Practicing Endodontics during COVID-19

By Ali Behnia, D.M.D., M.S.

In January 2020, a 35-year-old man presented at an urgent care clinic in the State of Washington and was diagnosed with the first documented case of COVID-19 in the United States. What has transpired since has been unimaginable for many of us. Not only do we stand at more than 4.5 million cases in the United States and over 17 million cases in the world, but the virus has left a carnage of lost jobs, lost businesses, and lost aspirations.

While most dental practices have been financially impacted due to the pandemic, endodontics has largely prevailed. In April, an AAE survey indicated that 85% of endodontic practices were open, with 82% seeing emergencies only. By July, 90% of endodontists were practicing, with 85% of endodontists having returned to regular practice, including non-emergency care. According to current data from the ADA’s Health Practice Institute, 98% of dental offices in the U.S. are open in some capacity, with a patient volume and staffing at 90% and 70-75% of pre-COVID numbers, respectively. Endodontists have returned to a patient volume of 75-80% of pre-COVID numbers, the 2^nd highest among specialties after oral and maxillofacial surgeons.

Yet, many challenges remain. For example, over the last several months, the AAE has written letters to FEMA, state governors, and state health departments, worked with vendors, and joined the ADA and the Organized Dentistry Coalition (ODC) on various legislative initiatives to prioritize the availability of personal protective equipment (PPE) for endodontists. Yet, this continues to be a frustration and a challenge, with many of us developing our own workarounds to make do with the PPE that we have.

The Centers for Disease Control & Prevention (CDC), the Occupational Safety and Health Administration (OSHA), the American Dental Association (ADA), the Organization for Safety, Asepsis, and Prevention (OSAP) and other organizations have published expansive guidance to address many of the challenges of practicing dentistry in the COVID-19 area. However, they do not address a few unique challenges faced by endodontists such as the use of a microscope while wearing a face shield, and some recommendations are limited by the lack of available research.

Accordingly, AAE President Dr. Alan Gluskin nominated a Special Committee to Create Endodontic Specific Guidance in the COVID Era. I am honored to serve as the chair of the committee, alongside our colleagues Dr. Louis Berman, Dr. Joseph Petrino, Dr. Richard Rubin, and Dr.  Derrick Wang. The charge of the committee is to develop guidance specific to the safe and effective practice of endodontics during and after the pandemic, including addressing the resurgence and potential recurrence or variation of the virus in the future.

The committee strives to publish guidance that is based upon evidence, or at least research. The committee has reviewed existing infection control protocols and guidance from several organizations, as well as available studies. However, the paucity of evidence continues to challenge the committee, as it does all organizations in efforts to provide sound guidance. Studies by Dental Advisor are presently underway to assess the actual reach of aerosols in the dental practice as well as the efficacy of air purifiers, external evacuation systems and internal evacuation systems. Moreover, the Foundation For Endodontics (FFE), and other organizations, have made it a priority to focus on COVID-19 research.

In the meantime, the committee recognizes that endodontists continue to face challenges. Accordingly, as an interim peer-to-peer effort, the committee has excerpted a few key CDC and OSHA recommendations of particular relevance to endodontics, coupled with a few practices adopted by fellow endodontists on specific challenges not fully addressed by existing guidelines. The following information is not intended to supplant existing guidance.

Patient Care:

If the patient expresses symptoms of a fever (100.4 degrees F or higher, per the CDC), cough, sore throat, shortness of breath, flu-like symptoms, recent and abrupt loss or reduction of the sense of smell and/or taste, or close personal contact with a suspected or laboratory-confirmed COVID-19 patient in the past two weeks:

1. 1. Delay the appointment for 14 days while the patient self-quarantines.
   2. Inform the referring general dentist.
   3. Advise the patient to contact their primary care physician for appropriate care.
   4. Contact the patient periodically via teledentistry or telephone to assess their condition/status.

PPE & its Use with a Surgical Operating Microscope:

1. For aerosol generating procedures for patients assumed to be non-contagious, the CDC recommends an N95 or higher level of protection, if available, but allows for the use of the highest level surgical mask available in combination with a full-face shield if a respirator is not available. (Note: Do not perform aerosol generating procedures (e.g., apicoectomy) on patients suspected of having COVID-19 without an N95 or higher level respirator.)
2. You can use an alternative to the N95, such as the KN95, but only buy a KN95 with a head strap (not just ear loops), and ensure that the seller is a NIOSH approval holder by checking this site – https://wwwn.cdc.gov/niosh-cel/. Also, check filtration efficiency results at https://www.cdc.gov/niosh/npptl/respirators/testing/default.html. Many endodontists are using the KN95 mask in combination with a surgical mask.
3. 

   Dr. Behnia’s microscope shield

   If you’re left with a surgical mask and a full-face shield, and need to use a surgical operating microscope,
   there are various industry and makeshift options for shielding an operating microscope. While not necessarily endorsed by the AAE, the following examples have been shared by endodontic peers:

   1. A polycarbonate shield mounted to the microscope with an attached high velocity vacuum hose ventilation systems.
   2. A plastic drape added to a Dura-Lar shield and a saliva ejector attached to the rubber dam.
   3. A microscope shield protecting endodontists from “splash back”.
   4. Various makeshift options shared by fellow endodontists include a face shield made for a motorcycle helmet with a hole cut to fit an eyepiece and lined with foam for stability. For more makeshift options, please visit this and other conversations on AAE Connection.

Imaging in Endodontic Practice:

1. Intraoral radiograph acquisition is important to endodontics but can potentially increase aerosol generation, in comparison to extraoral radiographs. Take appropriate precautions as needed.
2. The use of cone beam CT has grown more prevalent in endodontics. If using cone beam CT, one reference indicated that patients may retain their masks. However, please note that many masks have metal in the nose pieces and will require their removal for cone beam CT use.

Minimizing Aerosol Generation and Exposure, beyond PPE:

Have patients use a preprocedural mouth rinse (PPMR) and use four-handed high volume suction. Use a well-adapted rubber dam, seal the clamp area with paste, and disinfect the tooth and the isolation area with Sodium Hypochlorite.

Operatory Disinfection:

While the CDC has redacted its recommendation of a 15-minute waiting period prior to cleaning an operatory, team members should nonetheless refrain from entering the operatory once the patient has left, until the protected team member has cleaned and disinfected the area.

Air Filtration:

The CDC suggests the use of a portable HEPA air filtration unit while the patient is undergoing, and immediately following, an aerosol generating procedure. However, some committee members have noted that there may be other air filtration systems that may be as effective or better in filtering and killing viruses. Moreover, a new study accepted for publication in Otolaryngology-Head and Neck Surgery indicates that HPEA purifiers “should be considered an adjunctive infection control measure and be undertaken with knowledge of HEPA filter functionality and limitations in mind.”[1]

The committee continues to actively monitor and review the latest research in an effort to develop more impactful guidance specific to the practice of endodontics. The committee will present more formal and comprehensive guidance upon the availability of additional evidence.

Meanwhile, please visit the AAE’s dedicated COVID-19 site – aae.org/covid – and read the AAE’s weekly Coronavirus Briefings – to stay abreast of the latest information on COVID-19. The AAE has also provided COVID-19 webinars on endodontic implications, recovery, teledentistry, respiratory protection, CDC guidance, and production.  For endodontic residents, the AAE has hosted virtual lectures weekly since April. Members are also encouraged to take advantage of AAE Connection to post inquiries and exchange ideas with  peers about practicing endodontics during COVID-19.

Should you have any questions or have any suggestions, please contact us at advocacy@aae.org. The AAE’s assistant executive director for advocacy and professional relations, Srini Varadarajan, J.D., has been immensely dedicated to participating in these conversations, and thus, I wish to acknowledge his great contributions as staff support.

[1] https://www.entnet.org/sites/default/files/uploads/sedaghat3_hepa_filters_in_era_of_covid-19.pdf