tic tool to detect the virus they found “SARS-CoV-2 was detected in all 25 patients’ first salivary swab, …” 7 The authors even noted that a positive salivary test occurred simultaneously as a negative nasopharyngeal test. 7 In another study of oropharyngeal sampling for COVID-19, To et al aimed to “ascertain the serial respira-tory viral load of SARS-CoV-2 in posterior oropharyngeal (deep throat) saliva samples from patients with COVID-19, and serum antibody responses.” 8 They found in 23 subjects that “salivary viral load was highest during the first week after symptom onset and subsequently declined with time…” Additionally, “In one patient, viral RNA was detected 25 days after symptom onset.” In another study by To et al, COVID-19 “was detected in the initial saliva specimens of 11 patients (91.7%).” 9 As such, saliva is potential source of infection of COVID-19. COVID-19 may be spread by airborne transmission. The report by the WHO also states "To the best of our understanding, the virus is primarily spread through contact and respiratory droplets, but there are still many unanswered questions around airborne transmission and more studies are urgently needed." 10 This is because COVID19 may be expelled during breathing, speaking, sneezing and coughing. 12 This assumption is based upon studies of other respiratory viral illnesses. For example, an editorial by Asadi et al stated “Recent work on influenza (another viral respira-tory disease) has established that viable virus can indeed be emitted from an infected individual by breathing or speaking, without coughing or sneez-ing.” 13 The WHO also stated that “Transmission of SARS-CoV-2 can occur through direct, indirect, or close contact with infected people through infected secre-tions such as saliva and respiratory secretions or their respiratory droplets, which are expelled when an infected person coughs, sneezes, talks or sings.” 10 COVID-19 infected persons who have symptoms may transmit the disease through droplets and close contact. The spread of SARS-CoV-2 is mostly attributed to respiratory expelled droplets. According to a report by the World Health Organization (WHO) in July 2020, “SARS-CoV-2 transmission appears to mainly be spread via droplets and close contact with infected symptomatic cases. In an analysis of 75,465 COVID-19 cases in China, 78-85% of clusters occurred within household settings, suggesting that transmission occurs during close and prolonged contact.” 10 Regarding close contact transmission, the WHO also stated “Outside of the household setting, those who had close physical contact, shared meals, or were in enclosed spaces for approximately one hour or more with symp-tomatic cases, such as in places of worship, gyms, or the workplace, were also at increased risk of infection.” 10 A typical dental appointment ranges between thirty to sixty minutes of close contact between patients and dental personnel within an enclosed space. Aerosol is a concern for the spread of respiratory infectious diseases. According to Judson et al, “Aerosols are particles suspended in air that can contain a variety of pathogens, including viruses, and there is ongoing debate about how to classify them. Many divide aerosols into the categories of small droplets (which some exclusively call aerosols) and large droplets, with small droplets having the potential to desiccate and form droplet nuclei that travel long distances, while large droplets do not evapo-rate before settling on surfaces.” 14 Although the evidence was theoretical and based upon mathematical models, earlier studies and articles that focused on the influenza virus demonstrated the potential for transmis-sion through droplets. 15 In a retrospective cohort based study, Fowler et al, examined the potential for nosocomial infections from endotracheal intubation of COVID-19 positive patients. They stated, “Nurses and physicians who directly partici-pated in endotracheal intubation had a dramatically increased risk of subsequently developing SARS.” 16 COVID-19 infected persons without symptoms may also transmit the disease. The WHO report also stated that “Early data from China suggested that people without symptoms could infect others.” 10 The report continued by stating “Multi-ple studies have shown that people infect others before they themselves became ill, which is supported by avail-able viral shedding data. One study of transmission in Singapore reported that 6.4% of secondary cases resulted from pre-symptomatic transmission. 10 One article referenced a report of an outbreak in a nursing home: “An important finding of this report is that more than half the residents of this skilled nurs-ing facility (27 of 48) who had positive tests were asymptomatic at testing. Moreover, live coronavirus clearly sheds at high concentrations from the nasal cavity even before symptom development.” 11 The authors continued “Asymptomatic transmission of SARS-CoV-2 is the Achilles’ heel of COVID-19 pandemic control through the public health strategies we have currently deployed.” 11 Children and special needs adults may especially expel the virus when crying or yelling and may not adhere to prevention protocols such as mask wearing. There is widespread acceptance of the airborne spread of coronavirus. 12 Children and special needs adults may expel COVID-19 virus at potentially greater levels if they are crying, expectorating, sniffling and coughing in an agitated state. Pediatric dentists are trained to provide care for children and adults with special healthcare needs, who often require additional care to ensure their treatment is safe and effective. Many of these patients are at increased risk of complications from COVID-19. The CDC states that “people with developmental or behav-ioral disorders who have serious underlying medical conditions may be at risk of serious illness.” 17 Therefore, 32 Spring 2021 JAOS
Journal of the American Orthodontic Society Spring 2021: Page 32
