Evidence to support safe return to clinical practice by oral health professionals in Canada during the COVID-19 pandemic: A report prepared for the Office of the Chief Dental Officer of Canada

November 2020 update

This evidence synthesis was prepared for the Office of the Chief Dental Officer, based on a comprehensive review under contract by the following:

Paul Allison, Faculty of Dentistry, McGill University
Raphael Freitas de Souza, Faculty of Dentistry, McGill University
Lilian Aboud, Faculty of Dentistry, McGill University
Martin Morris, Library, McGill University

Contents

Foreword to the first update

By Dr James Taylor, Chief Dental Officer of Canada

30 November 2020

Following the successful completion of the original document on 31 July 2020, the Office of the Chief Dental Officer of Canada (OCDOC) commissioned McGill University to produce three updates during the year following the first report. This is the first of those update reports, covering relevant literature published between 01 July and 31 October 2020. It is intended as an addendum to the original document, and should thus be used in conjunction with the original document. This document will reside alongside the original document in the public domain, to be accessible to decision makers as they carry out their respective responsibilities.

As with the original document, McGill University drafted a comprehensive knowledge update concerning key issues that inform the provision of oral health care by relevant providers in Canada during the COVID-19 pandemic. The OCDOC then reconvened the representative multidisciplinary knowledge-based group from the national oral health professional and federal government health domains. The group's role was to work collaboratively to contribute to the generation of a single high-level national evidence update document by the team from McGill.

The organizations participating in this collaboration included:

Federal Health Portfolio

National oral health regulatory federations

National oral health professional associations

National oral health academic association

OCDOC Mandate: to advance population-level oral health through health promotion, disease prevention and professional/technical guidance with an emphasis on vulnerable populations.

Introduction

During May and June 2020, a research team completed a rapid review of the literature to support the safe practice of Canadian dental professionals during the COVID-19 pandemic. Following input from stakeholders on the draft report in mid-July, the report was finalized and submitted July 31 and then published on the Canada.ca website in both official languages in September 2020. The review covered literature published from January 1 2000 to June 30 2020. With the rapid pace of new publications linked to the COVID-19 pandemic, the Chief Dental Officer of Canada determined that updates to the report are needed three times during the year following the first report. These updates are to cover scientific literature published between July 1 and October 31 2020, between November 1 2020 and February 28 2021 and finally between March 1 and June 30 2021. This is the first of those update reports adding relevant literature published during the period covering July 1 to October 31 2020.

This first update will use the same structure as the original report, addressing the same nine questions. In response to each question, we include: the rationale for the question (the same as the previous report); the summary response provided in the previous report; and then a summary of the new literature. The references are only those identified for the relevant update period (July 1 to October 31 2020) and appended tables contain only material from newly identified references. Readers should return to the previous report for original lists of references and other relevant material.

Project goal

To create a knowledge product around which the Office of the Chief Dental Officer of Canada can convene a representative knowledge-based group of the national oral health professional domain, in order to generate a single high-level national expert document which Canada's oral health regulatory authorities may then choose to consult in developing consistent guidance for their respective registrants at the Provincial/Territorial level. Further, educators, program officials and policy makers may also choose to consult this document as they carry out their respective responsibilities.

When reading this report it is important to recognize three essential points:

This document focuses on evidence that is categorized as high quality using internationally recognized hierarchies of evidence Footnote 1 Footnote 2 Footnote 3. These are in descending order:

  1. Systematic reviews and meta-analyses
  2. Randomised controlled trials with definitive results (confidence intervals that do not overlap the threshold clinically significant effect)
  3. Randomised controlled trials with non-definitive results (a point estimate that suggests a clinically significant effect but with confidence intervals overlapping the threshold for this effect)
  4. Cohort studies
  5. Case-control studies
  6. Cross sectional surveys
  7. Case reports
  8. Expert opinion

Specific objectives

  1. To update the previously published comprehensive review of the literature concerning key issues that inform the provision of oral health care by relevant providers in Canada during the COVID-19 pandemic. Those key areas are:
    1. Which patients are at greater risk of the consequences of COVID-19 and so consideration should be given to delaying elective in-person oral health care?
    2. What are the signs and symptoms of COVID-19 that oral heal professionals should screen for prior to providing in-person health care?
    3. What evidence exists to support patient scheduling, waiting and other non-treatment management measures for in-person oral health care?
    4. What evidence exists to support the use of various forms of personal protective equipment (PPE) while providing in-person oral health care?
    5. What evidence exists to support the decontamination and re-use of PPE?
    6. What evidence exists concerning the provision of aerosol-generating procedures (AGP) as part of in-person oral health care?
    7. What evidence exists to support transmission mitigation strategies during the provision of in-person oral health care?
    8. What evidence exists to support space ventilation strategies that reduce the risk of transmission?
    9. What evidence exists to support the disinfection of surfaces in spaces in which oral health care is provided?
  2. To prepare a written report documenting the updated findings of the aforementioned literature searches. The report is prepared in a manner that provides clear and concise information to decision-makers (individuals providers or organizational) highlighting where strong to no levels of scientific evidence exist to support different approaches.

Methods used to identify and include relevant literature

The same methodological approach was used for this update as was used in the original report. A more detailed methodological description is available in Appendix J. In summary, search words and phrases were identified for each of the above topic areas a) to i), and searches were performed for English language articles, in standard scientific literature databases for the period July 1 to October 31 2020. Two steps were then used to include publications in this report/process: i) step 1 was a review of abstracts to decide on the relevance of publication content for the topic areas; and ii) step 2 was to include only those publications reporting the results of prospective cohort studies, randomized controlled trials, systematic reviews and/or meta-analyses. Steps 1 and 2 were done by one author and a random number of publications were reviewed in the same way by a second author so as to ensure reliability of the findings. An additional, separate search was performed of the bibliography supporting relevant national, provincial and state guidelines concerning oral health care provision during the COVID-19 pandemic in Canada and the USA. Any publications identified in this bibliography that were not in our aforementioned search, but which fulfilled the quality criteria in step 2 and were published during the relevant period were also included in this update report.

With respect to step 1, concerning relevant subject areas, as well as searching for COVID-19 and SARS-CoV-2, we also searched for similar respiratory tract viruses such as SARS, MERS, H1N1 and influenza. In reporting the results of our work, we have made clear whether the evidence concerns COVID-19, SARS-CoV-2, SARS, MERS, H1N1, influenza and sometimes other pathogens. In reality, much of the work reported is in the form of systematic reviews that cover a range of relevant pathogens and diseases.

With respect to step 2, concerning the inclusion of only that evidence fulfilling certain levels of quality, this was taken to enable this review to focus only on strong evidence in support of various approaches and concepts. This means that any evidence we highlight is of high quality. However, where we state that there is no evidence using our quality criteria, it does not mean there is no evidence at all, rather it means that evidence that exists is not of high enough quality to be included in our review. This is particularly important to note in the context of the current pandemic wherein there are a very high number of publications emerging from rapidly performed research, which for good reasons, may not be of the quality ideally desired. There are also many documents containing the opinions of experts, which are valuable in the circumstances, but which are recognized to be low in the hierarchy of quality of evidence.

Report structure

This report will address each of topics a) to i) in turn. For each topic, we provide the rationale for the question (the same as the previous report); the summary response provided in the previous report; and then a summary of the new literature, stating how strong the evidence is. The main body of the report contains only these summaries; however, each topic has an appendix containing a tabular summary of included papers, with summary data where appropriate. Readers of this report who are interested in more detailed information will need to access the relevant papers themselves. We also make clear where evidence is related to COVID-19/SARS-CoV-2 or related to similar respiratory tract viruses such as SARS, MERS, H1N1 and influenza. Finally, where pertinent, we refer readers to relevant Health Canada websites.

Summary of update report

This section provides an overview of the findings reported in the different sections. For more detailed information and for the references, see the relevant sections.

We identified a large number of new systematic reviews and meta-analyses concerning the symptoms of people diagnosed with COVID-19 and the risk factors for serious consequences such as hospitalization, ventilation and death among those patients. Many of these reviews and analyses confirmed data presented in the previous report. The evidence is strong that the most common signs and symptoms experienced by people diagnosed with COVID-19 are fever, cough, fatigue and muscle aches, shortness of breath, sputum, headache, sore throat and gastrointestinal symptoms, including diarrhea. New strong evidence has emerged reporting loss of sense of smell and altered sense of taste as common symptoms. With respect to risk factors for serious consequences of COVID-19, the evidence is strong for increased risk among people with cardiovascular diseases, hypertension, diabetes, chronic respiratory diseases, liver and kidney diseases, obesity and smokers. Newly added risk factors are people with cancer and cerebrovascular conditions. In terms of sociodemographic factors, the evidence is strong that increased age augments the risk of serious consequences, with this increased risk beginning to emerge particularly for those 60 years and older. There is now good evidence in the international literature indicating men being at increased risk for COVID-19 and its consequences, although it is not clear why - is it biological or because of their work, socializing habits and/or smoking and alcohol consumption? However, it is important to note that in Canada, the incidence of COVID-19 is higher in women. There is also some evidence to indicate that when studies control for socioeconomic factors, there are no racial differences in serious consequences for COVID-19.

While the evidence concerning the disease itself is increasingly strong, the evidence supporting different interventions pertinent to oral health care remains minimal and weak and relatively little work has been published in the period since the first report. In terms of clarifying guidance for oral health professionals, one systematic review highlights the categories of actions in pre-treatment, during treatment and post-treatment phases of care that organizations around the world have concentrated on, although this does not mean the relevant actions are based on evidence, rather that these are common areas to consider. Another review of guidelines for dental care during the pandemic noticed an increasing focus on preventive and non-Aerosol Generating Procedures (AGPs) and another highlighted the need to develop an evidence-based classification of AGPs and non-AGPs in dentistry rather than the theoretical approaches used thus far.

In terms of PPE, the picture remains unclear in terms of evidence directly related to oral health care, although the evidence does suggest using combined forms of facial covering (for example, face visor and N95 mask) is better than just one, as no single interventions are fully effective in preventing transmission. There is emerging evidence that N95 masks can be microwaved and re-used at least once without loss of function but there remains no evidence supporting various mitigating approaches such as use of pre-treatment mouthwash, rubber dam and high-volume evacuation. There is evidence that chlorhexidine mouthwash reduces bacterial colony-forming units but none on this or other mouthwashes concerning viruses or disease transmission.

There is emerging evidence concerning the risk factors for Health Care Workers (HCWs) contracting COVID-19, plus the impacts of the disease on them, which are both relevant in terms of considering how to mitigate risks and impacts. Suggestions have been made for HCWs concerning reducing hours and increasing mental support services.

Report results

a. Which patients are at greater risk of the consequences of COVID-19 and so consideration should be given to delaying elective in-person oral health care?

We identified multiple systematic reviews, meta-analyses and a few cohort studies adding to the knowledge and understanding of which patient groups are at greater risk of severe consequences of having COVID-19. The large majority of these studies confirmed findings we described in the previous report. Nevertheless, there have been some important additional findings with strong evidence supporting them. Recently published reviews and meta-analyses confirmed the increased risk for serious consequences of COVID-19 including hospitalization, ventilation and death for people with cardiovascular diseases Footnote 4 Footnote 5 Footnote 6 Footnote 7 Footnote 8 Footnote 9 Footnote 10 Footnote 11 Footnote 12 Footnote 13 Footnote 14 Footnote 15 Footnote 16 Footnote 17, hypertension Footnote 4 Footnote 5 Footnote 6 Footnote 7 Footnote 8 Footnote 9 Footnote 10 Footnote 11 Footnote 12 Footnote 17 Footnote 18 Footnote 19 Footnote 20, respiratory diseases Footnote 5 Footnote 7 Footnote 10 Footnote 11 Footnote 12 Footnote 18 Footnote 21 Footnote 22 Footnote 23, diabetes Footnote 4 Footnote 5 Footnote 7 Footnote 8 Footnote 10 Footnote 11 Footnote 19 Footnote 20 Footnote 24 Footnote 25 Footnote 26 Footnote 21 Footnote 27 Footnote 28, liver Footnote 12 Footnote 29 Footnote 30 Footnote 31 and kidney diseases Footnote 5 Footnote 8 Footnote 11 Footnote 12 Footnote 14 Footnote 32 Footnote 33 Footnote 34 Footnote 22 Footnote 35 Footnote 36 Footnote 37 Footnote 38 Footnote 39 plus for smokers Footnote 18. New information adds to the list of at-risk people who are obese Footnote 20 Footnote 40 Footnote 41 Footnote 42 Footnote 43, have cancer Footnote 11 Footnote 44 Footnote 45 Footnote 46 Footnote 47 and cerebrovascular conditions Footnote 10 Footnote 11 Footnote 12 Footnote 13 Footnote 17 Footnote 48 Footnote 49 Footnote 50 Footnote 51.

Concerning age and sex, again there has been additional high-quality evidence published. It is clear that increased age increases the risk of serious consequences Footnote 20 Footnote 49 Footnote 52 Footnote 53 with one review clarifying that the peak increase in risk is for serious consequences starts to occur for those 50-59 years of age but the largest risk increase is for the 60-69 year olds compared to those in their 50s, although the risk keeps increasing with older age Footnote 52. With respect to sex, it is now clear from the international literature that the incidence of COVID-19 is greater in men than women Footnote 10 Footnote 19 Footnote 54 Footnote 55. However, it is important to note, as shown on the webpage COVID-19 epidemiological and economic research data, that in Canada, the incidence of COVID-19 is higher in females compared to males, although this varies by age group. In terms of disease outcomes, again the international literature shows men are at increased risk for serious consequences of COVID-19 including death Footnote 20 Footnote 54 Footnote 56 Footnote 57 Footnote 58 However, these studies also pointed out that it is not clear why men are at greater risk for worse outcomes. They could be at increased risk because of the nature of their work, their socializing habits, their smoking, alcohol consumption and/or levels of comorbidities Footnote 20 Footnote 58. In Canada, there have been more hospitalizations and deaths among women but more men admitted to intensive care units (again see COVID-19 epidemiological and economic research data). It is also important to recognize that certain groups in the population face greater risk due to social, economic and occupational vulnerabilities (see Vulnerable populations and COVID-19 l). Further research needs to be performed to better understand the different levels of risk experienced by various groups in the population.

Canada COVID-19 weekly epidemiology report. Further research needs to be performed to better understand this phenomenon.

With respect to COVID-19 in pregnancy, the evidence remains relatively limited because the numbers are considerably smaller than in the broader population studies. Nevertheless, there is limited, emerging evidence that pregnant women with COVID-19 are at increased risk for complications with their pregnancy Footnote 59 Footnote 60 Footnote 61 Footnote 62. There is also emerging limited evidence concerning the problems suffered by neonates who are COVID-19 positive Footnote 59 Footnote 60 Footnote 63 Footnote 64 Footnote 65. With respect to the possibility of vertical transmission from mother to foetus, one systematic review reported zero such cases Footnote 64 while two others reported rates of 2-3.2% of neonates testing positive for SARS-Cov-2 among babies born to mothers who were also SARS-Cov-2 positive Footnote 61 Footnote 66.

A good evidence-supported document concerning the risk factors for severe COVID-19 disease can be found at: People who are at high risk for severe illness from COVID-19.

b. What are the signs and symptoms of COVID-19 that oral health care professionals should screen for prior to providing in-person care?

We identified multiple systematic reviews and meta-analyses plus prospective cohort studies adding to the now strong literature on the signs and symptoms of COVID-19. The additional literature we identified largely confirmed the summary and list of symptoms provided in the earlier report (fever, cough, shortness of breath, fatigue and muscle weakness and aches, headache and digestive symptoms such as diarrhea Footnote 5 Footnote 9 Footnote 10 Footnote 19 Footnote 67 Footnote 68 Footnote 69 Footnote 70 Footnote 71 Footnote 72), although notable new information has been added. This includes new signs and symptoms now recognized as among those often shown by people with COVID-19, including anosmia (lost sense of smell; 39-88%) Footnote 69 Footnote 70 Footnote 73 Footnote 74 and dysgesia (altered sense of taste; 81%) Footnote 74. There were also important additions to the previous list of signs and symptoms, including loss of appetite (34%) Footnote 5, myocardial injury (16%) Footnote 75, dizziness (6%) Footnote 19 and confusion/agitation (5%) Footnote 70. On top of this, there has been additional literature concerning symptoms experienced by children with COVID-19, including fever (53%), cough (39%) and sore throat (14%) Footnote 76. The evidence concerning the symptoms experienced by pregnant women with COVID-19 remains relatively limited compared to the general population but new information now available includes estimates of the proportion of pregnant women with viral pneumonia (71-89%) Footnote 60, fever (44-63%) Footnote 60 Footnote 65 Footnote 77, cough (36-71%) Footnote 60 Footnote 65 Footnote 77, dyspnea (13-34%) Footnote 65 Footnote 77 and myalgia or fatigue (11%) Footnote 60.

A good evidence-supported document concerning signs and symptoms of COVID-19 can be found at the following link: COVID-19 signs, symptoms and severity of disease: A clinician guide.

c. What evidence exists to support patient scheduling, waiting and other non-treatment management measures for in-person oral health care?

Again, several relevant systematic reviews were identified. One relevant publication reviewed COVID-19 transmission risk and protection protocols published by organizations in countries throughout the world and in academic journals Footnote 78. They categorized the approaches they found common to all protocols in these publications into pre-, during and post-dental treatment measures as per Table 1 below. It is important to note that this summary of factors common to all reviewed dental COVID-19 protocols does not necessarily reflect any evidence to support their inclusion, or exactly what the advice for each factor is, rather it is a list of factors in dental COVID-19 dental protocols that were common to all review publications.

Table 1. Measures recommended in dental protocols identified in systematic review by Banakar et al Footnote 78.
Stage of care Measures recommended

Pre-dental treatment
Before entering a dental office

At the dental office

Patient triage, identification potential COVID-19 cases, delay of non-urgent dental care, management of dental appointments, active and culturally safe screening of dental staff.

Active and culturally safe screening of patients, physical distancing in the dental office, cleaning and disinfection measures for patients, use of facemasks by everyone entering the dental office, patient education, use of personal protective equipment (PPE) by the dental team and management of the dental operatory room.

During dental treatment Maintaining hand hygiene, offering preoperative anti-microbial mouth rinse to patients, using rubber dams, high-volume saliva ejectors, and extraoral dental radiographs, using 4-handed dentistry, avoiding aerosol-generating procedures, one-visit treatment and environmental cleaning and disinfection procedures.
Post-dental treatment Cleaning and disinfecting reusable facial protective equipment, as well as management of laundry and medical waste.

This list of factors to consider and the categorization of the stages of pre-, during and post-dental treatment was very similar to those documented in two other systematic reviews on the subject Footnote 79 Footnote 80. A review of guidelines for pediatric dentistry during the COVID-19 pandemic published throughout the world made similar observations but in addition, focused on the need for preventive and non-AGPs Footnote 81. The authors mentioned focusing on using approaches including telehealth, using fluoride varnish and resin or sealing non-cavitated caries, using atraumatic restorative technique (ART), interim therapeutic restorations, indirect pulp capping, the Hall technique and silver diamine fluoride Footnote 81.

d. What evidence exists to support the use of various forms of personal protective equipment (PPE) while providing in-person oral health care?

We identified several systematic reviews with relevant information. One investigated the use of powered air-purifying respirators (PAPR) compared to N95 masks and other devices in the prevention of viral infection of health care workers, focusing on SARS-Cov-2, SARS-Cov-1, MERS and Ebola viruses. This review reported no difference in HCW infection rates using PAPR versus other respirator devices. They did note however, increased heat tolerance for HCWs using PARP but more difficulty communicating and with mobility Footnote 82. Another review investigated the benefits for oral and maxillofacial surgeons of using N95 versus surgical masks when performing AGPs Footnote 83. They concluded that most studies comparing the two showed no difference in infection rates of HCWs but there was some evidence suggesting that N95 masks may be better when performing an AGP with a patient known to be COVID-19 positive or whose status is unknown Footnote 83. Another review of N95 and surgical masks and eyewear use in dental care reported that combined use of two or more measures (for example, mask and facial visor) is effective as a barrier to aerolized microbes, although this can be affected by multiple factors such as airflow dynamics, aerolized particle size, prolonged wearing and wetness of masks and poor fit. Importantly, they noted that no intervention on its own has been demonstrated effective at preventing infection Footnote 84. We identified no research evidence that referred specifically to KN95 masks.

Another review investigated the physical and mental health impacts of COVID-19 on HCWs during the pandemic Footnote 85 and reported that working in a high-risk setting, having a COVID-19-diagnosed family member, inadequate hand hygiene, improper PPE use, close contact with patients ≥ 12 times daily, extended contact hours (≥15 daily) and unprotected exposure are associated with increased risk of COVID-19-related impacts for HCWs Footnote 85. They also noted that prolonged PPE usage led to cutaneous manifestations and skin damage, that HCWs experienced high levels of depression, anxiety, insomnia and distress, and that female HCWs and nurses are disproportionately affected Footnote 85. All this suggests the need for vigilance with infection control procedures, shorter work hours and mental health support for HCWs Footnote 85.

The Health Canada website also has information concerning PPE.

e. What evidence exists to support the decontamination and re-use of PPE?

We identified one additional systematic review on this subject Footnote 86. The review investigated the use of microwave and heat-based decontamination of N95 masks and found that microwave irradiation may provide safe and effective viral decontamination for N95 masks while conserving function but that autoclaving did not do the latter so is not supported. The authors did however note that more research needs to be performed in "real world settings" to confirm their conclusions Footnote 87.

f. What evidence exists concerning the provision of aerosol-generating procedures (AGP) as part of in-person oral health care?

We identified two systematic reviews with relevant subject matter published during the period July to October inclusive. One systematic review confirmed that SARS-Cov-2 is present in saliva and as well as sputum and the nasopharynx and concluded that saliva could be used to test for COVID-19 Footnote 88. Another rapid systematic review was performed with the aim of classifying aerosol generating procedures (AGPs) Footnote 89. They identified a list of procedures with strong agreement in the literature that they were AGPs. This list did not include dental procedures and the authors hypothesized that this non-inclusion of dental procedures is because they comprise a wide range of acts some of which are AGP and others are not Footnote 89. This raises the important point that the dental professions need to identify AGPs versus non-AGPs within dental procedures and this needs to be based on sound principles and science. This is important because it has implications for the use of PPE and other interventions while performing dental procedures.

g. What evidence exists to support transmission mitigation strategies during the provision of in-person oral health care?

As previously mentioned, we identified a systematic review confirming that SARS-Cov-2 is present in saliva and as well as in sputum and the nasopharynx Footnote 88. This is important to consider in the context of this topic concerning mitigating strategies. We also identified several systematic reviews published in the relevant period investigating a number of mitigating strategies during the provision of dental care and other health care procedures. A Cochrane review looked at a range of mitigating strategies including high volume evacuation, dental isolation combination systems, rubber dam and disinfectants, including disinfectant coolants Footnote 90. The authors observed that all the studies included in their review investigated interventions' effects on colony forming units of bacteria, not viruses or respiratory disease transmission. They nevertheless concluded that there was probably benefit in using all the tested interventions but that the evidence to support them was weak Footnote 90. Another Cochrane review investigated the potential protective effect against COVID-19 transmission of health care workers using antimicrobial mouthwashes and/or nasal sprays and identified no studies, although they did note a few relevant on-going randomized trials Footnote 91. Another systematic review investigated the specific question "Does hydrogen peroxide mouthwash (at any concentration) have a virucidal effect?" and identified no research fulfilling their quality criteria addressing this question, thereby concluding that there is no evidence to support the use of hydrogen peroxide mouthwash to control viral load Footnote 92. A rapid systematic review noted the possible beneficial effect of hypertonic saline nasal washes and mouth washes to mechanically reduce viral load and so potentially reduce risk of transmission from patients with COVID-19 to others Footnote 93. Finally, another systematic review investigated the potential benefits of anti-microbial mouthwashes in managing COVID and found no clinical studies, only in vitro evaluations of chlorhexidine, povidone-iodine and C31G. The review noted that all these mouthwashes demonstrated reduced viral load in in vitro studies but recognized the lack of clinical evidence Footnote 94.

In summary, there remains no evidence concerning interventions to mitigate viral or COVID-19 transmission during dental treatments but there is good evidence supporting Chlorhexidine mouthwash reducing bacterial load (this was identified in the previous version of this report). Evidence for other interventions is weak and equivocal.

h. What evidence exists to support space ventilation strategies that reduce the risk of transmission?

We identified one systematic review published in the relevant period and with pertinent information Footnote 90. This Cochrane systematic review of multiple interventions to reduce aerosols during dental procedures reported one study with only two participants suggesting a stand-alone ventilation system may reduce aerosols during cavity preparation and ultrasonic scaler use Footnote 90. It also reported another study with 50 participants suggesting laminar flow with a HEPA filter may reduce aerosols at 76cm from the floor and 20-30cm from a patient's mouth. However, they stated that no studies reported on viral contamination or disease transmission, rather they concerned bacterial contamination and the evidence was of low certainty Footnote 90.

i. What evidence exists to support the disinfection of surfaces in spaces in which oral health care is provided?

We identified one additional systematic review covering surface disinfection published during this period Footnote 95. This review investigated the use of surface decontamination against SARS-Cov-2 and against airborne pathogens and directly transmitted viral pathogens in dental settings. They found no evidence that fulfilled their quality criteria concerning SARS-Cov-2. However, they reported finding good quality evidence that 70% ethanol and 0.5% sodium hypochlorite used as surface disinfectants reduce the possibility of surface transmission of respiratory viruses. They recommended applying these disinfectants on surfaces for 1 minute to reduce the risk of contamination with SARS-Cov-2 Footnote 95.

It is important to note that Health Canada has lists of surface disinfectants and hand sanitizers that it states are supported by evidence and likely to be effective against SARS-CoV-2.

Glossary of abbreviations

Abbreviation
Explanation
AGP
Aerosol-generating procedures
CDC
Centers for Disease Control and Prevention
CFU
Colony-Forming Unit
CHX
Chlorhexidine
COVID-19
Coronavirus disease 2019
HVE
High-Volume Evacuation
H1N1
Influenza A
ICU
Intensive Care Unit
IgM
Immunoglobulin M
MERS
Middle East Respiratory Syndrome
PPE
Personal Protective Equipment
RCT
Randomized Controlled Trials
SARS
Severe Acute Respiratory Syndrome
SARS-CoV-2
Severe Acute Respiratory Syndrome Coronavirus-2
SR
Systematic Review
TMD
Temporomandibular disorders
UVGI
Ultra-violet Germicidal Irradiation

Appendix A: Key findings for topic a) patients at greater risk of the consequences of COVID-19

Condition Main findings SourceFootnote a

Strong evidence

Cardiovascular disease
Higher risk for:
(i) COVID-19 admitted in ICU (55% of 896 participants); odds: 3.11x greater

Higher risk for:
(i) severe COVID-19 (9.7% to 17.9%); odds: 3.0 to 4.6 x greater

Higher chance of death: 19%; odds: 2.25 - 5.58 x greater

Cardiac arrythmias: 16.6% to 19% patients with COVID-19.

SR and meta-analysis: Abate SM et al. Footnote 4; SR: Bennett et al. Footnote 5; SR and meta-analysis: Hessami et al. Footnote 6;
SR and meta-analysis: Liu et al. Footnote 7; SR and meta-analysis: N et al. Footnote 8; SR and meta-analysis: Meena et al. Footnote 9; SR and meta-analysis: Qiu et al. Footnote 10; SR and meta-analysis: Singh et al. Footnote 11; SR and meta-analysis: Wu et al. Footnote 12; SR and meta-analysis: Yu et al. Footnote 13

SR and meta-analysis: Hessami et al. Footnote 6; SR and meta-analysis: Yu et al. Footnote 13;SR and meta-analysis: Figliozzi et al. Footnote 14; SR and meta-analysis: Pranata et al. Footnote 15; SR: Shafi et al. Footnote 17

SR and meta-analysis:2- Pranata et al. Footnote 16;

Hypertension Higher risk for:
(i) COVID-19 admitted in ICU (38% of 896 participants); odds:1.95- 2.40x greater

Higher risk for:
(i) severe COVID-19 (17.4%- 43%); odds: 2.40 to 2.95x greater

Higher chance of death (odds: 2.60x greater)

Cohort Study: 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19, 257 were critically ill: 162 presented hypertension (63%).

SR and meta-analysis: Abate SM et al. Footnote 4
SR and meta-analysis: Hessami et al. Footnote 6; SR and meta-analysis: Li et al. Footnote 18;

SR: Bennett et al. Footnote 5; SR and meta-analysis: Di Carlo et al. Footnote 19; SR and meta-analysis: Liu et al. Footnote 7; SR and meta-analysis: N et al. Footnote 8; SR and meta-analysis: Meena et al. Footnote 9; SR and meta-analysis: Qiu et al. Footnote 10; SR: Shafi et al. Footnote 17; SR and meta-analysis: Singh et al. Footnote 11; SR and meta-analysis: Wu et al. Footnote 12;

SR and meta-analysis: Hessami et al. Footnote 6;

Cohort Study: Cummings et al. Footnote 20

Acute cardiac Injury Higher chance of death (odds: 10.58 - 13.48x greater)

Higher risk for admitted in ICU: odds 15.58 x greater

Higher chance of death 15%

Incidence 24.4% (542 of 2224 patients with COVID-19)

SR and meta-analysis: Figliozzi et al. Footnote 14; SR and meta-analysis: Hessami et al. Footnote 6; SR and meta-analysis: Huang et al. Footnote 21; SR and meta-analysis: Li et al. Footnote 18; SR and meta-analysis: Potere et al. Footnote 35
Coronary heart disease Higher chance of death (odds: 3.78x greater)

Higher risk for:
admitted in ICU: odds 2.61- 2.66x greater;
Higher risk for:
severe COVID-19 (3.8%)

SR and meta-analysis: Hessami et al. Footnote 6; SR and meta-analysis: Li et al. Footnote 18
Chronic obstructive pulmonary disease Higher risk for:
(i) severe COVID-19 (risk: less 4%; 1.9x- 5.8x)
(ii) COVID-19 mortality (60% more)
SR: Bennett et al. Footnote 5; SR and meta-analysis: Li et al. Footnote 18; SR and meta-analysis: Liu et al. Footnote 7; SR and meta-analysis: Singh et al. Footnote 11; SR and meta-analysis: Wu et al. Footnote 12
Acute Respiratory Syndrome Higher risk for:
(i) severe COVID-19: 33.15% to 34%; risk: 26.12x greater
SR and meta-analysis: Huang et al. Footnote 21; SR and meta-analysis: Khateri et al. Footnote 22; SR and meta-analysis: Qiu et al. Footnote 10
Respiratory disease, general Asthma: Higher chance of COVID-19 mortality (odds:0.96x greater) SR and meta-analysis: Wang et al. Footnote 23
Cancer Higher chance of severe COVID-19: less 4%; odds: 2.17 to 2.2x greater for malignancies;
Higher chance of mortality COVID-19: 20.83 to 25.6% (odds: 2.25 - 2.97x greater for malignancies)

Higher chance for admitted in ICU: odds 2.88x greater

Cohort Study: 319 (30·6%) of 1044 patients died, 295 (92·5%) of whom had a cause of death recorded as due to COVID-19.

The all-cause case-fatality rate in patients with cancer after SARS-CoV-2 infection was significantly associated with increasing age (odds 0·10x greater 40-49 years; 0·48x greater 80 years and older).

Cohort Study: 800 patients with a diagnosis of cancer and symptomatic COVID-19. 226 (28%) patients died and risk of death was significantly associated with:
(I) advancing patient age (odds 9·42x)
(ii) male (odds 1·67x)
(iii) presence of comorbidities such as hypertension (odds: 1·95x) and cardiovascular disease (odds:2·32x)

SR and meta-analysis: Singh et al. Footnote 11; SR and meta-analysis: Tian et al. Footnote 44
SR and meta-analysis: Cheruiyot et al. Footnote 45; SR and meta-analysis: Salunke et al. Footnote 46; SR and meta-analysis: Tian et al. Footnote 44

SR and meta-analysis: Salunke et al. Footnote 46;

Cohort Study: Lee et al. Footnote 47

Cohort Study: 2. Lee et al. Footnote 96

Smoking, current Association to severe (ICU): P =.003. SR and meta-analysis: Li et al. Footnote 18;
Obesity Cohort Study: 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19, 257 were critically ill: 119 presented obesity (46%).

Higher chance of mortality COVID-19: 85.3%; odds: 0.17 - 3.93 x greater for obesity and age > 60 years;
Odds: 1.84x greater for obesity and associate comorbidities.

Higher risk for:
(i) severe COVID-19 (odds: 3.11 x greater for obesity and age > 60 years);
(ii) severe COVID-19: 56.2%; odds: 0.09 - 1.88 x greater for obesity.

Cohort Study: Cummings et al. Footnote 20;

SR and meta-analysis: Du et al. Footnote 40; SR and meta-analysis: Hussain et al. Footnote 41

SR and meta-analysis: Du et al Footnote 40; SR and meta-analysis: Malik et al. Footnote 42; SR and meta-analysis: Sales-Peres et al. Footnote 43

Diabetes mellitus The cumulative prevalence of diabetes in COVID-19 patients was 14.5%. As for diseases similar to COVID-19, the overall prevalence of diabetes was 54.4% in MERS, and for H1N1 influenza it was 14.6%.
The mortality rate: 36% for MERS-Cov, 6% SARS-Cov-1, 10% SARS-Cov-2.

Higher risk for:
(i) COVID-19 admitted in ICU (31% of 896 participants); odds: 3.17x

Higher risk for:
(i) severe COVID-19 (3.8%- 22.2%); odds: 1.32- 3.07x greater

Higher chance of mortality COVID-19: 18%; odds: 2.12- 2.96 x greater

Meta-analysis: severe COVID-19 was associated with higher blood glucose (odds: 2.10- 2.21 greater).

Cohort Study: 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19, 257 were critically ill: 92 presented diabetes (36%).

SR and meta-analysis: Abdi et al. Footnote 24; SR and meta-analysis: Pinedo-Torres et al. Footnote 25

SR and meta-analysis: Abate SM et al. Footnote 4; SR and meta-analysis: Li et al. Footnote 18;

SR: Bennett et al. Footnote 5; SR and meta-analysis: Di Carlo et al. Footnote 19; SR and meta-analysis: Liu et al. Footnote 7; SR and meta-analysis: N et al. Footnote 8; SR and meta-analysis: Qiu et al. Footnote 10; SR and meta-analysis: Singh et al. Footnote 11;

SR and meta-analysis: Guo et al. Footnote 26, SR and meta-analysis: Huang I et al. Footnote 21, SR: Shafi et al. Footnote 17

SR and meta-analysis: Chen J et al. Footnote 27; SR and meta-analysis: Mantovani et al. Footnote 28;

Cohort Study: Cummings et al. Footnote 20

Cerebro-vascular diseases Higher risk for mortality (odds: 1.42 to 2.78x greater).
4% to 48.8%

Higher COVID-19 severity (odds: 3.004x greater)

SR and meta-analysis: Flores-Perdomo et al. Footnote 48; SR: Ghannam et al. Footnote 49; SR and meta-analysis: Li et al. Footnote 18; SR and meta-analysis: MadaniNeishaboori, et al. Footnote 50; SR and meta-analysis: Patel et al. Footnote 51; SR and meta-analysis: Qiu et al. Footnote 10; SR: Shafi et al. Footnote 17; SR and meta-analysis: Singh et al. Footnote 11; SR and meta-analysis: Wu et al. Footnote 12; SR and meta-analysis: Yu et al. Footnote 13
Chronic kidney diseases Higher COVID-19 severity 4% to 5.2%; odds 5.32x greater;

Higher risk for mortality (odds: 1.84x greater).

SR and meta-analysis: Kunutsor et al. Footnote 32; SR and meta-analysis: N et al. Footnote 8; SR and meta-analysis: Singh et al. Footnote 11

SR and meta-analysis: Wu et al. Footnote 12

Acute kidney injury Higher risk for:
(i) severe COVID-19 (6%- 11%);
(ii) severe COVID-19 (odds: 8.11 to 18.5 x greater);
(iii) mortality COVID-19 (odds: 14.63 to 23.9 x greater);

Higher risk for mortality:
(i) SARS : 86.6%;
(ii) COVID-19: 67% - 94%;
(iii)MERS: 68.5%.

Higher chance of death (odds: 5.13 x greater)

SR: Bennett et al. Footnote 5; SR and meta-analysis: Cheruiyot et al. Footnote 33; SR and meta-analysis: Huang et al. Footnote 34
SR and meta-analysis: Khateri et al. Footnote 22; SR and meta-analysis: Kunutsor et al. Footnote 32; SR and meta-analysis: Potere et al. Footnote 35; SR and meta-analysis: Robbins-Juarez
et al. Footnote 36; SR and meta-analysis: Shao et al. Footnote 37
SR and meta-analysis: Oliveira et al. Footnote 38; SR and meta-analysis: Ouyang et al. Footnote 39;

SR and meta-analysis: Figliozzi et al. Footnote 14.

Liver diseases Higher COVID-19 severity: odds 0.81x greater.

Higher chance of death: odds 1.78 to 3.46 x greater;
Odds 1.48x greater for Chronic liver injuries
Odds 1.68x greater for Acute liver injuries

SR and meta-analysis: Kulkarni et al. Footnote 29

SR and meta-analysis: Kovalic et al. Footnote 30
SR and meta-analysis: Wu et al. Footnote 12;
SR and meta-analysis: Sharma et al. Footnote 31

Effect of age in COVID-19 Higher chance of death in patients aged 60 to 69 years compared with those aged 50 to 59 years (odds: 3.13x greater).

Cohort Study: 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19: median age 62 years (IQR 51-72).

71.4% of the hospitalized older adults require supplementary oxygen.

Systematic Review and Meta-analysis: Bonanad et al. Footnote 52; SR: Ghannam et al. Footnote 49

Cohort Study: Cummings et al. Footnote 20

SR: Neumann-Podczaska et al. Footnote 53

Effect of sex difference in COVID-19
Higher COVID-19 incidence in men (meta-analysis: 50-66% of the studies);

Higher COVID-19 severity: odds 1.46x greater for male;

Higher chance of death: odds 1.32 - 1.81x greater; odds 1.69x greater pre-existing comorbidities.

Meta-analysis factors which have an effect on sex difference in COVID-19:
(I) Smoking: 75% male x 25% female
(ii) Hypertension: 59.7% male x 40.3% female
(iii)Diabetes: 71.1% male x 28.9% female
(iv) Chronic respiratory disease: 79% male x 21% female
(v) Cardiovascular disease: 81.7% male x 18.3% female
(vi) Death: 78.8% male x 21.2% female

Cohort Study: 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19: 171 (67%) male.

Cohort study: 1564 patients with COVID-19: 903 (57.7%) male vs 661 (42.3%) female.

SR and meta-analysis: Abate BB et al. Footnote 54; SR and meta-analysis: Di Carlo et al. Footnote 19; SR and meta-analysis: Qiu et al. Footnote 10; SR and meta-analysis: Nasiri et al. Footnote 55

SR and meta-analysis: Ortolan et al. Footnote 56

SR and meta-analysis: Jutzeler et al. Footnote 57; SR and meta-analysis: Ortolan et al. Footnote 56

SR and meta-analysis: Abate BB et al. Footnote 54

Cohort Study: Cummings et al. Footnote 20

Cohort study: Hewitt et al. Footnote 58

Endocrine disorder Higher risk for:
(i) severe COVID-19 (9.3%)
SR: Bennett et al. ( Footnote 5
Vitamin D insufficiency Cohort study: association with mortality from respiratory diseases during 15 years of 9548 adults aged 50-75 years:
(I) 41% of respiratory disease mortality was statistically attributable to vitamin D insufficiency or deficiency.
Cohort Study: Brenner et al. Footnote 97
SR: Galmes et al Footnote 98
Anaemia/iron metabolism/Ferritin level (I) Increased ferritin rates in severe patients compared with the level in non‐severe patients (odds: 397.77 to 563.98);
(ii) Non‐survivors had a significantly higher ferritin level compared with the one in survivors (odds: WMD 677.17).
(iii) Patients with one or more comorbidities (Severe acute liver injury, diabetes, thrombotic complication, and cancer): significantly higher levels of ferritin than those without (P <.01).
SR and meta-analysis: Cheng et al. Footnote 99; SR and meta-analysis: Taneri et al. Footnote 100
Arterial Thrombosis/ Coagulopathy Higher risk for mortality:
(i) 20% of 52 patients;
(ii) occurs in approximately 4% of critically ill COVID-19 patients.
(iii) 6% of 999 patients
SR and meta-analysis: Potere et al. Footnote 35
Acute cardiac Injury Higher chance of death: 15.68%; odds: 10.58 x greater SR and meta-analysis: Figliozzi et al. Footnote 14
Limited evidence
Nutrients deficiency omega-3 fatty acids, vitamin A, vitamin D, vitamin E, vitamin B1, vitamin B6, vitamin B12, vitamin C, iron, zinc, and selenium: supplementation with these nutrients may be effective in improving the health status of patients with viral infections SR: BourBour et al. Footnote 101

Pregnancy: Women's and perinatal/neonatal health

Common complications maternal /foetal (156 patients):
(i) intrauterine/foetal distress (14%);
(ii) premature rupture of membranes (8-14.3%;
(iii) 2.9% high risk for pregnant with COVID-19.
SR: Akhtar et al. Footnote 59; SR and meta-analysis: Diriba et al. Footnote 60; SR and meta-analysis: Kotlyar et al. Footnote 61

Cohort Study: Tanacan et al. Footnote 62

The neonatal clinical manifestations of COVID-19 (108 patients):
(I) shortness of breath (6%)
(ii) gastrointestinal symptoms (4%),
(iii) fever (3%).

Among 91 neonates who were tested, 8 (8.8%) were positive for nucleic acids or antibodies for SARS-CoV-2. Additionally, 28 (26.7%) of the neonates were symptomatic.

SR: Akhtar et al. Footnote 59

SR and meta-analysis: Chi et al. Footnote 63

~1%- 2.7% maternal death and 3 -31.3% admissions to ICU; with intubation 3.4%; Neonatal and intrauterine deaths: 0.3%- 2.2% SR and meta-analysis: Diriba et al. Footnote 60; SR: Huntley et al. Footnote 64; SR and meta-analysis: Khalil et al. Footnote 65
Vertical Transmission rate: 0% of 310;

Meta-analysis: 936 neonates from mothers with coronavirus disease 2019, 27 neonates had a positive (2 to 3.2%) for vertical transmission.

SR: Huntley et al. Footnote 64

SR and meta-analysis: Kotlyar et al. Footnote 61; SR: Turan et al. Footnote 66

HIV It is not clear if there is an increased risk of worse outcomes of COVID‐19 for AIDS patients.

Cohort Study: 63% with COVID-19 had at least one comorbidity (mostly hypertension and diabetes); 4% died.

SR: Cooper et al. Footnote 102

Cohort Study: Viscarra et al. Footnote 103

Appendix B: Key findings for topic b) clinical signs and symptoms of COVID-19

Sign/symptom Frequency SourceFootnote a
Strong evidence
Fever 78 to 98% SR and meta-analysis: Meena et al. (9); Nasiri et al. Footnote 55; Qiu et al. Footnote 10;
SR: Bennett et al. Footnote 5;
Cough 22.4 to 78% SR and meta-analysis: Meena et al. Footnote 9; Nasiri et al. Footnote 55; Qiu et al. Footnote 10;
Dyspnea/shortness of breath 38.8% to 85.7% SR and meta-analysis: Qiu et al. Footnote 10
Myalgia or fatigue 22 to 65% SR: Almqvist et al. Footnote 69; SR and meta-analysis: Di Carlo et al. Footnote 19; SR and meta-analysis: Qiu et al. Footnote 10;
Headache 8 to 14% SR: Almqvist et al. Footnote 69; SR: Chen et al. Footnote 70; SR and meta-analysis: Di Carlo et al. Footnote 19
Gastrointestinal symptoms Higher chance of mortality COVID-19: 15%; odds: 0.91 x greater

Abdominal pain: 6.2%

SR and meta-analysis: Gul et al. Footnote 71; SR and meta-analysis: Mao et al. Footnote 72; SR: Meena et al. Footnote 9; SR and meta-analysis: Tariq et al. Footnote 68
Diarrhea 12.4% SR and meta-analysis: Tariq et al. Footnote 68
Anosmia
39-88% SR: Almqvist et al. Footnote 69; SR: Chen et al. Footnote 70; SR and meta-analysis: Chua et al. Footnote 73; SR and meta-analysis: Di Carlo et al. Footnote 19; SR: Samaranayake et al. Footnote 74
Dysgesia 81.34% SR: Samaranayake et al. Footnote 74
Anorexia /loss of appetite 33.7% SR: Bennett et al. Footnote 5
Impairment of consciousness (also termed "confusion" or "agitation") 4.5 to 5.1%
more frequently in severe or critical COVID-19 (11.9%) vs non-critical COVID-19 patients (3.2%)
SR: Chen et al. Footnote 70
Others: seizures, stroke, Guillain-Barré syndrome From 70 patients:
(I) Stroke: 39 (53.4%)
(ii) Guillain-Barre syndrome and variants: 18 (24.7%);
(iii) meningitis, encephalitis, encephalopathy, or myelitis:11 (15.1%);
(iv) seizures: 5 (6.8%).
SR and meta-analysis: Chua et al. Footnote 73
Dizziness 6.1% SR and meta-analysis: Di Carlo et al. Footnote 19
Myocardial Injury 16% SR and meta-analysis: De Lorenzo et al. Footnote 75, Li et al. Footnote 67

Children

Fever Common (53%) SR and meta-analysis: Zhang et al. Footnote 76
Cough Common (39%) SR and meta-analysis: Zhang et al. Footnote 76
Sore throat/pharyngeal erythema Common (14%) SR and meta-analysis: Zhang et al. Footnote 76
General considerations 18% of 551 cases were asymptomatic. SR and meta-analysis: Zhang et al. Footnote 76
Limited evidence
Pregnant women
Fever Common (44%- 63.3%) SR: Ashraf et al. Footnote 77; SR and meta-analysis: Diriba et al. Footnote 60; SR and meta-analysis: Khalil et al. Footnote 65;
Cough Common (36.3%- 71.4%) SR: Ashraf et al. Footnote 77; SR and meta-analysis: Diriba et al. Footnote 60; SR and meta-analysis: Khalil et al. Footnote 65
Dyspnea Common (12.7%- 34.4%) SR: Ashraf et al. Footnote 77; SR and meta-analysis: Khalil et al. Footnote 65
Myalgia or fatigue Common (11.4%) SR and meta-analysis: Diriba et al. Footnote 60
Severe pneumonia Common (71-89%) SR and meta-analysis: Diriba et al. Footnote 60

Appendix C: Key findings for topic c) non disease-specific approaches to assist with non-treatment patient management measures for in-person oral health care

Approach Main findings SourceFootnote a
Limited evidence
Dental office
Before entering a Dental office (I) Patient triage (identification of possible suspects);
(ii) delay of non-urgent dental care;
(iii) management of dental appointments;
(iv) active screening of dental staff.
SR: Banakar et al. Footnote 78; Cabrera-Tasayco et al. Footnote 79; Siles-Garcia et al. Footnote 80 Al-Halabi et al. Footnote 81;
At the Dental office (I) Active screening of patients (the temperature of the patient should be taken); (ii) management of social distancing in the dental office; (iii) offering sanitation measures to the patients;
(iv) use of facemasks by everyone entering the dental office, patient education, use of PPE by the dental team;
(v) management of dental operatory room are among the procedures required to be carried out in dental offices;
SR: Banakar et al. Footnote 78; Cabrera-Tasayco et al. Footnote 79; Al-Halabi et al. Footnote 81; Siles-Garcia et al. Footnote 80;
Post dental treatment

(I) Cleaning and disinfecting reusable facial protective equipment, Non-disposable equipment (for example,, handpieces) and surfaces;
(ii) management of laundry and waste according the type.
SR: Banakar et al. Footnote 78; Cabrera-Tasayco et al. Footnote 79; Al-Halabi et al. Footnote 81; Siles-Garcia et al. Footnote 80
Frequent handwashing break the transmission cycle of respiratory diseases and reduce the risk of transmission by 6 to 14% SR: Siles-Garcia et al. Footnote 80
Level of PPE
Masks or respirators worn by health care professionals Little evidence supporting a use of masks with pores of less than 50 μm is necessary for dental professionals.

Little evidence supporting a use of different garments to enhance biosecurity: disposable surgical cap, breathing mask (N95 or FFP2), disposable long-sleeved gown with elasticized wrist cuffs, lenses, facial visor, disposable gloves, and boots.

SR: Banakar et al. Footnote 78



SR: Cabrera-Tasayco et al. Footnote 79

Specific settings, general precautions
Long-term care settings Little evidence supports that Disinfectants such as 0.1-0.5% sodium hypochlorite, 62-71% ethanol, or 2% glutaraldehyde can be used for surface decontamination, as well as 62% ethanol or 2% glutaraldehyde in freshly prepared solutions and adequate concentrations. SR: Cabrera-Tasayco et al. Footnote 79
Dental laboratories Little evidence supports a disinfection method should be used for any material extracted from the mouth and sent to the laboratory to prevent cross-contamination. SR: Cabrera-Tasayco et al. Footnote 79

Appendix D: Key findings for topic d) PPE for providing in-person healthcare

Approach Main findings SourceFootnote a
Limited evidence for COVID-19 (including strong evidence for other diseases)
Risk factors for HCW Associated with transmission of SARS-CoV-2:
(I) Scarcity of PPE: 42.5%
(ii) Inadequate PPE and hand hygiene: 14.2%
(iii) Improper PPE: odd 2.82 greater for risk of contamination.

Prolonged PPE usage (more than 6 h of continuous PPE use and more than 10 times/day hand hygiene):
(I) cutaneous manifestations and skin damage (97%):
-nasal bridge (N95 face
mask and/or goggle (83%);
-dryness/tightness
(70.3%);
-desquamation (62.2%).

Use prolonged of respirators by dental professionals was associated:
(I) headaches (47.5%);
(ii) severe exertion and discomfort (50.8%);
(iii) moderate concentration problems (54.3%);
(iv) moderate breathing difficulties (63.5%);
(v) impaired work ability (85.5%).

SR: Sant'Ana et al. Footnote 104; Scoping Review: Shaukat et al. Footnote 85

Scoping Review: Shaukat et al. Footnote 85

Scoping Review: Farronato et al. Footnote 105

Face shields and eye protection Could effectively reduce the risk of inhalation of over 90% expelled particulate matter following aerosol generation;
transmission of SARS-CoV-2 through the conjunctive in an HCW who was wearing only a protective N95 respirator.
SR: Samaranayke et al. Footnote 84
Respirators Among 256 dentists the prolonged use was associated with:
(I) headaches (47.5%)
(ii) severe exertion and discomfort (50.8%)
(iii) moderate concentration problems (54.3%)
(iv) moderate breathing difficulties (63.5%)
(v) impaired work ability (85.5%)
Scoping Review: Farronato et al. Footnote 105
Cloth masks Presence of filtration in evaluated fabrics:
(i) Hybrid of cotton/chiffon: 95.2 to 98.8% of efficiency;
(ii) hybrid of cotton/silk: 92.2 to 95.8% of efficiency;
(iii) cotton quilt: 94.2 to 97.8% of efficiency.
Not recommended for HCW.
SR: Santos et al. Footnote 87
N95 masks vs surgical masks N95 respirators were the favorite in all scenarios, except:
(I) when performing non-AGP medical procedures on symptomatic patients: favored surgical masks;
(ii) when performing AGP medical procedures on COVID positive patients: favored N99 respirators.

N95 respirators offered better protection compared with the surgical masks, for (bacterial) particles 20 lm in diameter where efficiency estimates ranged from 2% to 92%

SR: Zhang et al Footnote 83

SR: Samaranayke et al. Footnote 84

Powered air-purifying respirator (PAPR) Limited literature supporting the PAPR use during epidemics/pandemics of SARS-CoV-1, SARS-CoV-2, MERS, and Ebola. SR: Licina et al. Footnote 82

Appendix E: Key findings for topic e) decontamination and re-use of PPE

Approach Main findings SourceFootnote a
Limited evidence
N95 respirators
Microwave Microwave-generated steam:
(I) 90 seconds, 3 cycles: 65% of aerosol penetration reduction through N95;
(ii) 120 seconds, 1 cycle: 65%of aerosol penetration reduction through N95;
(iii) 45- 90 seconds, 1 cycle: log10 viral reduction factor for Escherichia virus MS2;
(iv) 120 seconds, 1 cycle: log10 viral reduction factor for H1N1.
(v) 120 seconds, 3 cycles: ≥ 90% fit pass rate for all models.
(vi) Physical traits: slight separation of nose cushion from model 3M1870 (N=4); Melting of strap on models KCPFR 174 and KCPFR 95-270.

Dry Microwave:
(I) 120-240 seconds, 1 cycle: 25% of aerosol penetration reduction through N95;
(ii)120 seconds, 1 cycle: 85% of aerosol penetration reduction through N95;
(iii) Physical traits: Melting of model 3M 8000 after 240 seconds and 3M1870 after 120 seconds.

SR: Gertsman et al. Footnote 86
Moist Heat Incubation (I) 30min, 60C, 3cycles: 74% of aerosol penetration reduction through N95;
(ii) 20 min, 65C, 1 cycle: 72% of aerosol penetration
reduction through N95;
(iii) ≥ 90% fit pass rate for all models.
(iv) Physical traits: slight separation of nose cushion from model 3M1870 (N=3);
SR: Gertsman et al. Footnote 86
Dry Heat (I) 60 min, 80C, 1 cycle: 86% of aerosol penetration reduction through N95;
(ii) 60 min, 80-120C, 1 cycle: 34% of aerosol penetration reduction through N95;
(iii) 60 min or more, 70C, 1 cycle: log10 viral reduction factor for SARS-Cov-2;
(iv) Fit factor > 100 for all models, after 2 heat cycles;
(v) Physical traits: Melting of some models at temperature ≥ 100C (KCPFR 95-270 and 3M 8000) but no changes at lower temperature.
SR: Gertsman et al. Footnote 86
Autoclave (I) 15-30min,121C, 1 cycle: odd: 25.85 of aerosol penetration reduction through N95;
(ii) Fit factor > 100 for most models, after 10 cycles.
(iii) Physical traits: Masks deformed, shrunken and stiff (models 3M 8000 and 3M 8210).
SR: Gertsman et al. Footnote 86

Appendix F: Key findings for topic f) the provision of aerosol-generating procedures (AGP)

Condition Main findings SourceFootnote a
Limited evidence in relation to COVID-19/SARS-CoV-2
Saliva contamination SARS-CoV-2 was detected in saliva specimens in aproximatelly 90-95% of patients. SR: Fakheran et al. Footnote 88
Limited evidence for SARS, MERS, H1N1, Influenza and bacteria
Consensus of AGP procedures generating (i) intubation and extubation procedures: 100%
(ii) bronchoscophy: 94%
(iii)oral and dental procedures: 78%
SR: Jackson et al. Footnote 89

Appendix G: Key findings for topic g) mitigation strategies (for example, rubber dam, mouth rinses etc.) during the provision of in-person oral health care

Intervention Main findingsFootnote b SourceFootnote a
Limited evidence in Dental Procedures
High‐volume evacuator (i) The use reduces bacterial contamination in aerosols: less than one foot (~ 30 cm) from a patient's mouth (odds 2.06 greater); but not in longer distances (44% of reduction).
(ii) The use may not be more effective than conventional dental suction (saliva ejector or low‐volume evacuator) at 40 cm (28% of reduction of bacteria).
SR: Kumbargere et al. Footnote 90
Dental isolation combination system (Isolite) and a saliva ejector low‐volume evacuator) (i) During AGPs procedures: 80% of CFU reduction;
(ii) After AGPs procedures: 71% of CFU reduction;
SR: Kumbargere et al. Footnote 90
Rubber dam
of rubber dam may make no difference in CFU at the) and occipital region of the operator (MD 0.77, 95% CI −0.46 to 2.00).
During dental treatment:
(i) With Rubber Dam at one-metre (odd: 13.04 reduction in CFU);
(ii) With Rubber Dam at the forehead (odd: 2.70 reduction in CFU);
(iii) With rubber dam + HVE may reduce CFU more than cotton roll plus HVE on the patient's chest (odd: 234.05 reduction in CFU) and dental unit light (odd: 12.55 reduction in CFU).
SR: Kumbargere et al. Footnote 90
Mouth Rinse solutions
Hydrogen Peroxide In Medical Procedures:
Little scientific evidence to support any virucidal activity, including against SARS-CoV-2, because of the lack of substantivity.
SR: Ortega et al. Footnote 92
Hypertonic Saline In Medical Procedures:
Nasal irrigation: 35% of viral shedding in ICU; positive effects in acute sinusites.
SR: Singh et al. Footnote 93
Oral Rinse Chlorhexidine (CHX) In Dental Procedures:
Before dental procedures: lesse effective than Polvidine in eliminating COVID-19.
During ultrasonic scaling: odd 122.22 of CFU reduction.

In Medical Procedures:
Before gargling undergoing ventilation to prevent pneumonia (29% bio-aerosol reductions).
SR: Moosavi et al. Footnote 94

SR: Kumbargere et al. Footnote 90
SR: Singh et al. Footnote 93

Herbal rinse In medical procedures:
Before gargling presented 85% less incidence of Influenza in elderly people.
SR: Singh et al. Footnote 93
Povidine-Iodine In Dental Procedures:
During ultrasonic scaling: odd 640.16 of CFU reduction.

In Medical Procedures:
No studies for COVID-19
Before gargling presented 36% positive effect in ICU.
Before gargling presented reduction of viral load against enveloped viruses;
MERS-CoV, SARS-CoV and Influenza H1N1 presented reduction of viral tires (4.40-6.00 log10 TCID\50ml).
SR: Kumbargere et al. Footnote 90
SR: Burton et al. Footnote 91
SR: Singh et al. Footnote 93
SR: Moosavi et al. Footnote 94

Appendix H: Key findings for topic h) space ventilation strategies to reduce the risk of transmission

Ventilation setting Main findings SourceFootnote a
Limited evidence in relation to SARS-CoV and MERS-CoV and microorganisms
Air cleaning systems in Dental office
Using a local stand‐alone air cleaning system (ACS):(i) during cavity preparation (odd: 13.25 of reduction of AGP per cubic metre);
(ii) using ultrasonic scaling (odd: 13.25 of reduction of AGP per cubic metre).
Using a laminar flow in the dental clinic combined with a HEPA filter:
(i) reduce contamination approximately 76 cm from the floor (odd: 417.10 of reduction of CFU per cubic feet per minute per patient);
(ii) reduce contamination approximately 20 cm to 30 cm from the patient's mouth (odd: 252.68 of reduction of CFU per cubic feet per minute per patient).
SR: Kumbargere et al. Footnote 90

Appendix I: Key findings for topic i) disinfection of surfaces in spaces in which oral health care is provided

Approaching/Intervention Main findings SourceFootnote a
Limited evidence in relation to different virus

Disinfectants

Chlorine
Viral disinfection on different surfaces:
(i) Plastics: >2.78 log TCID 50/ml reduction of Influenza A \ H1N1
(ii) Stainless Steel: >3 log TCID 50/ml reduction of HCov 229E; >3 log TCID 50/ml reduction of parainfluenza virus; >3 log TCID 50/ml reduction of Type 5 Adenovirus.
SR: Barbato et al. Footnote 95


Alcohols
Viral disinfection of different surfaces:
(i) Plastics: >2.78 log TCID 50/ml reduction of Influenza A \ H1N1
(ii) Stainless Steel: >4log TCID 50/ml reduction of Adenovirus; >3 log TCID 50/ml reduction of HCov 229E; >3 log TCID 50/ml reduction of parainfluenza virus; >3 log TCID 50/ml reduction of Type 5 Adenovirus.
SR: Barbato et al. Footnote 95
Peracetic Acid
Viral disinfection of different surfaces:
(i) Stainless Steel: >4log TCID 50/ml reduction of Adenovirus
(ii) Glass: >4log TCID 50/ml reduction of Adenovirus
SR: Barbato et al. Footnote 95
Glutaraldehyde
Viral disinfection of different surfaces:
(i) Stainless Steel: >4log TCID 50/ml reduction of Adenovirus and >3 log TCID 50/ml reduction of HCov 229E; >3 log TCID 50/ml reduction of parainfluenza virus; >3 log TCID 50/ml reduction of Type 5 Adenovirus.
SR: Barbato et al. Footnote 95
Povidone- Iodine
Viral disinfection of different surfaces:
(i) Stainless Steel: >4log TCID 50/ml reduction of Adenovirus and <3 log TCID 50/ml
reduction of HCov 229E; >3 log TCID 50/ml reduction of parainfluenza virus; <3 log TCID 50/ml reduction of Type 5 Adenovirus.
SR: Barbato et al. Footnote 95

Appendix J: Methods used to identify and include relevant literature

This report was structured as a rapid review of the evidence to support safe provision of oral health care during the COVID-19 pandemic. Different search strategies were tailored for nine key areas ("a" to "i"); available evidence was divided according to those key areas.

J.1. Eligibility criteria

J.1.1. Study types and design

Besides studies in the field of COVID-19/SARS-CoV-2, we also included studies on closely related respiratory viruses, comprising SARS, MERS, H1N1, influenza and common cold. Eligible study designs were: systematic reviews (SR), scoping reviews, randomized controlled trials (RCT) and prospective cohort studies. We considered only manuscripts written in English as potential sources of study data.

The paucity of literature on SARS-CoV-2 infection control has led us to extend inclusion criteria for key areas "f", "g", "h" and "i". Therefore, studies related to airborne bacterial contamination were also included for those areas.

J.1.2. Types of conditions and interventions

Each key review area approached a distinct set of conditions and/or interventions of relevance for oral health care. In brief, those were conditions leading to higher risk of morbidity or mortality by COVID-19, approaches to protect healthcare professionals and patients from infection in different moments (i.e. physical distancing, aerosol-generating procedures, asepsis/disinfection and PPE). We expect conditions and interventions of relevance for the viruses mentioned above to be potentially relevant for COVID-19/SARS-CoV-2, even if as with poorer generalizability - studies reporting them would be considered as weaker sources of evidence.

Specific conditions and interventions were:

  1. Comorbidities and other health conditions able to increase the risk of COVID-19-related complications, including death;
  2. Clinical signs and symptoms expected with COVID-19 and observable by dental professionals before rendering in-person care;
  3. Non-treatment approaches to provide in-person dental care, including patient scheduling, waiting and others (for example,, teledentistry-based interventions);
  4. Different PPE for in-person dental care, based on studies from different areas of health (not restricted to dental professions);
  5. Decontamination of PPE, aiming at their possible reuse;
  6. Aerosols generated by dental procedures, and their relevance for the transmission of COVID-19;
  7. Methods to mitigate cross-infection by aerosols during in-person provision of oral health care, including rubber dam and pre-operatory mouthwashes;
  8. Spatial ventilation strategies to reduce the risk of transmission;
  9. Disinfection of surfaces where oral health care is provided.

Since, at the time of preparing this review, there is no available vaccine for COVID-19, we have not considered that kind of intervention. We did not include prophylactic antiviral regimens for the same reason, for either patients or health care professionals. Since there is potential for vaccines and antivirals to become parts of dental professionals' routine after their development, we may consider including them in future updates.

J.1.2. Outcomes

This review considered any outcome related to the severity of COVID-19 as relevant, including signs/symptoms, complications and incident comorbidities, disease-specific severity indexes, and survival/death. Whenever relevant, measures of contamination (for example, % contaminated per group, or microbial counts on disinfected surfaces) and adverse effects (for example,, rash caused by prolonged mask wearing) were considered.

Whenever relevant for each study key area, a brief description of patient and professional perception was provided. This would be done quantitatively (by numbers, for example, % of dentists who disinfect impressions before sending to the laboratory) or qualitatively (by a concise narrative of key perceptions).

J.2. Search strategy

J.2.1. Electronic searches

We performed systematic literature searches separated by key areas in the following databases: CINAHL, Embase (Ovid), MEDLINE (Ovid) and SCOPUS, restricting our search to a period of 4 months (July 1st 2020 to October 31st 2020). Different search strategies were prepared for key areas "a" to "i" and adapted for each database. Given their similar nature, some pairs of key areas employed a single search (i.e, "a"+"b"; "c"; "d"+"e"; "f"+"g"; "h" and "I"), totalling six searches.

Please refer to Table J1 at the end of this Appendix for the terms used in the electronic searches.

J.2.2. Researching other resources

We reviewed the list of references of all papers included in the report to identify other potentially relevant studies ("reference mining").

J.3. Data collection and analysis

J.3.1. Selection of studies

Two researchers (L.A. and R.S.) examined the titles and abstracts from each search to decide on their exclusion. A third researcher (P.A.) tackled any disagreement between the two reviewers during the selection of titles and abstracts.

Potential inclusion (including cases of insufficient information for exclusion) led to the revision of full text versions by two researchers (R.S. and P.A.). For full text selection, any disagreement was decided by a consensus meeting with a third researcher (L.A.). Although we always reached consensus, the third researcher would have the final decision in cases of persisting disagreement.

In the case of having two or more manuscripts describing the same study, those references would count as a single included study.

J.3.2 Data extraction/management, and quality of studies

Studies were classified according to the level of evidence provided: SR>RCT>prospective cohort. Scoping reviews were considered due to the breadth of information rather than strength of evidence. Since this is a rapid review on a vast amount of key areas, no in-depth quality assessment was performed - instead, we classified sources of evidence as "strong", "limited" or "none" for each specific condition/intervention.

J.3.2.1 Eligibility Criteria for Key areas A and B

Our search yielded several redundant studies for key areas A and B. That led us to restrict our eligibility criteria, by including only systematic reviews. As decision criteria for inclusion, this report considered as a systematic review just those studies with:

  1. a well-defined goal and/or research question, based on participant/patient type, exposure and outcome variables;
  2. systematic study selection, by using reproducible methods (including clear search strategy and eligibility criteria);
  3. quality assessment of reviewed literature (for example,, application of standard quality assessment questionnaires for clinical studies);
  4. any strategy to synthetize obtained data (including meta-analysis) or at least a critical description primary study data, if studies cannot be pooled.

Primary studies for key area A were restricted to prospective ones. This enabled us to focus on high-level evidence. The latter restriction was not applied to key area B, given the non-analytical nature of the question.

Scoping reviews and other primary studies, including retrospective cohort, were still eligible for key areas C to I. Thus, broader information was reviewed for those areas with more scarce evidence.

J.2. Description of studies

J.2.1. Results of the search

The search strategy retrieved 6,263 study titles and abstracts. After examining those references, 6,054 clearly did not meet the inclusion criteria and were excluded. Two hundred and nine full text reports of potentially relevant studies were obtained for further evaluation. After excluding 100 full reports, our sample totaled 102 study reports.

According to each section, articles were included. Appendix Table J2 shows the selection of the publication for inclusion in the systematic review.

Appendix Table J2. Yield of the six electronic search strategies, in terms of the number of reports

Key areas Total Excluded Included
A + B 690 608 82 (11.8%)
C 3,558 3,554 4 (0.1%)
D + E 618 610 8 (1.3%)
F + G 829 822 7 (0.8%)
H 73 72 1 (1.4%)
I 488 487 1 (0.2%)
No data No data   Total = 103

* There were several articles identified for more than one topic (for instance, 7 articles were identified for topics A and B) hence the total in the table (103 included articles) is slightly greater than the 102 articles in the reference list.

J.2.2. Included studies

Most included studies were published in the last 10 years. All the reports were published between August and October 2020. Regarding study design, the majority of our inclusions were SR (n=100, 92%). We have also included seven scoping reviews (n=2, 2%), as well seven prospective cohort study (6%).

J.2.3. Measures of treatment effect and Unit of analysis issues

Included studies underwent qualitative analysis and separate data extraction, without further efforts for quantitative synthesis. Please refer to the main document and Appendices A to I for the description and results of included studies.

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Footnote 61

A. M. Kotlyar, O. Grechukhina, A. Chen, S. Popkhadze, A. Grimshaw, O. Tal, H. S. Taylor and R. Tal, " Vertical transmission of coronavirus disease 2019: a systematic review and meta-analysis," American Journal of Obstetrics & Gynecology, vol. 31, no. 0, p. 31, 2020.

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Footnote 62

A. Tanacan, S. A. Erol, B. Turgay, A. T. Anuk, E. I. Secen, G. F. Yegin, S. Ozyer, F. Kirca, B. Dinc, S. Unlu, E. G. Yapar Eyi, H. L. Keskin, D. Sahin, A. A. Surel and O. Tekin, "The rate of SARS-CoV-2 positivity in asymptomatic pregnant women admitted to hospital for delivery: Experience of a pandemic center in Turkey.," European Journal of Obstetrics & Gynecology & Reproductive Biology, vol. 253, no. 0, pp. 31-34, 2020.

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Footnote 63

H. e. a. Chi, ""Clinical features of neonates born to mothers with coronavirus disease-2019: A systematic review of 105 neonates," Journal of microbiology, immunology, and infection, vol. 20, pp. 1684-1182, 2020.

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Footnote 64

B. J. F. Huntley, E. S. Huntley, D. Di Mascio, T. Chen, V. Berghella and S. P. Chauhan, "Rates of Maternal and Perinatal Mortality and Vertical Transmission in Pregnancies Complicated by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Co-V-2) Infection: A Systematic Review.," Obstetrics & Gynecology, vol. 136, no. 2, pp. 303-312, 2020.

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Footnote 65

A. Khalil, E. Kalafat, C. Benlioglu, P. O'Brien, E. Morris, T. Draycott, S. Thangaratinam, K. Le Doare, P. Heath, S. Ladhani, P. von Dadelszen and L. A. Magee, "SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes," EClinicalMedicine, vol. 25, no. 0, 2020.

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Footnote 66

O. Turan, A. Hakim, P. Dashraath, W. J. L. Jeslyn, A. Wright and R. Abdul-Kadir, "Clinical characteristics, prognostic factors, and maternal and neonatal outcomes of SARS-CoV-2 infection among hospitalized pregnant women: A systematic review.," International Journal of Gynecology and Obstetrics, vol. 151, no. 1, pp. 7-16, 2020.

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Footnote 67

J.-W. Li, T.-W. Han, M. Woodward, C. S. Anderson, H. Zhou, Y.-D. Chen and B. Neal, " The impact of 2019 novel coronavirus on heart injury: A Systematic review and Meta-analysis.," Progress in Cardiovascular Diseases, vol. 63, no. 4, pp. 518-524, 2020.

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Footnote 68

R. Tariq, S. Saha, F. Furqan, L. Hassett, D. Pardi and S. Khanna, " Prevalence and Mortality of COVID-19 Patients With Gastrointestinal Symptoms: A Systematic Review and Meta-analysis," Mayo Clinic Proceedings, vol. 95, no. 8, pp. 1632-1648, 2020.

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Footnote 69

J. Almqvist, T. Granberg, A. Tzortzakakis, S. Klironomos, E. Kollia, C. Ohberg, R. Martin, F. Piehl, R. Ouellette and B. V. Ineichen, "Neurological manifestations of coronavirus infections - a systematic review.," Annals of Clinical & Translational Neurology, vol. 7, no. 10, pp. 2057-2071, 2020.

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Footnote 70

X. Chen, S. Laurent, O. A. Onur, N. N. Kleineberg, G. R. Fink, F. Schweitzer and C. Warnke, "A systematic review of neurological symptoms and complications of COVID-19.," Journal of Neurology, vol. 20, no. 0, p. 20, 2020.

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Footnote 71

F. Gul, K. B. Lo, J. Peterson, P. A. McCullough, A. Goyal and J. Rangaswami, "Meta-analysis of outcomes of patients with COVID-19 infection with versus without gastrointestinal symptoms," Baylor University Medical Center Proceedings, vol. 33, no. 3, pp. 366-369, 2020.

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Footnote 72

R. Mao, Y. Qiu, J. S. He, J. Y. Tan, X. H. Li, J. Liang, J. Shen, L. R. Zhu, Y. Chen, M. Iacucci, S. C. Ng, S. Ghosh and M. H. Chen, "Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic reviewand meta-analysis.," The Lancet. Gastroenterology & Hepatology, vol. 5, no. 7, pp. 667-678, 2020.

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Footnote 73

T. H. Chua, Z. Xu and N. K. K. King, "Neurological manifestations in COVID-19: a systematic review and meta-analysis," Brain Injury, vol. 0, no. 0, 2020.

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Footnote 74

L. P. Samaranayake, K. S. Fakhruddin, P and C. uwawala, " Sudden onset, acute loss of taste and smell in coronavirus disease 2019 (COVID-19): a systematic review," Acta Odontologica Scandinavica, vol. 78, no. 6, pp. 467-473, 2020.

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Footnote 75

A. De Lorenzo, D. A. Kasal, B. R. Tura, C. C. Lamas and H. C. Rey, " Acute cardiac injury in patients with COVID-19," American Journal of Cardiovascular Disease, vol. 10, no. 2, pp. 28-33, 2020.

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Footnote 76

L. Zhang, T. G. Peres, M. V. F. Silva and P. Camargos, " What we know so far about Coronavirus Disease 2019 in children: A meta-analysis of 551 laboratory-confirmed cases," Pediatric Pulmonology, vol. 55, no. 8, pp. 2115-2127, 2020.

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Footnote 77

M. A. Ashraf, P. Keshavarz, P. Hosseinpour, A. Erfani, A. Roshanshad, A. Pourdast, P. Nowrouzi-Sohrabi, S. Chaichian and T. Poordast, "Coronavirus Disease 2019 (COVID-19): A Systematic Review of Pregnancy and the Possibility of Vertical Transmission," Journal of Reproduction and Infertility, vol. 21, no. 3, p. 157, 2020.

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Footnote 78

M. B. L. K. J. D. e. a. Banakar, "COVID-19 transmission risk and protective protocols in dentistry: a systematic review," BMC Oral Health, p. 75, 2020.

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Footnote 79

F. D. P. Cabrera-Tasayco, J. M. Rivera-Carhuavilca, K. J. Atoche-Socola, C. Pena-Soto and L. E. Arriola-Guillen, " Biosafety measures at the dental office after the appearance of COVID-19: A systematic review," Disaster medicine and public health preparedness, vol. 0, no. 0, pp. 1-16, 2020.

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Footnote 80

A. A. Siles-Garcia, A. G. Alzamora-Cepeda, K. J. Atoche-Socola, C. Peña-Soto and L. E. Arriola-Guillén, "Biosafety for dental patients during dentistry care after COVID-19: A review of the literature. Disaster Medicine and Public Health Preparednes," Disaster Medicine and Public Health Preparedness, vol. 0, no. 0, 2020.

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Footnote 81

M. Al-Halabi, A. Salami, E. Alnuaimi, M. Kowash and I. Hussein, "Assessment of paediatric dental guidelines and caries management alternatives in the post COVID-19 period. A critical review and clinical recommendations.," European Archives of Paediatric Dentistry: Official Journal of the European Academy of Paediatric Dentistry, vol. 21, no. 5, pp. 543-556, 2020.

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Footnote 82

A. Licina, A. Silvers and R. L. Stuart, "Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases - A systematic review of evidence," Systematic Reviews, vol. 9, no. 1, 2020.

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Footnote 83

M. e. a. Zhang, "Masks or N95 Respirators During COVID-19 Pandemic-Which One Should I Wear?."," Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons, pp. 31090-9, 2020.

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Footnote 84

L. P. Samaranayake, K. S. Fakhruddin, H. C. Ngo, J. W. W. Chang, P and C. uwawala, "The effectiveness and efficacy of respiratory protective equipment (RPE) in dentistry and other health care settings: a systematic review.," Acta Odontologica Scandinavica, vol. 0, no. 0, pp. 1-14, 2020.

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Footnote 85

N. A. D. &. R. J. Shaukat, "Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review.," Int J Emerg Med, vol. 13, p. 40, 2020.

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Footnote 86

S. Gertsman, A. Agarwal, K. O'Hearn, R. Webster, A. Tsampalieros, N. Barrowman, M. Sampson, L. Sikora, E. Staykov, R. Ng, J. Gibson, T. Dinh, K. Agyei, G. Chamberlain and J. D. McNally, "Microwave- and heat-based decontamination of N95 filtering facepiece respirators: a systematic review," Journal of Hospital Infection., vol. 0, no. 0, 2020.

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Footnote 87

T. D. C. P. P. N. F.-M. C. M. R. N. A. Santos M, " Are cloth masks a substitute to medical masks in reducing transmission and contamination? A systematic review.," Braz Oral Res, vol. 30, no. 34, p. e123, 2020.

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Footnote 88

D. M. K. A. Fakheran O, "Saliva as a diagnostic specimen for detection of SARS-CoV-2 in suspected patients: a scoping review," Infect Dis Poverty, vol. 9, no. 1, p. 100, 2020.

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Footnote 89

D. D. W. G. e. a. Jackson T, "Classification of aerosol-generating procedures: a rapid systematic review," BMJ Open Respiratory Research, vol. 7, p. e000730, 2020.

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Footnote 90

E. P. P. M. N. M. S. G. V. J. Kumbargere Nagraj S, "Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases," Cochrane Database of Systematic Reviews, no. 10, 2020.

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Footnote 91

C. J. G. B. G. A.-M. M. A. S. A. W. K. W. H. Burton MJ, "Use of antimicrobial mouthwashes (gargling) and nasal sprays by healthcare workers to protect them when treating patients with suspected or confirmed COVID‐19 infection," Cochrane Database of Systematic Reviews, no. 9, 2020.

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Footnote 92

K. L. Ortega, B. O. Rech, G. L. C. El Haje, C. B. Gallo, M. Perez-Sayans and P. H. Braz-Silva, "Do hydrogen peroxide mouthwashes have a virucidal effect? A systematic review.," The Journal of hospital infection, vol. 12, no. 0, 2020.

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Footnote 93

S. Singh, N. Sharma, U. Singh, T. Singh, D. Mangal and V. Singh, "Nasopharyngeal wash in preventing and treating upper respiratory tract infections: Could it prevent COVID-19?," Lung India, vol. 37, no. 3, pp. 246-251, 2020.

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Footnote 94

M. S. Moosavi, P. Aminishakib and M. Ansari, "Antiviral mouthwashes: possible benefit for COVID-19 with evidence-based approach," Journal of Oral Microbiology, vol. 12, no. 1, 2020.

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Footnote 95

L. Barbato, F. Bernardelli, G. Braga, M. Clementini, C. Di Gioia, C. Littarru, F. Oreglia, M. Raspini, E. Brambilla, I. Iavicoli, V. Pinchi, L, L. i, N. M. Sforza, R. Cavalcanti, A. Crea and F. Cairo, "Surface disinfection and protective masks for SARS-CoV-2 and other respiratory viruses: A review by SIdP COVID-19 task force.," Oral Diseases, vol. 0, no. 0, 2020.

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Footnote 96

L. Y. W. Lee, J. B. Cazier, T. Starkey, C. D. Turnbull, R. Kerr, G. Middleton, L. Y. Lee, V. Angelis, R. Arnold, V. Bisht, N. A. Campton, J. Chackathayil, V. W. Cheng, H. M. Curley and M. Fittall, "COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study," Lancet, vol. 395, no. 10241, pp. 1919-1926, 2020.

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Footnote 97

H. Brenner, B. Holleczek and B. Schöttker, "Vitamin D Insufficiency and Deficiency and Mortality from Respiratory Diseases in a Cohort of Older Adults: Potential for Limiting the Death Toll during and beyond the COVID-19 Pandemic?," Nutrients, vol. 12, p. 2488, 2020.

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Footnote 98

S. Galmes, F. Serra and A. Palou, "Current state of evidence: Influence of nutritional and nutrigenetic factors on immunity in the COVID-19 pandemic framework," Nutrients, vol. 12, no. 9, pp. 1-33, 2020.

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Footnote 99

L. Cheng, H. Li, L. Li, C. Liu, S. Yan, H. Chen and Y. Li, "Ferritin in the coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis.," Journal of Clinical Laboratory Analysis, vol. 34, no. 10, p. E23618.

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Footnote 100

P. E. Taneri, S. A. Gomez-Ochoa, E. Llanaj, P. F. Raguindin, L. Z. Rojas, Z. M. Roa-Diaz, D. J. Salvador, D. Groothof, B. Minder, D. Kopp-Heim, W. E. Hautz, M. F. Eisenga, O. H. Franco, M. Glisic and T. Muka, "Anemia and iron metabolism in COVID-19: a systematic review and meta-analysis," European Journal of Epidemiology, vol. 35, no. 8, pp. 763-773, 2020.

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Footnote 101

F. BourBour, S. Mirzaei Dahka, M. Gholamalizadeh, M. E. Akbari, M. Shadnoush, M. Haghighi, H. Taghvaye-Masoumi, N. Ashoori and S. Doaei, "Nutrients in prevention, treatment, and management of viral infections; special focus on Coronavirus," Archives of physiology and biochemistry, vol. 0, no. 0, pp. 1-10, 2020.

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Footnote 102

T. J. Cooper, B. L. Woodward, S. Alom and A. Harky, "Coronavirus disease 2019 (COVID‐19) outcomes in HIV/AIDS patients: a systematic review.," HIV Medicine, vol. 21, no. 9, pp. 567-577, 2020.

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Footnote 103

P. Vizcarra, M. J. Perez-Elias, C. Quereda, A. Moreno, M. J. Vivancos, F. Dronda, J. L. Casado and C.-I. Team, "Description of COVID-19 in HIV-infected individuals: a single-centre, prospective cohort.," The Lancet. HIV, vol. 7, no. 8, pp. e554-e564, 2020.

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Footnote 104

G. I. A. M. A. F. T. M. P. M. S. S. L. A....... C. E. B. Sant'Ana, "Infection and death in healthcare workers due to COVID-19: A systematic review.," Acta Paulista De Enfermagem, vol. 33, no. 4, pp. 1-9, 2020.

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Footnote 105

M. Farronato, E. Boccalari, E. Del Rosso, V. Lanteri, R. Mulder and C. Maspero, "A Scoping Review of Respirator Literature and a Survey among Dental Professionals.," International Journal of Environmental Research & Public Health [Electronic Resource], vol. 17, no. 16, p. 17, 2020.

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Footnotes

Footnote a

SR: Systematic review

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Footnote b

Units for CFU: colony-forming unit (count of viable bacteria)

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