Researchers at the University of São Paulo Medical School (FM-USP) have found that SARS-CoV-2 infects and replicates in the salivary glands, according to Agencia FAPESP.

Analysis of samples from three types of salivary gland obtained during a minimally invasive autopsy procedure performed on patients who died from complications of COVID-19 at Hospital das Clínicas, FM-USP’s hospital complex, showed that tissues specializing in producing and secreting saliva serve as reservoirs for the novel coronavirus.

The discovery helps explain why the virus is so abundant in saliva and has enabled scientists to develop saliva-based diagnostic tests for COVID-19.

“This is the first report of a respiratory virus’s capacity to infect and replicate in salivary glands,” said first author Bruno Fernandes Matuck, a PhD candidate at USP’s dental school.

“Until now, it was thought that only viruses that cause highly prevalent diseases such as herpes used salivary glands as reservoirs. The discovery may help explain why SARS-CoV-2 is so infectious,” he said.

A previous study by the same researchers had already demonstrated the presence of RNA from SARS-CoV-2 in the periodontal tissue of patients who died from COVID-19.

SARS-CoV-2 is highly infectious compared to other respiratory viruses, the researchers said, so they hypothesized that it may replicate in salivary gland cells and be present in saliva without coming into contact with nasal and lung secretions.

Prior research detected ACE2 receptors in salivary gland ducts. The spike protein in SARS-CoV-2 binds to ACE2 to invade and infect cells.

More recently, other researchers have conducted studies in animals showing that other receptors besides ACE2 such as transmembrane serine protease 2 (TMPRSS2) and furin, both of which are present in salivary glands, are targets of SARS-CoV-2.

To test this hypothesis in human beings, the researchers performed ultrasound-guided autopsies on 24 patients who died of COVID-19, with a mean age of 53, to extract tissue samples from the parotid, submandibular, and minor salivary glands.

The tissue samples were submitted to molecular analysis (RT-PCR), which detected the presence of the virus in more than two-thirds of the samples.

Immunohistochemistry, which is a form of immunostaining in which antibodies bind to the antigen in the tissue sample, a dye is activated, and the antigen can be seen under a microscope, also demonstrated the presence of the virus in the tissue.

Finally, examination under an electron microscope detected not just the presence of the virus but also its replication in cells and the type of organelle it uses to replicate.

“We observed several viruses clustering in salivary gland cells, which showed that they were replicating there. They weren’t in these cells passively,” said Matuck.

The researchers now plan to see whether the mouth can be a direct point of entry for SARS-CoV-2 given that ACE2 and TMPRSS2 are found in various parts of the oral cavity as well as in gum tissue and oral mucosa.

In addition, the mouth has a larger contact area than the nasal cavity, which is widely considered the main way into the body for the virus, the researchers said.

“We’re going to partner with researchers at the University of North Carolina in the United States to map the distribution of these receptors in the mouth and quantify viral replication in oral tissues,” said principal investigator Luiz Fernando Ferraz da Silva, a professor at FM-USP.

“The mouth could be a viable medium for the virus to enter the body directly,” said Matuck.

Another idea is to find out whether older people have more ACE2 receptors in their mouths than younger people, given the decrease in salivary secretion with age, the researchers said.

Nevertheless, the researchers said, they found a high viral load even in older patients, who have less salivary tissue.

“These patients had almost no salivary tissue, almost only fatty tissue. Even so, viral load was relatively high,” Matuck said.

The study, “Salivary Glands Are a Target for SARS-CoV-2: A Source for Saliva Contamination,” was published by the Journal of Pathology.

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The US Food and Drug Administration (FDA) is revoking the emergency use authorizations (EUAs) of all disposable respirators that have not been approved by the National Institute of Occupational Safety and Health (NIOSH), which include imported disposable respirators such as KN95s, along with EUAs for decontamination and bioburden reduction systems.

The FDA said that its actions are consistent with updated recommendations from the Centers for Disease Control and Prevention (CDC) that healthcare facilities not use crisis capacity strategies and should promptly return to conventional practices.

Also, the FDA said, its actions are consistent with the recently published emergency temporary standard from Occupational Safety and Health Administration (OSHA) to protect healthcare workers requiring healthcare employers to provide NIOSH-approved or FDA-authorized respirators for workers potentially exposed to COVID-19.

“Throughout the pandemic, the FDA has worked closely with our federal partners at the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health, the Occupational Safety and Health Administration, and with manufacturers to protect our frontline workers by facilitating access to the medical supplies they require,” said Suzanne Schwartz, MD, MBA, director of the Office of Strategic Partnerships and Technology Innovation in the FDA’s Center for Devices and Radiological Health.

“As a result of these efforts, our country is now better positioned to provide healthcare workers with access to NIOSH-approved N95s rather than using non-NIOSH-approved respirators or reusing decontaminated disposable respirators,” Schwartz said.

All manufacturers of decontamination and bioburden reduction systems have requested, and the FDA has proceeded with, the revocation of their EUAs, effective June 30, 2021.

“Early in the public health emergency, there was a need to issue emergency use authorizations for non-NIOSH-approved respirators as well as decontamination and bioburden reduction systems to disinfect disposable respirators,” Schwartz said. “Today, those conditions no longer exist. Our national supply of NIOSH-approved N95s is more accessible to our healthcare workers every day.”

Since the beginning of the pandemic, the FDA said, NIOSH has approved more than 875 respirator models or configurations, with some of these manufactured by approximately 20 new, domestic NIOSH-approval holders. Also, there are now more than 6,400 total respirator models or configurations on the NIOSH-certified equipment list that have met NIOSH-approved EUA criteria and thus are FDA authorized. These include

• More than 600 filtering facepiece respirator (FFR) models, of which there are more than 530 N95 FFR models
• More than 5,500 elastomeric respirator configurations, including new elastomeric respirators without an exhalation valve
• More than 360 powered air purifying respirator configurations

The FDA’s EUA revocation of all non-NIOSH-approved disposable FFRs follows earlier actions to limit authorization of imports of non-NIOSH-approved FFR respirators, imports of non-NIOSH-approved FFRs manufactured in China, and decontamination and bioburden reduction systems for disposable respirators, the FDA said.

The FDA said it also has withdrawn two related decontamination and bioburden reduction guidance documents:

• Recommendations for Sponsors Requesting EUAs for Decontamination and Bioburden Reduction Systems for Face Masks and Respirators During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency: Guidance for Industry and Food and Drug Administration Staff
• Enforcement Policy for Bioburden Reduction Systems Using Dry Heat to Support Single-User Reuse of Certain Filtering Facepiece Respirators During the Coronavirus Disease (2019) Public Health Emergency

The FDA recommends that healthcare personnel transition from extended use of disposable respirators to single-use for single-patient interactions as appropriate.

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Many common dental procedures have very low risk for increasing the aerosol spread of COVID-19, according to the University of Bristol, while some procedures such as ultrasonic scaling did not generate any aerosol other than from the clean instrument itself.

Conducted by the University of Bristol, University Hospitals Bristol, the Weston NHS Foundation Trust, and the North Bristol NHS Trust, the study is the largest to date to specifically measure aerosol generation from dental instruments in real-patient clinical scenarios, the researchers said.

As part of the AERosolisation and Transmission of SARS-CoV-2 in Healthcare Settings (AERATOR) study, the research aimed to measure the amount of aerosol produced by a range of dental procedures caried out on patients.

Where aerosol was detected in patient procedures, the researchers compared the size distributions of the aerosol to the aerosol produced by the dental instrument itself when used in a non-patient phantom head control.

The study found that ultrasonic instruments commonly used for dental scaling produced much lower aerosol concentrations than the high-speed dental drill despite both instruments requiring the same precautions.

Also, aerosol produced during ultrasonic scaling was consistent with the clean aerosol produced by the instrument itself and did not show that additional aerosol is produced that could potentially spread COVID-19.

“Our study confirms much of the guidance around dental procedures deemed as low risk of spreading COVID-19 is correct but suggests that the ultrasonic instrument could be seen as lower risk than it currently is,” said joint first author Tom Dudding, BDS, a restorative dentistry specialty trainee at the Bristol Dental School.

“Our findings could allow the expansion of dental, hygiene, and therapy work as it would reduce the need for additional precautions such as additional personal protective equipment and fallow times when using this instrument,” Dudding said.

“Our study provides strong evidence to confirm many of the common dental procedures have very low risk of increasing the aerosol spread of COVID-19,” said Mark Gormley, BDS, consultant senior lecturer at the Bristol Dental School and joint senior author.

“We also found that some other procedures, such as ultrasonic scaling, do not appear to generate additional aerosol above that of the instrument itself and do not increase the risk to dentists relative to the risk of being near the patient,” Gormley said.

For procedures such as the high-speed and slow-speed drilling commonly used for dental fillings, crown preparations, and polishing, the researchers said, the next step would be to repeat these experiments with instruments that can further differentiate between aerosol produced by the dental instrument and aerosol that has been contaminated by bodily fluids such as saliva, the researchers said. If no contaminated aerosol is identified, these instruments also would be safe for use without additional precautions, the researchers said.

The researchers also will consider conducting a non-inferiority, randomized controlled trial of additional precautions such as personal protective equipment and fallow time versus pre-pandemic precautions in dental practices, they said. The study would look at the difference in infection rates in patients and dental staff across the two groups with no difference demonstrating the additional precautions are not needed.

The study, “A Clinical Observational Analysis of Aerosol Emissions from Dental Procedures,” was published by medRxiv.

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Oral health providers across the country could serve as a critical access point for additional booster shots required to ensure continued immunity against COVID-19, according to the CareQuest Institute for Oral Health.

Studies are currently underway in the United States and abroad to examine the efficacy of booster shots in bolstering protection against the virus, CareQuest said. Also, officials with the Biden administration and the CEO of Pfizer have indicated that booster shots likely will be necessary to continue protection against COVID-19.

According to CareQuest’s survey of nearly 400 oral health providers nationwide, 49% said they either already administer the COVID-19 vaccine or are interested in doing so.

“If we want to ensure equitable and comprehensive distribution of the COVID-19 vaccine and potential booster shots, oral health professionals must be part of the solution,” said Dr. Myechia Minter-Jordan, president and CEO of CareQuest.

“Dentists and hygienists have the trust of their patients and the training and capability to administer vaccines safely. According to our survey, dentists stand ready and willing to help, and we encourage states to include them as an essential part of their ongoing vaccination programs,” she said.

Annually, more than 19 million people visit the dentist but not a primary care physician or other medical professional, CareQuest said. Many dental professionals, especially those operating in community healthcare settings such as Federally Qualified Health Centers (FQHCs) are well positioned to serve as public health access points for vaccinations, CareQuest said.

Dental providers in public health settings like FQHCs are 10 times more likely to be offering COVID-19 vaccines than providers in private practice, CareQuest said. As racial and ethnic disparities persist in vaccination rates among Black and Latino communities, increasing access points in public health settings is a critical way to reduce existing gaps, CareQuest said.

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Despite the remarkable progress of vaccination in the United States and other countries such as the United Kingdom, the COVID-19 pandemic is unfortunately far from over. The catastrophic situation in India and Brazil highlights the tragic consequences of the sidelining of science.  

Meanwhile, healthcare professionals still face several challenges given the threat of new variants, the lack of biomarkers to identify those at risk for severe complications and death, the lack of predictable treatment, and the scarcity of knowledge on the duration of the immunity conferred by the vaccines. It has become clear that hidden sources of infection may play a crucial role in the pathogenesis of severe COVID-19.

The Role of Oral Health

Last year, after reading about the importance of inflammatory markers in the progression of COVID-19 lung disease, particularly IL-6, my research partner Carla Cruvinel Pontes, DDS, MsC, PhD, and I wrote an article suggesting a link between periodontal disease and its potential to contribute to elevated local and systemic IL-6 levels.

Since then, our findings have been corroborated by clinical studies suggesting high IL-6 levels to be a strong predictor of severe acute respiratory syndrome in COVID-19 patients and periodontitis to be a risk factor for complications. Notably, the study from Marouf et al. (2021) showed that periodontitis resulted in 8.8 times higher risk for death, 4.6 times higher risk for needing mechanical ventilation, and 3.5 times higher risk for ICU admission after accounting for significant confounders, such as age, comorbidities, and smoking.

At the beginning of 2021, I was contacted by an experienced radiologist and medical educator from the UK, Dr. Graham Lloyd-Jones. He had also been in contact with a professor from Birmingham and former president of the European Academy of Periodontology, Iain Chapple. Together, Dr. Cruvinel Pontes, Dr. Lloyd-Jones, Prof. Chapple, and I decided to expand our understanding of the role that oral health, particularly periodontitis, can play in the pandemic.

Our collaboration resulted in the development of a solid medical hypothesis, recently published in the Journal of Oral Medicine and Dental Research, which has been in the spotlight on more than 200 websites worldwide, live radio, and TV. Here, we explain the reasons behind the vast public interest in our study and why it has the potential to change the course of the pandemic.

When a Hypothesis Is More Than a Concept

Many hypotheses are born from scientific exploration. It is crucial to mention that our hypothesis study was born from radiologic lung image findings from COVID-19 patients, and not simply from scientific curiosity. Simply put, Dr. Lloyd-Jones noticed that the disease pattern seen radiographically in COVID-19 lung disease did not match other viral lung infections.

COVID-19 lung disease develops in the base of the lung, as opposed to the mid- and upper areas, as typically seen with infections caused by inhaled pathogens. Vascular changes in small lung vessels are evident early in the disease process in computed tomography (CT) images, including peripheral vasodilation, immunothrombosis, and small filling defects (clots). Microangiopathy and pulmonary infarcts, characterizing thrombosis on both sides of the capillary bed (in both venules and arterioles), have been confirmed in lung autopsies.

Based on the radiological findings, COVID-19 initial lung disease seems to be vascular in nature, as opposed to a primary disease of the trachea and airways. But how does it reach the lung vessels?

With the knowledge that saliva is a reservoir for the virus and that salivary viral levels are strong predictors of poor outcome and disease severity, as well as findings suggesting that SARS-CoV-2 does not reach the lungs through inhalation, we propose that the virus enters the blood circulation in the mouth, from where it reaches the lungs.

The oral cavity biological foundation for this model includes:

• Many oral and gingival cells express ACE-2 receptors, including cells from the gingival sulcus.
• SARS-CoV-2 RNA has been found in saliva and gingival crevicular fluid. The virus can invade salivary glands and mucosal and gingival cells.
• The periodontal environment can favor viral replication and passage through the permeable sulcular or pocket epithelium. Poor oral hygiene, periodontal inflammation, and viral-bacterial synergy can potentially mediate SARS-CoV-2 entrance to the mucosal or gingival blood circulation.
• Higher severity of COVID-19 and risk of death have been linked to periodontitis.
• Other respiratory conditions have been linked to periodontal disease and poor oral hygiene.

COVID-19 and periodontitis have multiple common risk factors, such as aging, specific ethnic groups, male sex, type A blood group, obesity, cardiovascular disease, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, dementia, Down syndrome, learning difficulty, and physical disability (see the figure).

What Does It Mean If This Model Is Correct?

If the hypothesis is proven correct, decreasing the viral load in saliva can mitigate transmission and decrease the risk for lung complications and death. Simple measures can prevent the virus from entering the blood circulation in the oral cavity.

For example, maintenance of optimal daily oral hygiene can fight infection, including toothbrushing twice daily for at least 2 minutes with a fluoridated toothpaste, along with daily interdental cleaning. Periodontitis patients are likely to need longer brushing times.

Also, the use of commercial mouthwash products can inactivate the virus in vitro, whether it’s 15 ml of 0.05% to 0.1% cetylpyridinium chloride (CPC) for 30 seconds twice a day, or 20 ml of 0.147% ethyl lauroyl arginate (ELA) for 30 seconds twice a day. However, daily oral hygiene cannot be replaced by the use of oral rinses.

Regular dental visits are essential to preventing infection as well.

Can Oral Rinses Prevent COVID-19 Lung Disease?

Currently, there is a scarcity of clinical studies on the effect of oral rinses in COVID-19. However, because these over-the-counter products are widely available and have been proven to be safe for unsupervised home use, we suggest the use of CPC and ELA mouthwashes before and after social interactions.

This simple measure can potentially lower the risk for viral entrance to the blood circulation and COVID-19 lung disease while we wait for clinical studies to confirm their efficacy. In places where oral rinses may not be available, studies on pulmonary conditions indicate that even boiled water that has cooled down or a saline solution can be used as an oral rinse to decrease the salivary viral load.

Simple Preventive Measures Can Make a Difference

The reason why health authorities worldwide are not implementing non-invasive, inexpensive, and preventive measures is obscure. In countries such as Brazil and India, the devastating situation has been linked to the overlooking of science. In fact, scientific opinions have been ignored in multiple countries.

As healthcare professionals, we have strong reasons to believe that the mouth plays a crucial role in the pandemic. We urge health authorities and professionals to recommend preventive measures in private and public contexts, especially CPC and ELA oral rinses. Due to their availability, general safety, and potential to decrease COVID-19 lung disease, need for mechanical ventilation, and death, we believe that this recommendation can truly make a difference.

Results from ongoing studies will certainly shed more light on the efficacy of mouthwash products against COVID-19. Meanwhile, let’s do our part and listen to what science is telling us. It strongly suggests that COVID-19 lung complications can start in the mouth, so this is also where preventive measures should begin.

Reference

Lloyd-Jones G, Molayem S, Pontes CC, Chapple I. (2021) The COVID-19 Pathway: A Proposed Oral-Vascular-Pulmonary Route of SARS-CoV-2 Infection and the Importance of Oral Healthcare Measures. J Oral Med and Dent Res. 2(1):1-25.

Dr. Molayem received both his bachelor of arts in history and DDS at UCLA. Thereafter, he completed a specialty program in periodontics at the Herman Ostrow USC School of Dentistry. He is the founder of both the UCLA and USC Journals of Dental Research, which have been going on for 13 and 11 years, respectively. He has lectured and has published in dental implants and periodontics and is the co-founder of Synergy Specialists, the largest agency for traveling dental specialists in the United States. Dr. Molayem has been practicing periodontics in a private practice setting in Southern California for the past 10 years. More recently, he has been conducting research and has published the most comprehensive connection to date between the mouth and COVID-19 in the Journal of the California Dental Association. He can be reached at smolayem@gmail.com.

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Ninety-five percent of the 3,400 respondents in a recent DentaVox survey said they have become significantly more demanding of hygiene at the dentist’s office due to the COVID-19 pandemic.

Also, 50% said that the disinfection of dental equipment was the most important hygienic measure that dental offices need to ensure, followed by 22% who said that often-touched surfaces need to be disinfected to maintain proper hygiene in dental practices.

However, DentaVox said, only 61% of respondents said they have actually seen the dental staff disinfecting dental equipment, and 46% have seen staff disinfect often-touched surfaces.

According to the poll, 9% said the use of personal protection equipment (PPE) and 5% said that handwashing and sanitizing were the most important hygiene protocols. On a related note, 67% of respondents have seen dental staff wash their hands, and 50% have seen staff change their PPE.

Meanwhile, 4.2% of respondents said that keeping the office organized was most important, prompting DentaVox to note how tidiness may be confused with hygiene, which the World Health Organization says “refers to conditions and practices that help to maintain health and prevent the spread of diseases.”

Cleanliness is often considered hygienic too, DentaVox said, though that is a misconception as well. Cleaning is the removal of visible dirt, while hygienic cleaning also eliminates invisible dirt, germs, and other pathogens. And while tidiness may mean neat and organized, it does not guarantee cleanliness or good hygiene, DentaVox said.

Also, only 0.76% called open windows and 4.1% called air purification and disinfection priorities, even though 23% said they have seen dental staff opening windows during their last dental visit and 25% said they spotted some sort of air purification system.

Disposable shoe covers are mandatory in many dental clinics, but only 1.3% of respondents said that washing floors was necessary to hygiene, and 18% have seen staff washing floors during their last dental visit.

First impressions matter too, with 55% of respondents forming a first impression simply by looking around the dental office, and 19% of them noting how it smells. Other respondents checked the cleaning protocols or asked or were informed by the staff about the last cleaning session.

The largest proportion of respondents, 41%, judge the hygiene in the office by the state of the tools and equipment used during an appointment. Next came the condition of the entire treatment room at 29%, the condition of the waiting room at 12%, and the condition of the surgical room at 9%.

Only 4% said that the way the dental staff was dressed mattered, while 3.76% said the state of the bathroom was the best indicator for hygienic cleanliness in the dental office. As for PPE, respondents would like to see dental staff wear:

• Protective gloves: 93%
• Face masks: 88%
• Goggles: 61%
• Disposable coats: 46%
• Shoe covers: 39%
• Caps: 16%
• Shields: 15%

During their last dental visit, more than 90% of respondents said their dentist wore gloves and masks; 62% said their dentist wore goggles; 46% said their dentist wore a disposable coat; 35% said their dentist wore shoe covers. Caps and shields were part of their outfit less frequently, which DentaVox called a serious lapse on the dentists’ part.

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Since March 2020, businesses of all kinds have suffered from uncertainty about both the health and financial crises of the global pandemic. Dental practices across the United States were forced to alter not only their services but also their bottom lines.

While relief programs provided funding throughout the past year to keep businesses afloat, there are further opportunities that could benefit dental practices both retroactively and in the near future.

“This past year has had a significant effect on all of us in the dental profession,” said Michael Eggnatz, DDS, former president of the Florida Dental Association.

In fact, roughly three-quarters of dentists closed their offices to all patients aside from emergency appointments. At least 90% of dental practices reported either closures or significant reductions in patient visits during that time.

“We were only allowed to open if we had the appropriate personal protective equipment (PPE), all of which were in very short supply or unavailable,” Eggnatz said of Florida’s initial mandate in late March. “Our office finally opened part-time on May 26 when we could order and secure enough PPE and other equipment to keep our patients and our office team safe.”

What Eggnatz’s office also did was keep employees on the payroll, qualifying the practice for various forms of relief. Not only did his office receive Paycheck Protection Program (PPP) funds, but he also learned of the Employee Retention Tax Credit (ERTC) through his local accountant.

Working With a Professional

Tricia and Eric Golomb are the owners of a South Florida branch of Payroll Vault, a national payroll franchise whose local owners work with business owners in their specific area. The Golombs dedicated much of their efforts in the past year to ensure businesses in their community got as much relief as they could, and they say dental practices are uniquely qualified to receive that support.

“That’s a scary situation, and I can only imagine being a dentist at that time, both making sure you’re protecting everyone and also dealing with the uncertainty of your business going forward,” Tricia said. “The most important thing is just helping businesses in our community because it’s such a complex law that people don’t necessarily know about. At the end of the day, that’s funding due to them which could help their business.”

For so many business owners, dentists included, the added pressure of educating themselves in the moment while still trying to perform their everyday functions has proved a struggle, specifically as rules and guidelines change for the various relief programs.

For example, the PPP has evolved several times, from changing guidelines from the first and second rounds of loans to whether or not those funds are forgivable. Combine that with legislation such as the Families First Coronavirus Response Act, Economic Injury Disaster Loans, and now the ERTC, and there is no shortage of information for business owners to pore over.

“Unless you’re an accounting or payroll professional, it is difficult to navigate the nuances of the PPP landscape and the guidelines for the ERTC,” Eggnatz said. “But essentially because I kept my staff employed despite the loss in revenue, Tricia let me know I could expect to receive tens of thousands of dollars through that credit.”

In addition to the retroactive relief for 2020 struggles, the Golombs’ and other Payroll Vault offices around the country see the ERTC as one of the most important opportunities for small businesses going forward, including dental practices. The program extends through 2021, meaning businesses still rebounding due to patient hesitancy and health concerns could receive support. And because so many dental practices kept their staffs intact, that opportunity is available to many practices around the country.

The Need to Be Proactive

Still, with so many moving parts, it’s essential to be proactive. Legislation such as the PPP and ERTC are both new programs and frequently evolving, putting an emphasis on education between business owners and their financial and professional advisors.

“The most important thing is communication and setting expectations so they can plan for their practice,” said Eric Golomb. “One of the key things in 2020 was amending a return, which makes it a slower process on top of the IRS being backed up. It could be several months before that money comes in. But the current process for 2021 is much more of a normal turnaround if you plan right.”

No matter the state or city where a dental practice resides, there are still relief options that are likely to help bridge the gap between now and the return to normal patient visits expected in post-pandemic life.

“I try to look for the silver lining in the most difficult of times, and we all have been through the difficult year of the pandemic in 2020,” said Eggnatz, who has already determined possible uses for the ERTC funds he received.

“Finding these relief opportunities has definitely been a silver lining,” he continued. “This is money that I can use to invest in my business. It will allow me to provide the latest scanning technology in dentistry to give my patients the best care and the treatment that they deserve.”

Mr. Manning is the founder and CEO of Payroll Vault, an outsourced payroll and HR service for small businesses. He started Payroll Vault in 2007 and began franchising in 2012, now with more than 60 locations across the United States. He also is the former owner of Insperience Business Services and is the coauthor of the book Six Steps to Small Business Success.

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The combined use of a high-volume evacuator (HVE) with an intraoral suction device significantly reduces the amount of microbial aerosols generated during dental cleanings, according to the Loma Linda University (LLU) School of Dentistry, improving safety for patients and dental professionals alike.

Researchers at the school found a threefold reduction in microbial aerosols with the simultaneous use of an HVE plus an additional suction device placed in a patient’s mouth compared to using an HVE only.

The spread of COVID-19 and expanding understanding about its routes of transmission, including airborne respiratory droplets, sparked the researchers’ determination to investigate aerosol dispersion during dental procedures, said Montry S. Suprono, DDS, MSD, director of the LLU Center for Dental Research and the study’s principal investigator.

“Once organizations like the WHO and CDC released reports describing the virus’s modes of transmission, we quickly understood how dentistry would be affected because a number of dental procedures generate aerosols,” said Suprono. “So, we wanted to figure out ways to minimize the risks by decreasing the amount of aerosols that are generated during dental procedures.”

The clinical trial involved more than 90 dental student participants who served as operators and patients at the LLU dental clinic. The researchers collected aerosol samples by placing blood agar plates, which are dishes intended to collect the aerosols, in various zones throughout the clinic such as shelves and patients’ chests for intervals of time before, during, and after dental cleanings.

The procedures were conducted using a split-mouth design. Operators used both the HVE and intraoral suction device on one side of the patient’s mouth during one round of the cleaning and then only the HVE on the other side of the patient’s mouth for the other round. After collecting the aerosols in the various agar plates, samples were incubated for two days, and microbial levels of each sample were measured.

The highest microbial counts came from the plates positioned on patients in the operating zone compared to plates placed on mobile trays and shelves farther away. Also, microbial levels during procedures were highest compared to pre-treatment and post-treatment levels. And compared to using the HVE alone, the combination of the HVE and an intraoral suction device significantly reduced the amount of microbial aerosols generated.

Furthermore, microbial levels before procedures were similar to microbial levels after procedures, meaning that a 30-minute time interval for air change and for the aerosols to settle down on surfaces post-procedure appears to be adequate, the researchers said.

“We now know dental professionals should allow for aerosols to settle for some time before sanitizing the treatment area and that the risk between patients is minimal if time is allowed,” Suprono said.

Suprono hopes the research will inform and guide best clinical practices to enhance safety and hygiene during dental cleanings. There also remains ample opportunity to consider other types of dental procedures or equipment in evaluating aerosol generating, he said. Understanding aerosol dynamics through computerized simulations and modeling constitutes another rapidly developing area of research as well, he added.

The researchers will continue studying personal protective equipment, aerosols, and air quality as it pertains to dental practice, Suprono said.

“These kinds of inquiries and research are critical to evaluate how dentistry currently works now and how it could evolve in the future with the goal of improving the safety for our patients and dental professionals,” said Suprono.’

The study, “A Clinical Investigation of Dental Evacuation Systems in Reducing Aerosols,” was published by the Journal of the American Dental Association.

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The Harvard School of Dental Medicine (HSDM) and the World Health Organization Regional Office for Africa (WHO AFRO) have partnered to address critical oral health challenges in the African region that have gotten worse due to the COVID-19 pandemic.

The project aims to build on the capacity of primary care workers in oral health promotion and oral disease prevention and control to better address the unmet demand for oral health services and strengthen oral healthcare systems, the partners said.

The team will develop an online oral health training program that will leverage digital technologies and mobile health initiatives for workforce development, the partners said.

HSDM was selected to support the project based on extensive faculty expertise and experience in global workforce development, including in the African region, with existing partnerships in Rwanda, the partners said.

Additional work in this area also includes HSDM’s leadership in the design of the Global Health Starter Kit, an online, open access curriculum now in use in 30 countries, the partners said.

The first phase of the project will involve the creation and implementation of a pilot training program focused on community health workers in Angola, Kenya, Liberia, and Senegal, with a goal to scale to remaining WHO AFRO member states and expand training for additional primary care workers in the future.

“These collaborative efforts are among the first to translate exciting progress in policy and research into practice through responsive workforce capacity building,” said project lead Dr. Brittany Seymour, associate professor of oral health policy and epidemiology (OHPE) and HSDM global health discipline director.

Earlier this year, recognizing the global oral disease epidemic and scarcity of dental human and financial resources available, a WHO resolution prioritized oral health in its global health and development agenda. This call to action emphasized improving oral health as part of universal health coverage and non-communicable disease prevention and control efforts.

Dr. Donna Hackley, an OHPE instructor, also will serve on the project. She has played a significant role in the Human Resources for Health Rwanda, Dentistry program since 2013, HSDM said, where she led the implementation and accreditation of the first dental school in Rwanda.

“We value community-based collaboration and input. Local insight and expertise will be essential to the success of this project,” said Hackley.

Dr. Jane Barrow, associate dean for global and community health and executive director for HSDM’s Initiative to Integrate Oral Health and Medicine, will work with the project team. She initially was involved in the 2011 United Nations Summit on NCDs oral health side session as well as the 2019 UN Summit on Universal Health Care, which drew attention to growing global oral health concerns, HSDM said.

“Our new collaboration with the WHO Regional Office for Africa builds from the 2011 UN Political Declaration on the Prevention and Control of Non-communicable Diseases, which named oral diseases as a major global problem,” Barrow said.

“We will work to align this training program with goals and policies emphasized at the UHC Summit oral health meeting, which include strengthening efforts to address oral health as part of universal health coverage and primary care,” Barrow said.

The workforce training program was initiated within the WHO Prevention of Noncommunicable Diseases, Oral Health Programme. The HSDM team will work with Dr. Yuka Makino, WHO technical officer for oral health at the WHO Regional Office for Africa and author of Ending Childhood Dental Caries: WHO Implementation Manual 2019.

“We are rethinking the future of the oral healthcare system, including through education and training and using digital platforms to improve the capacity of primary care workers as well as taking a more integrated approach to oral health service provision to meet the huge needs,” said Makino.

More than 480 million people in the African region suffer from oral diseases such as dental caries and periodontal diseases, WHO said. However, oral health remains a low priority in many countries, leading to inadequate financial and technical investment that undermine prevention and care services.

Disruptions by the COVID-19 pandemic in the health sector have exacerbated oral health services in the region, WHO said, with approximately 90% of countries responding to a WHO survey reporting a complete or partial disruption of oral health services between February and July 2020. Countries have since made efforts to restore delivery of essential services, WHO said.

The collaboration’s online training will target health workers at the primary care facility level. Africa had 3.3 dentists per 100,000 people between 2014 and 2019, which is almost less than a tenth the global ratio of 32.8 per 100,000, according to the WHO National Health Workforce Account Data Platform.

“Oral health services in most African countries are centered around oral health professionals and oral diseases. This means that there is little collaboration across and beyond health sectors,” said Makino.

“As such, prevention of oral diseases by controlling modifiable risk factors such as tobacco use, alcohol consumption, and an unhealthy diet high in free sugars, which are common to the four leading noncommunicable diseases (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) is difficult,” said Makino.

“I am honored and grateful to be a part of this exciting effort,” said Seymour. “It really is an opportunity to turn vision into reality, to build on the incredible momentum from the United Nations Sustainable Development Goals and Summits. I have high hopes for what we can achieve together for oral health in Africa moving ahead.”

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