The Importance of Dental Hygiene During the Pandemic

Inside Dental Hygiene spoke to Joseph Greenberg, DMD, a private practitioner in Villanova, Pennsylvania, and longtime educator, about recent assertions that dental hygiene is a nonessential service.

Inside Dental Hygiene
The CDC issued guidelines about person-to-person transmission of COVID-19. What were some of the key takeaways for you?

Joseph R. Greenberg, DMD
I will quote their report, because it is very important to listen to their words and respond to them: “Current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with the virus that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouth, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity.” Additionally, Amy Baxter, MD, of Pain Care Labs in Atlanta, Georgia, said recently that the nose is where the viral load is heaviest, and that is interconnected with the mouth. We are dealing with a droplet-borne infection, and the biggest target is the mouth. Shouldn’t we as dental professionals be consulted about how to reduce the risk of infection if a droplet gets into our mouth? Of course, we will be wearing masks if we possibly can in dental practices, but out there in the public, what happens? Droplets get into the mouth, and if masks are not being worn, which mouths will be infected, which mouths will be a welcoming home for the virus, and which mouths will not? That has to do with personal oral hygiene.

The idea that we should stay away from our dental hygienist and not worry about our mouths being clean is a mistake. Higher amounts of inflammation can develop in the mouth when people are under stress, when they are not able to visit their dentist on a regular basis as determined by the dentist. Some patients need to have their teeth cleaned three to four times per year or more because of their inflammatory conditions. In order for a virus to take hold, it needs a susceptible host. Some people will get it and some will not. The numbers of coronavirus infections are high, and the numbers of deaths, fortunately, are low; there are many people being exposed who are not getting sick. In my opinion, healthy oral conditions such as reduced inflammation and reduced biofilm likely have helped those people, along with clean noses and protected or healthy eyes. In the mouth, we need healthy saliva, and that comes from having a clean mouth, where biofilm is disrupted daily and where dental hygienists can do their jobs on a regular basis.

Inside Dental Hygiene
What sorts of preventive oral health measures specifically would you say are most important right now?

Joseph R. Greenberg, DMD
Flushing and washing. Many are saying we need to have our patients do pre-rinsing, but I am not convinced what the agent should be. Should it be peroxide? Should it be a diluted solution of bleach? Thomas Rams, DDS, MHS, PhD, at Temple University has shown in lectures that a diluted solution such as perhaps a 0.5 tsp to 1 tsp of bleach in a full glass of water is a way to kill bacterial invasions. There are no studies yet on the efficacy for COVID-19, but there likely will be.

Many of the solutions being offered are opinions, because while we prefer science based on randomized controlled clinical trials, we will not have those on the agents to kill or inactivate COVID-19 for some time. One potential solution I believe is promising is xylitol, a 5-carbon natural sugar that is used in some toothpastes, nasal sprays, and eye drops. Xylitol has been shown in some studies to inactivate viruses in the nasal passages, and it is a harmless product for humans to use. Xlear, a manufacturer of xylitol, has been working with Utah State Institute for Antiviral Research and has found that the combination of ingredients in Xlear Nasal Spray is as effective against SARS-CoV-2 at 90% ethanol is. If xylitol is proven to deactivate or kill the coronavirus that causes COVID-19 in the oral environment, then that could be very useful because we can apply it directly. Antibiotic treatment requires such a large dose to get through the blood and into the biofilm of the mouth; biofilm is very resistant to penetration. A dental hygienist or dentist, however, can disrupt it mechanically. Then, by applying a topical agent, we do not endanger the entire body by taking high doses of systemic drugs. Using local agents, whether xylitol or something else that proves to be safe and effective, is a much more intelligent, scientific way to combat this disease.

Inside Dental Hygiene
What impact could oral health education have, particularly on underserved communities?

Joseph R. Greenberg, DMD
Our at-risk communities have a higher death rate with COVID-19. Homeless people and poverty-stricken people do not have the ability to distance or the oral health literacy that higher socioeconomic people do. That is where we can really help, because the next wave—if there is one—could hit inner cities, areas of poverty, and third-world countries. We need to help those people, and we can. We have an opportunity to make such a significant impact on those people through oral health literacy and nutrition.

Inside Dental Hygiene
It sounds like the overall message is that we have all heard about the risk of transmission based on visiting the dental practice, but we are not hearing enough about how oral hygiene measures can help prevent the spread of the virus.

Joseph R. Greenberg, DMD
Absolutely. Dental hygienists want to serve their patients as well as possible, and they want to educate their patients. The hygienist has the time and focus to really help patients learn and raise their health literacy. It is a big mistake for some state officials to say that dental hygiene visits are nonessential. With a virus that spreads with oral contact, dental hygiene services are more important than ever.