key: cord-0766909-v75qvb1i
authors: Persoon, Ilona F.; Stankiewicz, Nikolai; Smith, Andrew; de Soet, Hans (J.J.); Volgenant, Catherine M.C.
title: A review of respiratory protection measures recommended in Europe for dental procedures during the COVID-19 pandemic
date: 2020-07-30
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.07.027
sha: 0cd660fef93d660ec824cf0ee10ded4825e075ad
doc_id: 766909
cord_uid: v75qvb1i

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The main mode of transmission of the SARS-CoV-2 virus is via respiratory droplets and aerosols 1 . During the COVID-19 pandemic period, the World Health Organisation (WHO) recommends wearing respiratory protection when undertaking aerosol generating procedures (AGP) to reduce the risks of cross-infection between patients and healthcare worker (HCW) and vice versa 2 . Patients who tested positive for this virus are known to carry high numbers of virus particles in their saliva and on their tongue 3 . Dentistry poses a particular challenge due to the large number of aerosol and droplet generating procedures undertaken in the oral cavity and the very close proximity (<0.5m) of dental HCWs to the plume of aerosolised respiratory secretions. The availability of healthcare personal protective equipment (PPE) has been put under considerable strain due to the COVID-19 pandemic 4 . In some countries, shortages of PPE have necessitated sessional use of equipment that was previously deemed single patient use 2 . Therefore, facemask recommendations may not be based solely on maximum protection, but also on pragmatism including availability and areas of priority within a region's healthcare system.

A review of protocols for dentistry during the peak of the COVID-19 epidemic was undertaken, focussing on respiratory protection measures during dental procedures for the European continent. European dental association web sites were screened for information on guidance or protocols regarding SARS-CoV-2 and PPE.

Documents in languages other than English or Dutch were translated into English using Google Translate. After obtaining the data, the results were presented to experts involved in dentistry and oral microbiology within Europe for verification.

Three categories of respiratory protection measures were identified within the protocols; medical (surgical) facemasks, filtering facepiece particles (FFP)2 and FFP3.

Of the 24 included European countries, 75% recommend respiratory protection FFP2 / FFP3 when performing AGP in patients with symptoms of COVID-19, and 25% recommend referral or postponing treatment (results per country are available upon request). These practices are in accordance with the WHO guidance 2 . The potential for transmission from asymptomatic or pre-symptomatic carriers was identified as a concern in many of the countries, especially if an AGP was necessary. When patients do not show symptoms of COVID-19, 54% of countries recommend respiratory protection FFP2 / FFP3 when performing AGP. A considerable number of countries also recommend respiratory protection FFP2 / FFP3 when performing non AGPs, both in patients with (63%) and without symptoms of COVID-19 (33%). These masks filter significantly more effectively and have a better fit compared to medical facemasks; studies showed 9% total leakage of fine particles when using FFP2equivalent respirators, whereas the leakage for medical facemasks was 22-35% 8 .

However, the effectiveness of these respirators to prevent transmission of pathogens highly depends on proper fit and use of the equipment 9 In conclusion, the recommendations on respiratory protection when undertaking dental healthcare in European countries vary considerably. This highlights the need for a task force to re-examine the evidence base for respiratory viral transmission during dental procedures and support closer alignment of guidelines throughout the dental healthcare sectors.

Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals

Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages

Consistent detection of 2019 novel coronavirus in saliva

Suchomel M COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves and gowns

proposal for a risk-adapted approach to ensure patient and healthcare worker safety

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Estimating the generation interval for coronavirus disease (COVID-19) based on symptom onset data

The effectiveness of respiratory protection worn by communities to protect from volcanic ash inhalation. Part II: Total inward leakage tests

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Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis

The authors would like to express their gratitude to all