I am Dr.
Chad Gehani, president ofthe American Dental Association.
the COVID-19 pandemic has changed theway we live and work.
this has been a very difficult time for the dentalcommunity.
but, from one practicing dentist to another, I would like toreassure you that ADA has our backs.
and, our association is working to ensurethat you have what you need to navigate these times safely.
on April 1st weissued interim guidance for performing urgent and emergency procedures at thistime.
today, we have assembled a panel of experts to answer your questions aboutthe interim guidance.
now, I would like to welcome the ADA's executive directorDr.
Kathy O'Loughlin, who will serve as today's moderator.
thank you, Dr.
in the last several days the ADA has received a number of questions about theinterim guidance from dentists all over the country.
to best answer thesequestions, I'm pleased to be joined by three leading experts in the field ofdentistry who helped develop the interim guidance we are discussing today: Dr.
MiaGeisinger, Marcelo Araujo and Dr.
Mia Geisinger is Chair of theADA Council on Scientific Affairs.
She is also a professor and director ofadvanced education in periodontology at the University of Alabama School ofDentistry.
she received her DDS from Columbia University School of DentalMedicine, and her certificate in periodontology and master of science degreefrom the University of Texas Health Science Center in San Antonio.
Marcelo Araujo is the ADA Chief Science Officer, CEO of the ADA Science andResearch Institute, and the CEO of the ADA Foundation.
Araujo received hisdoctorate in dental surgery and earned a certificate in periodontology at theUniversity of Ghana Theo in Rio de Janeiro, Brazil.
he received his PhD inepidemiology and community health in masters of sciences, oral sciences, fromthe University of New York at Buffalo where he also completed a two and a halfyear fellowship in periodontology research and teaching.
Dave Preble isthe senior vice president of the Practice Institute in his 15th year atthe ADA.
he practiced dentistry for over 20 years, holds a legal degree and is the certified association executive.
Dave is a fellowof both the American College of Dentists and the American College of LegalMedicine.
thank you all for joining us today.
how would you summarize theinterim COVID-19 guidance recently released by the ADA? Well Kathy, I thinkthis document summarizes, not only what the science has provided so far in termsof data related to COVID-19 and dentistry, but as well as what the regulatoryagencies in other health care agencies has provided through healthcareprofessions and how to reduce the risk when treating their patients.
yeah, Ispecifically I think the flow charts — where we are calling them the algorithms —they help the dentists understand what are the steps and all the rightquestions they have to ask their patients when treating them during anemergency procedure.
we really need to focus on reducing the risk ofcontamination, for both dental professionals and the patients, and makesure that we can control this outbreak of the virus.
in terms of emergency andurgent procedures, don't these procedures produce aerosols that put ourselves, ourteams, and any subsequent patience entering our office, at risk forCOVID-19 transmission, Dr.
Geisinger? that's certainly a concern, Kathy.
and, youknow, I think that if you look at the third algorithm, this type of carewithout appropriate PPE does leave the clinician at moderate to high risk.
it isreally the rationale for many of the recommendations that we have made in thedecision-making process outlined in these algorithms.
so, at this point, dentistsare unable to obtain face shields or N95 respirators and other personalprotective equipment or PPE.
hospitals and medical settings are the prioritiesfor receiving this type of equipment.
so, who is managing the PPE shortage issue?well, in the immediate future there's no real management going on because PPEavailability is entirely out of our sphere of influence because of thefactors that you mentioned in your question.
but, ADA is in contact with thedental trade alliance and all of the suppliers of this equipment, so we can atleast stay informed about when the supply and availability will becomebetter for dentists.
we're also looking into the possibility of developing somesort of affinity programs with PPE suppliers.
The ADA is recommending that suppliers.
the ADA is recommending thatmembers wear surgical masks, if available, N95 respirators, for all procedures.
The recommendations alsoprocedures the recommendations also suggest that surgical masks should bedisposed of after each patient.
how can the ADA provide these recommendationswhen front line hospital workers can't even get proper PPE to treat knownCOVID positive patients? Well, Kathy, I think one of the things we have to have inmind to start is the distance between the dentist and the patient during treatment.
we're in very close proximity.
and, we understand now that the CDC and othergovernment agents also are considering talking and breathing apotential aerosol producing action.
so, we really need to ensure that ourdentists and our members and their patients are safe.
but, most likely, is to ensure that the treatment can be provided into the low-risk environment.
are there any options for dentists to consider beyond N95 respirators andsurgical masks with face shields? yes.
last week the FDA announced emergencyuse authorization of KN95 respirators commonly manufactured inChina.
these are similar to the N95 respirators in terms of particlefiltration.
but, just like an N95, it's important for the user to do a seal andfit test after donning.
Kathy, may I add something else to this? one of thequestions I was asked this week was related to the difference of what [.
]are being called N95 mask and N95 mask with a respirator.
what we see is that ifyou look into the two devices they are very similar.
the main difference is that N95 [with a] respirator you will see is the one that on thefront on the area of the mouth, it looks like there is a filter.
so, when theperson is breathing through the mask there is another layer of filtrationhappening.
so far, as we look into the science and the and the differencebetween the two, we haven't seen much more difference between them, as bothtype of masks are meeting the standard.
and, we are trying to ensure that, not only ourrecommendations are based on science and publications, but also looking to what itis that there is this standard.
that's why so the importance of ADA ANSIstandards and other things here highlight the fact that we can helpdecrease the truth.
so, it's likely that this will be the new standard for PPE indentistry, since this has not been recommended until now? could you just confirm?I believe it I believe it will be none of us have a clear crystal ball, but, Ithink I would just turn the question around.
now that we know of the presenceof this sort of respiratory disease that can only be filtered properly throughthe N95 wouldn't we want it to be the standard I think is the better way tosay that in the algorithms describing how to triage and screen patients andalso manage the transmission of koban 19:00 why is the ATA recommending thatpeople who are suspected to have Kobuk 19 be sent to the emergency departmentfor dental treatment so if you look at that algorithm to the decision switchpoint is really the signs and symptoms of acute respiratory distress arespiratory symptoms and in patients that have a fever and those symptoms areeven without a fever and those symptoms going to the emergency room iscritically important to make sure that they are screened and receive the carethat they need for their overall health and then their dental needs can beaddressed subsequently based upon the findings of those investigations in theinterim guidance indicates that if a standard surgical mask is used during anaerosol generating procedure then the patient needs to get tested for coded19:00 because it is a moderate to high risk situation for the health careprovider in subsequent patients and staff members how am I supposed torequire subsequent patients to be tested for koban 19 when it's alreadyextraordinarily difficult to have that testing done well that's an importantquestion without an easy answer the the idea behind using a surgical mask onlywithout a face shield without goggles without all the other things that youwould need to bring it down to a moderate risk is one of those thingsthat the dentist would likely have to evaluate whether they want to do thatprocedure at all with that level of protectionthe burden that this testing would place on the hospital system is something thatthere's no real way about around we obviously want to deal with dentalemergencies to alleviate that burden but do it in such a way that the dental teamis not at a high risk if a rubber team is used concurrently with the high speedhandpiece and the tooth has been disinfected after application of therubber dam is the risk level the same and does the patient still need to betested well the the rubber then adds another layer of protection for bothsides for both the dentist and the patient in terms of thealgorithm what we have seen is that we are focusing on the protection ofdentists and that's why they use a mask and face use etc if they use a rubberdam is added during the procedure I think it's important that the dentistsunderstand that they need to figure out the best way to treat the patients toreduce the issues that they need to be treated and at the same time protectthemself so yes the level of the risk may reduce we are based basing this onanecdotal data we don't see a lot of publications related to this but indiscussions that we have had with clinicians and others we see that theymay help reduce with it you know in relation to rinse protocols is theevidence informing the use of hydrogen peroxide and povidone related to theireffect on viruses like coded 19 well there there aren't any clinical studiessupporting the virus idle effects of any pre procedural mouth risk againstTsarskoe b2 however since Tsarskoe b2 may be vulnerable to oxidation commonlyused pre procedural mouth Ridge such as 1.
5 percent hydrogen peroxideFrances may be considered but considering that the microscopicparticles that we are trying to be protected from are coming from thepatient's lungs a mouth rinse is not going to be a panacea unless you'regoing to have the patient rinse after every breath they take can we addsomething else to this is you have to understand that the difference between avirus and other type of microorganism in the virus is basically what we see isthat it's a layer of fat with RNA inside and these two braces have being able tolook to break down that fat that creates and protects their RNA which is veryvery important for the multiplication of the virus once invades the cells so theassumption that this one of these two virus will kill wound is to erases willkill the virus this based on the action on peroxide hydrogen peroxide in in fatlayers or povidone exactly we don't know a lot about how all the type of mouthroom once we rings you may decrease in the risk at that point but you don'tknow what's happening because the virus is on the lung right in the lung and andif the patient will cost during the process the procedure that fires may bethe load may be exposed again because there is also racing is good to startthe process and I don't know if Mia wants to add anything in there on thepractice that she has seen but I think it helps to understand how these twotypes of my friends is why they have been said that they are potentiallycontrol but if the only other thing I would add marcello is that chlorhexidinegluconate which is a commonly used pre procedural mouth rinse has not beenshown to be effective for virus idle action in these cases so while that maybe effective for bacterial seidel uses it likely is an ineffective freeprocedural mouth rinse in this case and the guidance flowchartsbe modified to include recommended procedures to avoid the generation ofaerosols well so at this point we are really focusing on the on the emergencyprocedures but most important the focus of this algorithm is to ask the dentistto use clinical judgment when deciding how to treat the patient there are a lotof procedures there there's the list of procedures that we radiate hasidentified as emergency procedures that we recommend to be treated but I thinkit's important that the dentists use their clinical judgement when decidingwhat to do that's why it will be very difficult for us to include all of themin these algorithms and we need make sure we want to make sure that thedentists use this algorithm together with the list of the statistic we arethen also considering the definition of what is and what is not an aerosolproducing procedure may be under closer scrutiny too because in the medicalworld if they're considering an intubation being an aerosol producingprocedure just because you're in the patient's face when the patient isbreathing then this this idea of aerosol producing procedures is not just what wedo with handpieces or scaling instrumentsso what garden should be given to a patient with a true dental emergency whois known to have an active coded 19:00 infectionso current CDC guidelines for both patients with known coded 19 infectionsand Pui patients under investigation for such infections recommend that anynecessary medical treatment be carried out in an air room a negative pressureroom to reduce the spread of the virus in aerosols throughout the the facilityand most gentle offices are not currently able to provide that type ofenvironment so providing emergency care even in very serious emergencies forthose patients in a private practice dental office if if those guidelines arenot being able to be met does convey a risk to staff dentists and evensubsequent patients for infection with Tsarskoe v2 and subsequent developmentof kovat 19 so individuals with an active infection need to be advised goto their emergency department contact them by phone prior and learn whatarrangements can be made for them to come in and receive the care that theyneed in the safest possible environment why don't the recommendations from theCDC mention the use of rubber Damoh isolation at this point the city'sinterim guidance does not include insight about how to provide safe carewe know that the their recommendations are evolving as of today April 7th wethink that they are based on the publication's that we have seen so farbut as during our conversations with the agency we know that they keep monitoringthe work and we are trying to do our members and other contacts that we haveunderstand if the use of rubber dam will add a real protect I don't know if youhave seen any any data any and anything they can actno I mean currently they're their recommendations really don't delve intothis very much but I do think the the rapidity at which some of these rapidreviews are getting out there into the scientific literature should help informfuture evolving recommendations both on the part of the ATA and on the part ofnational agencies do you anticipate the ad ace interim guidance will remainpermanent once things kind of come back to normal in a few months it seems likerunning a dental practice under these conditions will be almost impossiblewhile the interim guidance is informed by the latest recommendations fromhealth care agencies like the World Health Organization and the Centers forDisease Control and Prevention as well as the scientific literature and weintend to revise and update them as new data emerge though these recommendationsare not necessarily going to be relevant after the coab in nineteen crisis isover but we have to understand that we will have learnings from this pandemicand those learnings will influence how we move forward what seems impossiblenow may not be what defines the future Dave I'd also like to say that we may belooking at this from a static standpoint in terms of technology but as this movesforward we may also see advanced technology that that marries up with ourour advances in knowledge that allows us to have options that we currently don'thave well I'd like to extend sincere thanks to all the panelists today youwere terrific thank you for doing this thank you thank you for the opportunitythank you dr.
Lachlan and many thanks to our panelists for sharing theirexpertise with us The Cove 8:19 situation is evolving and the 80s workcontinues dentists like you are essential to the welfare of ourcommunities and our association will continue to support you we will getthrough this together thank you for joining and stay well you.