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What the dental community has learned from COVID-19

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Prof. Nagihan Bostanci from the Department of Dental Medicine at Karolinska Institutet in Stockholm in Sweden. (Image: EFP)

The dental profession was hit hard by COVID-19, and there was great uncertainty about how to properly manage patient care at the start of the pandemic. Now that some research has been done, experts at EuroPerio10, held on 15–18 June in Copenhagen in Denmark, reviewed what the dental community has learned. In this interview, Prof. Nagihan Bostanci from the Department of Dental Medicine at Karolinska Institutet in Stockholm in Sweden, who chaired the session, shared some insights about the link between periodontics and COVID-19, as well as systemic diseases such as rheumatoid arthritis (RA).

Prof. Bostanci, with regard to clinical practice, what is the most important insight you and your session speakers have gained from the pandemic?
We all agree that the COVID-19 pandemic has generated several challenges for oral health professionals and for those studying dentistry across the world, but has also presented us with new opportunities.

All dental professionals were uniquely challenged to provide safe and effective patient care during the pandemic. An important lesson was that dental aerosols were not as great a risk as we thought. It is quite likely that the initially higher risk of exposure for dental care professionals was caused by close proximity consultations with patients without oral health professionals wearing  type RII masks. Once those masks were worn as part of the enhanced personal protective equipment protocols, there was clear evidence that incidence rates for new infections in dental care professionals dropped to background population levels. Therefore, we need to continue with these masks during face-to-face consultations, despite wearing a mask hindering trying to build a rapport with the patient.

The experts of the EuroPerio10 session. From left: Prof. Purnima Kumar, Prof. Saso Ivanovski and Prof. Iain Chapple. (Image: DTI)

With regard to periodontitis and COVID-19, it is clear that the human oral cavity is prone to viral infection. Now there is evidence that SARS-CoV-2 can infect the gingiva and replicate itself in the tissue, likely transmitting the virus through the oral mucosa to other parts of the gastrointestinal tract. As saliva can also be a reservoir for SARS-CoV-2, any breach in the immune defence of the oral cavity may facilitate entrance of the virus to the vasculature through the gingival sulcus or periodontal pocket. Thus, a possible association between COVID-19 and periodontitis has been hypothesised. There is some evidence of an increased risk of COVID-19 complications in patients with a history of periodontitis. Therefore, it is suggested that daily oral hygiene and oral healthcare should be prioritised, as such measures could be potentially lifesaving for COVID-19 patients.

Regarding the new opportunities created by the pandemic, salivary diagnostics has emerged as an important testing option for COVID-19, given the importance of the mouth as a site of infection by SARS-CoV-2. Saliva has great potential in non-invasive chair diagnostics for both oral health and general health screenings.

The convergence of oral and systemic health requires the constructive synergy of various health- and technology-related disciplines

In another EuroPerio10 session on the association of periodontal disease with systemic disorders, you spoke about the link between RA and periodontitis. Could you provide a brief background to your study of this topic?
Over the last two decades, aided by the advent of technologies that provided a more holistic understanding of the microbiological and immunological factors underlying periodontitis, there has been an increasing body of evidence associating periodontitis with various systemic conditions, including RA. Several investigations have suggested that periodontal pathogens such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans are able to generate microbial and host-derived citrullinated peptides, which are the hallmark of RA autoimmunity.

It is fascinating that the link between a dysfunctional oral microbiota and RA was already reported in 460 bc by Hippocrates, who observed empirically that extracting diseased teeth helped cure arthritis! Nowadays, we have the scientific tools to better approach this relationship, to better understand the aetiology of RA and to ultimately propose improved prevention strategies and early diagnosis to patients.

Do you have any specific guidance for clinicians seeking to provide improved care for patients with one or both of these conditions?
I would recommend to oral health specialists to systematically check for cases of RA in their patients’ first-degree relatives when taking their medical history. This way, they can detect an accumulation of risk factors at an early stage, that is, identify a genetic background that is prone to the development of RA. They can then suggest appropriate periodontal treatment and possibly recommend a visit to the rheumatologist to address other risk factors, such as smoking. Conversely, it may be beneficial for rheumatologists treating at-risk or affected patients to suggest a visit to the dentist to assess periodontal health status and to avoid potentially cumulative risk factors, that is, to rule out the co-occurrence of periodontitis.

Given the increasing number of links being found between oral health and general health, do you think that the role of dentists in the healthcare system needs to be adapted?
It has long been recognised that oral health is the mirror of general health. We definitely need to move towards integrated care, meaning that oral health should be an integral part of primary healthcare. The significance of such an inter-sectoral approach has already been identified by the World Health Organization and the European Federation of Periodontology. The convergence of oral and systemic health requires the constructive synergy of various health- and technology-related disciplines.

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