Review Article

Sailing through the COVID-19 Pandemic and Beyond: An Evidence-Based Analysis for Dental Healthcare and Practice


This integrative review aims to provide a consolidated evidence-based appraisal of the most up-to-date guidelines and recommendations of international public and professional health regulatory bodies in relation to preparedness framework for restructuring safe delivery of dental services amid and beyond the coronavirus disease-2019 (COVID-19) pandemic. Most recent updated guidelines for dental professionals from major international health regulatory bodies were reviewed. PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, WHO COVID-19 and LILACS databases, along with relevant preprints were searched, and citations were checked up to January 23, 2021. The search was performed by one author. Shortlisted articles were read and brought to consensus to be included in the study by at least two co-authors. In case of any disagreement between the judgements, an independent co-author’s decision was taken as final. Of 849 records searched, 61 articles were included in the study. Following content analysis of the global guidelines and the collected prevailing evidence, the common themes and recommendations of different guidance documents were collated and summarized into seven domains. Most guidelines have a consensus regarding implementation of rigorous administrative, engineering and environmental infection control strategies. However, variations do exist with regard to the use of respirators in non-aerosol-generating procedure (non-AGP) settings, employment of airborne precautions during non-AGPs, use of supplemental air-handling systems, and preoperative use of mouthwashes. This evidence-based analysis can serve as a useful reopening resource tool and facilitate effective restructuring for delivery of optimal, equitable and safe dental practices globally, during and while emerging from the pandemic.

1. World Health Organization. (2020 COVID-19 Weekly epidemiological update - 19 January 2021 Available at: / Accessed January 23, 2021
2. Centre for Disease Control and Prevention (CDC), Emerging SARS-CoV-2 Variants. Updated Jan. 15, 2021. Available at: Accessed January 23, 2021.
3. Oran DP, Topol EJ. Prevalence of asymptomatic SARS-CoV-2 infection: A narrative review. Ann Intern Med. 2020 Sep;173(5):362-7.
4. Moghadas SM, Fitzpatrick MC, Sah P, Pandey A, Shoukat A, Singer BH, et al. The implications of silent transmission for the control of COVID-19 outbreaks. Proc Natl Acad Sci U S A. 2020 Jul;117(30):17513-5.
5. Furukawa NW, Brooks JT, Sobel J. Evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. Emerg Infect Dis. 2020 Jul;26(7):e201595.
6. Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020 Dec;15(4):564-7.
7. To KK, Tsang OT, Yip CC, Chan KH, Wu TC, Chan JM, et al. Consistent Detection of 2019 Novel Coronavirus in Saliva. Clin Infect Dis. 2020 Jul;71(15):841-3.
8. Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et al. High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci. 2020 Feb;12(1):8.
9. Occupational Safety and Health Administration (OSHA). COVID-19 Control and Prevention Dentistry workers and employers. 2020. Available at: / Accessed January 23, 2021.
10. OCDO, NHS. Standard operating procedure - Transition to recovery, A phased transition for dental practices towards the resumption of the full range of dental provision, Published 27 October 2020: Version 4. Available at: Accessed January 23, 2021.
11. Westgarth D. How does dentistry move from survival to revival? BDJ In Pract. 2020 Aug;33:12-6.
12. COVID-19 Dental Services Evidence Review Working Group Recommendations for the re-opening of dental services: a rapid review of international sources. 6 May 2020, Substantial update 16 May 2020. Available at: Accessed January 23, 2021.
13. Centre for Disease Control and Prevention (CDC), Guidance for Dental Settings, Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Pandemic. December 4, 2020. Available at: Accessed January 23, 2021.
14. DHSC, PHW, PHA, HPS, PHS, PHE and NHS, COVID-19: infection prevention and control dental appendix. Updated 21 January 2021. Available at: Accessed January 23, 2021.
15. European Centre for Disease Prevention and Control. COVID-19 infection prevention and control measures for primary care, including general practitioner practices, dental clinics and pharmacy settings: first update. 19 October 2020. ECDC: Stockholm; 2020. Available at: /Accessed January 23, 2021.
16. Australian Department of Health, Guidance on use of personal protective equipment (PPE) in non-inpatient healthcare settings, during the COVID-19 outbreak. - Version 8 (19/11/20). Available at: Accessed January 23, 2021.
17. World Health Organization. (‎2020. Considerations for the provision of essential oral health services in the context of COVID-19: interim guidance, 3 August 2020. Available at: Accessed January 23, 2021.
18. Indian Ministry of Health & Family Welfare (2020). Guidelines for Dental Professionals in Covid-19 pandemic situation. 19 May 2020. Available at: Accessed January 23, 2021.
19. DHSC, PHW, PHA, HPS, PHE, NHS, COVID-19 COVID-19: Guidance for maintaining services within health and care settings: infection prevention and control (IPC) recommendations, Revised version 1.1, 21 January 2021. Available at: Accessed January 23, 2021.
20. Zhang R, Li Y, Zhang AL, Wang Y, Molina MJ. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proc Natl Acad Sci USA. 2020 Jun;117(26):14857-63.
21. Tang S, Mao Y, Jones RM, Tan Q, Ji JS, Li N, et al. Aerosol transmission of SARS-CoV-2? Evidence, prevention and control. Environ Int. 2020 Nov;144:106039.
22. Somsen GA, van Rijn C, Kooij S, Bem RA, Bonn D. Small droplet aerosols in poorly ventilated spaces and SARS-CoV-2 transmission. Lancet Respir Med. 2020 Jul;8(7):658-9.
23. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Apr;382(16):1564-7.
24. Fears AC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of Severe Acute Respiratory Syndrome Coronavirus 2 in Aerosol Suspensions. Emerg Infect Dis. 2020 Sep;26(9):2168-71.
25. Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NK, et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature. 2020 Jun;582(7813):557-60.
26. Leung NHL, Chu DKW, Shiu EYC, Chan KH, McDevitt JJ, Hau BJP, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020 May;26(5):676-80.
27. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020 Jun;395(10242):1973-87.
28. Bullard J, Dust K, Funk D, Strong JE, Alexander D, Garnett L, et al. Predicting infectious SARS-CoV-2 from diagnostic samples. Clin Infect Dis. 2020 May 22:ciaa638.
29. World Health Organization, Transmission of SARS-CoV-2: implications for infection prevention precautions. Scientific brief - 9 July 2020. Available at: Accessed January 23, 2021.
30. Australian Guidelines for the Prevention and Control of Infection in Healthcare, Canberra: National Health and Medical Research Council (2019). Available at: Accessed January 23, 2021.
31. Kratzel A, Todt D, V'kovski P, Steiner S, Gultom M, Thao TTN, et al. Inactivation of severe acute respiratory syndrome coronavirus 2 by WHO-recommended hand rub formulations and alcohols. Emerg Infect Dis. 2020 Jul;26(7):1592-95.
32. Kenters N, Eikelenboom-Boskamp A, Hines J, McGeer A, Huijskens EGW, Voss A. Product dose considerations for real-world hand sanitizer efficacy. Am J Infect Control. 2020 May;48(5):503-6.
33. World Health Organization 2009 )‎ Natural ventilation for infection control in health care settings. . Available at: Accessed January 23, 2021.
34. European Centre for Disease Prevention and Control. Heating, ventilation and air-conditioning systems in the context of COVID-19. 10 November 2020. Stockholm: ECDC; 2020. Available at: Accessed January 23, 2021.
35. Heating, Ventilation and Air Conditioning (HVAC) Systems;19 Aug 2020. Available at: Accessed January 23, 2021.
36. American Society of Heating RaA-CE. ASHRAE position document on infectious aerosols Atlanta: ASHRAE; 2020. Available at: Accessed January 23, 2021.
37. Darnell ME, Subbarao K, Feinstone SM, Taylor DR. Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV. J Virol Methods. 2004 Oct;121(1):85-91.
38. Dietz L, Horve PF, Coil DA, Fretz M, Eisen JA, Van Den Wymelenberg K. 2019 novel coronavirus (COVID-19) pandemic: Built environment considerations to reduce transmission. Msystems. 2020 Apr;5(2):e00245-20.
39. Kitagawa H, Nomura T, Nazmul T, Omori K, Shigemoto N, Sakaguchi T, et al. Effectiveness of 222-nm ultraviolet light on disinfecting SARS-CoV-2 surface contamination. Am J Infect Control. 2020 Sep:S0196-6553(20)30809-9.
40. Buonanno M, Welch D, Shuryak I, Brenner DJ. Far-UVC light (222 nm) efficiently and safely inactivates airborne human coronaviruses. Sci Rep. 2020 Jun;10(1):10285.
41. COVID-19: Infection prevention and control risk management, Australian Commission on Safety and Quality in Healthcare. (04/08/2020) Available at: Accessed January 23, 2021.
42. Ren Y, Feng C, Rasubala L, Malmstrom H, Eliav E. Risk for dental healthcare professionals during the COVID-19 global pandemic: An evidence-based assessment. J Dent. 2020 Oct;101:103434.
43. Innes N, Johnson IG, Al-Yaseen W, Harris R, Jones R, Kc S, et al. A systematic review of droplet and aerosol generation in dentistry. J Dent. 2020 Dec;105:103556.
44. Health Protection Scotland. SBAR: Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker, 16 October 2020. Available at: Accessed January 23, 2021.
45. Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, et al. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020 Jul;47 Suppl 22:4-60.
46. Ilhan B, Bayrakdar İS, Orhan K. Dental radiographic procedures during COVID-19 outbreak and normalization period: recommendations on infection control. Oral Radiol. 2020 Oct;36(4):395-9.
47. Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev. 2020 Apr 15;4(4):CD011621.
48. Benzian H, Niederman R. A dental response to the COVID-19 pandemic-safer aerosol-free emergent (SAFER) dentistry. Front Med (Lausanne). 2020 Aug;7:520.
49. Kumbargere Nagraj S, Eachempati P, Paisi M, Nasser M, Sivaramakrishnan G, Verbeek JH. Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases. Cochrane Database Syst Rev. 2020 Oct;10:CD013686.
50. Urquhart O, Tampi MP, Pilcher L, Slayton RL, Araujo MWB, Fontana M, et al. Nonrestorative treatments for caries: Systematic review and network meta-analysis. J Dent Res. 2019 Jan;98(1):14-26.
51. Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020 Mar;382(12):1177-9.
52. Bidra AS, Pelletier JS, Westover JB, Frank S, Brown SM, Tessema B. Rapid in-vitro inactivation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using povidone-iodine oral antiseptic rinse. J Prosthodont 2020 Jul;29(6):529-33.
53. Hassandarvish P, Tiong V, Mohamed NA, Arumugam H, Ananthanarayanan A, Qasuri M, et al. In vitro virucidal activity of povidone iodine gargle and mouthwash against SARS-CoV-2: implications for dental practice. Br Dent J. 2020 Dec:1-4.
54. Anderson DE, Sivalingam V, Kang AEZ, Ananthanarayanan A, Arumugam H, Jenkins TM, et al. Povidone-Iodine Demonstrates Rapid In Vitro Virucidal Activity Against SARS-CoV-2, The Virus Causing COVID-19 Disease. Infect Dis Ther 2020 Sep;9(3):669-75.
55. Meister TL, Brüggemann Y, Todt D, Conzelmann C, Müller JA, Groß R, et al. Virucidal Efficacy of Different Oral Rinses Against Severe Acute Respiratory Syndrome Coronavirus 2. J Infect Dis. 2020 Sep;222(8):1289-92.
56. Seneviratne CJ, Balan P, Ko KKK, Udawatte NS, Lai D, Ng DHL, et al. Efficacy of commercial mouth-rinses on SARS-CoV-2 viral load in saliva: randomized control trial in Singapore. Infection. 2020 Dec:1-7.
57. Koletsi D, Belibasakis GN, Eliades T. Interventions to reduce aerosolized microbes in dental practice: A systematic review with network meta-analysis of randomized controlled trials. J Dent Res. 2020 Oct;99(11):1228-38.
58. Kirk-Bayley J, Combes J, Sunkaraneni V, Challacombe S. The use of povidone iodine nasal spray and mouthwash during the current COVID-19 pandemic may reduce cross infection and protect healthcare workers (May 4, 2020).
59. Centers for Disease Control and Prevention, Guidelines for Infection Control in Dental Health-Care Settings— 2003. MMWR 2003;52(No. RR-17). Available at: Accessed January 23, 2021.
60. Department of Health. Decontamination: Health Technical Memorandum 0105 Decontamination in primary care dental practices. 2013. UK. Available at: Accessed January 23, 2021.
61. European Centre for Disease Prevention and Control, Disinfection of environments in healthcare and nonhealthcare settings potentially contaminated with SARS-CoV-2 Stockholm: ECDC; 2020. Available at: Accessed January 23, 2021.
62. Australian Department of Health (2020), Environmental cleaning and disinfection principles for health and residential care facilities - Version 5, 14/09/2020. Available at: Accessed January 23, 2021.
63. Chin AWH, Chu JTS, Perera MRA, Hui KPY, Yen HL, Chan MCW, et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe. 2020 May;1(1):e10.
64. Ijaz MK, Whitehead K, Srinivasan V, McKinney J, Rubino JR, Ripley M, et al. Microbicidal actives with virucidal efficacy against SARS-CoV-2. Am J Infect Control. 2020 Aug;48(8):972-3.
65. Chan KH, Sridhar S, Zhang RR, Chu H, Fung AY, Chan G, et al. Factors affecting stability and infectivity of SARS-CoV-2. J Hosp Infect. 2020 Oct;106(2):226-31.
66. Goyal SM, Chander Y, Yezli S, Otter JA. Evaluating the virucidal efficacy of hydrogen peroxide vapour. J Hosp Infect. 2014 Apr;86(4):255-9.
67. Block MS, Rowan BG. Hypochlorous Acid: A Review. J Oral Maxillofac Surg. 2020 Sep;78(9):1461-6.
68. Benson PE, Ebhohimen A, Douglas I. The cleaning of photographic retractors; a survey, clinical and laboratory study. Br Dent J. 2010 Apr;208(7):E14; discussion 306-7.
69. CDC, Background G. Laundry and Bedding - Guidelines for Environmental Infection Control in Health-Care Facilities. 2003. Available at: Accessed January 23, 2021.
70. World Health Organization (WHO), Guidance on regulations for the Transport of Infectious Substances 2013–2014. Available at: Accessed January 23, 2021.
71. Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database Syst Rev. 2020 Apr;4(4):CD013582.
72. CDC, Uses of Telehealth during COVID-19
in Low Resource Non-U.S. Settings. July 21, 2020. Available at: Accessed January 23, 2021.
73. Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ. 1995 Aug;311(7003):485.
74. To KK, Hung IF, Ip JD, Chu AW, Chan WM, Tam AR, et al. COVID-19 re-infection by a phylogenetically distinct SARS-coronavirus-2 strain confirmed by whole genome sequencing. Clin Infect Dis. 2020 Aug 25:ciaa1275.
75. Van Elslande J, Vermeersch P, Vandervoort K, Wawina-Bokalanga T, Vanmechelen B, Wollants E, et al. Symptomatic SARS-CoV-2 reinfection by a phylogenetically distinct strain. Clin Infect Dis. 2020 Sep 5:ciaa1330.
76. Shastri J, Parikh S, Agarwal S, Chatterje N, Pathak M, Sharma C, et al. Whole Genome Sequencing Confirmed SARS-CoV-2 Reinfections Among Healthcare Workers in India with Increased Severity in the Second Episode. 2020. Available at:
77. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 2020 May;368(6493):860-8.
78. Plog J, Wu J, Dias YJ, Mashayek F, Cooper LF, Yarin AL. Reopening dentistry after COVID-19: Complete suppression of aerosolization in dental procedures by viscoelastic Medusa Gorgo. Phys Fluids (1994). 2020 Aug;32(8):083111.
79. Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. Prev Chronic Dis. 2020 Aug;17:E82. doi: 10.5888/pcd17.200266. Erratum in: Prev Chronic Dis. 2020 Aug 27;17:E93.
IssueVol 19 (Continuously Published Article-Based) QRcode
SectionReview Article
COVID-19 Dentistry Evidence-Based Dentistry Risk Reduction Behavior

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Singh H, Sachdeva S, Srivastava D, Kapoor P, Sharma P, Maurya RK, Roy P. Sailing through the COVID-19 Pandemic and Beyond: An Evidence-Based Analysis for Dental Healthcare and Practice. Front Dent. 2022;19.