reviewed current in early identification and diagnosis lion individuals and resulted in 132,000
evidence related to the impact of SARS- of the disease through deciphering the deaths in 185 countries/regions. While
CoV-2/COVID-19 on dental care and mechanisms of dry mouth and loss government agencies, health care facil-
oral health with the aim to help dental of taste in patients with COVID-19. ities, and medical professionals world-
professionals better understand the Rapid testing for infectious diseases in wide mobilize to contain the virus, miti-
risks of disease transmission in dental dental offices via saliva samples may gate the transmission of the disease, and
settings, strengthen protection against be valuable in the early identification save the lives of patients with COVID-
nosocomial infections, and identify of infected patients and in disease 19, dental care and oral health research
areas of COVID-19–related oral health progress assessment. have rightfully taken a backseat during
research. When compared with other the pandemic to preserve scarce personal
recent pandemics, COVID-19 is less Knowledge Transfer Statement: protective equipment (PPE), observe
severe but spreads more easily, causing This commentary provides a timely social distancing, and protect the employ-
a significantly higher number of evidence-based overview on the impact ees and patients from risks of poten-
deaths worldwide. Protection of dental of COVID-19 on dental care and oral tial exposure and illness. With the rapid
patients and staff during COVID- health and identifies gaps in protection increase in confirmed cases of COVID-
19 is challenging due to the existence of patients and staff in dental settings. 19 in the United States, the Centers for
of patients who are infectious yet Oral symptoms are prominent before Disease Control and Prevention (CDC),
asymptomatic. Dental professionals fever and cough occur. Dental American Dental Association (ADA), and
are ill prepared for the pandemic, professionals may play an important state dental boards and associations have
as they are not routinely fitted for role in early identification and all issued guidance to advise dentists
the N95 respirators now required for diagnosis of patients with COVID-19. to halt elective dental services and treat
preventing contagion during dental only patients requiring emergency dental
treatments. Biological and clinical Keywords: SARS-CoV-2, dental facility, procedures.
evidence supports that oral mucosa urgent care, airborne transmission, dry SARS-CoV-2 differs significantly from
is an initial site of entry for SARS- mouth, ageusia the 2003 SARS-CoV and Middle East

DOI: 10.1177/2380084420924385. 1Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA. Corresponding authors: Y.F. Ren, Eastman Institute for
Oral Health, University of Rochester, 625 Elmwood Ave, Rochester, NY 14620, USA. Email: yanfang_ren@urmc.rochester.edu. E. Eliav, Eastman Institute for Oral Health,
University of Rochester, 625 Elmwood Ave, Rochester, NY 14620, USA. Email: eli_eliav@urmc.rochester.edu.
© International & American Associations for Dental Research 2020

1
 JDR Clinical & Translational Research
respiratory syndrome coronavirus (MERS-
CoV) not only in genome sequence
but also in its spike protein structures
(Kandeel et al. 2020; Ren et al. 2020),
which exhibit higher affinity to the
cellular entry receptor angiotensin-
converting enzyme 2 (ACE2), rendering
it much easier for SARS-CoV-2 to enter
human cells than SARS-CoV and MERS-
CoV. Consequently, COVID-19 spreads
much faster than SARS and MERS and
has caused more deaths than SARS and
MERS combined. Rapid transmission of
the disease and exponential increase
in number of confirmed cases—
coupled with evolving but limited
information about the transmission,
prevention, diagnosis, treatment, and
prognosis of the disease—have caused
much anxiety and confusion in the
community and affected the delivery
of vital health care services, including
dental treatments for those who need
emergency care.
Reports from Wuhan, China, the
epicenter of the pandemic, indicated that
SARS-CoV-2 infections did occur in a
small percentage of dental professionals,
and face masks and gloves were credited
for effectively preventing further spread
of the infections among colleagues in
close contact (Meng et al. 2020). These
authors state that dental staff should
be provided adequate PPEs when
providing dental emergency services,
including N95 masks, gloves, isolation
gowns, protective eye goggles, face
shields, and head and shoe covers
(Meng et al. 2020). Such measures of
personal protection were effective, as
no transmission from patients to dental
staff was reported in China. However,
these PPEs are at present in critical short
supply in the United States, even for
medical staff who provide direct care
to patients with COVID-19 in hospital
emergency rooms and intensive care
units, and it is practically impossible for
dental providers to acquire and utilize
the full list of PPEs included in this
recommendation. The Pennsylvania state
health department issued guidance that
initially required using PPEs similar to
this list and engineering control, such
2
Month 2020
as negative-pressure isolation rooms overview focuses on issues important to
with HEPA filtration (high-efficiency dental care and oral health and is not
particulate air), when treating dental intended to be a comprehensive review
emergency patients, which essentially of SARS-CoV-2 and COVID-19.
precluded all dental clinics in the state
to provide dental emergency care, as Bare Basics of SARS-CoV-2
none of the available dental facilities
SARS-CoV-2 is an enveloped positive-
could meet such stringent requirement.
stranded RNA virus, which is a
This guidance was later revised to allow
betacoronavirus within the Nidovirales
urgent or emergency dental treatments
order of viruses (Gorbalenya et al. 2020).
with PPEs and disinfection procedures
The host-derived membrane is studded
consistent with usual standard of care in
with glycoprotein spikes and surrounds
patients not suspected of having COVID-
the RNA genome. Replication of viral
19 (Pennsylvania Department of Health
RNA occurs in the host cytoplasm
2020).
through the action of RNA polymerase.
Dental emergency services are vital
The spike protein projects through
to the community in the time of the
the viral envelope and mediates ACE2
COVID-19 pandemic, which puts a heavy
receptor binding and fusion with the
strain on critical health care resources.
host cell membrane (Xu, Chen, et al.
Aside from life-threatening dental
2020). In more simple terms, SARS-CoV-2
emergencies, such as uncontrolled oral
can be described as a piece of genetic
tissue bleeding, head and neck fascial
material (RNA) wrapped in a coat of
space infection, or facial trauma that
proteins that have spikes helping the
may compromise the patient’s airway,
virus enter human cells and hijack them,
patients with severe dental pain that
creating copies of itself and eventually
cannot be controlled with over-the-
killing the host cells. It is of practical
counter analgesics or patients with
importance to understand that the virus
minor dental trauma may clog hospital
is only “alive” when inside the cells and
emergency rooms that are already
that it is inert and cannot replicate itself
overburdened with patients with COVID-
when outside the body (Koonin and
19 or other medical emergencies. The
Starokadomskyy 2016). While outside
ADA (2020c) developed guidance on
the body, the protein structure of SARS-
dental emergency and nonemergency
CoV-2 can be easily unwrapped or
dental procedures, which includes a
disassembled by common disinfectants
rather inclusive list of urgent dental care
within 5 min (Chin et al. 2020), which
treatments aiming at minimizing pain,
effectively render the virus harmless
preventing infections, and reducing
since it will not be able to enter the cells
discomforts. As dental professionals
and replicate without the protein coat
treating emergency patients in the
and spikes.
time of uncertainty in the midst of the
COVID-19 pandemic, it is urgent that
Spread of SARS-CoV-2
we develop adequate understanding
from Human to Human
of the disease, especially its modes
of transmission, and adopt prudent Though SARS-CoV-2 was generally
measures to protect our patients and considered a novel coronavirus
our staff to the best of our capacity. We transmitted from bat to human via an
therefore provide the following overview intermediate host, such as a pangolin
on SARS-CoV-2/COVID-19 and its impact (Lam et al. 2020; Li, Giorgi, et al. 2020) or
on oral health and dental care. We fully other animals (Li, Zai, et al. 2020; Luan
understand that knowledge about the et al. 2020) in a wet market in Wuhan,
virus and the disease is rapidly evolving, China, a group of leading virologists
and we advise caution and reference to from the United States, United Kingdom,
the most up-to-date evidence from peer- and Australia recently described that
reviewed scientific publications. This this virus may have been circulating in
 Vol. XX • Issue X
human populations for an extended
period before it acquired the ability
of causing human diseases through
genomic adaptations during undetected
human-to-human transmissions
(Andersen et al. 2020). These researchers
analyzed available genomic sequence
data of known coronavirus strains and
determined that the receptor-binding
domain sections of SARS-CoV-2 spike
proteins could become so effective in
binding to ACE2 only through a long
process of natural selections. Clinical
and epidemiologic studies suggest
that human-to-human transmission is
most frequently realized through direct
or indirect contact with virus-laden
respiratory droplets discharged from
infected individuals while coughing
and sneezing (Chen 2020; Wu et al.
2020). These droplets vary in size, from
a few micrometers to a hundred, and
may travel in air for distances from a
few feet to several meters (Kunkel et al.
2017; Liu et al. 2017). In theory, smaller
droplets (5 to 10 µm) or droplet nuclei
(<5 µm) produced by coughing or
sneezing can be inhaled by a person in
very close proximity and directly cause
transmission of the disease, as they may
float in the air for an extended period,
especially in a closed space with poor
ventilation (An et al. 2020). SARS-CoV-2
transmission may also occur indirectly,
when a person comes into contact with
fomites, such as the hand or clothes of
an infected patient or the door handles,
counter surfaces, dinning utensils, and
other objects touched, used, or soiled
by respiratory droplets from an infected
patient. It is believed that SARS-CoV-2
cannot penetrate the keratin layer of
intact human skin but may enter human
body through mucosal surfaces when
contaminated hands touch the mouth,
noses, and eyes.
The possibility for airborne
transmission of SARS-CoV-2 remains an
item of debate among infectious disease
experts. SARS-CoV-2 virus was found to
remain in floating aerosols for up to 3 h
in a laboratory experimental study (van
Doremalen et al. 2020). Some studies
found that the viral RNA of SARS-CoV-2
is present in air samples in isolation
rooms and quarantine facilities (Santarpia
et al. 2020) and in and around hospitals
and department store entrances (Liu
et al. 2020), while other studies did not
find the viral RNA in air samples where
the patients with COVID-19 were treated
(Cheng et al. 2020; Ong et al. 2020). In
a scientific brief published March 27,
2020, the World Health Organization
(2020) stated that there is no sufficient
evidence that SARS-CoV-2 is airborne
and that presence of the virus RNA in
aerosols does not indicate that viable
virus is transmissible. To date, infectious
disease experts and policy makers in
countries such as China and South
Korea are convinced that SARS-CoV-2 is
transmissible by air, like other infectious
respiratory diseases. As such, they have
stringent face mask policies in place for
citizens in public spaces and for health
care workers in medical facilities. Yet,
the World Health Organization and
policy makers in the United States and
some European countries have taken a
more evidence-based approach while
awaiting more concrete findings on
the effectiveness of universal masking,
namely by insisting that only patients
with confirmed or suspected COVID-
19 wear face masks as well as the
health care workers who treat them. As
emerging evidence supports that SARS-
CoV-2 is transmissible by air during
normal talking and breathing (Asadi
et al. 2020), more stringent face mask
policies in health care facilities and
public spaces are likely to come.
Though fecal-oral transmission has
been proposed as a possibility because
the viral RNA was detectable in stools
and anal swabs (Gu et al. 2020; Zhang
et al. 2020), a recent study indicated that
no viable virus could be isolated from
stool samples (Wölfel et al. 2020). The
clinical and public health significance
of fecal-oral transmission is therefore
unclear and needs confirmatory studies.
In summary, SARS-CoV-2 is most
frequently transmitted from human
to human through direct contact with
respiratory droplets and through
indirect contact with fomites. Airborne
Dental Care under the Clouds of COVID-19
transmission and fecal-oral transmission
are also likely, but concrete confirmatory
evidence is lacking.
Transmission from Asymptomatic
or Presymptomatic Patients
with COVID-19
As mentioned earlier, SARS-CoV-2
spreads much faster than SARS-CoV
and MERS-CoV, which can partially
be explained by a higher binding
efficiency of SARS-CoV-2 spike protein
to human ACE2 receptors (Walls et al.
2020). With increased understanding
about the natural course of the disease,
including its virologic and clinical
manifestations, we now know that
COVID-19 is less severe overall, having
a lower fatality rate (2%) than SARS
(10%) or MERS (34%; Mahase 2020),
and that many patients with COVID-19
have mild or no symptoms, especially
at early stages of the disease. Virologic
studies show that viral load is highest
in the first week of COVID-19, when
the symptoms are generally mild (To,
Tsang, Leung, et al. 2020; Wölfel et al.
2020). Some individuals infected with
SARS-CoV-2 may never show symptoms
themselves but become the source of
the disease transmission within close
contacts (Hu et al. 2020). A recent
epidemiologic study indicated that nearly
17% of the patients with COVID-19 are
asymptomatic and that the transmission
rate from asymptomatic patients (4.1%)
is statistically similar to that from
symptomatic patients (6.3%; Chen, Wang,
et al. 2020). These findings suggest that
transmission from asymptomatic patients
to healthy individuals is likely a hallmark
of COVID-19 that distinguishes it from
SARS and MERS and contributes to rapid
spread of the disease in the community.
Reports from Japan show that 18%
to 30% of the infected patients were
asymptomatic (Mizumoto et al. 2020;
Nishiura et al. 2020). With escalating
rates of screening and testing, emerging
data from European countries and
the United States point to even higher
proportions of asymptomatic patients
with COVID-19. News media reported
3
 JDR Clinical & Translational Research
on April 2, 2020, that nationwide
data from Iceland showed that 50%
of those who tested positive said that
they were asymptomatic, and the CDC
director stated that an estimated 25% of
coronavirus carriers in the United States
have no symptoms (CNN 2020).
“Asymptomatic patients” reported in
scientific literature and mass media refer
to individuals who test positive for SARS-
CoV-2 RNA but do not have any of the
hallmark symptoms of COVID-19 at
the time of the test. Some patients may
never show symptoms, but others may
develop symptoms later and are more
accurately defined as “presymptomatic”
(Kimball et al. 2020). Such distinction
is important only in statistical terms, as
they are counted as different types of
patients. In reality, asymptomatic and
presymptomatic patients are both major
sources of SARS-CoV-2 transmission,
as they are covert and show no
warning signs to health care workers or
laypersons at the time of contact.
Oral Health Implications of
SARS-CoV-2 and COVID-19
Oral mucosa has been implicated as a
potential route of entry for SARS-CoV-2
(Peng et al. 2020). The SARS-CoV-2
cellular entry receptor ACE2 was found
in various oral mucosal tissues, especially
in the tongue and floor of the mouth
(Xu, Zhong, et al. 2020). ACE2-positive
cells were also detected in buccal and
gingival epithelial cells. The presence
of ACE2 receptors in oral tissues
suggests that it is biologically plausible
for the oral cavity to be the initial site
of entry for SARS-CoV-2. Habitual and
unintentional hand-mouth contact is a
common phenomenon in social and
private settings, which is consistent
with the mode of transmission of SARS-
CoV-2 described earlier. In addition to
inadequate hand hygiene and possible
direct transmission through hand-
mouth contact, oral ingestion of food
contaminated by infected patients might
be a possibility in regions where dinning
from shared dishes with friends and
family is customary. Dinning with family
4
or friends was reported to be a risk
factor of transmission from symptomatic
and asymptomatic patients in China
(Chen, Wang, et al. 2020).
Loss of taste (ageusia) has been
reported in patients with COVID-19
(Chen, Zhao, et al. 2020; Gautier and
Ravussin 2020; Giacomelli et al. 2020).
Approximately 50% of the patients
reported loss of taste (Chen, Zhao,
et al. 2020; Giacomelli et al. 2020). It
is particularly interesting that loss of
taste occurred before hospitalization in
the early stage of the disease in 91% of
these patients and that this symptom
is persistent (Giacomelli et al. 2020).
Using the COVID Symptom Tracker app
developed in King’s College London,
researchers found that loss of taste and
smell is a key symptom for patients
with COVID-19. The app tracked 1,702
patients tested for COVID-19, with 579
positive results and 1,123 negative, and
showed that 59% of patients who were
COVID-19 positive reported loss of taste
and smell, as compared with only 18% of
those who tested negative. Self-reported
loss of taste and smell is much stronger
in predicting a positive COVID-19
diagnosis than self-reported fever (King’s
College London 2020). Taste organs are
widely distributed in oral tongue, where
96% of the oral ACE2-positive cells reside
(Xu, Zhong, et al. 2020). Loss of taste as
an early symptom of COVID-19 before
fever and other symptoms occur lends
support to the hypothesis that oral cavity,
particularly tongue mucosa, might be an
initial site of infection by SARS-CoV-2.
SARS-CoV-2 has been consistently
detected in whole saliva at an early stage
of the disease (To, Tsang, Chik-Yan Yip,
et al. 2020) and in saliva collected from
the duct opening of the salivary glands
at a late stage (Chen, Zhao, et al. 2020).
It has been shown that ACE2-positive
salivary gland epithelial cells are early
targets of SARS-CoV in nonhuman
primates and that salivary gland
functions may be affected at an early
stage of the disease (Liu et al. 2011). At
48 h after intranasal viral challenges, viral
loads of SARS-CoV were significantly
higher in saliva than in blood samples
Month 2020
(Liu et al. 2011). These findings suggest
that oral symptoms may occur due to
impediment of salivary flow in these
patients. A cross-sectional survey of 108
patients with confirmed COVID-19 in
Wuhan indeed found that 46% of the
patients reported dry mouth as one of
their symptoms (Chen, Zhao, et al. 2020).
However, the temporal sequence of oral
dryness and COVID-19 diagnosis is not
clear and warrants further exploration.
In summary, empirical, biological,
and clinical evidence supports that oral
mucosa is an initial site of entry for
SARS-CoV-2 and that oral symptoms,
including loss of taste/smell and dry
mouth, might be early symptoms of
COVID-19 before fever, dry cough,
fatigue, shortness breath, and other
typical symptoms occur. The mechanism
and prognosis of oral symptoms of
COVID-19 are not clear. Dentists and
dental researchers could play a more
active role in the early diagnosis,
prevention, and treatment of COVID-19
and its related research.
Provision of Dental Care during
the COVID-19 Pandemic
In response to the rapid spread of
COVID-19 across the country, the ADA
issued its initial recommendation on
March 16, 2020, for dentists nationwide
to postpone elective dental procedures
and focus on emergency dental care
only for 3 wk. This recommendation
was extended to April 30, 2020, when
the ADA announced the publication
of detailed interim guidance on the
management of emergency and
urgent dental care (ADA 2020a) as a
complement to the list of emergency
and urgent dental procedures published
earlier (ADA 2020c).
Howitt Dental Urgent Care (HDUC)
at the University of Rochester Eastman
Institute for Oral Health (UR-EIOH) is a
7-operatory clinic dedicated to treating
patients who have dental emergencies
and are in need of urgent care. Since
March 16, 2020, the UR-EIOH started
to postpone and cancel scheduled
visits at general dentistry and specialty
 Vol. XX • Issue X
clinics and adopted policies to provide
only urgent care following the ADA
guidance. Some patients who are in
need of urgent dental care are therefore
diverted from HDUC to general dentistry
and specialty care clinics to reduce
waiting room crowding and patient
and staff densities in the clinic. Patient
visits to the UR-EIOH were reduced by
approximately 85%, to a total of about
80 urgent care visits per day. Most of
the patients (96%) seen in the urgent
care clinic had moderate to severe pain
associated with pulpal or periapical
inflammation, dentoalveolar infections,
and trauma. These types of pain could
not be managed with over-the-counter
analgesics, and many patients require
antibiotics, prescription analgesics,
and/or definitive treatment, such as
tooth extraction, incision and drainage,
or root canal therapy, to eliminate
the disease and prevent spread of
the infection. Had the dental urgent
care service not been available, these
patients would have likely visited the
hospital emergency department for
pain management, adding strains to
the already overburdened emergency
rooms from COVID-19 and other medical
emergencies. Dental urgent care service
is especially important at a time when
most dental clinics are closed following
the ADA guidance. We anticipate that
some of the clinics will not be able to
provide urgent care services to their
patients due to staffing issues or lack of
adequate PPEs.
With the extension of the urgent
care–only guidance period, we expect
that more and more patients will
need definitive treatments, as dental
pain or infection cannot be managed
with medications long-term. Though
we have, to a great extent, avoided
aerosol-generating procedures—such as
those needing the use of a high-speed
handpiece due to the lack of adequate
PPEs at the earlier stage (hoping that
the pandemic would be over soon and
we could resume routine care in a few
weeks)—we now know that we need
to adjust our plan and be prepared to
perform the procedures that carry risks
but benefit our patient long-term. During
the first 2 wk after the ADA published
its urgent care recommendation,
approximately 30% of patients at HDUC
received tooth extraction and incision
and drainage, and 70% received
palliative treatments and prescription
of antibiotics. This is a significant
reversal from the time before COVID-
19, when 70% of our patients received
definitive treatments and 30% received
palliative treatments and prescriptions
(unpublished data). With improved
availability of PPEs and publication
of the ADA guidance on minimizing
risk of COVID-19 transmission, we
should be able to improve our ability to
provide the best care possible for our
patients.
Protection of Patients and Staff
in Dental Urgent Care Settings
In its interim guidance on minimizing
risk of COVID-19 transmission in dental
offices, the ADA (2020b) provided 3
algorithms to assist dentists in making
decisions on patient triage, evaluating
for COVID-19, and minimizing risks for
patients and staff during emergency or
urgent dental treatments. The goal is
to minimize risks of transmission while
allowing the provision of needed urgent
care. Though the risk to patients and
staff should be small if the guidance
is followed, uncertainties exist given
the high number of asymptomatic
patients and the possibility of airborne
transmission. Screening for fever and
contact history may not be productive
because many patients who are infected
with the virus can be asymptomatic or
undiagnosed (Bwire and Paulo 2020;
Hu et al. 2020; Quilty et al. 2020) and
can equally transmit the disease as the
symptomatic cases (Chen, Wang, et al.
2020). The prevalence of COVID-19 in
the community remains to be low in
many areas, but it may change rapidly
with time. Therefore, we may soon face
the question if we should assume that
every patient who comes to a dental
office is a patient with COVID-19 and,
if so, what preventive and protective
Dental Care under the Clouds of COVID-19
measures during dental treatments are
appropriate for the safety of the patients
and staff.
According to the ADA and CDC
guidance, patients with active COVID-
19 infection should not be seen in
dental settings. Patients who present
for emergency and urgent dental
care should be evaluated for signs
and symptoms of COVID-19 and for
determination of whether they can be
seen in a dental office. For patients who
have fever and signs and symptoms of
acute respiratory infection or have no
fever but signs and symptoms of acute
respiratory infection, the ADA guidance
states that they need to go to the hospital
emergency department for treatment
and the doctor needs to page infection
control. If patients have neither fever
nor signs and symptoms or have only
fever, they can be seen at the dental
setting as the fever might be caused by
dental infections. Patients not suitable
to be seen in the dental setting include
those who had exposure to an individual
with suspected or confirmed COVID-19
infection, traveled to countries currently
under a travel ban, or were exposed
to confirmed SARS-CoV-2 biologic
material directly or indirectly, because
risk of transmission increases with these
exposures (ADA 2020a). This guidance
will be able to minimize the risk of
exposures in dental offices provided that
the number of asymptomatic patients
with COVID-19 is negligible and that
the number of confirmed, suspected,
or potentially exposed patients is
low in the surrounding communities.
Otherwise, this screening strategy will
not work because it cannot identify
asymptomatic patients or those exposed
to asymptomatic patients and it adds
burden to emergency departments
that are struggling to save lives of
the seriously ill. An ideal solution is
to provide rapid COVID-19 testing
in the dental urgent care clinic with
the available point-of-care test kit
that produces results in minutes. This
can be a great opportunity for dental
professionals to contribute to the fight
against COVID-19 by expanding the
5
 JDR Clinical & Translational Research
testing capacity and identifying patients
early. This may be difficult to realize at
this time due to the shortage of testing
equipment but should be considered if
the equipment becomes available.
According to the interim guidance
of the ADA (2020a, 2020b), if patients
have no known exposure to COVID-19,
recently tested negative, or recovered
from COVID-19 infection, they can be
treated in the dental office if they have
a dental emergency or urgent condition
that cannot be postponed without
causing significant pain or distress.
Protection and prevention measures
depend on if the treatment procedures
will produce aerosols. For non–aerosol-
generating procedures, surgical face
masks and basic clinical PPE (including
eye protection) are adequate, and
approved disinfection procedures should
be performed immediately after every
procedure. For aerosol-generating
procedures, fitted N95 respirators, full-
face shields, and basic clinical PPE
(including eye protection) are required,
and approved disinfection procedures
should be performed immediately after
every procedure. If fitted N95 respirators
and full-face shields are not available,
there might be moderate to high risks of
exposure, and the dental team may need
to be put into a 14-d quarantine after
the aerosol-generating procedure due to
the existence of asymptomatic patients.
We believe that these guidelines are
judicious and useful, but the requirement
“You and your staff have N95 respirators
fitted to your face” may deserve further
explanation. Does this mean that dentists
and staff need to be formally fit tested
for using the N95 respirators? Or is it
acceptable to just use an N95 respirator
that you feel fits? In addition to improved
filtration efficiency, the main advantage
of an N95 respirator over a surgical mask
is that it can achieve a tight seal that
prevents air leakage around the edges.
Appropriate use of N95 respirators
requires an annual fit test via a standard
protocol that includes a pass/fail result
that relies on the individual’s sensory
(taste or smell) detection of a test agent,
such as Saccharin (sweetener) or Bitrex
6
(bitter) solutions (CDC and National
Institute for Occupational Safety and
Health 2020). As there are many models
and different sizes of N95 respirators,
a successful fit test only qualifies you
to use the specific brand and size of
respirator that you wore during that
test (CDC and National Institute for
Occupational Safety and Health 2020).
Therefore, it should be apparent that
“N95 respirators fitted to your face”
mean that you and your staff have been
fit tested for an N95 respirator that you
use in your clinic or facility. However,
this requirement probably will preclude
most, if not all, dentists in private
practices from participating in providing
urgent care services during the COVID-
19 pandemic, as an annual N95 fit test
is not part of the dental practice routine.
At the UR-EIOH, residents and faculty
members who have clinical privileges
at the medical center are fitted for N95
respirators annually, but those who work
in the dental clinic alone have not been
fit tested. Though we are working with
the medical center to have all residents
and faculty members fitted for the N95
respirators, it takes time to complete
the test. In the mean time, we have
to minimize the number of aerosol-
generating procedures to protect the
faculty and resident providers and staff.
N95 respirators, gloves, full-face
shields, eye protection goggles with
side shields, isolation gowns, and head
covers were recommended for aerosol-
generating procedures by the state
health commission in China and proven
effective, as no staff or patients were
infected with the disease in dental clinics
throughout the country (Meng et al.
2020; Peng et al. 2020; Yang et al. 2020;
Zhang and Jiang 2020). Face shields and
eye protection goggles are considered
essential in dental procedures that
produce spatter or aerosol because
ocular exposure is likely a route of
transmission for the SARS-CoV-2 virus
(Li, Lam, et al. 2020; Lu et al. 2020).
As described earlier, the SARS-CoV-2
virus does not replicate or “grow” outside
the body, and its protein structure
can be disrupted by many common
Month 2020
disinfectants. However, the virus may
retain viability for an extended period,
from several hours to several days, and
on different surfaces, such as metal,
glass, plastic, wood, or paper (Kampf
et al. 2020; van Doremalen et al. 2020),
but it can be effectively inactivated
in 1 to 5 min by many disinfectants,
including 70% ethanol, 0.1% sodium
hypochlorite, 1% povidone-iodine, and
0.5% hydrogen peroxide (Chin et al.
2020; Kampf et al. 2020). Povidone-
iodine mouthwash has been shown to
have strong viricidal activities against
SARS-CoV and MERS-CoV after 15 s of
exposure (Eggers et al. 2018). The CDC
(2020) has published an interim infection
prevention and control guidance for
dental settings during the COVID-
19 response and lists >300 products
approved for SARS-CoV-2 disinfection.
For aerosol-generating procedures,
patients should be instructed to use
1% povidone-iodine or 1.5% hydrogen
peroxide mouth rinses for 1 min before
the procedure, and a rubber dam should
be used to reduce saliva contamination
and aerosol generation during the
procedure. After the procedure, all
exposed surfaces of the operatory,
including chairs, desks, cabinets, and
door handles, should be cleaned with
0.1% sodium hypochlorite. Though these
steps are all helpful in reducing the
risks of nosocomial infections in dental
offices, adequate hand washing with
soap between patients and after touching
any nonsterile objects remains the most
effective way to prevent the transmission
of COVID-19.
In summary, protection of patients and
staff during COVID-19 is challenging
due to the existence of patients who
are infectious yet asymptomatic. Dental
clinics and dental professionals are
not well prepared to perform aerosol-
generating procedures at the time of the
infectious respiratory disease pandemic,
as they are not routinely fitted for the N95
respirators required for these procedures.
It is fortunate that SARS-CoV-2 is sensitive
to many common disinfectants and that
the risks for dental providers and patients
are small if prudent measures are taken
 Vol. XX • Issue X
following the ADA and CDC guidance,
including frequent hand washing and
judicious use of PPEs.
Looking Ahead
The COVID-19 pandemic has exposed
significant gaps in the collective response
of global health care systems to a public
health emergency. Though dentistry is
a relatively small part in the COVID-19
response, dental professionals should
take this opportunity to assess the role of
dental care in a public health emergency,
look into the future, and determine
what we can improve to better serve
our patients and protect our staff should
a similar event happen again. With the
successive emergence of SARS-CoV
in 2003, H1N1 in 2009, MERS in 2012,
Ebola in 2018, and SARS-CoV-2 in 2020,
global public health emergencies and
pandemics of infectious diseases are no
longer rare, once-in-a-lifetime events.
Dentistry as an integral part of the health
care system should be prepared to play
a more active role in the fight against
emerging life-threatening diseases.
Dental education, research, clinical
practices, and public health should
consider the following aspects during
and after the COVID-19 pandemic:
•• Improve public health emergency
preparedness throughout the den-
tal health care system. Proper donning
and doffing of N95 respirators, surgical
masks, and isolation gowns may need
to be included in the dental training
curriculum and dental practice routine.
•• Explore the value of rapid testing for
infectious diseases in dental offices
via saliva samples. The best way to
fight against the COVID-19 pandemic
or similar outbreaks is to rapidly test
the population, identify those who are
infected but asymptomatic, trace those
in close contact with the patients, and
isolate them to prevent further spread
of disease. Rapid testing in dental
offices via saliva samples could con-
tribute to disease containment as well
as protect dental staff from acciden-
tal exposures. With the progression
of the pandemic, testing for antibod-
ies against SARS-CoV-2 will help us to
identify those who have already devel-
oped immunity to the disease through
covert infections.
•• Increase research efforts in aero-
sol control in dental offices, includ-
ing improving engineering control in
dental office design. Negative-pressure
rooms are effective in reducing risks of
transmission for infectious respiratory
diseases. It may be time to consider
negative-pressure dental operatories,
at least in academic health centers and
dental school clinics, in the era of fre-
quent respiratory disease pandemics.
•• Initiate and participate in scientific
research projects to discover the impact
of COVID-19 and other infectious dis-
eases on oral health. Preliminary data
indicate that oral symptoms are prom-
inent in many patients with COVID-
19, especially in the early stages before
other symptoms occur. Dental and oral
health researchers may play a more
active role in early identification and
diagnosis of the disease through deci-
phering the mechanisms of dry mouth
and loss of taste and smell in patients
with COVID-19.
Author Contributions
Y.F. Ren, contributed to conception,
design, and data analysis, drafted the
manuscript; L. Rasubala, contributed
to data analysis, critically revised the
manuscript; H. Malmstrom, contributed
to data analysis and interpretation,
critically revised the manuscript; E. Eliav,
contributed to conception, design, data
analysis, and interpretation, drafted
the manuscript. All authors gave final
approval and agree to be accountable for
all aspects of the work.
Acknowledgments
The authors received no financial
support and declare no potential
conflicts of interest with respect to the
authorship and/or publication of this
article.
ORCID iD
Y.F. Ren https://orcid.org/0000-0001
-6428-2252
Dental Care under the Clouds of COVID-19
References
American Dental Association. 2020a. ADA
interim guidance for management of
emergency and urgent dental care
[accessed 2020 Apr 3]. https://www
.ada.org/~/media/CPS/Files/COVID/
ADA_Int_Guidance_Mgmt_Emerg-
Urg_Dental_COVID19.pdf?utm_
source=cpsorg&utm_medium=covid-cps-
virus-lp&utm_content=cv-pm-ebd-interim-
flowchart&utm_campaign=covid-19
American Dental Association. 2020b. ADA
interim guidance for minimizing risk of
COVID-19 transmission [accessed 2020
Apr 3]. https://www.ada.org/~/media/CPS/
Files/COVID/ADA_COVID_Int_Guidance_
Treat_Pts.pdf?utm_source=cpsorg&utm_
medium=covid-cps=virus-lp&utm_
content=cv-pm-ebd-interim-response&utm_
campaign=covid-19
American Dental Association. 2020c. What
constitutes a dental emergency? [accessed
2020 Apr 2]. https://success.ada.org/~/
media/CPS/Files/Open%20Files/ADA_
COVID19_Dental_Emergency_DDS.pdf?_
ga=2.78740951.215793349.1585680652-
310524266.1585339538
An N, Yue L, Zhao B. 2020. Droplets and
aerosols in dental clinics and prevention and
control measures of infection. Zhonghua
Kou Qiang Yi Xue Za Zhi. 55:E004.
Andersen KG, Rambaut A, Lipkin WI, Holmes
EC, Garry RF. 2020. The proximal origin of
SARS-CoV-2. Nat Med. 26(4):450–452.
Asadi S, Bouvier N, Wexler AS, Ristenpart
WD. 2020. The coronavirus pandemic
and aerosols: does COVID-19 transmit via
expiratory particles? Aerosol Sci Technol.
doi:10.1080/02786826.2020.1749229
Bwire GM, Paulo LS. 2020. Coronavirus
disease-2019: is fever an adequate screening
for the returning travelers? Trop Med Health.
48:14.
Centers for Disease Control and Prevention.
2020. Interim infection prevention and
control guidance for dental settings during
the COVID-19 response [accessed 2020 Apr
6]. https://www.cdc.gov/coronavirus/2019-
ncov/hcp/dental-settings.html
Centers for Disease Control and Prevention,
National Institute for Occupational
Safety and Health. 2020. The need
for fit testing during emerging
infectious disease outbreaks [accessed
2020 Apr 7]. https://blogs.cdc.gov/
niosh-science-blog/2020/04/01/
fit-testing-during-outbreaks/
Chen J. 2020. Pathogenicity and transmissibility
of 2019-nCoV—a quick overview and
7
 JDR Clinical & Translational Research
comparison with other emerging viruses.
Microbes Infect. 22(2):69–71.
Chen L, Zhao J, Peng J, Li X, Deng X, Geng
Z, Shen Z, Guo F, Zhang Q, Jin Y, et al.
2020. Detection of 2019-nCoV in saliva and
characterization of oral symptoms in COVID-
19 patients [epub ahead of print 19 Mar
2020]. https://ssrn.com/abstract=3557140.
doi:10.2139/ssrn.3557140
Chen Y, Wang A, Yi B, Ding K, Wang H,
Wang J, Shi H, Wang S, Xu G. 2020. The
epidemiological characteristics of infection
in close contacts of COVID-19 in Ningbo
City [article in Chinese]. Chinese Journal
of Epidemiology. http://html.rhhz.net/
zhlxbx/028.htm.
Cheng VCC, Wong SC, Chen JHK, Yip CCY,
Chuang VWM, Tsang OTY, Sridhar S, Chan
JFW, Ho PL, Yuen KY. 2020. Escalating
infection control response to the rapidly
evolving epidemiology of the coronavirus
disease 2019 (COVID-19) due to SARS-
CoV-2 in hong kong. Infect Control Hosp
Epidemiol [epub ahead of print 5 Mar 2020]
in press. doi:10.1017/ice.2020.58
Chin A, Chu J, Perera M, Hui K, Yen H-L,
Chan M, Peiris M, Poon L. 2020. Stability
of SARS-CoV-2 in different environmental
conditions [epub ahead of print 2 Apr
2020] in press. Lancet Microbe. doi:10.1016/
S2666-5247(20)30003-3
CNN. 2020. US coronavirus cases pass 200,000:
more states are saying stay at home
[accessed 2020 Apr 2]. https://www.cnn
.com/2020/04/01/health/us-coronavirus-
updates-wednesday/index.html.
Eggers M, Koburger-Janssen T, Eickmann M,
Zorn J. 2018. In vitro bactericidal and
virucidal efficacy of povidone-iodine gargle/
mouthwash against respiratory and oral tract
pathogens. Infect Dis Ther. 7(2):249-259.
Gautier JF, Ravussin Y. 2020. A new symptom of
COVID-19: loss of taste and smell. Obesity
(Silver Spring) [epub ahead of print 1 Apr
2020] in press. doi:10.1002/oby.22809
Giacomelli A, Pezzati L, Conti F, Bernacchia D,
Siano M, Oreni L, Rusconi S, Gervasoni C,
Ridolfo AL, Rizzardini G, et al. 2020. Self-
reported olfactory and taste disorders in
SARS-CoV-2 patients: a cross-sectional study.
Clin Infect Dis [epub ahead of print 26 Mar
2020] in press. doi:10.1093/cid/ciaa330
Gorbalenya AE, Baker SC, Baric RS, de Groot
RJ, Drosten C, Gulyaeva AA, Haagmans
BL, Lauber C, Leontovich AM, Neuman
BW, et al. 2020. The species severe acute
respiratory syndrome-related coronavirus:
classifying 2019-nCoV and naming it SARS-
CoV-2. Nat Microbiol. 5(4):536–544.
8
Gu J, Han B, Wang J. 2020. COVID-19:
gastrointestinal manifestations and potential
fecal-oral transmission. Gastroenterology
[epub ahead of print 3 Mar 2020] in press.
doi:10.1053/j.gastro.2020.02.054
Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H,
Chen W, Lin Y, Zheng Y, et al. 2020. Clinical
characteristics of 24 asymptomatic infections
with COVID-19 screened among close
contacts in nanjing, china. Sci China Life Sci
[epub ahead of print 4 Mar 2020] in press.
doi:10.1007/s11427-020-1661-4
Kampf G, Todt D, Pfaender S, Steinmann E.
2020. Persistence of coronaviruses on
inanimate surfaces and their inactivation
with biocidal agents. J Hosp Infect.
104(3):246–251.
Kandeel M, Ibrahim A, Fayez M, Al-Nazawi M.
2020. From SARS and MERS CoVs to SARS-
CoV-2: moving toward more biased codon
usage in viral structural and nonstructural
genes. J Med Virol [epub ahead of print 11
Mar 2020] in press. doi:10.1002/jmv.25754
Kimball A, Hatfield KM, Arons M, James A,
Taylor J, Spicer K, Bardossy AC, Oakley
LP, Tanwar S, Chisty Z, et al. 2020.
Asymptomatic and presymptomatic SARS-
CoV-2 infections in residents of a long-term
care skilled nursing facility—King County,
Washington, March 2020. MMWR Morb
Mortal Wkly Rep. 69(13):377–381.
King’s College London. 2020. Loss of smell and
taste a key symptom for COVID-19 cases
[accessed 2020 Apr 3]. https://www.kcl
.ac.uk/news/loss-of-smell-and-taste-a-key-
symptom-for-covid-19-cases.
Koonin EV, Starokadomskyy P. 2016. Are viruses
alive? The replicator paradigm sheds decisive
light on an old but misguided question. Stud
Hist Philos Biol Biomed Sci. 59:125–134.
Kunkel SA, Azimi P, Zhao H, Stark BC, Stephens
B. 2017. Quantifying the size-resolved
dynamics of indoor bioaerosol transport and
control. Indoor Air. 27(5):977–987.
Lam TT, Shum MH, Zhu HC, Tong YG, Ni XB,
Liao YS, Wei W, Cheung WY, Li WJ, Li LF,
et al. 2020. Identifying SARS-CoV-2 related
coronaviruses in malayan pangolins. Nature
[epub ahead of print 26 Mar 2020] in press.
doi:10.1038/s41586-020-2169-0
Li JO, Lam DSC, Chen Y, Ting DSW. 2020. Novel
coronavirus disease 2019 (COVID-19): the
importance of recognising possible early
ocular manifestation and using protective
eyewear. Br J Ophthalmol. 104(3):297–298.
Li X, Giorgi EE, Marichann MH, Foley B,
Xiao C, Kong X-P, Chen Y, Korber
B, Gao F. 2020. Emergence of SARS-
CoV-2 through recombination and
Month 2020
strong purifying selection. bioRxiv [epub
ahead of print 22 Mar 2020] in press.
doi:10.1101/2020.03.20.000885
Li X, Zai J, Zhao Q, Nie Q, Li Y, Foley BT,
Chaillon A. 2020. Evolutionary history,
potential intermediate animal host, and
cross-species analyses of SARS-CoV-2. J Med
Virol [epub ahead of print 27 Feb 2020] in
press. doi:10.1002/jmv.25731
Liu L, Li Y, Nielsen PV, Wei J, Jensen RL. 2017.
Short-range airborne transmission of
expiratory droplets between two people.
Indoor Air. 27(2):452–462.
Liu L, Wei Q, Alvarez X, Wang H, Du Y, Zhu H,
Jiang H, Zhou J, Lam P, Zhang L, et al. 2011.
Epithelial cells lining salivary gland ducts are
early target cells of severe acute respiratory
syndrome coronavirus infection in the upper
respiratory tracts of rhesus macaques.
J Virol. 85(8):4025–4030.
Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NK,
Sun L, Duan Y, Cai J, Westerdahl D, et al.
2020. Aerodynamic characteristics and rna
concentration of SARS-CoV-2 aerosol in
Wuhan hospitals during COVID-19 outbreak.
bioRxiv. doi.org/10.1101/2020.03.08.982637
Lu CW, Liu XF, Jia ZF. 2020. 2019-nCoV
transmission through the ocular surface must
not be ignored. Lancet. 395(10224):e39.
Luan J, Jin X, Lu Y, Zhang L. 2020. SARS-CoV-2
spike protein favors ace2 from bovidae and
cricetidae. J Med Virol [epub ahead of print
1 Apr 2020] in press. doi:10.1002/jmv.25817
Mahase E. 2020. Coronavirus COVID-19 has
killed more people than SARS and MERS
combined, despite lower case fatality rate.
BMJ. 368:m641.
Meng L, Hua F, Bian Z. 2020. Coronavirus
disease 2019 (COVID-19): emerging
and future challenges for dental
and oral medicine. J Dent Res [epub
ahead of print 12 Mar 2020] in press.
doi:10.1177/0022034520914246
Mizumoto K, Kagaya K, Zarebski A, Chowell
G. 2020. Estimating the asymptomatic
proportion of coronavirus disease 2019
(COVID-19) cases on board the Diamond
Princess cruise ship, Yokohama, Japan, 2020.
Euro Surveill. 25(10). doi:10.2807/1560-7917.
ES.2020.25.10.2000180.
Nishiura H, Kobayashi T, Suzuki A, Jung SM,
Hayashi K, Kinoshita R, Yang Y, Yuan B,
Akhmetzhanov AR, Linton NM, et al. 2020.
Estimation of the asymptomatic ratio of
novel coronavirus infections (COVID-19).
Int J Infect Dis [epub ahead of print 13 Mar
2020] in press. doi:10.1016/j.ijid.2020.03.020
Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT,
Wong MSY, Marimuthu K. 2020. Air, surface
 Vol. XX • Issue X
environmental, and personal protective
equipment contamination by severe acute
respiratory syndrome coronavirus 2 (SARS-
CoV-2) from a symptomatic patient. JAMA
[epub ahead of print 4 Mar 2020] in press.
doi:10.1001/jama.2020.3227
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B.
2020. Transmission routes of 2019-nCoV and
controls in dental practice. Int J Oral Sci.
12(1):9.
Pennsylvania Department of Health. 2020.
Revised guidance on COVID-19 for dental
health care personnel in Pennsylvania
[accessed 2020 Apr 2]. https://www.health
.pa.gov/topics/disease/coronavirus/Pages/
Dental-Care.aspx.
Quilty BJ, Clifford S, Flasche S, Eggo RM.
2020. Effectiveness of airport screening
at detecting travellers infected with
novel coronavirus (2019-nCoV). Euro
Surveill. 25(5). doi:10.2807/1560-7917.
ES.2020.25.5.2000080
Ren LL, Wang YM, Wu ZQ, Xiang ZC, Guo L,
Xu T, Jiang YZ, Xiong Y, Li YJ, Li XW, et al.
2020. Identification of a novel coronavirus
causing severe pneumonia in human: a
descriptive study. Chin Med J (Engl) [epub
ahead of print 11 Feb 2020] in press.
doi:10.1097/CM9.0000000000000722
Santarpia JL, Rivera DN, Herrera V, Morwitzer
MJ, Creager H, Santarpia GW, Crown KK,
Brett-Major D, Schnaubelt E, Broadhurst
MJ, et al. 2020. Transmission potential of
SARS-CoV-2 in viral shedding observed at
the University of Nebraska Medical Center.
medRxiv. doi:10.1101/2020.03.23.20039446
To KK, Tsang OT, Chik-Yan Yip C, Chan KH,
Wu TC, Chan JMC, Leung WS, Chik TS, Choi
CY, Kandamby DH, et al. 2020. Consistent
detection of 2019 novel coronavirus in
saliva. Clin Infect Dis [epub ahead of print
12 Feb 2020] in press. doi:10.1093/cid/
ciaa149
To KK, Tsang OT, Leung WS, Tam AR, Wu TC,
Lung DC, Yip CC, Cai JP, Chan JM, Chik TS,
et al. 2020. Temporal profiles of viral load
in posterior oropharyngeal saliva samples
and serum antibody responses during
infection by SARS-CoV-2: an observational
cohort study. Lancet Infect Dis [epub ahead
of print 23 Mar 2020] in press. doi:10.1016/
S1473-3099(20)30196-1
van Doremalen N, Bushmaker T, Morris DH,
Holbrook MG, Gamble A, Williamson BN,
Tamin A, Harcourt JL, Thornburg NJ, Gerber
SI, et al. 2020. Aerosol and surface stability
of SARS-CoV-2 as compared with SARS-
CoV-1. N Engl J Med. 382(16):1564–1567.
Walls AC, Park YJ, Tortorici MA, Wall A, McGuire
AT, Veesler D. 2020. Structure, function,
and antigenicity of the SARS-CoV-2 spike
glycoprotein. Cell [epub ahead of print 6
Mar 2020] in press. doi:10.1016/
j.cell.2020.02.058
Wölfel R, Corman VM, Guggemos W, Seilmaier
M, Zange S, Müller MA, Niemeyer D,
Jones TC, Vollmar P, Rothe C, et al. 2020.
Virological assessment of hospitalized
patients with COVID-2019. Nature [epub
ahead of print 1 Apr 2020] in press.
doi:10.1038/s41586-020-2196-x
World Health Organization. 2020. Modes of
transmission of virus causing COVID-
19: implications for IPC precaution
recommendations 2020 [accessed 2020 Apr
Dental Care under the Clouds of COVID-19
2]. https://www.who.int/publications-detail/
modes-of-transmission-of-virus-causing-
covid-19-implications-for-ipc-precaution-
recommendations.
Wu Y-C, Chen C-S, Chan Y-J. 2020. The
outbreak of COVID-19: an overview. J Chin
Med Assoc. 83(3):217–220.
Xu H, Zhong L, Deng J, Peng J, Dan H,
Zeng X, Li T, Chen Q. 2020. High expression
of ACE2 receptor of 2019-nCoV on the
epithelial cells of oral mucosa. Int J Oral Sci.
12(1):8.
Xu X, Chen P, Wang J, Feng J, Zhou H, Li X,
Zhong W, Hao P. 2020. Evolution of the
novel coronavirus from the ongoing Wuhan
outbreak and modeling of its spike protein
for risk of human transmission. Sci China
Life Sci. 63(3):457–460.
Yang Y, Soh HY, Cai ZG, Peng X, Zhang Y,
Guo CB. 2020. Experience of diagnosing
and managing patients in oral maxillofacial
surgery during the prevention and control
period of the new coronavirus pneumonia.
Chin J Dent Res. 23(1):57–62.
Zhang W, Du RH, Li B, Zheng XS, Yang XL, Hu
B, Wang YY, Xiao GF, Yan B, Shi ZL, et al.
2020. Molecular and serological investigation
of 2019-nCoV infected patients: implication
of multiple shedding routes. Emerg Microbes
Infect. 9(1):386–389.
Zhang W, Jiang X. 2020. Measures and
suggestions for the prevention and
control of the novel coronavirus in
dental institutions. Frontiers of Oral and
Maxillofacial Medicine. doi:10.21037/
fomm.2020.02.01
9
 JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al

Original Paper

Dentists’ Awareness, Perception, and Attitude Regarding

COVID-19 and Infection Control: Cross-Sectional Study Among
Jordanian Dentists

Yousef Khader1, SCD; Mohannad Al Nsour2, PhD; Ola Barakat Al-Batayneh1, FRACDS; Rami Saadeh1, PhD; Haitham
Bashier2, PhD; Mahmoud Alfaqih1, PhD; Sayer Al-Azzam1, PhD; Bara’ Abdallah AlShurman1, MSc
1
Jordan University of Science and Technology, Irbid, Jordan
2
Global Health Development/Eastern Mediterranean Public Health Network, Amman, Jordan

Corresponding Author:
Yousef Khader, SCD
Jordan University of Science and Technology
Alramtha-Amman Street
Irbid, 22110
Jordan
Phone: 962 796802040
Email: yskhader@just.edu.jo

Abstract
Background: Despite the availability of prevention guidelines and recommendations on infection control, many dental practices
lack the minimum requirements for infection control.
Objective: This study aimed to assess the level of awareness, perception, and attitude regarding the coronavirus disease
(COVID-19) and infection control among Jordanian dentists.
Methods: The study population consisted of dentists who worked in private clinics, hospitals, and health centers in Jordan. An
online questionnaire was sent to a sample of Jordanian dentists in March 2020. The questionnaire was comprised of a series of
questions about dentists’ demographic characteristics; their awareness of the incubation period, the symptoms of the disease,
mode of transmission of COVID-19 and infection control measures for preventing COVID-19; and their attitude toward treating
patients with COVID-19.
Results: This study included a total of 368 dentists aged 22-73 years (mean 32.9 years, SD 10.6 years). A total of 112 (30.4%)
dentists had completed a master or residency program in dentistry, 195 (53.0%) had received training in infection control in
dentistry, and 28 (7.6%) had attended training or lectures regarding COVID-19. A total of 133 (36.1%) dentists reported that the
incubation period is 1-14 days. The majority of dentists were aware of COVID-19 symptoms and ways of identifying patients at
risk of having COVID-19, were able to correctly report known modes of transmission, and were aware of measures for preventing
COVID-19 transmission in dental clinics. A total of 275 (74.7%) believed that it was necessary to ask patients to sit far from each
other, wear masks while in the waiting room, and wash hands before getting in the dental chair to decrease disease transmission.
Conclusions: Jordanian dentists were aware of COVID-19 symptoms, mode of transmission, and infection controls and measures
in dental clinics. However, dentists had limited comprehension of the extra precautionary measures that protect the dental staff
and other patients from COVID-19. National and international guidelines should be sent by the regional and national dental
associations to all registered dentists during a crisis, including the COVID-19 pandemic, to make sure that dentists are well
informed and aware of best practices and recommended disease management approaches.

(JMIR Public Health Surveill 2020;6(2):e18798) doi: 10.2196/18798

KEYWORDS
COVID-19; infection; dentist; infection control

http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 1

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR PUBLIC HEALTH AND SURVEILLANCE
Introduction
Background
The coronavirus disease (COVID-19) is a newly discovered
viral infection that started in Wuhan, China and caused the
outbreak of pneumonia in the rest of the world. It seems that
the rapidly spreading virus is more contagious than severe acute
respiratory syndrome coronavirus and Middle East respiratory
syndrome coronavirus [1]. A suggested route of
human-to-human transmission is through airborne droplets,
touching or coming into contact with an infected person or a
contaminated surface. Moreover, other routes such as blood or
saliva have not been explored but are possible because of the
documented transmission of blood-borne infectious diseases
such as HIV/AIDS, hepatitis C virus, and hepatitis B virus
through blood or saliva. These routes of transmission increase
the concern about a similar route of transmission for COVID-19
in the dental setting [2].
COVID-19 and Dental Treatment
A large number of medical staff were reported to have acquired
the disease while working with infected individuals [3]. The
dental clinic is not an exception for a similar possibility of
transmitting and acquiring the infection between staff or
individuals; moreover, the dental clinic could be a riskier
environment for spreading the virus because of the close contact
with patients and the nature of the dental treatment [4]. Although
patients diagnosed with COVID-19 are not supposed to receive
dental treatments, dental emergencies can occur, and close
contact would be unavoidable. Furthermore, both the relatively
prolonged incubation period of the disease (the median
incubation period was estimated to be 5.1 days, 95% CI 4.5-5.8
[5] or up to 14 days for some cases [6,7] before any symptoms
could even be detected) and the postinfection period make it
challenging for medical staff to recognize the existence of
COVID-19 infections, which could increase the transmission
of the disease during these lay periods. Therefore, patients
infected with COVID-19, without showing symptoms, are of a
great threat to dentists and other members of the dental team.
Dentists, thereby, should entertain a high level of awareness
and integrity to deal with the disease and be able to control and
manage its spread.
There are practical guidelines recommended for dentists and
dental staff by the Centers for Disease Control and Prevention
(CDC), the American Dental Association (ADA), and the World
Health Organization to control the spread of COVID-19 [8-10].
Like with other contagious infections, these recommendations
include personal protective equipment, hand washing, detailed
patient evaluation, rubber dam isolation, antiretraction
handpiece, mouth rinsing before dental procedures, and
disinfection of the clinic. In addition, some guidelines and
reports have provided useful information about the signs and
symptoms of the disease, ways of transmission, and referral
mechanisms to increase dentists’ knowledge and prevention
practices, so they could contribute, at a population level, in
disease control and prevention [1,8].
http://publichealth.jmir.org/2020/2/e18798/
XSL• FO
RenderX
Khader et al
Objectives
Despite the availability of prevention guidelines and
recommendations on disease control, many dental practices lack
the minimum requirements of infection control, which resulted
from the low interest in taking the mandatory precautions. This
lack of interest in making an extra, but essential, effort could
be attributed to the high volume of patients treated in clinics
that charge low or reduced dental fees [11,12]. This situation
is true for many settings, including some dental clinics in Jordan,
which, like many other countries, has a wide range of dental
facilities from clinics that properly apply infection control
measures to clinics that poorly apply prevention measures. It is
important to implement sound prevention measures in dental
clinics and to increase the level of awareness among dentists to
improve their prevention. Hence, this study aimed to assess the
level of awareness, perception, and attitude regarding COVID-19
and infection control among Jordanian dentists.
Methods
Study Population
Our study population consisted of dentists who work in Jordan,
regardless of their place of work, in either private clinics,
hospitals, or health centers. This survey was conducted in March
2020. An online questionnaire using Google Forms was used
to collect the data. The sample of dentists was selected through
Facebook groups for dentists. These groups were created by
members of the Jordan Dental Association, and only dentists
who work in Jordan can be involved in these groups by
confirming their registration with the Jordanian dental
association and their places of work. Although there were
numerous groups, only five groups were randomly chosen:
Jordanian dentists, dentists without borders, Jordanian dental
club, Jordanian society of pediatric dentistry, and Jordanian
dentists’ forum. Within the five selected groups, 700 dentists
were randomly selected to participate in the study by their
Facebook profiles. However, each participant who was randomly
selected was contacted individually to make sure that they were
a dentist and worked in Jordan. The questionnaires were
anonymous to maintain the privacy and confidentiality of all
information collected in the study. Ethical approval was obtained
from the Institutional Review Board at Jordan University of
Science and Technology.
Study Instrument
The questions on the survey were developed after reviewing
pertinent literature and the international guidelines [1,8-10].
The questionnaire was designed in English and comprised of a
series of questions pertaining to sociodemographic
characteristics, the knowledge of dentists, and their attitudes
and perceptions toward COVID-19 and infection control in
dental clinics. The survey was a structured multiple-choice
questionnaire divided into sections: dentists’ demographic and
profession-related characteristics; dentists’ awareness of
incubation period, the symptoms of the disease, the mode of
transmission of COVID-19, and infection control measures for
preventing COVID-19; and dentists’ attitude toward treating
patients with COVID-19.
JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 2
(page number not for citation purposes)
 JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al

Data Analysis
Data were analyzed using SPSS (IBM Corp). Descriptive
statistical analysis was used to describe items included in the
survey. Means and standard deviations were used to describe
the continuous variables, and percentages were used to describe
the categorical data.
Results
participated out of 700 invited dentists). Their age ranged from
22-73 years with a mean of 32.9 (SD 10.6) years. Years of dental
practice ranged from 1-30 years with a mean of 9.4 (SD 8.9)
years. The participants’ characteristics are shown in Table 1. A
total of 112 (30.4%) had completed a master or residency
program in dentistry, 195 (53.0%) had received training in
infection control in dentistry, and 28 (7.6%) had attended
training or received lectures regarding COVID-19.

Participants’ Characteristics
This study included a total of 368 (245 females and 123 males)
dentists, forming a response rate of about 52.6% (386

Table 1. The characteristics of the 368 dentists enrolled in the study.

Variable Dentists, n (%)
Gender
Female 245 (66.6)
Male 123 (33.4)
Age (years)
<30 199 (54.1)
≥30 169 (45.9)
Years of practice
<5 185 (50.3)
5-10 59 (16.0)
>10 124 (33.7)
Region
Middle 190 (51.6)
North 148 (40.2)
South 30 (8.2)
Health sector
University clinics 112 (30.4)
Military sector 28 (7.6)
Private sector 144 (39.1)
Public sector 84 (22.8)

reported that patients with COVID-19 infection may present

Awareness About the Incubation Period, Symptoms,
and Mode of Transmission of the COVID-19 Infection
When asked about the incubation period, over one-third of
dentists correctly reported 1-14 days. The percentage of dentists
who reported the different symptoms of the COVID-19 infection
are shown in Table 2. The majority reported fever and cough
as symptoms. Diarrhea, vomiting, and runny nose were reported
by almost one-third of dentists. Joint and muscle pain was
reported by only a few dentists. Over one-third of the dentists
with no symptoms. When they were asked about aspects that
should be considered to identify patients at risk of having
COVID-19, 316 (85.9%) mentioned the presence of symptoms
of a respiratory infection, 347 (94.3%) mentioned history of
travel to areas experiencing transmission of COVID-19, and
345 (93.8%) mentioned history of contact with possible infected
patients. In addition, most dentists correctly reported known
modes of transmission (Table 2).

http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 3

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al

Table 2. Dentists’ awareness about incubation period, symptoms, and mode of transmission of the coronavirus disease infection (N=368).
Variable Dentists, n (%)
Incubation period (days)
1-14 133 (36.1)
2-7 12 (3.3)
7-14 162 (44.0)
7-21 days 61 (16.6)

Symptoms of the COVID-19a infection

Fever 363 (98.6)
Cough 335 (91.0)
Shortness of breath 316 (85.9)
Diarrhea 147 (39.9)
Vomiting 119 (32.3)
Runny nose 133 (36.1)
Sore throat 105 (28.5)
Red eyes 28 (7.6)
Skin rash 21 (5.7)
Joint or muscle pain 7 (1.9)
May present with no symptoms 127 (34.5)
Mode of transmission
Coughing and sneezing 333 (90.5)
Hand shaking 315 (85.6)
Touching surfaces such as doorknobs and tables 343 (93.2)

a
COVID-19: coronavirus disease.

equipment can help prevent transmission from patients with

Awareness of Measures for Preventing COVID-19
Transmission in Dental Clinics
The majority of the 368 dentists reported that cleaning hands
frequently by using alcohol-based hand rub or soap and water,
routinely cleaning and disinfecting surfaces in contact with
known or suspected patients, and wearing personal protective
known or suspected COVID-19. The percentages of dentists
who reported other specific measures are shown in Table 3.
Almost all dentists (n=359, 97.6%) reported that it is important
to change both masks and gloves regularly to decrease the
possibility of transmitting infections to patients and to
themselves.

Table 3. Dentists’ awareness of measures for the prevention of coronavirus disease transmission in dental clinics (N=368).
Measures for prevention Dentists, n (%)
Frequently clean hands by using alcohol-based hand rub or soap and water 354 (96.2)
Routinely clean and disinfect surfaces in contact with known or suspected patients 347 (94.3)
Personal protective equipment such as dental goggles, masks, and gloves 342 (92.9)
Put facemask on known or suspected patients 325 (88.3)
Avoid moving and transporting patients out of their area unless necessary 310 (84.2)
All health staff members wear protective clothing 304 (82.6)
Place known or suspected patients in adequately ventilated single rooms 284 (77.2)

one-third (n=135, 36.7%) of dentists believed that COVID-19

Perception of COVID-19 is not a serious public health issue. The majority (n=360, 97.8%)
A total of 65 (17.7%) of the 368 dentists perceived COVID-19 reported that it is important to educate people about COVID-19
as very dangerous, 264 (71.7%) perceived it as moderately to prevent the spread of the disease.
dangerous, and 35 (9.5%) perceived it as not dangerous. Almost

http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 4

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR PUBLIC HEALTH AND SURVEILLANCE
Attitude Toward Treatment of Patients With
COVID-19
More than half (n=203, 55.2%) of the 368 dentists reported that
COVID-19 symptoms often resolve with time and do not require
any special treatment. Regarding dentists’ precautionary actions
in the dental clinic, a total of 275 (74.7%) believed that it was
necessary to ask patients to sit far from each other, wear masks
while in the waiting room, and wash hands before getting in the
dental chair to decrease disease transmission, while 80 (21.7%)
believed that this was not necessary and could cause panic.
However, a total of 304 (82.6%) dentists reported that they
prefer to avoid working with a patient with a suspected case of
COVID-19.
Dentists reported different attitudes toward a patient sneezing
or coughing in their clinics: 161 (43.8%) mentioned that they
would refer the patient to the hospital without treating them, 17
(4.6%) mentioned that they would refuse treating the patient
and ask them to leave the clinic, 182 (49.5%) mentioned that
they would treat the patient and ask them to go to the hospital.
Moreover, a total of 119 (32.3%) dentists reported that they
would allow any of their dental staff to work with patients if
they had flu-like symptoms. Only 214 (58.2%) reported that
they know whom to contact in a situation where there has been
an unprotected exposure to a patient with known or suspected
COVID-19, and 279 (75.8%) reported that they know what to
do if they have signs or symptoms suspected of COVID-19
infection.
For the dentists’ role in spreading information and increasing
awareness, a total of 249 (67.7%) dentists reported that the
dentist role in teaching others about COVID-19 is very
significant, and 94 (25.5%) reported that it is moderately
significant.
Discussion
This survey provides an insight on the level of awareness,
perception, and attitude of Jordanian dentists on infection control
with a special emphasis on COVID-19 at the time of the
outbreak in 2020. This study included a sample of Jordanian
dentists. Females were predominant in this sample, which might
be explained because the number of female dentists in Jordan
is higher than the number of male dentists based on the latest
Jordan Dental Association statistics [13].
The estimated incubation period of COVID-19 is up to 14 days
[6,7]. Dentists in this study varied in their knowledge about the
incubation period of the disease, but it is essential to know the
right incubation period because of its role in determining the
safe period to treat suspected patients [14]. However, it’s
imperative for dentists to carry on with preventive measures for
all their patients, all the time. Knowledge about respiratory
disease contagion was noticed in other studies to be lower
among dentists [15] than among other health care providers
[16], despite the proximity of patient to provider present in
dental care [4]. Nonetheless, Jordanian dentists in this sample
could identify the main symptoms of COVID-19, which helps
dentists to recognize the threat and take the necessary actions
and is considered essential in the management [14] and control
http://publichealth.jmir.org/2020/2/e18798/
XSL• FO
RenderX
Khader et al
of the spread of the disease [1]. Dentists response to prevention
measures were better for personal protective equipment and
disinfection and sanitation procedures than for measures applied
to dental staff or patients, such as special clothing or ventilation.
The latest precautionary actions could possibly be viewed by
dentists as extra protective measures that are not necessary when
combined with their understanding that infections occur mainly
through direct contact between mucous membranes and
contaminated hands [9].
There has been no evidence-based specific treatment for
COVID-19, and management of COVID-19 has been largely
supportive [8]. The current approach to COVID-19 is to control
the source of infection; use infection prevention and control
measures to lower the risk of transmission; and provide early
diagnosis, isolation, and supportive care for affected patients
[17]. This fact was reflected by the response of participants to
treatment; almost half of dentists thought that the disease
self-resolves over time with no need for special treatment. This
perception about the disease self-resolution resulted in most
participants perceiving COVID-19 as moderately dangerous
(n=264/368, 71.7%), and almost one-third believed that
COVID-19 was not a serious public health issue. Although their
perception about the disease self-resolution could have been
explained by their perception about its threat; there were no
“local” cases in Jordan at the time of data collection. In addition,
dentists’ perception about the seriousness of the disease could
be because some (n=80, 21.7%) did not see a need to ask
patients to sit far from each other, wear masks while in the
waiting room, or wash hands before getting in the dental chair
to decrease disease transmission. However, the vast majority
(n=304, 82.6%) would prefer to avoid working with a patient
with suspected COVID-19 because of the possibility of disease
transmission during incubation periods, during which no
symptoms may appear [1].
The attitude of dentists regarding what to do in case a patient
was sneezing or coughing in their clinics varied; 43.8% (n=161)
would refer the patient to the hospital without treating them,
4.6% (n=17) would refuse treatment, and 49.5% (n=182) would
treat the patient and then refer them to the hospital. Some
dentists (n=119, 32.3%) would allow their dental staff to work
with patients if they had flu-like symptoms. During the outbreak
of COVID-19, dentists should evaluate risk of transmission
through measurements of the temperature of every staff and
patient as a routine procedure. Patients should be asked about
their health status and any history of recent contact or travel
[8]; patients and their accompanying persons should be provided
with medical masks upon entry to the clinic. Patients with a
fever should be registered and referred to designated hospitals.
If a patient has been to any epidemic regions within the past 14
days, quarantining for at least 14 days is recommended. In areas
where COVID-19 spreads, nonurgent dental treatment should
be postponed [18]. It is still not known when treatments can be
done.
Over half of the dentists (n=214, 58.2%) knew whom to contact
in a situation of an unprotected exposure to a known or
suspected COVID-19 patient, and 75.8% (n=279) reported that
they knew what to do if they had signs or symptoms of a
suspected COVID-19 infection. By now, there has been no
JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 5
(page number not for citation purposes)
 JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al

consensus on provision of dental treatment during the
COVID-19 epidemic. Based on relevant guidelines and research,
dentists should take strict personal protection measures and
avoid or minimize operations that may produce droplets or
aerosols [18]. A 4-handed technique is useful for infection
control, and use of saliva ejectors with low or high volume
reduces droplet and aerosol production [1,9]. The consensus of
the vast majority (n=360, 97.8%) of dentists about the
importance of educating others about COVID-19 to prevent the
spread of the disease was high, but they should follow the
guidelines from the CDC and ADA and recommendations for
infection prevention and control based on the local epidemic
situation.
Despite the findings introduced here, it is important to stress
that this survey had limitations, including the relatively low
response rate, which resulted in a smaller than expected sample
size. This could have been caused by the short period of data
collection. However, this is considered a moderate sample size.
Moreover, this pandemic has caused many to be busy with
watching the news and taking care of personal affairs. This
means that those who were active on social media during the
short period of data collection were the only ones that had the
chance to participate in the study. This could result in selection
bias and sampling error, which prevents the ability to generalize
our results.
In conclusion, Jordanian dentists were aware of COVID-19
symptoms, mode of transmission, infection control, and
measures in dental clinics. However, dentists had limited
comprehension of the extra precautionary measures that protect
the dental staff and other patients from COVID-19. Guidelines
released by reputable institutions should be sent by the regional
and national dental associations to all registered dentists during
a crisis, including this COVID -19 pandemic, to make sure that
dentists are well informed and aware of the best practices and
recommended disease management approaches.

Conflicts of Interest
None declared.

References
1. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine.
J Dent Res 2020 Mar 12:22034520914246. [doi: 10.1177/0022034520914246] [Medline: 32162995]
2. Ibrahim NK, Alwafi HA, Sangoof SO, Turkistani AK, Alattas BM. Cross-infection and infection control in dentistry:
knowledge, attitude and practice of patients attended dental clinics in King Abdulaziz University Hospital, Jeddah, Saudi
Arabia. J Infect Public Health 2017;10(4):438-445 [FREE Full text] [doi: 10.1016/j.jiph.2016.06.002] [Medline: 27422140]
3. Secon H. Nearly 3,400 Chinese healthcare workers have gotten the coronavirus, and 13 have died. Business Insider 2020
Mar 04 [FREE Full text]
4. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment.
PLoS One 2017;12(5):e0178007 [FREE Full text] [doi: 10.1371/journal.pone.0178007] [Medline: 28531183]
5. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of coronavirus disease 2019
(COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med 2020 Mar 10. [doi:
10.7326/m20-0504]
6. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among
travellers from Wuhan, China, 20-28 January 2020. Euro Surveill 2020 Feb;25(5) [FREE Full text] [doi:
10.2807/1560-7917.ES.2020.25.5.2000062] [Medline: 32046819]
7. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel
coronavirus-infected pneumonia. N Engl J Med 2020 Mar 26;382(13):1199-1207. [doi: 10.1056/NEJMoa2001316] [Medline:
31995857]
8. World Health Organization. 2020 Mar 13. Clinical management of severe acute respiratory infection when COVID-19 is
suspected URL: https://tinyurl.com/s23yv4p
9. Centers for Disease Control and Prevention. 2020 Mar 27. CDC recommendation: postpone non-urgent dental procedures,
surgeries, and visits URL: https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html
10. The American Dental Association. 2020 Mar 27. Coronavirus frequently asked questions URL: https://success.ada.org/en/
practice-management/patients/coronavirus-frequently-asked-questions
11. Matsuda JK, Grinbaum RS, Davidowicz H. The assessment of infection control in dental practices in the municipality of
São Paulo. Braz J Infect Dis 2011 Feb;15(1):45-51. [doi: 10.1590/s1413-86702011000100009]
12. Mehtar S, Shisana O, Mosala T, Dunbar R. Infection control practices in public dental care services: findings from one
South African Province. J Hosp Infect 2007 May;66(1):65-70. [doi: 10.1016/j.jhin.2007.02.008] [Medline: 17433494]
13. Jordanian Dental Association. URL: https://www.jda.org.jo/index.php/component/k2/item/544.html
14. Gaffar BO, El Tantawi M, Al-Ansari AA, AlAgl AS, Farooqi FA, Almas KM. Knowledge and practices of dentists regarding
MERS-CoV. A cross-sectional survey in Saudi Arabia. Saudi Med J 2019 Jul;40(7):714-720 [FREE Full text] [doi:
10.15537/smj.2019.7.24304] [Medline: 31287133]
15. Baseer M, Ansari S, AlShamrani S, Alakras A, Mahrous R, Alenazi A. Awareness of droplet and airborne isolation
precautions among dental health professionals during the outbreak of corona virus infection in Riyadh city, Saudi Arabia.
J Clin Exp Dent 2016 Oct;8(4):e379-e387 [FREE Full text] [doi: 10.4317/jced.52811] [Medline: 27703605]
http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 6
(page number not for citation purposes)
XSL• FO
RenderX
 JMIR PUBLIC HEALTH AND SURVEILLANCE Khader et al

16. Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern
among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infect Dis 2017 Jan 03;17(1):4
[FREE Full text] [doi: 10.1186/s12879-016-2096-8] [Medline: 28049440]
17. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel
coronavirus-infected pneumonia in Wuhan, China. JAMA 2020 Feb 07. [doi: 10.1001/jama.2020.1585] [Medline: 32031570]
18. The American Dental Association. 2020 Mar 16. ADA recommending dentists postpone elective procedures URL: https:/
/tinyurl.com/wpp647r

Abbreviations
ADA: American Dental Association
CDC: Centers for Disease Control and Prevention
COVID-19: coronavirus disease

Edited by T Sanchez; submitted 19.03.20; peer-reviewed by O Beni Yonis, M Alyahya; comments to author 31.03.20; revised version
received 31.03.20; accepted 02.04.20; published 09.04.20
Please cite as:
Khader Y, Al Nsour M, Al-Batayneh OB, Saadeh R, Bashier H, Alfaqih M, Al-Azzam S, AlShurman BA
Dentists’ Awareness, Perception, and Attitude Regarding COVID-19 and Infection Control: Cross-Sectional Study Among Jordanian
Dentists
JMIR Public Health Surveill 2020;6(2):e18798
URL: http://publichealth.jmir.org/2020/2/e18798/
doi: 10.2196/18798
PMID:

©Yousef Saleh Khader, Mohannad Al Nsour, Ola Barakat Al-Batayneh, Rami Saadeh, Haitham Bashier, Mahmoud Alfaqih,
Sayer Al-Azzam, Bara’ Abdallah AlShurman. Originally published in JMIR Public Health and Surveillance
(http://publichealth.jmir.org), 09.04.2020. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete
bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license
information must be included.

http://publichealth.jmir.org/2020/2/e18798/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 2 | e18798 | p. 7

(page number not for citation purposes)
XSL• FO
RenderX
 Editorial

Rev Estomatol Herediana. 2020 Ene-Mar;30(1):5-6

DOI: https://doi.org/
Esta obra está bajo
una Licencia Creative Commons
Atribución 4.0 Internacional

NUEVO CORONAVIRUS 2019 (COVID-19):

Consejos para el odontólogo
New Coronavirus 2019 (COVID-19): Tips for the dentist

Se ha generado preocupación mundial por la propagación de un nuevo coronavirus, que apareció en la ciudad
china de Wuhan. La Organización Mundial de la Salud (OMS), el día 11 de febrero del 2020, anunció que
el nombre oficial de esta enfermedad que está causando el brote del nuevo coronavirus 2019 es COVID-19.
Los Centros para el Control y la Prevención de Enfermedades (CDC) están vigilando de cerca este brote de
enfermedad respiratoria causada por este nuevo coronavirus. Esta es una situación emergente que está cambiando
rápidamente y los CDC continuarán brindándonos información actualizada a medida que esté disponible, para
proteger la salud de las personas, y actúa rápidamente cada vez que hay un problema potencial para la salud
pública (1). En total más de 30 países están afectados por el coronavirus COVID-19, por lo que la OMS advierte
sobre el riesgo de una pandemia, por lo que ahora es momento de prepararse.

Es probable que este virus haya surgido originalmente de una fuente animal, pero se ha confirmado que puede
transmitirse de persona a persona a través de ñas gotitas de flugge (hasta 1 metro de distancia) (2). En relación
al diagnóstico, la secuencia genética del COVID-19 se puso a disposición de la OMS el 12 de enero de 2020 y
esto ha facilitado a los laboratorios de diferentes países a producir pruebas de diagnóstico de PCR específicas
para detectar la nueva infección. El COVID-19 es un β CoV del grupo 2B con al menos un 70% de similitud en
la secuencia genética con el SARS-CoV (3).

En las infecciones confirmadas, los síntomas de los casos de enfermedad notificados han variado desde
personas levemente enfermas hasta personas gravemente enfermas y que han muerto. Los síntomas
pueden incluir: fiebre, tos, dificultad para respirar. Los CDC creen que los síntomas podrían aparecer
en tan solo 2 días o hasta 14 días después de la exposición (1).

El nuevo coronavirus (COVID-19) es una amenaza de enfermedad infecciosa nueva y emergente. Todavía hay
mucha incertidumbre en torno a su presentación clínica, pero el espectro de la enfermedad puede variar de
leve a moderada, a neumonía o infección respiratoria aguda grave. Las personas con COVID-19 “posible” o
“confirmado” no deben ser atendidas para recibir atención dental de rutina y se les debe pedir que pospongan su
tratamiento hasta la resolución clínica (4).

En la práctica dental general, se recomienda que antes de la cita se puede evitar que las personas con COVID-19
“posible” o “confirmado” lleguen a la consulta. Si una persona asiste a la cirugía dental y que padece síntomas
respiratorios y confirma que ha viajado a un área de riesgo, se le debe recomendar que regrese a casa y se
comunique con su médico. No deben asistir a su cirugía. Si un caso “posible” o “confirmado” presenta un
problema dental agudo que requiere atención dental urgente, el paciente deberá ser derivado para su manejo
en un entorno apropiado con medidas de prevención y control de infecciones. Una vez que el individuo ha
sido transferido de las instalaciones, no debe usarse la habitación donde fue colocado o aislado. La puerta de la
habitación debe permanecer cerrada hasta que se haya limpiado con detergente y desinfectante. Una vez que se
Rev Estomatol Herediana. 2020 Ene-Mar;30(1) 5
 NUEVO CORONAVIRUS 2019 (COVID-19): Consejos para el odontólogo
Editorial / Editorial Sonia Sacsaquispe-Contreras

ha completado este proceso, la sala se puede volver a usar de inmediato. Se debe seguir las instrucciones para la
limpieza ambiental después de un caso sospechoso (4). Seguir escrupulosamente todas las normas universales de
desinfección y esterilización habituales.

En relación a la prevención, importante porque, no existe una vacuna para prevenir esta cepa del coronavirus. La
OMS, recomienda evitar el contacto cercano con personas que sufren infecciones respiratorias agudas. Estas
medidas incluyen (5):
• El lavado de manos es clave para la prevención. Se recomienda hacerlo con frecuencia, principalmente, tras
el contacto directo con personas enfermas o su entorno.
• Evitar tocarse con las manos sin lavar, los ojos, la nariz y la boca.
• Evitar el contacto cercano con personas enfermas.
• Si está enfermo, quedarse en casa.
• Al toser o estornudar, cubrirse la nariz y la boca con un pañuelo desechable y luego eliminarlo.
• Los objetos y las superficies que se tocan frecuentemente, limpiar y desinfectar usando un producto común
de limpieza de uso doméstico.

Los dentistas están sometidos a riesgo de generar aerosoles, por lo que se recomienda el uso de mascarillas FFP2
valvuladas. Algunas recomendaciones acerca de las mascarillas (5):
• Si está usted sano, solo necesita llevar mascarilla si atiende a alguien en quien se sospeche la infección.
• Lleve mascarilla si tiene tos o está estornudando.
• Las mascarillas son eficaces si se combinan con el lavado frecuente de manos con una solución hidroalcohólica
o con agua y jabón.
• Si usa una mascarilla quirúrgica habitual (las de tela no se recomiendan), aprenda a usarla y eliminarla
correctamente cada 2 horas para evitar su deterioro y pérdida de eficacia.

Como se sabe, no hay ningún tratamiento antiviral específico que se recomiende, por lo que su conocimiento y
prevención son fundamentales. Las personas infectadas deben recibir cuidados de apoyo para ayudar a aliviar los
síntomas y en casos graves, debe incluir atención médica para apoyar el funcionamiento de los órganos vitales (3).

Sonia Sacsaquispe-Contreras 1,a,b,c,d

REFERENCIAS BIBLIOGRÁFICAS Nacional de Salud; 2020. (Citado el 17 de febrero del 2020)

Disponible en: https://dsi.ins.gob.pe/coronavirus/
1. Organización Panamericana de la Salud. Actualización Epi-
4. Health Protection Scotland. COVID-19 Advice for Dental
demiológica: Nuevo coronavirus (COVID-19) 14 de febrero
Teams. National Services Scotland. Glasgow: Health Pro-
de 2020. Washington DC: Organización Panamericana de la
tection Scotland; 14 February 2020. (Citado el 17 de fe-
Salud; 2020.
brero del 2020) Disponible en: https://www.hps.scot.nhs.
2. Organización Panamericana de la Salud. Coronavirus di-
uk/a-toz-of-topics/novel-coronavirus-2019-ncov/
sease Covid-19 [internet]. Washington DC: Organiza-
5. Centros para el Control y la Prevención de Enfermedades.
ción Mundial de la Salud;2020. (Citado el 17 de febrero
Coronavirus 2019 (COVID-19). Washington DC: Centros
del 2020) Disponible en: https://www.paho.org/hq/index.
para el Control y la Prevención de Enfermedades; 2019. (Ci-
php?option=com_content&view=article&id=15696:coro-
tado el 17 de febrero del 2020) Disponible en:https://www.
navirus-disease-covid-19&Itemid=4206&lang=es
cdc.gov/coronavirus/2019-ncov/index-sp.html
3. Instituto Nacional de Salud: Coronavirus. Lima: Instituto

1 International Association of Oral Pathologists. Sheffield, Inglaterra.

a
Cirujano Dentista.
b
Especialista en Medicina y Patología Oral.
c
Magister en Estomatología.
d
Doctor en Estomatología.

6 Rev Estomatol Herediana. 2019 Oct-Dic;29(4)

 Critical Review
Public Health
Luciano José PEREIRA(a)
Cassio Vicente PEREIRA(b)
Ramiro Mendonça MURATA(c)
Vanessa PARDI(c)
Stela Márcia PEREIRA-DOURADO(a)
Universidade Federal de Lavras – UFLA,
(a) and private sectors, are high-risk settings of cross infection among
Departamento de Ciências da Saúde,
Lavras, MG, Brazil.
Centro Universitário de Lavras – Unilavras,
(b) aims to compile current available evidence on prevention strategies for
Faculdade de Odontologia, Lavras,
MG, Brazil.
East Carolina University – ECU, School of
(c)
Dental Medicine, Greenville, SC, USA.
Declaration of Interests: The authors
certify that they have no commercial or
associative interest that represents a conflict
of interest in connection with the manuscript.
Corresponding Author:
Luciano José Pereira
E-mail: lucianopereiraufla@gmail.com
https://doi.org/10.1590/1807-3107bor-2020.vol34.0041
Submitted: April 7, 2020
Accepted for publication: April 13, 2020
Last revision: April 14, 2020
Biological and social aspects of
Coronavirus Disease 2019 (COVID-19)
related to oral health
Abstract: The expansion of coronavirus disease 2019 (COVID-19)
throughout the world has alarmed all health professionals. Especially
in dentistry, there is a growing concern due to it’s high virulence
and routes of transmission through saliva aerosols. The virus keeps
viable on air for at least 3 hours and on plastic and stainless-steel
surfaces up to 72 hours. In this sense, dental offices, both in the public
patients, dentists and health professionals in the clinical environment
(including hospital’s intensive dental care facilities). This manuscript
dental professionals. Besides, we briefly describe promising treatment
strategies recognized until this moment. The purpose is to clarify
dental practitioners about the virus history and microbiology, besides
guiding on how to proceed during emergency consultations based on
international documents. Dentists should consider that a substantial
number of individuals (including children) who do not show any signs
and symptoms of COVID-19 may be infected and can disseminate the
virus. Currently, there is no effective treatment and fast diagnosis is still
a challenge. All elective dental treatments and non-essential procedures
should be postponed, keeping only urgent and emergency visits to the
dental office. The use of teledentistry (phone calls, text messages) is a
very promising tool to keep contact with the patient without being at
risk of infection.
Keywords: Coronavirus; Public Health; Practice Management, Dental;
Infections; Dentistry.
Introduction
Coronavirus is a family of viruses that causes respiratory infections
including the new coronavirus (SARS-CoV-2) discovered in December 2019
in China. Coronaviruses represent enveloped, positive stranded RNA virus
that contains four genera: Alpha-, Beta-, Gamma-, and Deltacoronavirus.1 Six
different coronavirus have been identified in humans: HCoV-OC43, -229E,
HCoV-NL63, HKU1, the Middle East respiratory syndrome (MERS)-CoV
and (SARS)-CoV.2 Although the latter virus became widely discussed
recently, the first human coronaviruses were isolated for the first time in
1937.3 The denomination coronavirus was due to its microscopic aspect
Braz. Oral Res. 2020;34:e041 1
 Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health
resembling crown-like spikes on its surface and
the main host receptor for humans seems to be the
angiotensin-converting enzyme 2 (ACE2).4
This recent COVID-19 turned into a global
public health outbreak. 5,6 It is transmitted after
contact with infected surfaces and with infected
patient’s fluids, including saliva and aerosol.6,7 These
characteristics place the dental offices as main risk
settings of cross infection among patients, dentists
and health professionals in the clinical environment,
including hospital’s dental intensive care facilities.8
Dental practitioners are exposed to close contact to
patients, to saliva aerosol, blood and handle sharp
contaminated instruments.9
After the World Health Organization (WHO)
pandemic declaration, institutions like the General
Coordination of Oral Health from the Brazilian Health
Ministry published a Technical Note with the main
clarifications regarding dental practice considering
the Coronavirus pandemic.10 Centers for Disease
Control and Prevention (CDC) and American Dental
Association (ADA) are recommending dentists to
postpone elective procedures and concentrating on
emergency or urgent dental care in order to reduce
COVID-19 infection,11,12 similar to what several cities
in China have done.13
As health professionals, it is extremely relevant
that dentists be aware of the biological and social
characteristics involved in COVID-19 pandemic,
contributing to the clarification of the population and
adopting finest clinical measures to avoid unnecessary
risks to contain the perioperative transmission.8 Based
on the current available evidence related to oral health
care, the aim of the present critical appraisal is to
compile prevention strategies for dental professionals
and clarify dental practitioners about the virus history,
pathogenesis, current pharmacological clinical trials,
and measures to minimize economic and health
consequences to the oral health system.
Microbiological aspects
This new health problem emerged from a public
market in which animals are kept and traded alive in
Wuham – China. It became the focus of global attention
after the spread of an unknown cause epidemic
pneumonia. At first, these cases of pneumonia
2 Braz. Oral Res. 2020;34:e041
were monitored and tested in the laboratory for
coronavirus and possible influenza infections. On
January 7, 2020, Chinese authorities announced that
a new type of Coronavirus was isolated: the new
Coronavirus, nCoV.14
This new viral agent, which until that moment
has not been identified in humans before, was called
SARS-CoV-2 and is able to cause respiratory infectious
disease that is called COVID-19. Previous occurrence
of coronavirus such as the Severe Acute Respiratory
Syndrome (SARS) (SARS-CoV) and Middle East
Respiratory Syndrome (MERS) (MERS-CoV) left 774
and 850 dead, respectively, reflecting the severity
of the threat and the urgency to control this new
outbreak as soon as possible.15
T he genom ic s e quence of t he new v i ra l
Coronavirus was immediately defined by public
health support and online community resources
“virological.org” on January 10 th (Wuhan-Hu-1,
GenBank accession number MN908947)16 followed
by four other deposited genomes on January 12th in
the database of viral genomic sequences maintained
by the Global Initiative on Sharing All Influenza
Data (GISAID).17 The clinical signs and symptoms
in the beginning suggested the presence of a virus
closely related to SARS outbreak in 2002/2003. This
species also comprised a large number of viruses
detected in rhinolophid bats in Asia and Europe.
17
After sequencing, the SARS-CoV-2 genome was
found to be 96.2% identical to the Bat RaTG13 coV,
while sharing 79.5% identity with the SARS-CoV. In
this way, the similarity between the genomes of the
viruses shows that the bat is the natural host of the
virus and SARSCoV-2 may have been transmitted to
humans, in an unknown way, through intermediate
hosts. Several studies suggest that the bat is the
potential reservoir of SARS-CoV-2. However, there
is evidence that the origin of SARS-CoV-2 was the
seafood market in Wuhan, China.18 Coronaviruses
(CoV) α- and β-CoV are capable of infecting mammals,
while γ- and δ-CoV tend to infect birds. Although
the six CoVs identified as human-susceptible viruses,
presented low pathogenicity, causing mild respiratory
symptoms similar to a common cold; SARS-CoV and
MERS-CoV may lead to severe and potentially fatal
respiratory tract infections.18,19
 Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM
Viruses are complex pathogens with a high capacity
to infect multiple host species, causing a variety
of diseases with numerous symptoms. CoVs are
pleomorphic RNA-viruses (subgenus sarbecovirus,
subfamily Orthocoronavirinae) characterized by high
speed of gene recombination due to constant errors
in their RNA polymerase-dependent replication
process (RdRP).18,20 The main steps involved in the
replication cycle of SARS-CoV-2 are: recognition
and binding to the host cell via membrane fusion
or endocytosis mechanism. After the invasion, the
viral genome is released; then occurs translation of
the viral polymerase protein; RNA replication; sub-
genomic transcription; translation of viral structural
proteins; viral structural proteins combination with
the nucleocapsid; formation of mature virions and
finally the release of mature virions by exocytosis. At
the end of the cycle, newly mature virions are released
and may infect new targets and the cycle repeats
itself continuously.15 During their replication cycle,
two-thirds of the viral RNA encode 16 non-structural
proteins (NSPs). The other one-third of the virus
genome encodes four essential structural proteins,
including: spike glycoprotein (S), small envelope
protein (E), matrix protein (M) and nucleocapsid
protein (N), and also other accessory proteins.18,21
Host factors can also influence susceptibility to
infection and disease progression. Research shows
that SARS-CoV-2 use angiotensin-converting enzyme
2 (ACE2). The S-glycoprotein located on the surface of
the coronavirus can bind to the ACE2 receptor on the
surface of human cells. After binding to the host cell
membrane, the RNA of the viral genome is released
into the cytoplasm and translates two polyproteins,
pp1a and pp1ab that encode non-structural proteins
and form the replication and transcription complex
(RTC) and the replication cycle continues as stated
above 18. Host antiviral defense plays an important
role in the course of SARS-CoV-2 infection. As the
first line of defense against viruses, type I interferon
(IFN) plays a critical role in initiating host antiviral
responses. Following virus infection, the host innate
immune system is activated by the recognition of
viral-specific components such as ssRNA, dsRNA or
glycoproteins.22 The Toll-like and RIG-I-like receptors
are the most common host pattern recognition
receptors (PRRs) that respond to RNA viruses.23 The
domains then initiate an antiviral signaling cascade
by leading the phosphorylation and activation of
IRF3 and NF-κB, leading to the production of type I
IFN. IFN-β secretion induces IFN-stimulated genes,
which will induce the expression of host antiviral
effector factors.24
Viruses have developed the capacity to escape
host immune detection and to suppress the host
IFN system. 25 Viruses encode viral proteins
that interfere with PRRs signaling pathways to
increase an early benefit against host defense. For
example, the SARS-CoV N proteins inhibit RIG-I
ubiquitination and thus suppress the release of type
I IFN,26 SARS-CoV M proteins prevents the TRAF3/
TBK1 complex formation and inhibits TBK1/IKKε-
dependent activation of IRF3/IRF7 transcription
factors.27 Lastly, the repressive modifications that
are induced by the nonstructural SARS-CoV nsp1
protein blocks host mRNA translation28 and mediates
host mRNA degradation.29
Human-to-human transmission of SARS-CoV-2
occurs primarily between family members, including
relatives and friends who have more intimate contact
with infected or asymptomatic patients or carriers.
As an emerging acute respiratory infectious disease,
COVID-19 spreads mainly through the respiratory tract
pathways through droplets, respiratory secretions and
direct contact even at a low infectious dose. Likewise,
the presence of SARS-CoV-2 in swabs from fecal and
blood samples has been identified, indicating the
possibility of multiple routes of infection.18
Based on the current epidemiological investigation,
the incubation period is from 1 to 14 days, mainly from
3 to 7 days, being contagious in its latency period. It
is highly transmissible in humans, especially in the
elderly and people with underlying diseases. Patients
with COVID-19 have symptoms such as fever, malaise
and cough. Most adults or children infected with
SARS-CoV-2 have mild flu-like symptoms. However,
a few patients also progress to a critical condition and
rapidly develop acute respiratory distress syndrome,
respiratory failure, multiple organ failure and even
die.18,30 There are still many gaps in knowledge about
the epidemiology and clinical overview of COVID-19,
including the exact incubation period, the possibility
Braz. Oral Res. 2020;34:e041 3
 Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health
of transmission from asymptomatic carriers and the
rate of transmissibility. However, human-human
transmission has been rapidly proven and remains
responsible for the continued spread of the disease.
Reliable laboratory diagnosis is among the
priorities to facilitate public health interventions. In
acute respiratory infections, RT-PCR is routinely used
to detect viruses caused by respiratory secretions.
During international health emergencies, the viability
of real-time detection of the virus by real-time
RT-PCR has been demonstrated through coordination
between public laboratories and universities. 17
SARS-CoV-2 Drug Therapy
Drugs tested effective for SARS-CoV and/or MERS
have been included in the WHO mega clinical trial –
SOLIDARITY.31 For its study, WHO chose a nucleotide
analogue Remdesivir; the malaria medication
chloroquine (and its analog hydroxychloroquine);
a combination of the anti-HIV drugs lopinavir and
ritonavir; and that combination plus interferon-b.
Re mde s iv i r i s a n a nt iv i r a l p r o d r ug o f
remdesivirtriphosphate with in vitro activity against
coronaviruses.32,33 Remdesivir-TP acts as an inhibitor of
RNA-dependent RNA polymerases and competes with
adenosine-TP for incorporation into emerging viral
RNA chains.34 Hydroxyhloroquine and chloroquine
have in vitro activity against SARS-CoV-2 32,35–37
and the mechanism of action includes inhibition
of viral enzymes (RNA polymerase), viral protein
glycosylation, virus assembly, new virus particle
transport, and virus release. Other mechanisms
may also involve ACE2 receptor inhibition, decrease
acidity in endosomes, and immunomodulation of
cytokine release.5,32,36
The third arm of SOLIDARITY combines two
HIV protease inhibitor drugs, lopinavir-ritonavir.
The combination shown in vitro and in vivo potential
activity for SARS-CoV and MERS-CoV 38,39 and the
mechanism of action involves the inhibition of Mpro,
an essential enzyme for coronavirus replication 40.
Recent report published in The New England Journal of
Medicine41 was not encouraging and the combination
of lopinavir-ritonavir did not differ significantly from
“standard care” group.
4 Braz. Oral Res. 2020;34:e041
The fourth arm of SOLIDARITY combines
lopinavir-ritonavir with interferon-b. The activation
of innate antiviral response by interferon should
have beneficial effects at least in the initial stage of
infection. However, cautions should still be observed
and the possibility that interferon might exacerbate
inflammation during the late phase of SARS-CoV-2
infection cannot be excluded.42
Lastly, clinical trials are being conducted to
evaluate the use of SARS-CoV-2 convalescent plasma
from persons who have recovered from COVID-19
that potentially contain antibodies to treat patients
with life-threatening viral infections.43 A group led
by Lei Liu44 gave convalescent plasma (total dose:
400 mL with a SARS-CoV-2-specific antibody-IgG
titer greater than 1:1,000) to five critically ill patients
and the symptoms diminished in all of them within
ten days. Even though these cases reported by Shen
et al 44 are compelling, this investigation has some
limitations. The intervention was not evaluated
in a randomized clinical trial, and the outcomes
in the treatment group were not compared with
outcomes in a control group - patients who did not
receive the intervention. Moreover, patients received
numerous other therapies (antiviral and steroids),
and the convalescent plasma was administered up
to 21 days, and it is not clear whether this timing is
optimal or if earlier administration potentially have
been associated with different outcomes. Despite
these limitations, the study does provide important
evidence to support the possibility of evaluating this
therapy in more rigorous studies.
Dental practice in the Covid-19
scenario
Risk scenario
Dentists are among the professionals with the
greatest exposure to COVID-19. The oral cavity and the
work environment represent a high potential source
for transmissibility and susceptibility to this and other
etiological agents.7,45,46 The context of undocumented
infections is significant, which facilitates the rapid
spread of SARS-CoV-2. A substantial number of
individuals do not show any signs and symptoms
or have mild symptoms. These individuals serve
 Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM
as the primary source for the majority of reported
cases and, therefore, for health teams that can
become multipliers.47,48
The rapid identification of COVID-19 cases is crucial
for the containment of the pandemic. However, it is
still challenging due to the lack of pathognomonic
symptoms, coupled with the limited capacity to
perform specialized polymerase chain reaction
(PCR) tests49 - which also have limitations. The need
to develop fast accurate molecular diagnostics is
mandatory to identify a large number of infected
patients and asymptomatic carriers, in order to
prevent the transmission of the virus and ensure
proper conduct.50,51 Rapid tests can facilitate elective
care in the future since the risk of contamination by
SARS-CoV-2 would be ruled out. However, the dentist
can never neglect the existence of other diseases
transmitted by saliva and aerosol, such as hepatitis
B, measles and tuberculosis.52,53,54
Dentists should receive and make great efforts
regarding preventive care and testing, as they can
seriously affect the flattening of the epidemic curve,
avoiding the collapse of the health system. Several
modeling studies and scenario comparisons - both
related to the current pandemic situation and those
already experienced especially in China and Italy
- have shown that combined interventions must
be implemented, both for the population and for
health professionals. General measures for all health
professionals including dentists comprise daily
monitoring of the temperature and testing the health
care provider team; use of N95 masks; distance from
the workplace (when possible) with the implementation
of network communication technologies with patients;
social distance; mobility restriction measures; avoid
crowd places; diagnostic tests and isolation of infected
individuals as well as their families.55–60 Especially for
dentists it is necessary to follow guidance protocols
and new tools/technologies for dental practice aimed
at safeguarding oral health professionals, as well as
the population under their care.59,61
Dental treatment during the Covid-19
Pandemic
Due to the nature of the dental treatment, several
procedures, as the use of high-speed handpiece
or ultrasonic scalers generates aerosol (very small
particles or droplets) that can be inhaled, absorbed
by the skin or set in nearby surfaces.62 According
to the last Scientific Brief published by the World
Health Organization, 63 the transmission of the
SARS-CoV-2 can occur by respiratory droplets from
direct contact with an infected person (distance
less than 1m), indirect contact with contaminated
surfaces or objects and by aerosol produced during
procedures performed on infected patients. Based
on that, dental and health organizations have issued
recommendations to postpone all elective dental
treatments and non-essential procedures and limit
services only to urgent and emergency visits.10,11,12
Dental health care personnel (DHCP) should be aware
of the mechanisms of transmission, the expanded
infection control procedures, be able to identify
patients with signs / symptoms of COVID-19 and
have a clear understanding of what characterizes
a dental emergency, urgent dental care and non-
emergency dental treatment.
During the COVID-19 pandemic, DCHP should use
telecommunication or teledentistry prior the dental
treatment to evaluate the needs of the patient and
to minimize the risk of infection, asking if patient
has fever, cough or shortness of breath (ADA)64 and
have traveled national or internationally (CDC).65,66
When possible, dentist should offer advice, prescribe
medication for analgesia and/or antimicrobial (when
appropriate) and postpone the visit of the patient to
the office, but keep direct contact with the patient
by phone or text message.67 If patient presents a
dental emergency (potentially life threatening), as
an uncontrolled bleeding, or an urgent dental need
that requires relieve of severe pain and/or risk of
infection,68 and present sign/symptom of respiratory
infection, this patient should not be seen in a dental
office and should be referred for an emergency care
facility where Transmission-Based Precautions (N95
masks, Airborne Infection Isolation Room for example)
are available (ADA).64
In the United Kingdom, the National Health
Service (NHS) is working with dental practices
and community dental services to establish Local
Dental Urgent Care System in every region. These
dental offices will accommodate visits of all types of
Braz. Oral Res. 2020;34:e041 5
 Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health
patients, including those with suspected or confirmed
COVID-19, patients that are shielded, vulnerable or
patients without any of those specific conditions. In
those places dental public health practitioners will be
available and will have access to the FFP3 respirator
to perform the treatment.67
In most countries, cases of dental emergency or
urgent dental care on patients without any signs and
symptoms of COVID-19 can be treated at the dental
office. However, since there is a large number of
asymptomatic cases of Covid-19,47 the dentist should
take extra precautions when seeing the patient
and not assume he/she is COVID-19 free. Besides
the asymptomatic patients, dental practitioners
should be aware that children represent a significant
transmission risk to the virus since they present
milder symptoms than adults.69 It is important to
maintain patient isolation (have only one patient in
the waiting room), adhere to the infection control
protocol: standard procedure of putting on and
removing all Personal Protective Equipment (PPE),
including gown, goggles, N95 mask with face full
shield and gloves.64 Before every treatment, patient
should use a mouth rinse with 1% or 1.5% hydrogen
peroxide or 0.2% povidone 9,64 and should wear goggles
and bib during the whole procedure. To minimize
the aerosol production, dentists should use hand
instrumentation, high-volume saliva ejector and
dental dam during the treatment and refrain to use
3-in-1 syringe.61
Intraoral radiographs should be avoided since
it can induce coughing; the office space should
be limited to the patient and to the operator and
dental assistant. After the treatment, the DCHP
should wear appropriate PPE to proceed with the
cleaning and disinfection of the room and equipment
using the recommended disinfecting products.64
Besides, dentists should reconsider the use of sedation
(inhalation and pharmacological) to manage severe
anxiety or phobia in the dental settings and focus
on non-pharmacological techniques to minimize the
potential risk of needing life support measures that
involve the manipulation of airways and aerosolization
(inhalation sedation).8
In a specific situation where the patient has an
unavoidable emergency and no signs and symptoms
6 Braz. Oral Res. 2020;34:e041
of COVID-19 and the dentist does not have a N95
mask or higher level, he/she must wear surgical
mask in a single use, goggles and face shield to treat
a patient, but be aware that the risk of contamination
will be moderate.64 There is a limitation in following
this procedure since there is current community
spread of COVID-19 with asymptomatic cases in
the population. Current research shows that the
prognosis of patients with COVID-19 is worst for those
older than 60 years of age or presenting underlying
diseases (diabetes, hypertension or cardiovascular
disease, for example).70 In this sense, members of the
health team must use clinical judgment and take all
precautions to prevent transmission.
In this unprecedented situation, it is advisable
to look for and apply the most recent protocols and
guidance from your local dental organizations in
your country that are based in the current literature
and be aware that the COVID-19 pandemic brings
challenges to the dental health care providers
not only on their practices but on their financial
situation as well. A general flowchart (Figure) was
constructed based on the ADA’s Interim guidance
on minimizing COVID-19 transmission risk when
treating dental emergencies.64 As also stated in this
ADA’s document,64 Figure 1 does not constitute legal
advice or legal guidance. It only helps clinicians
for their own judgment about the risks of infection
while working in dental offices.
Perspectives
Health professionals are facing new challenges in
providing care to their patients. Remote treatment via
chat, video conversation, telemedicine, teledentistry
and other technologies have given rise to a new look
at the professional-patient relationship, opening
doors to an untapped universe, since most dentists
do not use them as part of their daily work.71It is
estimated that by 2025 over 60% of the population
will be using mobile internet.72 Therefore, mobile
technologies, including phones, are great allies to
community health even in low and middle-income
population.73–75 Individuals that still do not have
access to mobile services would also benefit due to
diminishing waiting lines in local health assistance,
at the nearest Primary Health Units.
 Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM

*Use of N95 mask denotes low risk of infection

# If no N95 available, refer patient to a facility that has N95. If not feasible, use your clinical judgment and precautions of infection control.
Dentist and staff must wear surgical facemasks, goggles and full-face shields, with other basic clinical PPE and follow disinfection procedures
immediately after every procedure. Use of surgical facemasks denotes moderate risk of infection. DCHP should quarantine for 14 days and
communicate with patients that were seen after that day. Procedures involving aerosol should be scheduled for the last appointment of the
day. Dentists should avoid intra-oral radiographs, prefer hand instrumentation, and use high-volume saliva ejector and dental dam during the
treatment.
This figure was constructed using free images obtained at: https://smart.servier.com/ and https://www.freepik.com/.

Figure 1. Flowchart based on the American Dental Association Interim Guidance for Management of Emergency and Urgent
Dental Care on 04/01/2020 and do not constitute legal advice or legal guidance.

In private offices, the limitation on dental and
medical activities to only urgent and emergency
procedures presents a strong impact on the economy
of these sectors.76 This economic crises have raised
reflections and concerns that go beyond clinical
security and social detachment and have highlighted
the importance of social security and financial
education. Such factors must also be taken into account
by the entities that guide dental practice, in order to
generate discussions to support the dentists on those
occasions where they will have to keep distance from
their routine clinical tasks during COVID-19.
The dental class, which comprises in its vast
majority, autonomous professionals, should recover
the issues of financial education, frequently so distant
from the contents of the academic curriculum. There
is an evident scarcity of articles related to financial
education for dental offices. Emergency financial
reserve, funds to deposit this reserve and long-term
investments, public or private pension, should be
part of the incisive recommendations to this group.
Other professional classes are raising these issues
concerning this urgent moment to guarantee social
security for all and to go beyond the packages
proposed by governments.77 Such strategies must
be sustainable, long-term, with a view to protecting
the self-employed and avoiding an unprecedented
economic crisis.
Conclusions
This recent COVID-19 turned into a global public
health outbreak. It is transmitted after contact with
infected surfaces and with infected patient’s fluids,
including saliva and aerosol. A substantial number
of individuals do not show any signs and symptoms
and may disseminate the virus. These characteristics
put the dental offices as main risk settings of cross
infection among patients and dentists. Currently
there is no effective treatment and fast diagnosis is
still a challenge. All elective dental treatments and
non-essential procedures should be postponed,
keeping only urgent and emergency visits to the dental
office. Unexpected situations like this pandemic,

Braz. Oral Res. 2020;34:e041 7

 Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health

brings financial issues to the dental team; in this way, Acknowledgments

financial education become very important subject
to be discussed during the professional school. The
use of telecommunication (phone calls, text messages)
and teledentistry are very promising tools to keep
contact with the patient without put them in high
risk of infection.
National Council for Scientific and Technological
Development (Conselho Nacional de Desenvolvimento
Científico and Tecnológico - CNPq), and the
Coordination for the Improvement of Higher Education
Personnel (Coordenação de Aperfeiçoamento de Nível
Superior - CAPES).

References

1. Corman VM, Muth D, Niemeyer D, Drosten C. Hosts and sources of endemic human coronaviruses. Adv Virus Res. 2018;100:163-88.
https://doi.org/10.1016/bs.aivir.2018.01.001
2. Marra MA., Jones SJM., Astell CR., Holt RA., Brooks-Wilson A., Butterfield YSN., et al. The genome sequence of the SARS-associated
coronavirus. Science. 2003 May;300(5624):1399-404. https://doi.org/10.1126/science.1085953
3. Wolff MH, Sattar SA, Adegbunrin O, Tetro J. Environmental survival and microbicide inactivation of coronaviruses. In: Schmidt A, Wolff
MH, Weber O. Coronaviruses with special emphasis on first insights concerning SARS. Base: Birkhäuser; 2005. p. 201-12.
4. Abbag HF, El-Mekki AA, Al Bshabshe AA, Mahfouz AA, Al-Dosry AA, Mirdad RT, et al. Knowledge and attitude towards the Middle East
respiratory syndrome coronavirus among healthcare personnel in the southern region of Saudi Arabia. J Infect Public Health.
2018 Sep - Oct;11(5):720-2. https://doi.org/10.1016/j.jiph.2018.02.001
5. Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the
treatment of COVID-19. J Crit Care. 2020 Mar; pii::S0883-9441(20)30390-7. https://doi.org/10.1016/j.jcrc.2020.03.005
6. Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as
compared with SARS-CoV-1. N Engl J Med. 2020 Mar;NEJMc2004973. https://doi.org/10.1056/NEJMc2004973
7. Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig.
2020 Apr;24(4):1619-21. https://doi.org/10.1007/s00784-020-03248-x
8. Souza RC, Costa PS, Costa LR. Dental sedation precautions and recommendations during the COVID-19 pandemic. Braz J Dent. 2020
Apr;77(0):1-3. https://doi.org/10.18363/RBO.V77.2020.E1788
9. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020
Mar;12(1):9. https://doi.org/10.1038/s41368-020-0075-9
10. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde (SAPS). . Atendimento odontológico no SUS. Brasília, DF; 2020. [cited
2020 Mar 31]. Available from: http://www.crosp.org.br/uploads/arquivo/ab69d79b87d04780af08a70d8cee9d70.pdf
11. Centers of Disease Control and Prevention – CDC. Recommendation: postpone non-urgent dental procedures, surgeries, and visits.
centers of disease control and prevention. 2020 [cited 2020 Mar 31]. Available from: https://www.cdc.gov/oralhealth/infectioncontrol/
statement-COVID.html
12. American Dental Association – ADA. ADA recommending dentists postpone elective procedures. American Dental Assocaition. 2020
[cited 2020 Mar 31]. Available from: https://www.ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-
postpone-elective-procedures
13. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res.
2020 Mar:22034520914246. https://doi.org/10.1177/0022034520914246
14. Sahin A, Erdogan A, Mutlu Agaoglu P, Dineri Y, Cakirci A, Senel M, et al. 2019 Novel Coronavirus (COVID-19) outbreak: a review of the
current literature. Eurasian J Med Investig. 2020;4(1):1-7. https://doi.org/10.14744/ejmo.2020.12220
15. Iqbal HM, Romero-Castillo KD, Bilal M, Parra-Saldivar R. The emergence of novel-coronavirus and its replication cycle: an overview.
J Pure Appl Microbiol. 2020;14(March):6146.
16. Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. A new coronavirus associated with human respiratory disease in China. Nature.
2020 Mar;579(7798):265-9. https://doi.org/10.1038/s41586-020-2008-3
17. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DK, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time
RT-PCR. Euro Surveill. 2020 Jan;25(3). https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045
18. Chen Y, Liu Q, Guo D. Emerging coronaviruses: genome structure, replication, and pathogenesis. J Med Virol. 2020 Apr;92(4):418-23.
https://doi.org/10.1002/jmv.25681

8 Braz. Oral Res. 2020;34:e041

 Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM

19. Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol. 2019 Mar;17(3):181-92.
https://doi.org/10.1038/s41579-018-0118-9
20. Su S, Wong G, Shi W, Liu J, Lai AC, Zhou J, et al. Epidemiology, genetic recombination, and pathogenesis of coronaviruses. Trends
Microbiol. 2016 Jun;24(6):490-502. https://doi.org/10.1016/j.tim.2016.03.003
21. Hussain S, Pan J, Chen Y, Yang Y, Xu J, Peng Y, et al. Identification of novel subgenomic RNAs and noncanonical
transcription initiation signals of severe acute respiratory syndrome coronavirus. J Virol. 2005 May;79(9):5288-95.
https://doi.org/10.1128/JVI.79.9.5288-5295.2005
22. Kato H, Takeuchi O, Sato S, Yoneyama M, Yamamoto M, Matsui K, et al. Differential roles of MDA5 and RIG-I helicases in the
recognition of RNA viruses. Nature. 2006 May;441(7089):101-5. https://doi.org/10.1038/nature04734
23. Chan YK, Gack MU. Viral evasion of intracellular DNA and RNA sensing. Nat Rev Microbiol. 2016 Jun;14(6):360-73.
https://doi.org/10.1038/nrmicro.2016.45
24. Schneider WM, Chevillotte MD, Rice CM. Interferon-stimulated genes: a complex web of host defenses. Annu Rev Immunol.
2014;32(1):513-45. https://doi.org/10.1146/annurev-immunol-032713-120231
25. Kindler E, Thiel V, Weber F. Interaction of SARS and MERS Coronaviruses with the Antiviral Interferon Response. Adv Virus Res.
2016;96:219-43. https://doi.org/10.1016/bs.aivir.2016.08.006
26. Hu Y, Li W, Gao T, Cui Y, Jin Y, Li P, et al. The severe acute respiratory syndrome coronavirus nucleocapsid inhibits type
i interferon production by interfering with TRIM25-Mediated RIG-I Ubiquitination. J Virol. 2017 Mar;91(8):e02143-16.
https://doi.org/10.1128/JVI.02143-16
27. Siu KL, Kok KH, Ng MH, Poon VK, Yuen KY, Zheng BJ, et al. Severe acute respiratory syndrome coronavirus M protein inhibits type I
interferon production by impeding the formation of TRAF3.TANK.TBK1/IKKepsilon complex. J Biol Chem. 2009 Jun;284(24):16202-9.
https://doi.org/10.1074/jbc.M109.008227
28. Tanaka T, Kamitani W, DeDiego ML, Enjuanes L, Matsuura Y. Severe acute respiratory syndrome coronavirus nsp1 facilitates
efficient propagation in cells through a specific translational shutoff of host mRNA. J Virol. 2012 Oct;86(20):11128-37.
https://doi.org/10.1128/JVI.01700-12
29. Huang C, Lokugamage KG, Rozovics JM, Narayanan K, Semler BL, Makino S. SARS coronavirus nsp1 protein induces template-
dependent endonucleolytic cleavage of mRNAs: viral mRNAs are resistant to nsp1-induced RNA cleavage. PLoS Pathog. 2011
Dec;7(12):e1002433. https://doi.org/10.1371/journal.ppat.1002433
30. Sun J, He WT, Wang L, Lai A, Ji X, Zhai X, et al. COVID-19: Epidemiology, Evolution, and Cross-Disciplinary Perspectives. Trends Mol
Med. 2020 Mar 21.https://doi.org/10.1016/j.molmed.2020.02.008
31. World Health Organization – WHO. “Solidarity” clinical trial for COVID-19 treatments. 2020 [cited 2020 Apr 10]. Available from:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-
trial-for-covid-19-treatments
32. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel
coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-71. https://doi.org/10.1038/s41422-020-0282-0
33. Agostini ML, Andres EL, Sims AC, Graham RL, Sheahan TP, Lu X, et al. Coronavirus susceptibility to the antiviral remdesivir
(GS-5734) is mediated by the viral polymerase and the proofreading exoribonuclease. MBio. 2018 Mar;9(2):e00221-18.
https://doi.org/10.1128/mBio.00221-18
34. Brown AJ, Won JJ, Graham RL, Dinnon KH 3rd, Sims AC, Feng JY, et al. Broad spectrum antiviral remdesivir inhibits human endemic
and zoonotic deltacoronaviruses with a highly divergent RNA dependent RNA polymerase. Antiviral Res. 2019 Sep;169:104541.
https://doi.org/10.1016/j.antiviral.2019.104541
35. Gao J, Tian Z, Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated
pneumonia in clinical studies. Biosci Trends. 2020 Mar;14(1):72-3. https://doi.org/10.5582/bst.2020.01047
36. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, et al. In Vitro antiviral activity and projection of optimized dosing design of
Hydroxychloroquine for the treatment of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020
Mar:ciaa237. https://doi.org/10.1093/cid/ciaa237
37. Colson P, Rolain JM, Lagier JC, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19. Int J
Antimicrob Agents. 2020 Mar;105932:105932. https://doi.org/10.1016/j.ijantimicag.2020.105932
38. Chen F, Chan KH, Jiang Y, Kao RY, Lu HT, Fan KW, et al. In vitro susceptibility of 10 clinical isolates of SARS coronavirus to selected
antiviral compounds. J Clin Virol. 2004 Sep;31(1):69-75. https://doi.org/10.1016/j.jcv.2004.03.003
39. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus:
a possible reference for coronavirus disease-19 treatment option. J Med Virol. 2020 Feb:jmv.25729. https://doi.org/10.1002/jmv.25729
40. Liu X, Wang XJ. Potential inhibitors against 2019-nCoV coronavirus M protease from clinically approved medicines. J Genet Genomics.
2020 Feb;47(2):119-21. https://doi.org/10.1016/j.jgg.2020.02.001

Braz. Oral Res. 2020;34:e041 9

 Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health

41. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with Severe Covid-19. N Engl J
Med. 2020 Mar:NEJMoa2001282. https://doi.org/10.1056/NEJMoa2001282
42. Kupferschmidt K., Cohen J. Race to find COVID-19 treatments accelerates. Science. 2020 Mar;367(6485):1412-3.
https://doi.org/10.1126/science.367.6485.1412
43. FDA. Recommendations for investigational COVID-19 Convalescent Plasma. 2020 [cited 2020 Apr 6]. Available from: https://www.
fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/investigational-covid-19-
convalescent-plasma-emergency-inds
44. Shen C, Wang Z, Zhao F, Yang Y, Li J, Yuan J, et al. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA.
2020 Mar. https://doi.org/10.1001/jama.2020.4783
45. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent
Assoc. 2004 Apr;135(4):429-37. https://doi.org/10.14219/jada.archive.2004.0207
46. 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 Feb;12(1):8. https://doi.org/10.1038/s41368-020-0074-x
47. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel
coronavirus (SARS-CoV2). Science. 2020 Mar;eabb3221. https://doi.org/10.1126/science.abb3221
48. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-
Infected Pneumonia in Wuhan, China. JAMA. 2020 Feb;323(11):1061. https://doi.org/10.1001/jama.2020.1585
49. Sun Y, Koh V, Marimuthu K, Ng OT, Young B, Vasoo S, et al. Epidemiological and clinical predictors of COVID-19. Clin Infect Dis. 2020
Mar:ciaa322. https://doi.org/10.1093/cid/ciaa322
50. Lee Y, Kang BH, Kang M, Chung DR, Yi GS, Lee LP, et al. Nanoplasmonic on-chip PCR for rapid precision molecular diagnostics. ACS
Appl Mater Interfaces. 2020 Mar;12(11):12533-40. https://doi.org/10.1021/acsami.9b23591
51. Li Z, Yi Y, Luo X, Xiong N, Liu Y, Li S, et al. Development and clinical application of a rapid IgM-IgG combined antibody test for SARS-
CoV-2 infection diagnosis. J Med Virol. 2020 Feb:jmv.25727. https://doi.org/10.1002/jmv.25727
52. Centers of Disease Control and Prevention – CDC. How TB Spreads. 2020 [Cited 2020 Apr 6]. Available from:
https://www.cdc.gov/tb/topic/basics/howtbspreads.htm.evention.
53. Centers of Disease Control and Prevention – CDC. Transmission of measles. 2020 [cited 2020 Apr 6]. Available from:
https://www.cdc.gov/measles/transmission.html
54. Centers of Disease Control and Prevention – CDC. Hepatitis B questions and answers for health professionals. 2020 [cited 2020 Apr 6].
Available from: https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#treatmenthttps://www.cdc.gov/measles/transmission.html
55. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J, Bania J, et al. The positive impact of lockdown in Wuhan on containing the
COVID-19 outbreak in China. J Travel Med. 2020 Mar:taaa037. https://doi.org/10.1093/jtm/taaa037
56. Ma QX, Shan H, Zhang HL, Li GM, Yang RM, Chen JM. Potential utilities of mask-wearing and instant hand hygiene for fighting
SARS-CoV-2. J Med Virol. 2020 Mar: https://doi.org/10.1002/jmv.25805
57. Pan X, Ojcius DM, Gao T, Li Z, Pan C, Pan C. Lessons learned from the 2019-nCoV epidemic on prevention of future infectious diseases.
Microbes Infect. 2020 Mar;22(2):86-91. https://doi.org/10.1016/j.micinf.2020.02.004
58. Kraemer MUG, Yang C-H, Gutierrez B, Wu C-H, Klein B, Pigott DM, et al. The effect of human mobility and control measures on the
COVID-19 epidemic in China. Science. 2020;4218(March):eabb4218. https://doi.org/10.1126/science.abb4218
59. Tan CC. SARS in Singapore: key lessons from an epidemic. Ann Acad Med Singapore. 2006 May;35(5):345-9.
60. Koo JR, Cook AR, Park M, Sun Y, Sun H, Lim JT, et al. Articles Interventions to mitigate early spread of SARS-CoV-2 in Singapore: a
modelling study. Lancet Infect Dis. 2020;3099(20):1-11. https://doi.org/10.1016/S1473-3099(20)30162-6
61. Kharma MY, Alalwani MS, Amer MF, Tarakji B, Aws G. Assessment of the awareness level of dental students
toward Middle East Respiratory Syndrome-coronavirus. J Int Soc Prev Community Dent. 2015 May-Jun;5(3):163-9.
https://doi.org/10.4103/2231-0762.159951
62. Centers of Disease Control and Prevention – CDC. Aerosols | NIOSH | CDC. 2020 [cited 2020 Apr 6]. Available from:
https://www.cdc.gov/niosh/topics/aerosols/
63. World Health Organization – WHO. Modes of transmission of virus causing COVID-19: implications for IPC precaution
recommendations. 2020 [cited 2020 Apr 6]. Available from: https://www.who.int/news-room/commentaries/detail/modes-of-
transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
64. American Dentistry Association – ADA. ADA interim guidance for minimizing risk of COVID-19 transmission. 2020 [cited 2020 Apr 1].
Available from: https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf
65. Centers of Disease Control and Prevention – CDC. Coronavirus and travel in the United States. 2020 [cited 2020 Apr 6]. Available from:
https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-in-the-us.html
66. Centers of Disease Control and Prevention – CDC. Travelers returning from international travel. 2020 [cited 2020 Apr 6]. Available from:
https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html

10 Braz. Oral Res. 2020;34:e041

 Pereira LJ, Pereira CV, Murata RM, Pardi V, Pereira-Dourado SM

67. NHS. NHS England and NHS Improvement. Issue 3, Preparedness letter for primary dental care. 2020 Mar 25 [cited 2020 Apr 2].
Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/issue-3-preparedness-letter-for-
primary-dental-care-25-march-2020.pdf
68. American Dentistry Association – ADA. What constitutes a dental emergency? 2020 [cited 2020 Apr 6]. Available from: https://success.
ada.org/~/media/CPS/Files/OpenFiles/ADA_COVID19_Dental_Emergency_DDS.pdf?utm_source=adaorg&utm_medium=covid-
resources-lp&utm_content=cv-pm-emerg-def&utm_campaign=covid-19&_ga=2.171390569.899008890.1586126066-
1720481024.1573059269
69. Mallineni SK, Innes NP, Raggio DP, Araujo MP, Robertson MD, Jayaraman J. Coronavirus disease (COVID-19): characteristics in children
and considerations for Dentists providing their care. Int J Paediatr Dent. 2020 Apr. https://doi.org/10.1111/ipd.12653
70. Cheng H, Wang Y, Wang GQ. Organ-protective effect of angiotensin-converting enzyme 2 and its effect on the prognosis of COVID-19.
J Med Virol. 2020 Mar. https://doi.org/10.1002/jmv.25785
71. Wright JH, Caudill R. Remote treatment delivery in response to the COVID-19 Pandemic. Psychother Psychosom. 2020 Mar;1-3:1-3.
https://doi.org/10.1159/000507376
72. GSMA. The mobile economy 2020. London: GSMA, 2020 [cited 2020 Apr 10]. Available from: https://www.gsma.com/mobileeconomy/
wp-content/uploads/2020/03/GSMA_MobileEconomy2020_Global.pdf
73. Ryan-Pettes SR, Lange LL, Magnuson KI. Mobile phone access and preference for technology-assisted aftercare among low-income
caregivers of teens enrolled in outpatient substance use treatment: questionnaire study. JMIR Mhealth Uhealth. 2019 Sep;7(9):e12407.
https://doi.org/10.2196/12407
74. Willcox M, Moorthy A, Mohan D, Romano K, Hutchful D, Mehl G, et al. Mobile technology for community health in Ghana: is maternal
messaging and provider use of technology cost-effective in improving maternal and child health outcomes at scale? J Med Internet Res.
2019 Feb;21(2):e11268. https://doi.org/10.2196/11268
75. Pattnaik A, Mohan D, Chipokosa S, Wachepa S, Katengeza H, Misomali A, et al. Testing the validity and feasibility of using a mobile
phone-based method to assess the strength of implementation of family planning programs in Malawi. BMC Health Serv Res. 2020
Mar;20(1):221. https://doi.org/10.1186/s12913-020-5066-1
76. Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 outbreak: an overview on dentistry. Int J Environ Res Public Health. 2020
Mar;17(6):E2094. https://doi.org/10.3390/ijerph17062094
77. European Federation of Journalists – EFJ. COVID-19: It is time to guarantee social security for all. 2020 [cited 2020 Apr 6]. Available
from: https://europeanjournalists.org/blog/2020/03/23/covid-19-it-is-time-to-guarantee-social-security-for-all/

Braz. Oral Res. 2020;34:e041 11

Putrino et al. BMC Oral Health (2020) 20:200
https://doi.org/10.1186/s12903-020-01187-3

RESEARCH ARTICLE Open Access

Coronavirus (COVID-19) in Italy: knowledge,

management of patients and clinical
experience of Italian dentists during the
spread of contagion
Alessandra Putrino1* , Mario Raso2, Cosimo Magazzino3 and Gabriella Galluccio4

Abstract
Background: The coronavirus infection that emerged in China in the last few months of 2019 has now spread
globally. Italy registered its first case in the second half of February, and in a short time period, it became the top
country in Europe in terms of the number of infected people and the first in the world in terms of deaths. The
medical and scientific community has been called upon to manage the emergency and to take measures. Dentists
also need to take new precautions during their clinical activity to protect themselves, coworkers and patients from
the risks of contagion and to avoid further spread of infection.
Methods: Following the data published in the international literature as well as the guidelines and directives
constantly updated by the WHO and by the national health authorities, a questionnaire to be completed
anonymously was submitted online to Italian dentists using social tools and online professional platforms. The
collected data were processed statistically, providing descriptive data and analysis of correlations of the most
significant parameters using the Pearson’s χ2, the Likelihood-Ratio χ2, Cramér’s V, Fisher’s exact test, Goodman and
Kruskal’s γ, and Kendall’s τb (p < 0.05).
Results: A total of 535 dentists from Italy participated in the survey. A good level of scientific knowledge about
coronavirus and the extra precautionary measures needed to limit the spread was related to the age of
respondents and their sex. Coming from areas with higher concentrations of cases affected knowledge, level of
attention and perception of risk related to dental activity.
Conclusions: At the moment, there are no therapies or vaccines to contain the infection with the new coronavirus
that is causing many infections, many of which are fatal, worldwide. Dentists are one of the categories at highest
risk of encountering diseases and infections because they work in close proximity with patients, and in their
procedures, there is always contact with aerosols with high bacterial and viral potential. Therefore, during this
COVID-19 emergency, it is important that dentists are properly informed and take the appropriate precautionary
measures.
Keywords: 2019 novel coronavirus, COVID-19, Dentistry, Health management, Knowledge, Survey

* Correspondence: alessandra.putrino@gmail.com
1
Advanced Training Course in Risk Management in Healthcare and
Professional Responsibility, University “Sapienza” of Rome, Piazzale Aldo Moro
5, 00185 Rome, Italy
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Putrino et al. BMC Oral Health (2020) 20:200
Background
Human coronaviruses are a group of RNA viruses able
to cause respiratory, gastrointestinal and central nervous
system diseases. The first human coronavirus (HCoV)
was detected in the mid-1960s [1]. In December 2019,
the seventh coronavirus known to infect humans was
found in China (Wuhan city, Hubei Province) [2]. On 12
January 2020, the World Health Organization (WHO)
announced the temporarily named nCoV-2019, now
called SARS-CoV-2, as the novel coronavirus pathogen
responsible for the increasing number of new pneumo-
nia cases [3, 4]. Since that day, the number of cases in
China and progressively in many other parts of the
world has increased (Fig. 1), and with it, the number of
people who died because of this infection as the primary
or contributory cause of preexisting illness [5]. On 11
March 2020, the WHO stated that the novel coronavirus
outbreak was a pandemic (Fig. 2). The scientific commu-
nity is still making numerous efforts to clarify the eti-
ology, pathogenicity, and characteristics of the virus to
establish the mechanisms underlying human-to-human
transmission and possible treatments [6–10]. Although
Fig. 1 Confirmed cumulative cases. Data Source: World Health Organization. Updated to March 28th 2020
Page 2 of 15
there are many cases of recovery, the number of de-
ceased subjects has increased with the spread, particu-
larly affecting older subjects with previous severe
pathologies [11, 12]. The first detection of the virus in
Italy was in a case of two Chinese tourists from Wuhan
who were later treated at the Spallanzani Hospital of
Rome. The entire tourist group of the Chinese couple
was then quarantined for two weeks in the same hospital
and then released after negative results of the clinical
and serologic controls [13].
On 21 February, the first locally transmitted case, a
38-year-old man who never travelled in China, emerged
in northern Italy, Lombardy region, Codogno town, and
since then, the number of cases has increased (Fig. 3) in
the whole area and progressively increased in many
other northern regions until the virus has spread to
affect the entire Italian territory. As the number of swab
tests for suspected cases has continued to increase, the
Italian authorities have started to adopt preventive mea-
sures to try to isolate the affected areas and block the
spread of the infections and a nationwide lockdown
went into effect on 10 March. The death toll, at the
Putrino et al. BMC Oral Health (2020) 20:200 Page 3 of 15

Fig. 2 Confirmed cumulative cases by country. Data Source: World Health Organization. Updated to March 28th 2020

Fig. 3 Trend of confirmed cases in Italy. Data Source: Italian Civil Protection Department. Updated to 28th March 2020
Putrino et al. BMC Oral Health (2020) 20:200 Page 4 of 15

Table 1 COVID-19 National trend updated to: March 28th 2020 a

REGIONS CONFIRMED CASES RECOVERED CASES DEATHS TOTAL CASES SWAB TESTS
Lombardy 24.509 8.962 5.944 39.415 102.503
Emilia-Romagna 9.964 1.075 1.344 12.383 52.991
Veneto 6.913 655 362 7.930 89.380
Piedmont 6.851 203 617 7.671 21.511
Tuscany 3.511 108 198 3.817 25.613
Marche 2.999 10 364 3.373 9.884
Lazio 2.181 200 124 2.505 27.179
Trentino-Alto Adige 2.163 267 184 2.614 14.729
Liguria 2.086 378 358 2.822 8.177
Campania 1.407 76 109 1.592 10.616
Apulia 1.358 29 71 1.458 11.500
Sicily 1.242 60 57 1.359 13.096
Friuli-Venezia Giulia 1.120 229 87 1.436 12.723
Abruzzi 1.027 30 76 1.133 7.003
Umbria 898 43 28 969 7.028
Sardinia 569 29 26 624 4.225
Calabria 523 11 21 555 7.760
Valle d’Aosta 468 2 41 511 1.380
Basilicata 178 1 3 182 1.421
Molise 98 16 9 123 807
Total 70.065 12.384 10.023 92.472 429.526
a
data source: Italian Civil Protection Department- Ministry of Health

moment, has reached 10,023 persons (mostly elderly
people with other preexisting diseases), and the number of
infected cases is greater than 70,065, with 12,384 recov-
ered (Table 1). Italian government, the Ministry of Health,
Civil Protection and other competent bodies at the local
level are constantly engaging in this emergency, providing
instructions to citizens and health workers and updating
the population on the evolution of the situation [14–17].
Even dentists have been involved in the management of
this emergency through indications on prevention and
safety measures to be observed in their clinical activity
due to the high level of exposure for operators and dental
patients. In the last weeks the number of health workers
infected has risen: many nurses and doctors on the cor-
onavirus front lines are working without adequate per-
sonal protective equipment (PPE), exposing themselves to
great risk and some of them have been infected while on
duty. Already, 50 doctors have died, and 4 of them were
dentists [18]. A direct correlation between their death and
coronavirus infection was not, however, ascertained but
many of them were engaged in the management of infec-
tions. The novel coronavirus was recently identified in the
saliva of infected patients. Dental clinical procedures gen-
erate droplets and aerosols that can lead to viral transmis-
sion [19]. Contamination on surfaces and diffusion by
contact, conceivable due to the characteristics of dental
activity, require a great deal of attention from dentists,
who should adopt simple but effective practical strategies
to stop the possible spread of the virus. The suggested
procedures include preappointment patient risk evaluation
through a specific questionnaire; frequent hand hygiene;
appropriate individual protective equipment; insulation of
the oral cavity with a rubber dam after mouth rinses,
which are suggested with peroxide 3%; the use of antire-
traction handpieces; disinfection after every dental treat-
ment; and appropriate waste management [20]. In Italy
there are more than 58,000 dentists (about 1 per
1000 inhabitants), differently distributed at the re-
gional level (Table 2). The management of dental ac-
tivity can play an important role in limiting the
infections. Due to the increasing involvement of a
large part of the population in the global epidemic
situation in Italy, the present study aimed to assess
the knowledge about the new coronavirus, the percep-
tion of risk and the clinical management of the risk
related to infection during the first month of the Ital-
ian epidemic in an online survey of Italian dentists.
Moreover, due to the rapid change in the number of
infected individuals, a further analysis aimed to evalu-
ate the progressive perception of the risks.
Putrino et al. BMC Oral Health (2020) 20:200 Page 5 of 15

Table 2 Distribution of dentists in Italy by Region

Regions Number of Dentists Percentages Population Inhabitants/Dentist rate number Dentist number for 1000 inhabitants
Piedmont 4.64 7,33 4.457.335 1.045 1,0
Valle d’Aosta 79 0,14 128.230 1.623 0,6
Lombardy 9.807 16,85 9.917.714 1.011 1,0
Trentino A.A. 827 1,42 1.037.114 1.254 0,8
Veneto 4.464 7,67 4.937.854 1.106 0,9
Friuli V.G. 1.539 2,64 1.235.808 803 1,2
Liguria 2.108 3,62 1.616.788 767 1,3
Emilia-Romagna 4.366 7,50 4.432.418 1.015 1,0
Tuscany 3.948 6,78 3.749.813 950 1,1
Umbria 945 1,62 906.486 959 1,0
Marche 1.839 3,16 1.565.335 851 1,2
Lazio 6.419 11,03 5.728.688 892 1,1
Abruzzi 1.199 2,06 1.342.366 1.120 0,9
Molise 303 0,52 319.780 1.055 0,9
Campania 4.779 8,21 5.834.056 1.221 0,8
Apulia 3.494 6,00 4.091.259 1.171 0,9
Basilicata 418 0,72 587.517 1.406 0,7
Calabria 1.883 3,24 2.011.395 1.068 0,9
Sicily 3.973 6,83 5.051.075 1.271 0,8
Sardinia 1.549 2,66 1.675.411 1.082 0,9
Total 58.203 100,0 60.626.442 1.042 1,0

Methods The generated link was shared on professional group

This study used a questionnaire-based survey. The ori-
ginal version of the survey was piloted among a group of
dentists to ensure suitability, validity, practicability and
interpretation of answers. On the basis of the comments
and suggestions obtained, the questionnaire was revised.
The questionnaire was developed and forwarded to ital-
ian dentists in Italian and translated into English for the
presentation of this research (Supplementary file 1). Sci-
entific bases for the development of questions about the
new coronavirus came from consultation of the scientific
literature available on this subject, more specifically ad-
dressed to virologists, specialists, biologists, and general
practitioners and epidemiological content that traced the
data on coronavirus infection since its first appearance
in China [2–10].
Additionally, as a source of scientific information and
as an aid for the processing of a part of the question-
naire presented to Italian dentists, circulars issued by the
Ministry of Health containing protocols and guidelines
aimed at health professionals during the outbreak and
informative material disclosed by dental associations
were also considered.
The questionnaire was uploaded online to the free sur-
vey platform Survio.com (© Survio, Hlinky 70, Brno,
Czech Republic) through a specially created user profile.
and contact networks on the main social channels (Lin-
kedIn, Facebook, and WhatsApp), inviting Italian den-
tists to share the link with other colleagues in further
professional groups to widen the spread of the survey as
much as possible. The assurance that those who would
respond to the survey were regular dentists was given by
the fact that all online professional groups and networks,
of which none of the Authors are an administrator, re-
ferred to (also for the dissemination of the question-
naire) by regulation are closed and approve registrations
only when the registration number of the national pro-
fessional register is originally provided. The responses
were validated only for fully completed questionnaires,
in fact the system automatically rejected incomplete
questionnaires.
The data collected were absolutely anonymous, and
tracing the identity of the subjects was not possible.
A total of 24 open- and close-ended questions were
developed (Table 3). Seven questions helped to obtain a
profile of the practitioner (age group; sex; type of clinical
activity-private, hospital or both; qualification-specialist
or not; territorial provenance-specifying region; the
number of citizens of their city; and the number of pa-
tients treated daily). Six questions were intended to
evaluate the direct influence of the coronavirus epidemic
Putrino et al. BMC Oral Health (2020) 20:200 Page 6 of 15

Table 3 Questionnaire and results

QUESTIONS AND ANSWERS RESULTS
1. Where do you work? (Choose an answer)
A) In a private dental office 416 77.8%
B) In a public hospital 18 3.4%
C) Both 101 18.9%
2. Which age group do you belong to? (Choose an answer)
A) Up to 35 years 174 32.5%
B) From 36 to 45 years old 146 27.3%
C) From 46 to 60 years old 179 33.5%
D) Over 60 36 6.7%
3. Are you a man or a woman? (Choose an answer)
A) Man 261 48.8%
B) Woman 274 51.2%
4. Are you a specialist? (Choose an answer)
A) Yes, in orthodontics 90 16.8%
B) Yes, in oral surgery 62 11.6%
C) Yes, in paediatric dentistry 9 1.7%
D) No 224 41.9%
E) No, but I predominantly practice a specific branch (e.g. implantprosthesis, endodontics, etc.) 150 28.0%
5. In your region (the one where you practice your professional activity) there
have been cases of Coronavirus infection? (Choose an answer)
A) Yes 374 69.9%
B) No 161 30.1%
6. In which region do you exercise your professional activity? (Open answer)
Results
detailed in
Fig.4
7. How many inhabitants are there in your city? (Choose an answer)
A) Less than 10,000 58 10.8%
B) 10,001 to 330,000 217 40.6%
C) Between 330,001 and 660,000 82 15.3%
D) Between 660,001 and 1 million 46 8,6%
E) Over 1 million 132 24.7%
8. How many patients attend your practice every day? (Choose an answer)
A) Less than 10 101 18.9%
B) No more than 10 172 32.1%
C) Beyond 10 262 49.0%
9. Since the Coronavirus outbreak, have you noticed a decrease in access to your dental office or public hospital you work in? (Choose an answer)
A) Yes 94 17.6%
B) No 270 50.5%
C) Yes, only after the spread of cases in our Country 122 22.8%
D) I don’t know 49 9.2%
10. From a scientific point of view, how much do you think you are informed about Coronavirus? (Choose an answer)
A) Not at all 5 0.9%
B) Little 78 14.6%
C) Enough, I think I’m sucly informed 250 46.7%
Putrino et al. BMC Oral Health (2020) 20:200 Page 7 of 15

Table 3 Questionnaire and results (Continued)

QUESTIONS AND ANSWERS RESULTS
D) Very, I think I am properly informed 152 28.4%
E) Very much, my knowledge on the topic is going hand in hand with updates from the international community 50 9.3%
11. How did you get the scientific informations about Coronavirus? (Choose one or more answers)
A) Television, online and/or print newspapers and social media 220 20.8%
B) Institutions (Minister of Health, Italian Government, Order of Physicians, etc.) 398 37.6%
C) Other colleagues 78 7.3%
D) Scientific literature 171 16.1%
E) Professional associations 180 17.0%
F) Other 8 0.8%
G) I am not informed 2 0.2%
12. Coronaviruses are a large family of viruses, known to infect both humans and some animals, whose primary target cells are those epithelial of the
respiratory and gastrointestinal tract.
How do you judge this statement? (Choose an answer)
A) True 390 72.9%
B) False 88 16.4%
C) I don’t know 57 10.7%
13. What does nCov mean? (Choose an answer)
A) A strain of coronavirus that had not previously been identical in humans 338 63.2%
B) The virus of the common cold 29 5.4%
C) The SARS virus 51 9.5%
D) I don’t know 117 21.9%
14. Is the SARS-Cov-2 virus causing the current coronavirus outbreak? (Choose an answer)
A) No it’s the SARS virus name only 120 22.4%
B) Yes, and it belongs to the same family of acute respiratory syndrome (SARS) virus 90 16.8%
C) Yes, and can also be named 2019-nCov 56 10.5%
D) Answers B and C are correct 236 44.1%
E) none of the previous 33 6.2%
15. What does COVID-19 mean? (Choose an answer)
A) The virus that causes the current outbreak 366 68.4%
B) The disease caused by the new coronavirus 143 26.7%
C) The drug used to treat infected patients 2 0.4%
D) None of the previous answers 24 4.5%
16. What are the most common symptoms in current coronavirus infection? (Choose an answer)
A) Just colds and coughs 2 0.4%
B) Fever, cough and respiratory difficulties 53 9.9%
C) From mild symptoms such as colds, sore throats, fever, muscle aches, coughs to more severe symptoms such as respiratory 463 86.5%
difficulties and pneumonia
D) Fever and pneumonia 16 3.0%
E) None of the above answers 1 0.2%
17. How is the new Coronavirus transmitted from person to person? (Choose an answer)
A) Only through saliva 3 0.6%
B) Through saliva, coughing, sneezing, contaminated hands 169 31.6%
C) Through direct personal contact with infected people 36 6.7%
D) None of the previous answers 1 0.2%
E) Options B and C are correct 326 60.9%
Putrino et al. BMC Oral Health (2020) 20:200 Page 8 of 15

Table 3 Questionnaire and results (Continued)

QUESTIONS AND ANSWERS RESULTS
18. Are you aware of the existence of a free online course on Coronavirus available to all medical and dental operators promoted by Fnomceo
(National Federation of Surgeons and Dentists)? (Choose an answer)
A) Yes and I’ve already done it 31 5.8%
B) Yes, I will 142 26.5%
C) Yes, but I don’t think I do 24 4.5%
D) No, I didn’t know it now and I will 284 53.1%
E) No, I didn’t know but I don’t think I do 54 10.1%
19. Did your patients ask you questions about Coronavirus? (Choose an answer)
A) Yes 349 65.2%
B) No 186 34.8%
20. Do patients seem concerned about the possibility of receiving dental visits/treatments safely? (Choose an answer)
A) Yes 207 38.7%
B) No 328 61.3%
21. Since the spread of Coronavirus in our Country have you taken precautions or taken special measures during the course of the professional
activity? (Choose an answer)
A) Yes 369 69.0%
B) No 166 31.0%
22. Which of these prevention methods are you possibly adopting? (Choose one or more answers)
A) Air exchange always between patients and periodically also in the waiting room 177 14.9%
B) In the history include informations about symptoms compatible with infection or recent trips to areas affected by contagion or 118 10.0%
frequenting with people from those areas (recommended by phone)
C) Constant use of IPR (individual protective devices) by all dental office/hospital staff 218 18.4%
D) Frequent hand and cleaning of the contact surfaces (e.g. handles or buttons) 234 19.7%
E) Alcohol disinfectant available to patients and carers for hand cleaning at the entrance 115 9.7%
F) All previous 300 25.3%
G) None of the previous 14 1.2%
H) Other 9 0.8%
23. How concerned are you about the spread of Coronavirus infection in our country? (Choose an answer)
A) Not at all 8 1.5%
B) Little 125 23.4%
C) Enough 270 50.5%
D) Very 89 16.6%
E) Very much 43 8.0%
24. One last question... Do you think that dental activity can be considered safe and free from the risk of contagion and spread of the virus for
operators and patients? (Choose an answer)
A) Yes 67 12.5%
B) No 468 87.5%

on the dentist’s clinical activity (presence or absence of
infected cases in their region; questions of patients about
coronavirus; patients appearing to be worried or not
about possible infections with coronavirus during dental
procedures; effective decrease or not in patient appoint-
ment number since the coronavirus outbreak onset;
adoption of special measures taken during professional
activity since the coronavirus emergency started in Italy;
and which prevention methods are possibly used).
The remaining eleven questions aimed to assess the
level of scientific knowledge on coronavirus from a
qualitative point of view and the dentist’s perception of
the problem related to this emergency in dental clinical
practice.
Each respondent to the questionnaire corresponded to
a form with all answers provided. The subjects were an-
onymous and were marked only with a number that
reflected the chronological order of compilation. The
Putrino et al. BMC Oral Health (2020) 20:200
form showed the day and time when the questionnaire
was completed.
The project did not need formal ethical approval
since it collected general opinions that do not con-
tain clinical data and neither personal data. Accord-
ing to the current Regulation of the Ethics
Committee of the Higher Institute of Health (Istituto
Superiore di Sanità), the ethical aspects that need
evaluation, approval and monitoring of trial proto-
cols relate to epidemiological, evaluation and
medical-social projects that require the collection of
personal data. According to the National Data Pro-
tection Authority (Garante per la Protezione dei Dati
Personali), “personal data” are first and last name,
images, tax code, IP address and license plate num-
ber. The compilation of the survey was anonymously
carried out on a voluntary basis without the possibil-
ity to trace the identity of the subjects, as the system
does not store even the IP addresses of the users
accessing the link. Before the start of the survey, in-
formed consent was presented on the main page; the
participant had to agree (by checking a box) that
their anonymously provided answers could be used
in this research for scientific purposes.
For statistical examination of the data, the online plat-
form automatically generated descriptive statistical ana-
lysis on the main page; the analysis could therefore be
downloaded as an Excel or SPSS spreadsheet for further
statistical analysis. In this study, descriptive statistical
analysis was carried out. Several measures of association
was performed including, the common Pearson’s χ2, the
Likelihood-Ratio χ2, Cramér’s V, Fisher’s exact test,
Goodman and Kruskal’s γ, and Kendall’s τb. The level of
statistical significance was set at 0.05. The software used
is STATA 15.1 (StataCorp LLC, TX, USA).
The Pearson’s and Likelihood-Ratio χ2 test for the in-
dependence of the rows and columns. The null hypoth-
esis (H0) is that there is no relationship. To reject this
we need a P < 0.05 (at 95% confidence).
Cramér’s V is a measure of association between
two nominal variables. It goes from 0 to 1, where 1
indicates strong association. γ and τb are measures
of association between two ordinal variables (both
have to be in the same direction, i.e. negative to
positive, low to high). Both go from − 1 to 1. Nega-
tive shows inverse relationship, closer to 1 a strong
relationship. γ is recommended when there are lots
of ties in the data. τb is recommended for square
tables.
Fisher’s exact test is used when there are very few
cases in the cells (usually less than 5, with an overall fre-
quency of less than 20%). It tests the relationship be-
tween two variables. The null is that variables are
independent [21–25].
Page 9 of 15
Results
The survey was online for 3 weeks from 23 February
2020 to 15 March 2020. The link received 795 visits, but
only 535 dentists responded to the survey by completing
it. The results of the descriptive statistics were collected
in Table 3.
Most dentists carried out their professional activity in
a private practice (77.8%).The age group of up to 35
years old (yo) and the group between 46 and 60 yo were
the most represented (respectively, between 32.5 and
33.5%). The distribution between the two sexes was
equivalent (48.8% males and 51.2% females).
Over 41.9% of dentists were General Dentists, 28% are
Dentists without a recognized dental specialty (Italian
Universities provide 3 years of postgraduate programs in
Orthodontics, Oral Surgery and Pediatric Dentistry.
They are the only recognized Dental Specialties) and
30.8% are Dental Specialists (16.8% were orthodontists,
approximately 12% were oral surgeons, and just over 2%
were specialists in pediatric dentistry).
The answers related to the geographical location of
the workplace mapped across the whole country, repre-
senting Italy from north to south and including the lar-
ger islands (Sicily and Sardinia) (Fig. 4).
Most of the respondents (40.6%) were from moder-
ately or highly populated cities. Fourty 9 % of the den-
tists who participated in the survey treat more than 10
patients per day. Almost 70 % of dentists completed the
questionnaire when there were positive cases in their re-
gion of SARS-CoV-2 infection.
Fifty percent of respondents did not notice a decrease
in visits since the outbreak spread. More than 65% of pa-
tients asked questions about coronavirus to their dentist.
According to the clinicians who participated in the
study, the majority of patients (more than 61%) would
not be worried about getting coronavirus infection dur-
ing dental treatment.
Almost 47% of dentists said they were fairly informed
about coronavirus. Despite of the self-estimated know-
ledge about the infection, answers to the following ques-
tions assessing knowledge on the subject revealed a
different reality. Most respondents obtained scientific in-
formation about coronavirus through Italian institutions
(37.6%); television, newspapers and social media (20.8%);
professional associations (17%); scientific literature
(l6.1%); and other colleagues (7.3%). Only a very small
percentage (0.8%) specified other channels of informa-
tion or that they were not fully informed (0.2%).
Almost 73% correctly answered the questions about
the definition of coronavirus, the 63.2% correctly an-
swered about nCoV and 44.1% about SARS-CoV-2.
Most respondents, on the other hand, incorrectly an-
swered the question on the definition of COVID-19 (al-
most 69%).
Putrino et al. BMC Oral Health (2020) 20:200
Fig. 4 The rectangles with the names of the different regions of Italy are accompanied by the number of dentists who participated in the survey.
The color scale distinguishes the different distribution of confirmed cases (data source: Italian Civil Protection, updated to March 28th 2020)
Almost 87% of the subjects were very clear about the
types of possible symptoms that accompany the infec-
tion, and in 60.9% of cases, they correctly indicated how
the new coronavirus is transmitted from person to
person.
However, the 63.2% of dentists knew that the National
Federation of Surgeons and Dentists (Federazione
Nazionale dei Medici Chirurghi ed. Odontoiatri-
FNOMCEO) has provided healthcare professionals with
a free online course to disseminate useful information
about the virus.
Sixty nine percent of dentists who completed the ques-
tionnaire had taken safety and prevention measures
against workplace infection since coronavirus spread. Al-
most 26% of them had taken all the recommended safety
measures (telephone history collection, increased fre-
quency of washing hands and environmental surfaces,
and personal protective equipment such as gloves, dis-
posable gowns and facemasks with adequate filters).
Fifty point 5 % of respondents were concerned
‘enough’ about the spread of infection in Italy. Overall,
almost 88% of dentists who took part in the survey
Page 10 of 15
considered the dental profession neither safe nor free
from the risk of contagion for both patients and health-
care professionals.
The measures of association results were collected in
Tables 4, 5 and 6. In regards to the sex (Table 4), both
χ2 test statistics show a significance level < 0.05 for qual-
ity of information (question number 10), level of infor-
mation related to questions 12 and 17 and for risk
perception related to question 23; so we can safely as-
sume that some differences exist between groups. There-
fore, we conclude that there is evidence of a statistically
significant difference between male and female on these
variables. We can confidently reject the null hypothesis
that these two variables are statistically independent in
that population. In other words, we can conclude that
there is some relationship between sex and each of these
four variables. In fact, for these variables the Cramér’s V
values are > 0.13, which indicates a non-negligible asso-
ciation. Moreover, the Goodman and Kruskal’s lambda
for the relationship between sex and level of information
related to question number 12, and sex and risk percep-
tion related to question 23 is > 0.22, in line with previous
Putrino et al. BMC Oral Health (2020) 20:200 Page 11 of 15

Table 4 Measures of association -gender

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb Fisher’s exact test
1. Gender- 9.6496** 9.8368** 0.1343 −0.0319 − 0.0185 (0.044)
QUALITY OF INFORMATION(10) (0.047) (0.043) (0.069) (0.040)
2. Gender- 3.8129 3.8238 0.0844 − 0.0871 −0.0491 (0.434)
LEVEL OF INFORMATION(18) (0.432) (0.430) (0.071) (0.040)
3. Gender- 9.2567*** 9.3697*** 0.1315 0.2681 0.1254 (0.010)
LEVEL OF INFORMATION(12) (0.010) (0.009) (0.086) (0.041)
4. Gender- 1.5626 1.5670 0.0540 −0.0029 −0.0015 (0.674)
LEVEL OF INFORMATION(13) (0.668) (0.667) (0.079) (0.041)
5. Gender- 0.7400 0.7403 0.0372 0.0243 0.0145 (0.947)
LEVEL OF INFORMATION(14) (0.946) (0.946) (0.066) (0.040)
6. Gender- 2.8786 3.6511 0.0734 0.0664 0.0318 (0.492)
LEVEL OF INFORMATION(15) (0.411) (0.302) (0.088) (0.042)
7. Gender- 5.1846 5.6270 0.0984 0.1794 0.0623 (0.190)
LEVEL OF INFORMATION(16) (0.269) (0.229) (0.121) (0.042)
8. Gender- 10.5200** 10.9648** 0.1402 −0.1012 −0.0523 (0.015)
LEVEL OF INFORMATION(17) (0.033) (0.027) (0.081) (0.042)
9. Gender- 1.7211 1.7214 −0.0567 −0.1221 − 0.0567 (0.192)
CORRECT RISK MANAGEMENT(22) (0.190) (0.190) (0.092) (0.043)
10. Gender- 24.9374*** 25.7561*** 0.2159 0.2272 0.1322 (0.000)
RISK PERCEPTION(23) (0.000) (0.000) (0.067) (0.040)
11. Gender- 1.2709 1.2717 0.0487 0.1466 0.0487 (0.296)
RISK PERCEPTION(24) (0.260) (0.259) (0.128) (0.043)
Notes: unequal variances assumed, after some checks. P-Values in parentheses. For Goodman-Kruskal’s γ and Kendall’s τ-b the Asymptotic Standard Errors (ASE)
are reported. p < 0.10, p < 0.05, p < 0.01

Table 5 Measures of association- age

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb Fisher’s exact test
12. Age- 39.3684*** 38.2612*** 0.1566 −0.0835 − 0.0580
QUALITY OF INFORMATION(10) (0.000) (0.000) (0.055) (0.038)
13. Age- 17.6918 18.1606 0.1050 −0.0814 −0.0547
LEVEL OF INFORMATION(18) (0.125) (0.111) (0.058) (0.039)
14. Age- 1.5170 1.5206 0.0377 −0.0131 −0.0072 (0.947)
LEVEL OF INFORMATION(12) (0.958) (0.958) (0.070) (0.039)
15. Age- 15.2818* 15.6249* 0.0976 −0.2079 −0.1289
LEVEL OF INFORMATION(13) (0.083) (0.075) (0.060) (0.038)
16. Age- 20.0687* 19.5222* 0.1118 −0.1332 −0.0948
LEVEL OF INFORMATION(14) (0.066) (0.077) (0.051) (0.036)
17. Age- 7.0758 7.9172 0.0664 0.1031 0.0588 (0.488)
LEVEL OF INFORMATION(15) (0.629) (0.543) (0.068) (0.039)
18. Age- 8.8334 10.1643 0.0742 0.0679 0.0280 (0.545)
LEVEL OF INFORMATION(16) (0.717) (0.602) (0.093) (0.038)
19. Age- 19.3533* 19.2796* 0.1098 0.0726 0.0446
LEVEL OF INFORMATION(17) (0.080) (0.082) (0.063) (0.039)
20. Age- 1.1150 1.1188 0.0457 −0.0303 −0.0166 (0.777)
CORRECT RISK MANAGEMENT(22) (0.773) (0.773) (0.072) (0.040)
21. Age- 13.6528 13.6826 0.0922 −0.0193 −0.0132
RISK PERCEPTION(23) (0.552) (0.550) (0.056) (0.038)
22. Age- 6.8839* 5.9705 0.1134 0.1004 0.0402 (0.093)
RISK PERCEPTION(24) (0.076) (0.113) (0.101) (0.041)
Notes: unequal variances assumed, after some checks. P-Values in parentheses. For Goodman-Kruskal’s γ and Kendall’s τ-b the Asymptotic Standard Errors (ASE)
are reported. p < 0.10, p < 0.05, p < 0.01
Putrino et al. BMC Oral Health (2020) 20:200 Page 12 of 15

Table 6 Measures of association- region

Pearson χ2 test LR χ2 test Cramér’s V Goodman-Kruskal’s γ Kendall’s τb
23. Region- 63.4819 68.3577 0.1722 −0.0254 −0.0197
QUALITY OF INFORMATION(10) (0.912) (0.820) (0.044) (0.034)
24. Region- 95.6957 99.0171* 0.2115 −0.0046 −0.0035
LEVEL OF INFORMATION(18) (0.111) (0.073) (0.047) (0.035)
25. Region- 43.3894 47.8005 0.2014 −0.0396 −0.0246
LEVEL OF INFORMATION(12) (0.329) (0.186) (0.055) (0.034)
26. Region- 88.8741*** 97.3943*** 0.2353 −0.0473 −0.0329
LEVEL OF INFORMATION(13) (0.009) (0.002) (0.049) (0.034)
27. Region- 114.5570*** 104.4948** 0.2314 0.0086 0.0068
LEVEL OF INFORMATION(14) (0.007) (0.034) (0.044) (0.035)
28. Region- 77.3373* 50.7542 0.2195 −0.0732 −0.0472
LEVEL OF INFORMATION(15) (0.065) (0.797) 0.058 (0.037)
29. Region- 77.2407 64.3017 0.1900 −0.0493 −0.0229
LEVEL OF INFORMATION(16) (0.567) (0.900) (0.081) (0.038)
30. Region- 76.1563 54.2159 0.1886 −0.0450 −0.0309
LEVEL OF INFORMATION(17) (0.601) (0.988) (0.053) (0.037)
31. Region- 42.1485*** 44.5656*** 0.2807 0.0276 0.0172
CORRECT RISK MANAGEMENT(22) (0.003) (0.001) (0.061) (0.038)
32. Region- 66.2305 68.6691 0.1574 0.0420 0.0322
RISK PERCEPTION(23) (0.996) (0.993) (0.045) (0.035)
33. Region- 23.0833 22.4473 0.2077 0.0816 0.0367
RISK PERCEPTION(24) (0.285) (0.317) (0.089) (0.040)
Notes: unequal variances assumed, after some checks. P-Values in parentheses. For Goodman-Kruskal’s γ and Kendall’s τ-b the Asymptotic Standard Errors (ASE)
are reported. p < 0.10, p < 0.05, p < 0.01

results. All these findings are confirmed by Fisher’s exact
test results, since in these four cases the hypothesis of
variables’ independence is rejected, and we conclude that
there is some kind of relationship between variables.
Concerning the age (Table 5), the Pearson and
Likelihood-Ratio χ2 tests present a P-Value < 0.05 only
for the relationship with the variable quality of informa-
tion (question number 10). We reject the null hypothesis
of no association at conventional level of statistical sig-
nificance, because it emerges a dependence of the rows
and columns. Thus, in this case we can conclude that
some differences emerge between groups. Moreover, in
this case Cramér’s V is > 0.15: there is a small but statis-
tically significant association between these variables.
If we consider the region (Table 6), the Pearson and
LR χ2 tests show a P-Value < 0.05 for level of informa-
tion related to questions number 13 and 14, and correct
risk management related to question number 22; there-
fore, we conclude that some relationship exists between
region and each of these three variables. Here, the Cra-
mér’s V are > 0.23, which indicate a statistically signifi-
cant association.
Discussion
Since SARS-CoV-2 can be transmitted from person to
person by droplets, contact and through saliva, dental
patients and dentists and their coworkers can be easily
exposed to novel coronavirus infections [19, 26, 27]. In
the period of contagion outbreak from the new corona-
virus, information about the virus has become increas-
ingly the subject of attention of the media, such as
television, the internet, and social channels. However, it
was only when the first cases began to register in Italy
that professional associations and dental professionals
began to take a deeper interest in the problem. Dental
professionals had to refer only to the official communi-
cation of the ministry, whose law decrees lacked specific
references to the dental profession.
Male dentists believed to be very well informed about
Coronavirus unlike female colleagues who had a more
cautious opinion on their knowledge of the subject
(Pearson χ2 test 9.6496- p 0.047; LR χ2 test 9.8368- p
0.043). Dentists between the ages of 46–60 believe they
were well informed compared to younger colleagues
who judged sufficient their knowledge (Pearson χ2 test
39.3684- p 0.000; LR χ2 test, 38.2612 –p 0.000). Male
dentists showed to have a significantly clearer idea of the
taxonomic characteristics of the virus (Pearson χ2 test
9.2567- p 0.010; LR χ2 test 9.3697- p 0.009). Most were
aware of the main features of coronaviruses but con-
fused the term COVID-19 with the virus itself (68.4%).
The definition of COVID-19 was provided more cor-
rectly by the dentists of Lazio, Lombardy, Emilia-
Romagna and Sicily but the same regions, with the ex-
ception of Sicily, reported the greatest number of incor-
rect answers (which overall exceeded the correct ones)
Putrino et al. BMC Oral Health (2020) 20:200
and attributed to this term the meaning of “virus that
causes the disease”(Pearson χ2 test 77.3373- p 0.065).
The question containing the request to identify the cor-
rect definition of COVID-19 was absolutely, among all
the questions in the questionnaire provided with the aim
of assessing scientific knowledge on the subject, the one
for which the largest number of wrong answers were
recorded.
In addition, most believed that the term SARS-CoV 2
is not related to the new coronavirus but is rather the
name of the SARS virus that caused an epidemic in
2002–2003 (22.4%). Dentists aged between 36 and 45
have identified the correct answer in a significantly
higher percentage than younger and older colleagues
(Pearson χ2 test 20.0687 - p 0.066; LR χ2 test, 19.5222
-p 0.077). Also on this definition, the dentists of Lazio
and Lombardy were those significantly better informed,
followed by their colleagues from Emilia-Romagna and
Campania (Pearson χ2 114.5570- p 0.007; LR χ2 test
104.4948- p 0.034).
The most informed dentists on the possibility to access
a free online course on the new Coronavirus promoted
by the FNOMCEO (National Federation of Surgeons
and Dentists) were those from Lazio, followed by those
from Lombardy, Sicily and Tuscany (LR χ2 test 99.0171-
p 0.073).
Quite important for the population and for the spread
of epidemics is the preventive approach of dentists. For
the possibilities of transmission from person to person,
most are properly informed (60.9%). Female dentists
were better informed on this aspect (Pearson χ2 test
10.5200- p 0.033; LR χ2 test 10.9648- p 0.027). Com-
pared to age, younger dentists were significantly better
informed about the transmission routes of the virus than
other age groups (Pearson χ2 test, 19.3533- p 0.080; LR
χ2 test 19.2796- p 0.082).
More than 87% of respondents to the survey were
aware of the wide variety of symptoms with which the
infection can occur, which is encouraging because it
means that a diagnostic suspicion and a report to the au-
thorities regulating the execution of swab tests of poten-
tially infected individuals can also be appropriately
carried out by a dentist. It is important to consider that
transmission may occur through asymptomatic patients
and that symptoms when COVID-19 is present can also
be mild and confused with a simple cold or flu [28]. Its
manifestation does not always culminate with severe
symptomatology accompanied by respiratory failure up
to interstitial pneumonia. The asymptomatic incubation
period takes approximately 1–14 days, and in these days,
persons without symptoms can spread the virus. For this
reason, it is important to add to the information re-
quired of the patient in the medical history, the report of
a possible contact with infected or potentially infected
Page 13 of 15
people or of trips to the areas where the infection has
spread. Many dentists (10%) who responded to the sur-
vey chose to ask this question of their patients, judging
it to be important. At the time of the virus’s main
spread, it was recommended to perform a telephone tri-
age even before seeing the patient to assess whether to
visit or to postpone the appointment.
At the time of the survey, performed between February
23rd and March 15th, just over 50% of dentists did not
notice a reduction in the number of visits despite the
spread of the virus. It must be specified that after two
weeks from the start of this research many work activ-
ities were suspended by the government by extraordin-
ary decree, but the clinical dental activity was allowed
only for the management of emergencies provided by
dentists equipped with adequate personal protective
equipment (PPE). The definition of “adequate PPE” for
dentists is a matter of debate because above all the surgi-
cal masks used routinely by dentists would not have suf-
ficient filters to protect from infection. The use of
facemasks with ffp2 or ffp3 filters, highly protective than
the surgical ones, does not seem to be considered neces-
sary for routine dental activity, even if this has not been
clearly said nor denied.
The absence of a sample calculation and the method-
ology used in the dissemination of the survey represent
limitations in this research. Anyway the distribution of
the respondents in the national territory was quite
homogenous (proportionate to the extension of the indi-
vidual regional territories) and the greatest proportion
came from medium-large cities. Although 65.2% of den-
tists said that patients have asked questions about cor-
onavirus, they agree that patients feeling worried about
contracting the infection through dental care has not
emerged (61.3%). Most of the dentists (69%) adopted
additional preventive practical measures, a sign of a
growing and widespread awareness (87.5%) of the risk of
contributing to the spread of contagion through dental
activity. There were regions where the number of den-
tists who claimed to have taken additional contagion
prevention measures during their clinical activity was
significantly higher than others. This was especially true
for regions such as Lazio, Lombardy, Emilia Romagna
and Campania. It is interesting to note that regions such
as Veneto which since the beginning of the spread of the
virus in Italy has been one of the first regions and
among the most affected had not the same attitude
(Pearson χ2 test, 42.1485- p 0.003; LR χ2 test 44.5656- p
0.001).
The female gender appeared significantly more con-
cerned than the male gender about the spread of Cor-
onavirus infection (Pearson χ2 test 24.9374- p 0.000; LR
χ2 test 25.7561, p 0.000). Dentists belonging to the
younger age groups were found to be much more
Putrino et al. BMC Oral Health (2020) 20:200
convinced than their older colleagues that this epidemic
has future repercussions on the dental profession as it is
not without risk (Pearson χ2 test, 6.8839- p 0.076).
Dental treatment procedures always involve close con-
tact with the patient, and this setup does not allow the
maintenance of an adequate safe distance. It is extremely
important that dentists equip themselves with appropri-
ate individual safety devices (masks, gloves, protective
goggles, hair caps and shirts). A recent article in the
New York Times, referring to the database “O’NET”
used by the Department of Labor to describe the various
physical aspects of different professions, highlighted that
the occupational categories in which you come into
physical contact with others are those where the risk of
COVID-19 is highest. Dentists are at the top of the rank-
ing for work-related risk [29]. In this survey, dentists af-
firmed the constant use of these safety devices as
prescribed by the Italian medical guidelines of safety in
workplaces [30]. When aerosol procedures are carried
out, the presence of saliva and blood increases the
spread of germs, bacteria and viruses. Ensuring a change
of air in the workplace and in the waiting room is a sim-
ple but important measure chosen by 14.9% of dentists
in this survey. This measure should always be adopted
by dentists and not only in this situation. Equally essen-
tial is to wash hands more frequently and disinfect them
with alcohol-based solutions. This provision should also
be encouraged for patients before entering the operating
dental unit. These recommendations, together with
those of not shaking hands with anyone, were accepted
by 9.7 and 19.7% of respondents, respectively. The data
that emerged on the cleansing measures also include the
cleaning of the clinical contact surfaces, such as buttons,
handles and work surfaces. Thorough cleaning has
proven to be a mandatory and indispensable choice for
prevention, as it is proven that the coronavirus family,
including SARS-CoV-2, can survive on plastic, metal
and glass surfaces for up to 9 days and can be efficiently
deactivated through disinfection procedures with 62–
71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium
hypochlorite within 1 min. The use of 0.05–0.2% ben-
zalkonium chloride or 0.02% chlorhexidine digluconate
does not have the same effectiveness [31]. It must be
said that the majority of dentists paid great attention to
the measures to be taken; indeed, 25.3% of them said
they had adopted all the preventive measures listed so
far.
Conclusions
This is the most severe epidemic that has hit Italy in the
past 100 years, and it will probably be one of the most
severe viral pandemics of modern times. As no specific
therapies are available at the moment for the new cor-
onavirus, prevention and early containment of further
Page 14 of 15
spread can be crucial to control the pandemic. For this
reason, dentists, similar to other medical practitioners,
aware of the risk associated with carrying out their pro-
fessional activity, at this moment limited to the manage-
ment of dental emergencies only, have the responsibility
in this situation to know the characteristics of the virus
through precise and accurate information and to assume
a careful and proactive attitude for the protection of
their patients and of their entire community, working in
the containment of this social emergency even if not dir-
ectly involved in the treatment of affected patients.
Dentists at this time, however, should only work if
they have the individual protective equipment recom-
mended to high-risk healthcare workers [32, 33]. After
the pandemic emergency when people’s professional ac-
tivities and lives can slowly return to normal, the experi-
ence and the not-quite-finished risk of a recurrence of
new cases of infection will require that dentists also fol-
low new health safety protocols whose definition will be
necessary.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12903-020-01187-3.
Additional file 1. “Questionnaire” contains the English version of the
questionnaire realized for the survey in this research.
Abbreviations
WHO: World Health Organization; PPE: Personal Protection Equipment
Acknowledgments
Not applicable.
Authors’ contributions
AP designed the study and was the major contributor to writing the
manuscript. MR coordinated the development of the online questionnaire,
data management and extrapolation. CM was responsible for statistical
analysis of the results. GG researched the bibliography sources and reviewed
the final manuscript. All authors read and approved the final manuscript.
Funding
No funding needed.
Availability of data and materials
The datasets used and/or analysed during the current study available from
the corresponding author on reasonable request.
Ethics approval and consent to participate
This research does not contain data require ethics approval. The current
Regulation of the Ethics Committee of the Higher Institute of Health (Istituto
Superiore di Sanità, Rome 12th May 2015) stipulates that projects with
epidemiological, medico-social and evaluative contents need evaluation, ap-
proval and monitoring of trial protocols only if they contain personal data
according to the legislative decrees on clinical trials and function of the eth-
ics committees (decreto legislativo 24 giugno 2003, n.211; decreto minister-
iale 8 febbraio 2013). The official definition of “personal data” is given by the
National Data Protection Authority (Garante per la Protezione dei Dati Perso-
nali, https://www.garanteprivacy.it/home/diritti/cosa-intendiamo-per-dati-per-
sonali – Regolamento (UE) 2016/679 art.9). The term “personal data” includes
information about first and last name, images, tax code, IP address and li-
cense plate number. The platform on which the anonymous questionnaire
was completed does not allow to trace the IP address of the person who
Putrino et al. BMC Oral Health (2020) 20:200
connected to the survey. Informed consent was presented on the main page
of the online platform used to complete the survey. Before the start of the
survey the participant had to accept and agree that filling out the questions
meant that his anonymously provided answers were used for the research
presented in the introduction.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Advanced Training Course in Risk Management in Healthcare and
Professional Responsibility, University “Sapienza” of Rome, Piazzale Aldo Moro
5, 00185 Rome, Italy. 2Italian Society for Applied and Industrial Mathematics
(SIMAI), Rome, Italy. 3Department of Political Sciences, University “Roma Tre”,
Rome, Italy. 4Department of Oral and Maxillofacial Sciences, University
“Sapienza”, Rome, Italy.
Received: 31 March 2020 Accepted: 1 July 2020
References
1. Hamre D, Procknow JJ. A new virus isolated from the human respiratory
tract. Exp Biol Med. 1966;121(1):190–3.
2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;S0140-
6736(20):30183–5.
3. World Health Organization (WHO). Coronavirus. https://www.who.int/health-
topics/coronavirus [Accessed 2020 Feb 19].
4. World Health Organization. (WHO. Novel Coronavirus (2019-nCoV). Situation
report–1. https://www.who.int/docs/default-source/coronaviruse/situation-
reports/20200121-sitrep-1-2019-ncov.pdf [Accessed 2020 Feb 19].
5. Centre for Health Protection. Severe respiratory disease associated with a
novel infectious agent-letters to doctors. https://www.chp.gov.hk/en/
miniweb/letters/100063.html [Accessed 2020 Feb 20].
6. Chan JF, Kok KH, Zhu Z, Chu H, KKW T, Yuan S, et al. Genomic
characterization of the 2019 novel human-pathogenic coronavirus isolated
from a patient with atypical pneumonia after visiting Wuhan. Emerg
Microbes Infect. 2020;9:221–36.
7. Chan JF, Yuan S, Kok KH, KKW T, Chu H, Yang J, et al. A familial cluster of
pneumonia associated with the 2019 Novel coronavirus indicating person-
to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):
469–70.
8. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia
outbreak associated with a new coronavirus of probable bat origin. Nature.
2020;579:270–3.
9. Wu A, Peng Y, Huang B, Ding X, Wang X, Niu P. Genome composition and
divergence of the novel coronavirus (COVID-19) originating in China. Cell
Host Microbe. 2020;11:327–8.
10. Shen Z, Xiao Y, Kang L, Ma W, Shi L, Zhang L, et al. Genomic diversity of
SARS-Cov-2 in Coronavirus Disease 2019 patients. Clin Infect Dis. 2020.
https://doi.org/10.1093/cid/ciaa203.
11. Bordi L, Nicastri E, Scorzolini L, Di Caro A, Capobianco MR, Castilletti C, et al.
Differential diagnosis in patients under investigation for the novel
coronavirus (SARS-CoV-2), Italy 2020. Euro Surveill. 2020;25(8):2000170.
12. Centers for Disease Control and Prevention (CDC). Coronavirus Disease 2019
(COVID-19). Atlanta: CDC; 2020. https://www.cdc.gov/coronavirus/2019-
ncov/about/symptoms.html [Accessed 2020 Feb 20].
13. Albarello F, Pianura E, Di Stefano F, Cristofaro M, Petrone A, Marchioni L,
et al. 2019-novel Coronavirus severe adult respiratory distress syndrome in
two cases in Italy: an uncommon radiological presentation. Int J Infect Dis.
2020;93:192–7.
14. Governo Italiano, Aggiornamento Coronavirus, 2020. http://www.governo.it/
it/approfondimento/coronavirus/13968 [Accessed 2020 Mar 8].
15. Ministero della Salute. Coronavirus. 2020. http://www.salute.gov.it/portale/
nuovocoronavirus/archivioNormativaNuovoCoronavirus.jsp [Accessed 2020
Mar 8].
Page 15 of 15
16. Protezione Civile Italiana. Emergenze Coronavirus. 2020. http://www.
protezionecivile.gov.it/attivita-rischi/rischio-sanitario/emergenze/coronavirus
[Accessed 2020 Mar 9].
17. Istituto Superiore di Sanità. Nuovo Coronavirus SARS-CoV-2. 2020. https://
www.epicentro.iss.it/coronavirus/. [Accessed 2020 Mar 10].
18. Federazione Nazionale dei Medici Chirurghi ed Odontoiatri. Elenco dei
Medici caduti nel corso dell’epidemia di COVID-19. 2020. https://portale.
fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/
[Accessed on 2020 Mar 14].
19. Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to
dentistry and potential salivary diagnosis. Clin Oral Invest. 2020. https://doi.
org/10.1007/s00784-020-03248-x.
20. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-
nCoV and controls in dental practice. Int J Oral Sci. 2020;12(9):1–6.
21. Cramér H. Mathematical methods of statistics. Princeton: Princeton
University Press; 1946.
22. Fisher RA. The logic of inductive inference. J R Stat Soc. 1935;98:39–82.
23. Goodman LA, Kruskal WH. Measures of association for cross classifications. J
Am Stat Assoc. 1954;49:732–64.
24. Kendall MG. The treatment of ties in rank problems. Biometrika. 1945;33:
239–51.
25. Pearson K. On the criterion that a given system of deviations from the
probable in the case of a correlated system of variables is such that it can
be reasonably supposed to have arisen from random sampling. Philos Mag.
1900;5(50):157–75.
26. Lu CW, Liu XF, Jia ZF. 2019-nCoV transmission through the ocular surface
must not be ignored. Lancet. 2020. https://doi.org/10.1016/S0140-
6736(20)30313-5.
27. KKW T, Tsang OTY, Yip CCY, Chan KH, Wu TC, Chan JMC, et al. Consistent
Detection of 2019 Novel coronavirus in saliva. Clin Infect Diseases. 2020.
https://doi.org/10.1093/cid/ciia149.
28. Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al.
Transmission of 2019-nCoV infection from an asymptomatic contact in
Germany. N Engl J Med. 2020;382:970–1.
29. Gamio L. The Workers Who Face the Greatest Coronavirus Risk. The New
York Times, 15th; 2020.
30. *D.lgs. 9 aprile 2008, n. 81 Testo coordinato con il D.Lgs. 3 agosto 2009, n.
106 in Gazzetta Ufficiale n. 101 del 30 aprile 2008 -Suppl. Ordinario n. 108)
(Decreto integrativo e correttivo: Gazzetta Ufficiale n. 180 del 05 agosto
2009 -Suppl. Ordinario n. 142/L.
31. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on
inanimate surfaces and their inactivation with biological agents. J Hosp
Infect. 2020;104(3):246–51.
32. World Health Organization. Shortage of personal protective equipment
endangering health workers worldwide. 2020. https://www.who.int/news-
room/detail/03-03-2020-shortage-of-personal-protective-equipment-
endangering-health-workers-worldwide [Accessed 2020 Mar 12].
33. World Health Organization. Rational use of personal protective equipment
for coronavirus disease 2019 (COVID-19). https://apps.who.int/iris/bitstream/
handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf
[Accessed 2020 Mar 12].
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
 Rocz Panstw Zakl Hig 2020;71(2):223-229
http://wydawnictwa.pzh.gov.pl/roczniki_pzh/ https://doi.org/10.32394/rpzh.2020.0115

ORIGINAL ARTICLE

COVID-19: A SURVEY ON KNOWLEDGE, AWARENESS

AND HYGIENE PRACTICES AMONG DENTAL HEALTH
PROFESSIONALS IN AN INDIAN SCENARIO

Ramandeep Singh Gambhir1, Jagjit Singh Dhaliwal2, Amit Aggarwal3, Samir Anand4,
Vaibhav Anand5, Amanpreet Kaur Bhangu6
1
Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
2
PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
3
Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, MM (Deemed
to be University), Mullana, India
4
Department of General Dentistry, Aesthetics-The Smile Partners, Zirakpur, Punjab, India
5
Department of Public Health Dentistry, Shaheed Kartar Singh Sarabha Dental College and Hospital,
Ludhiana, India
6
Department of General Dentistry, Community Dental Centre, Chandigarh, India

ABSTRACT
Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) continues to spread globally.
It has become a major cause of concern for health care professionals all over the world.
Objective. The aim of this study was to assess knowledge, awareness and hygiene practices regarding COVID-19 among
private dental practitioners practicing in Tricity (Chandigarh, Panchkula and Mohali) in India during these critical times.
Materials and Methods. A total of 245 private dentists participated in this cross-sectional survey and finally 215 constituted
the final sample size. A self-administered, multiple choice type questionnaire (verified by a specialist) was administered to
obtain information from the subjects. The questionnaire was divided into two parts and included 15 questions on knowledge
and awareness regarding COVID-19. Statistical analysis was done using ANOVA and Student’s t-test.
Results. Percentage of subjects who answered correctly regarding main symptoms of COVID-19 and primary mode of
transmission was 87% and 82.5% respectively. One-third of the subjects were not aware regarding Personal Protective
Equipment (PPE) to be used while rendering dental treatment. 75% of subjects were of the opinion that supportive care is
the current treatment regime for COVID-19. Less than one-third of subjects (30.2%) reported high scores. Education level
(p=0.018) and health sector profile (p=0.024) of the subjects were significantly associated with mean knowledge scores.
Conclusion. The findings of the present study showed that some notable deficiencies in knowledge existed among dental
professionals regarding some vital aspects of COVID-19. Therefore, there is an urgent need for improving dentists’
knowledge via health education and training programs. Further studies on the subject are also warranted once the situation
normalizes.

Key words: knowledge, pandemics, coronavirus, COVID-19, dentists, emergencies

INTRODUCTION
COVID-19 (Coronavirus Disease, 2019 & SARS-
CoV-2) is the newly discovered emerging respiratory
disease that is caused by a new member of the
coronavirus family called novel coronavirus [14]. The
epidemic of the disease which started in the month of
December 2019 in Wuhan city of China, has become
one of the major public health problems of this century
and is claiming thousands of lives everyday across
the globe [13]. Two main unique features of the virus
are its low pathogenicity and high transmissibility
that distinguish it from other members of the
coronavirus family such as SARS-CoV (Severe Acute
Respiratory Syndrome) and MERS-CoV (Middle
Eastern Respiratory Syndrome) [12]. It is a highly
infectious disease and its clinical symptoms include
fever, dry cough, myalgia and fatigue and severe cases
progressing to acute respiratory distress syndrome
leading to bleeding and coagulation dysfunction [2].

Corresponding author: Dr Ramandeep Singh Gambhir, Department of Public Health Dentistry, Rayat and Bahra Dental College and
Hospital, Mohali, Punjab, India, PIN-140104, Tel. +91-99156-46007, Fax- +91-160-5009680, e-mail: raman2g@yahoo.com
© Copyright by the National Institute of Public Health - National Institute of Hygiene
224 COVID-19: knowledge, awareness and hygiene among dental health professionals in India
The risk of increased severity is noticed in the elderly
and individuals with underlying chronic diseases.
Human-to-human transmission of the virus is
occurring through airborne droplets, contact or touch
of an infected person or from a contaminated surface.
According to recent reports, COVID-19 positive
cases have crossed 30000 in India, taking the total
number of deaths to 1583 [10]. However, still there
is no community transmission of the virus in India
as per reports of the Health Ministry barring a few
places of virus cluster designated as hot spots. The
entire country is in a state of ‘Lockdown’ (till 3rd May
as of now) and the government is issuing advisories
on daily basis for its citizens particularly regarding
delivery of essential health services and various
protective measures to be taken to guard oneself from
getting infected; the most important being staying at
home (Isolation and Social-Distancing) [10].
Health care workers are amongst the most
vulnerable group who have the greatest risk of getting
infected. There have been reports of medical staff
acquiring the disease while taking care and treating
infected individuals [11]. The dental operatory poses
a riskier environment because of high possibility
of cross-infection between dental practitioners and
patients. Although most of the dental clinics are closed
during these times, however dental emergencies do
come and it’s our moral duty to treat them thereby
establishing a close contact [6]. A COVID-19 positive
case can go symptomless for many days, therefore
various guidelines are recommended by Centre for
Disease Control and Prevention (CDC) and World
Health Organization (WHO) for dental health care
workers that adequate precautions can be taken [1,
15]. Still, the exact behaviour of the virus is not fully
understood by the scientists, making it even more
risky for a health practitioner. Therefore, the present
questionnaire survey was carried out to assess the
basic essential knowledge, awareness and hygiene
practices among dental health professionals regarding
COVID-19 in an Indian setting.
MATERIALS AND METHOD
Ethical clearance and informed consent
Ethical clearance from the Institutional Ethics
Committee and was obtained prior to the start of the
study. Informed consent was obtained from the subjects
for their willingness to participate in the study. The
study was conducted in March, 2020. Participation in
the study was voluntary and identification information
was not collected from the study subjects.
Study population and study sample
The present study was a descriptive cross-sectional
(questionnaire) study. The study population consisted
No 2
of dental health professionals who are engaged in
private practice in the Tricity (Chandigarh, Panchkula
and Mohali). List of all private dental practitioners of
the Tricity was obtained from Local Indian Dental
Association (IDA) bodies through email.
The sample size required for the study was
calculated using the following formula for sample size
calculation:
n = Z²1-(α / 2) × S2 / d2
where:
Z - is the standard normal score with 95%
confidence interval (CI) (a=0.05);
S - is the standard deviation of the variable;
d - is maximum acceptable error.
To take account of potential errors and sample loss,
which is common in cross-sectional studies, a  final
sample size was estimated to be 245.
In order to pick the study subjects from our sampling
frame (list of all practicing dentists), a simple random
sampling methodology was used. However, only 215
subjects returned the questionnaire that constituted
the final study sample.
Research instrument
A  self-designed questionnaire written in
English language was made specifically for the
study. A specialist in infectious and communicable
disease was consulted to verify the content of the
questionnaire. The questionnaire was pre-tested
for validity and reliability. The reliability of the
questionnaire was good (0.84). The questionnaire was
divided into two sections: (1) Section A was ‘General
section’ which comprised of socio-demographic
and professional details of the subjects (gender,
educational status, type of practice etc.). (2) Section
B comprised of 15 questions depicting knowledge and
awareness regarding COVID-19 (common symptoms,
mode of transmission, availability of vaccine,
various preventive measures, details of hygiene
practices etc.). The questionnaire was delivered to
the study subjects via email and WhatsApp (Social
Media Application) and not handed over personally
because of city ‘Lockdown’ to prevent the spread of
the virus. The subjects were given one week time to
fill the questionnaire and return it. Total knowledge/
awareness score was calculated on the basis of each
subject’s response. Each positive response was
awarded a score of ‘1’ and negative response as ‘0’.
The total score of the subject was calculated by adding
the sum of responses which ranged from 1 to 15, on
a  Likert Scale. The final scores were categorized at
three levels: low (0-5), medium (6-10) and high (11-15).
No 2 R.S. Gambhir, J.S. Dhaliwal, A. Aggarwal et al. 225

Statistical Analysis included a total of 215 subjects in which male subjects

Calculations were done using descriptive statistical (133, 61.8%) were in clear majority as compared to
analysis. Number and percentages were used to female subjects (82, 38.2%). Also, more number
compute results on categorical measurements. SPSS of subjects held a graduate degree (120, 55.8%) as
package version 19.0 (SPSS, Chicago, IL, USA) was compared to subjects holding a post graduate degree
used to statistically analyze the results. To find the in dentistry and majority of the subjects (127, 59%)
significance of study parameters between three or were engaged in both academic and private practice.
more groups of subjects, Analysis of Variance test Regarding years of practice, 59 (27.5%) subjects were
(ANOVA) was used and Student’s t-test was used to practicing for more than 10 years.
find significance between two groups. The significance
level was set at <0.05. Response to questions regarding COVID-19
Subjects’ response towards questionnaire regarding
RESULTS COVID-19 is depicted in Figure 1. Percentage of subjects
who answered correctly regarding main symptoms of
Socio-demographic and professional characteristics COVID-19 and primary mode of transmission was
Socio-demographic and professional profile of 87% and 82.5% respectively. One-third of subjects
study subjects is depicted in Table 1. The present study (33%) were unaware regarding mandatory Personal

Table 1. Socio-demographic and professional profile of study subjects

Profile Number Percentage
Male 133 61.8
Gender
Female 82 38.2
Graduate (BDS) 120 55.8
Educational status
Postgraduate (MDS) 95 44.2
Private clinic 88 41
Health Sector
Combined (Private & Academic) 127 59
Up to 5 74 34.4
Years of practice 5-10 82 38.1
More than 10 59 27.5

Figure 1. Subjects’ response to questionnaire on COVID-19

226 COVID-19: knowledge, awareness and hygiene among dental health professionals in India
Protective Equipment (PPE) that is required while
rendering dental treatment. When asked about any
nearby government designated facility for virus testing,
64.5% of subjects answered correctly. Approximately
42% of subjects had adequate knowledge regarding
vaccine trials to prevent COVID-19. Only 8.5% of the
subjects were providing emergency treatment at their
practice in these critical circumstances and 12.5%
of subjects showed their willingness to help health
workers in times of need. Two-third (75%) of the
subjects were of the opinion that supportive care is the
current treatment for COVID-19 and health authorities
can effectively prevent community transmission of the
virus. In addition, 59.5% of subjects had knowledge
regarding recent guidelines recommended by WHO
for health care workers.
Personal and clinic hygiene practices
Details regarding personal and clinic hygiene
practices are mentioned in Figure 2. It was reported
Figure 2. Personal and clinic hygiene practices among subjects
Table 2. Final knowledge scores of study subjects regarding COVID-19 (on the basis of Likert scale)
Number
Knowledge score
of subjects
Low 82
Medium 68
High 65
Total 215
No 2
that 94.2% (202) used alcohol rub or soap and water
to clean their hands after treating patients. Routinely
cleaning and disinfecting clinic surfaces were done by
86.2% (184) of subjects. Surprisingly, only 35.2% (75)
of subjects were conducting fumigation of the dental
operatory every week and only 32.4% (69) of study
subjects were disinfecting the lab work area daily.
Knowledge/awareness level of subjects
Only 30.2% (55) of subjects reported high
knowledge scores and 38.1% (92) of subjects were
having low knowledge scores (Table 2). There
was a  statistically significant association of mean
knowledge scores with education level (p=0.018) and
health sector profile (p=0.024) of the subjects whereas
no significant difference of knowledge score was
observed with gender and years of practice (p>0.05)
(Table 3).
Percentage
95% CI
of subjects
38.1 48.27-56.52
31.6 32.42-41.17
30.2 23.36-29.76
100
No 2 R.S. Gambhir, J.S. Dhaliwal, A. Aggarwal et al. 227

Table 3. Mean knowledge scores of subjects according to different socio-demographic variables

Socio-demographic profile Knowledge/Awareness score P-value

Gender Mean Standard Deviation

Male 7.42 1.36 F=1.512
Female 5.36 2.62 P= 0.062
Total 6.39 2.65
Education level
Graduate (BDS) 5.22 2.21 F= 2.826
Postgraduate (MDS) 7.76 3.26 P=0.018*
Total 6.49 2.42
Health sector
Private 5.12 1.23 F=2.225
Combined 8.01 4.55 P= 0.024*
Total 6.56 2.54
Years of practice
Up to 5 4.55 3.34
F= 3.454
5-10 4.67 2.75 P= 0.172
More than 10 6.71 4.21
Total 5.31 4.12
P<0.05 (Statistically significant), Tests used: Student -t test, ANOVA

DISCUSSION Following the pandemic alert by WHO, Government

The pandemic spread by COVID-19 has put the whole
world in a state of emergency as thousands of individuals
are losing their lives every day because of this life
threatening disease [16]. To the best of our knowledge, the
present study is first of its kind in the Indian subcontinent
examining the knowledge and awareness of dental health
professionals regarding this deadly disease. A close-
ended questionnaire was used in the study in order to
achieve a quicker response from the subjects in this state
of crisis [4]. It was observed in the study that majority
of the subjects had fair knowledge regarding COVID-19
and there were noteworthy deficiencies in some of the
important aspects.
Recent research has observed that asymptomatic
patients and patients in their incubation period are
also carriers of this particular virus which can lead to
disease transmission [7]. More than 80% of subjects
were aware of this fact in the present study which is
in congruence to findings of some other study as well
[6]. The use of PPE, like masks (N-95), gloves, gowns,
and goggles or face shields, is recommended to protect
skin and mucosa from (potentially) infected blood or
respiratory secretions [3]. Appropriate use significantly
reduces risk of viral transmission. Astonishingly, one-
third of subjects in the present study were not fully
aware regarding mandatory PPE which is in contrast to
findings of some other studies [6, 11].
of India provided diagnostic facilities for novel
coronavirus testing for suspected cases at designated
centres throughout the country [10]. More than 60%
of subjects were aware of such facility in our study.
The most effective and economical means to prevent
and control infectious diseases is though vaccines.
While most of the vaccines against COVID-19 are
under design and preparation, there are some that
have entered efficacy evaluation in animals and initial
clinical trials [17]. Only 41.6% of dental practitioners
in our study had basic knowledge regarding vaccine
developments.
Dental emergencies can occur and exacerbate in
a short period and therefore need immediate treatment.
Till now, there has been no consensus on the provision
of dental services during the current pandemic [15].
Though it is matter of personal choice, it was observed
that 8.5% of dental practitioners were providing
emergency dental services at their clinic. Moreover,
12.5% of the subjects were willing to help health care
workers in case there is shortage of health care staff.
Currently there is no specific treatment available
to treat COVID-19, so the management of COVID-19
has been largely supportive that includes infection
prevention and control measures to lower the risk of
transmission and isolation [9]. Two-third of the subjects
in our study agreed to this fact which is in contrast to
findings of a  recent study conducted on health care
workers in China [5]. The present study also reported
228 COVID-19: knowledge, awareness and hygiene among dental health professionals in India
that more than 60% of subjects were knowledgeable
regarding recent WHO guidelines for health care
workers while dealing with COVID-19 patients.
Hand hygiene has been considered the most vital
measure for minimizing the risk of transmitting
microorganism to patients [8]. More than 90% of subjects
used alcohol rub or soap and water to clean their hands
after treating patients in our study. Coronavirus-2 can
persist on surfaces for a few hours or up to several days,
depending on the nature of surface, the temperature, or
the humidity of the environment [15]. A vast majority of
subjects were routinely cleaning and disinfecting clinic
surfaces in the study. Fumigation of the dental operatory
with drawers open should be done at least once a week
to make the operating area completely sterile. However,
hardly one-third of subjects fumigated their clinics in
this study.
Subjects holding a post-graduate degree were more
knowledgeable as compared to graduates, stressing
the positive impact of education on knowledge scores
(p=0.018). Moreover, knowledge scores of subjects
doing combined practice were more as compared to
subjects doing only private practice (p=0.024). This
could be due to the reason that subjects engaged in
academic teaching are exposed to more learning
experiences which can lead to regular knowledge
updating. However, there was no statistically
significant relationship between knowledge scores
and years of practice (work experience) of subjects
(p>0.05) which is in agreement with findings of
another study on health care workers [5].
The present study had few limitations as well. The
sample size utilized in the study is small because the
whole city is under ‘Lockdown’ as panic created by
the pandemic has kept the people homebound who
are busy managing their personal affairs. As a result,
certain aspects related to COVID-19 could have been
possibly left behind. Moreover, the study relied upon
self-reported data, which is dependent upon subjects’
honestly and recall ability. Thus it may give rise to
recall bias.
CONCLUSION
The present study concluded that most of the
subjects had fair knowledge regarding COVID-19,
yet there were significant knowledge gaps in some of
the important aspects like knowledge regarding PEE,
vaccine trials etc. as less than one-third of subjects
reported high scores. These findings clearly indicate
the importance of improving subjects’ COVID-19
knowledge via health education and training
programs on infection control and hygiene practices
for COVID-19 across all healthcare professions. With
better understanding of viral features, epidemiologic
characteristics, clinical spectrum, and treatment,
No 2
efficient strategies can be formed to prevent, control,
and stop the spread of COVID-19. Recent guidelines
recommended by WHO and CDC should be followed
while treating patients in dental practices and dental
schools. Further studies involving larger sample size
should be conducted once things are under control
and this deadly disease is eradicated from the world.
Lastly, as a health care professional, it’s our moral
duty to support health care workforce in times of need
during this global epidemic.
REFERENCES
1. Centers for Disease Control and Prevention (CDC).
CDC Developing Guidance Regarding Responding to
COVID-19 in Dental Settings. Division of Oral Health,
National Center for Chronic Disease Prevention and
Health Promotion. Available from: https://www.cdc.
gov/oralhealth/infectioncontrol/statement-COVID.
html. Accessed on 11th April 2020.
2. Chen N., Zhou M., Dong X., Qu J., Gong F., Han Y., Qiu
Y., Wang J., Liu Y., Wei Y., Xia J., Yu T., Zhang X., Zhang.:
Epidemiological and clinical characteristics of 99 cases
of 2019 novel coronavirus pneumonia in Wuhan, China:
a descriptive study. Lancet. 2020;395:507-13.
3. Cook T.M.: Personal protective equipment during the
COVID-19 pandemic - a narrative review. Anaesthesia.
2020. doi: 10.1111/anae.15071.
4. Desai S.C., Reimers S.: Comparing the use of open
and closed questions for Web-based measures of the
continued-influence effect. Behav Res. 2019; 51:1426–40.
5. Huynh G., Nguyen T.N.H., Tran V.K., Vo K.N., Vo V.T.,
Pham L.A.: Knowledge and attitude toward COVID-19
among healthcare workers at District 2 Hospital, Ho
Chi Minh City. Asian Pac J Trop Med. 2020;13. doi:
10.4103/1995-7645.280396.
6. Khader Y.S., Nsour M.A., Al-Batayneh O.B., Saadeh R.,
Basheir H., Alfaqih M., Al-Azzam S., AlShurman B.A.:
Dentists’ awareness, perception, and attitude regarding
COVID-19 and infection control: A cross-sectional
study among Jordanian dentists. JMIR Public Health
Surveill. 2020;6:e18798.
7. Kolifarhood G., Aghaali M., MozafarSaadati H.,
Taherpour N., Rahimi S., Izadi N., Hashemi Nazari S.S.:
Epidemiological and Clinical Aspects of COVID-19;
a Narrative Review. Arch AcadEmerg Med. 2020;8:e41.
8. Larson E.L., Early E., Cloonan P., Sugrue S., Parides
M.: An organizational climate intervention associated
with increased handwashing and decreased nosocomial
infections. Behav Med. 2000:26(1):14–22.
9. Meng L., Hua F., Bian Z.:Coronavirus Disease 2019
(COVID-19): Emerging and Future Challenges for
Dental and Oral Medicine. J Dent Res. 2020. doi:
10.1177/0022034520914246.
10. Ministry of Health and Family Welfare, Government of
India [homepage on the internet]. Available at: www.
mohfw.gov.in Accesses on 5th May 2020.
11. Modi P.D., Nair G., Uppe A., Modi J., Tuppekar B.,
Gharpure A.S, Langade G.: Awareness Among
No 2 R.S. Gambhir, J.S. Dhaliwal, A. Aggarwal et al. 229

Healthcare Students and Professionals in Mumbai
Metropolitan Region: A Questionnaire-Based Survey.
Cureus. 2020;12: e7514. DOI 10.7759/cureus.7514.
12. Nemati M., Ebrahimi B., Nemati F.: Assessment of
Iranian Nurses’ Knowledge and Anxiety Toward
COVID-19 During the Current Outbreak in Iran. Arch
Clin Infect Dis 2020. In Press (In Press):e102848.
13. Phelan A.L., Katz R., Gostin L.O.: The novel coronavirus
originating in Wuhan, China: challenges for global
health governance [epub ahead of print 30 Jan 2020] in
press. JAMA. doi:10.1001/jama.2020.1097.
14. The Novel Coronavirus Pneumonia Emergency
Response Epidemiology Team. The epidemiological
characteristics of an outbreak of 2019 novel coronavirus
diseases (COVID-19) in China. Chin J Epidemiol. 2020;
41:145-51.
15. The World Health Organization (WHO). Clinical
management of severe acute respiratory infection
when novel coronavirus (nCoV) infection is suspected:
Interim guidance. Available from: https://www.who.
int/emergencies/diseases/novel-coronavirus-2019.
Accessed on 11th April 2020.
16. Velavan T.P., Meyer C.G.: The COVID-19 epidemic.
Trop Med Int Health. 2020;25:278-80.
17. Zhang J., Zeng H., Gu J., Li H., Zheng L., Zou Q.:
Progress and Prospects on Vaccine Development
against SARS-CoV-2. Vaccines (Basel). 2020;8. pii:
E153. doi: 10.3390/vaccines8020153.
Received: 17.04.2020
Accepted: 06.05.2020

This article is available in Open Access model and licensed under a Creative Commons Attribution-Non Commercial 3.0.Poland License (CC-BY-NC)
available at: http://creativecommons.org/licenses/by-nc/3.0/pl/deed.en
Clinical Oral Investigations
https://doi.org/10.1007/s00784-020-03248-x
LETTER TO THE EDITOR
Coronavirus COVID-19 impacts to dentistry and potential
salivary diagnosis
Robinson Sabino-Silva 1,2 & Ana Carolina Gomes Jardim 3 & Walter L. Siqueira 1
Received: 15 February 2020 / Accepted: 17 February 2020
# Springer-Verlag GmbH Germany, part of Springer Nature 2020
Summary
A novel coronavirus (COVID-19) is associated with human-
to-human transmission. The COVID-19 was recently identi-
fied in saliva of infected patients. In this point-of-view article,
we discuss the potential of transmission via the saliva of this
virus. The COVID-19 transmission via contact with droplets
and aerosols generated during dental clinical procedures is
expected. There is a need to increase investigations to the
detection of COVID-19 in oral fluids and its impact on the
transmission of this virus, which is crucial to improve effec-
tive strategies for prevention, especially for dentists and
healthcare professionals that perform aerosol-generating pro-
cedures. Saliva can have a pivotal role in the human-to-human
transmission, and non-invasive salivary diagnostics may pro-
vide a convenient and cost-effective point-of-care platform for
the fast and early detection of COVID-19 infection.
Current point of view
The present outbreak of the 2019 coronavirus strain (COVID-
19) constitutes a public health emergency of global concern
[1]. International centers for disease control and prevention
are monitoring this infectious disease outbreak; symptoms of
COVID-19 infection include fever, cough, and acute
Robinson Sabino-Silva, Ana Carolina Gomes Jardim and Walter L.
Siqueira contributed equally to this work.
* Walter L. Siqueira
walter.siqueira@usask.ca
1
College of Dentistry, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
2
Department of Physiology, Institute of Biomedical Sciences, Federal
University of Uberlandia, Uberlandia, Minas Gerais, Brazil
3
Laboratory of Virology, Institute of Biomedical Sciences, Federal
University of Uberlandia, Uberlandia, Minas Gerais, Brazil
respiratory disease, with severe cases leading to pneumonia,
kidney failure, and even death. The severe respiratory illness
caused by the COVID-19 was first detected in Wuhan, Hubei,
China, and infections have spread worldwide [2]. Currently,
the available COVID-19 genome sequences from clinical
samples suggest that this viral emergence is related to bat
coronaviruses [3]. Although the coronavirus infection in
humans frequently presents with mild severity, the
betacoronavirus infection of either the severe acute respiratory
syndrome coronavirus (SARS-CoV) [4] or the Middle East
respiratory syndrome coronavirus (MERS-CoV) [5] resulted
in higher mortality rates [6]. Given the novelty of COVID-19,
some characteristics of the virus remain yet unknown. The
COVID-19 outbreak serves as both a reminder and an oppor-
tunity to assist. Considering that COVID-19 was recently
identified in saliva of infected patients [7], the COVID-19
outbreak is a reminder that dental/oral and other health pro-
fessionals must always be diligent in protecting against the
spread of infectious disease, and it provides a chance to deter-
mine if a non-invasive saliva diagnostic for COVID-19 could
assist in detecting such viruses and reducing the spread.
The Chinese Centre for Disease Control and Prevention iso-
lated the COVID-19. It published the viral genome sequence data
immediately in international database banks GenBank and the
Global Initiative on Sharing All Influenza Data (GISAID) [8, 9].
This action enabled laboratories in several countries to develop
unique PCR tests focusing on the diagnosis of COVID-19 [8,
10]. Currently, the COVID-19 transmission routes are still to be
determined, but human-to-human transmission has been con-
firmed [10, 11]. The laboratory diagnostic tests should be per-
formed using nasopharyngeal, oropharyngeal, and blood sam-
ples. Expectorated sputum and other specimens in severe respi-
ratory disease should be considered as lower respiratory tract
samples [2, 12, 13]. Several potential scenarios of COVID-19
transmission have been described. The transmission via contact
with droplets from talking, coughing, sneezing (related to human
respiratory activities), and aerosols generated during clinical pro-
cedures is expected, as it would be for other respiratory

infections. The origin of droplets can be nasopharyngeal or oro-
pharyngeal, normally associated with saliva. Larger droplets
could contribute to viral transmission to subjects nearby, and,
on the other side, the long-distance transmission is possible with
smaller droplets infected with air-suspended viral particles [14].
Considering that laboratory diagnostic tests are also performed in
blood samples, the transmission by contaminated blood should
also be considered. In this context, healthcare workers, such as
dentists, may be unknowingly providing direct care for infected,
but not yet diagnosed COVID-19 patients, or those considered to
be suspected cases for surveillance [12, 13]. Asymptomatic in-
fections seem to be possible [15] and transmission may occur
before the disease symptoms appear. A recent clinical study in-
dicates that 29% of 138 hospitalized patients with COVID-19-
infected pneumonia in Wuhan, China, are healthcare workers
[16]. As in bronchoscopy [17], inhalation of airborne particles
and aerosols produced during dental procedures on patients with
COVID-19 can be a high-risk procedure in which dentists are
directly and closely exposed to this virus. Therefore, it is crucial
for dentists to refine preventive strategies to avoid the COVID-19
infection by focusing on patient placement, hand hygiene, all
personal protective equipment (PPE), and caution in performing
aerosol-generating procedures. The Interim Guidance for
Healthcare Professionals from CDC has been updated, and it is
subject to change as additional information on COVID-19 infec-
tion and transmission becomes available.
Diagnosis of COVID-19 can theoretically be performed
using salivary diagnosis platforms. Some virus strains have
been detected in saliva as long as 29 days after infection [18,
19], indicating that a non-invasive platform to rapidly differ-
entiate the biomarkers using saliva could enhance disease de-
tection. [20] Saliva samples could be collected in patients who
present with oropharyngeal secretions as a symptom [12, 13].
Bearing in mind the requirement of a close contact between
healthcare workers and infected patients to collect nasopha-
ryngeal or oropharyngeal samples, the possibility of a saliva
self-collection can strongly reduce the risk of COVID-19
transmission. Besides, the nasopharyngeal and oropharyngeal
collection promotes discomfort and may promote bleeding
especially in infected patients with thrombocytopenia. The
sputum of a lower respiratory tract was produced by only
28% of COVID-19 patients, which indicates a strong limita-
tion as specimen to diagnostic evaluation [7]. We suggest that
there is a minimum of three different pathways for COVID-19
to present in saliva: firstly, from COVID-19 in the lower and
upper respiratory tract [2, 3] that enters the oral cavity together
with the liquid droplets frequently exchanged by these organs.
Secondly, COVID-19 present in the blood can access the
mouth via crevicular fluid, an oral cavity-specific exudate that
contains local proteins derived from extracellular matrix and
serum-derived proteins [21]. Finally, another way for COVID-
19 to occur in the oral cavity is by major- and minor-salivary
gland infection, with subsequent release of particles in saliva
Clin Oral Invest
via salivary ducts. It is essential to point out that salivary gland
epithelial cells can be infected by SARS-CoV a short time
after infection in rhesus macaques, suggesting that salivary
gland cells could be a pivotal source of this virus in saliva
[22]. Additionally, the production of SARS-CoV-specific se-
cretory immunoglobulin A (sIgA) in the saliva of animal
models intranasally immunized was previously shown [23].
Considering the similarity of both strains, we speculate that
salivary diagnosis of COVID-19 could also be performed
using specific antibodies to this virus.
Further studies are needed to investigate the potential diag-
nostic of COVID-19 in saliva and its impact on transmission
of this virus, which is crucial to improve effective strategies
for prevention, especially for dentists and healthcare profes-
sionals that perform aerosol-generating procedures. Saliva can
have a pivotal role in the human-to-human transmission, and
salivary diagnostics may provide a convenient and cost-
effective point-of-care platform for COVID-19 infection.
Funding information This research was supported by the Canadian
Institutes of Health Research (CIHR grant nos. 106657 and 97577). The
authors received financial support from the Royal Society – Newton
Advanced Fellowship (grant reference NA 150195) and FAPEMIG (Minas
Gerais Research Foundation - SICONV 793988/2013; APQ-02872-16 and
APQ-03385-18). ACGJ received productivity fellowship (311219/2019-5)
from the CNPq (National Counsel of Technological and Scientific
Development). The Brazilian funding agencies CNPq, CAPES
(Coordination for the Improvement of Higher Education), and FAPEMIG
provide financial support to the National Institute of Science and
Technology in Theranostics and Nanobiotechnology - INCT-Teranano
(CNPq-465669/2014-0).
Compliance with ethical standards
Competing interests The authors declare that they have no competing
interests.
References
1. The Lancet (2020) Emerging understandings of COVID-19.
Lancet. 395(10221):311. https://doi.org/10.1016/S0140-6736(20)
30186-0
2. Zhu N, Zhang D, Wang W et al (2019) China Novel Coronavirus
Investigating and Research Team. A novel coronavirus from pa-
tients with pneumonia in China. N Engl J Med:2020. https://doi.
org/10.1056/NEJMoa2001017
3. Zhou P, Yang XL, Wang XG et al (2020) A pneumonia outbreak
associated with a new coronavirus of probable bat origin. Nature.
https://doi.org/10.1038/s41586-020-2012-7
4. Ksiazek TG, Erdman D, Goldsmith CS et al (2003) A novel coro-
navirus associated with severe acute respiratory syndrome. N Engl J
Med 348(20):1953–1966
5. de Groot RJ, Baker SC, Baric RS, Brown CS, Drosten C, Enjuanes
L, Fouchier RA, Galiano M, Gorbalenya AE, Memish ZA, Perlman
S, Poon LL, Snijder EJ, Stephens GM, Woo PC, Zaki AM, Zambon
M, Ziebuhr J (2013) Middle East respiratory syndrome coronavirus
(MERS-CoV): announcement of the Coronavirus Study Group. J
Virol 87(14):7790–7792. https://doi.org/10.1128/JVI.01244-13
Clin Oral Invest
6. Hui DSC, Zumla A (2019) Severe acute respiratory syndrome:
historical, epidemiologic, and clinical features. Infect Dis Clin N
Am 33(4):869–889. https://doi.org/10.1016/j.idc.2019.07.001
7. To KK, Tsang OT, Chik-Yan Yip C et al (2020) Consistent detection of
2019 novel coronavirus in saliva. Clin Infect Dis. https://doi.org/10.
1093/cid/ciaa149
8. Huang C, Wang Y, Li X et al (2020) Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China. Lancet
S0140-6736(20):30183–30185. https://doi.org/10.1016/S0140-
6736(20)
9. World Health Organization – WHO (2020a) Emergencies prepared-
ness, response. Pneumonia of unknown origin – China disease out-
break news; 12 January, Accessed 12 Jan 2020. Available at: https://
www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/
10. Wu A, Peng Y, Huang B et al (2020) Genome composition and
divergence of the novel coronavirus (COVID-19) originating in
China. Cell Host Microbe S1931–3128(20):30072-X. https://doi.
org/10.1016/j.chom.2020.02.001
11. Shu Y, McCauley J (2017) GISAID: global initiative on sharing all
influenza data - from vision to reality. Euro Surveill 22(13). https://
doi.org/10.2807/1560-7917.ES.2017.22.13.30494
12. ECDC - European Centre for Disease Prevention and Control;
European surveillance for human infection with novel coronavirus
(COVID-19); 22 January, Accessed 28 Jan 2020. Available at:
https://www.ecdc.europa.eu/en/european-surveillance-human-
infection-novel-coronavirus-COVID-19
13. World Health Organization-WHO (2020) Global surveillance for
human infection with novel coronavirus (COVID-19) Interim guid-
ance. 21 January, Accessed 28 Jan 2020. Available at: https://www.
who.int/docs/default-source/coronaviruse/20200121-global-
surveillance-for-COVID-19.pdf
14. Xie X, Li Y, Sun H, Liu L (2009) Exhaled droplets due to talking
and coughing. J R Soc Interface 6(Suppl 6):S703–S714. https://doi.
org/10.1098/rsif.2009.0388.focus
15. Chan JF, Yuan S, Kok KH et al (2020) A familial cluster of pneu-
monia associated with the 2019 novel coronavirus indicating
person-to-person transmission: a study of a family cluster. Lancet.
https://doi.org/10.1016/S0140-6736(20)30154-9
16. Wang D, Hu B, Hu C et al (2020) Clinical characteristics of 138
hospitalized patients with 2019 novel coronavirus-infected pneu-
monia in Wuhan, China. JAMA. https://doi.org/10.1001/jama.
2020.1585
17. Group of Interventional Respiratory Medicine, Chinese Thoracic
Society (2020) [Expert consensus for bronchoscopy during the epidem-
ic of 2019 Novel Coronavirus infection (Trial version)]. 43(0):E006.
doi: https://doi.org/10.3760/cma.j.issn.1001-0939.2020.0006
18. Barzon L, Pacenti M, Berto A, Sinigaglia A, Franchin E, Lavezzo E,
Brugnaro P, Palù G (2016) Isolation of infectious Zika virus from saliva
and prolonged viral RNA shedding in a traveller returning from the
Dominican Republic to Italy, January 2016. Euro Surveill 21(10):
30159. https://doi.org/10.2807/1560-7917.ES.2016.21.10.30159
19. Zuanazzi D, Arts EJ, Jorge PK, Mulyar Y, Gibson R, Xiao Y, Bringel
Dos Santos M, Machado MAAM, Siqueira WL (2017) Postnatal iden-
tification of zika virus peptides from saliva. J Dent Res 96(10):1078–
1084. https://doi.org/10.1177/0022034517723325
20. Segal A, Wong DT (2008) Salivary diagnostics: enhancing disease
detection and making medicine better. Eur J Dent Educ 12(Suppl
1):22–29. https://doi.org/10.1111/j.1600-0579.2007.00477.x
21. Silva-Boghossian CM, Colombo AP, Tanaka M et al (2013)
Quantitative proteomic analysis of gingival crevicular fluid in dif-
ferent periodontal conditions. PLoS One 8(10):e75898. https://doi.
org/10.1371/journal.pone.0075898
22. Liu L, Wei Q, Alvarez X et al (2011) Epithelial cells lining salivary
gland ducts are early target cells of severe acute respiratory syndrome
coronavirus infection in the upper respiratory tracts of rhesus macaques.
J Virol 85(8):4025–4030. https://doi.org/10.1128/JVI.02292-10
23. Lu B, Huang Y, Huang L, Li B, Zheng Z, Chen Z, Chen J, Hu Q,
Wang H (2010) Effect of mucosal and systemic immunization with
virus-like particles of severe acute respiratory syndrome coronavi-
rus in mice. Immunology. 130(2):254–261. https://doi.org/10.1111/
j.1365-2567.2010.03231.x
Publisher’s note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.