If the Coronavirus Were Red: Unresolved Concerns on COVID-19 Transmission in Oral Health Education

As the COVID-19 pandemic rages on in the middle of the current “Phase 2” of reopening, dentistry continues to face its field-unique challenges (Lo Giudice, 2020). While COVID-19 transmission in dentistry has a very high, not yet validated, theoretical risk (Levit & Levit, 2020), we hypothesize that oral health education might expose dental health care providers to an additional risk. Surprisingly, to the best knowledge of the authors, concerns on COVID-19 transmission due to oral hygiene education were not yet raised in the indexed literature nor appropriate attitudes to safely accomplish such a pivotal part of oral health were suggested.

Continuous face-to-face dental hygiene education remains the cornerstone of almost every treatment plan in the daily dental practice. Moreover, primary preventive dentistry is also the leading modality in maintaining dental health in educational institutions, elder care facilities and institutions for handicapped. Sure, currently oral health education may be partially converted to online basis by means of telemedicine (Gadbury-Amyot, 2020; Villa et al., 2020). However, many reasons exist why telemedicine cannot fully substitute for the traditional face-to-face interaction and individual training. Additionally, large groups of patients for whom good oral hygiene is critical for their health have no access or ability to use the required technology. These mostly belong to the society’s less fortunate sectors—pediatric patients in high risk, medically compromised, or mentally retarded patients and elderly.

Dental hygiene education involves unique patient–instructor microenvironment, where COVID-19 might be easily disseminated by saliva associated respiratory droplets by the following routs. First, suction evacuation system is inapplicable during the hygiene practice due to its distraction to the educational process. Second, manual tooth brushing and more so rotating or sonic electric toothbrushes generate droplets and, probably, aerosol. Unfortunately, worldwide manufacturers were uncooperative with our queries on empirical data on droplets and aerosol generation by their sonic or rotating-oscillating electric toothbrushes. Third, patients contaminate their hands during the hygiene practice with saliva and dental plaque and are more prone to SARS-CoV-2 transmission by hands.

While the mechanisms leading to COVID-19 transmission by oral hygiene appliances remain to be established, we suggest the following recommendations: (1) Educate patients behind a transparent wall, preferably in a separate well-ventilated room, equipped with microphones and loudspeakers; (2) if not possible, use the best possible personal protective equipment and educate the patient from a distance of at least 2 meters (6.56 feet); (3) sanitize the hands of the patient and the hygiene appliances immediately after the oral health session; (4) diminish or avoid using electric toothbrushes until their extent of aerosol and droplets generation is well studied and documented.

The readership is pleased to share their experience in frontal oral hygiene education amid the COVID-19 era. Also, empirical data on aerosol and droplets generation by various manual and electric toothbrushes urgently required.