A blueprint for recovery for the postcoronavirus (COVID-19) world.

Novel coronavirus (COVID‐19) is changing society. In the last several weeks, infections and deaths have accumulated, even as we attempt to “shelter in place” and stay “healthy at home.” This unprecedented time has influenced behavior and permitted much contemplation, gratitude, and prayer. Our thoughts during this time have focused on our emergence from the pandemic and what reopening may look like in the postcoronavirus world.

Reopening will benefit from the acronym “RPM,” an acronym I (CSM) teach my students for management of dental patients who suffer from a variety of illnesses and infections. Here, the “R” stands for risk assessment and reduction, the first step in the sequence. The “P” stands for prevention, and “M” stands for manage the problem. If “R” and “P” are well conceived and implemented, often there is no need to apply “M.”

“R” and “P” represent key aspects to success in the postcoronavirus world. In the United States, the federal government has rolled out a phased approach to reopening, (https://www.whitehouse.gov/wp‐content/uploads/2020/04/Guidelines‐for‐Opening‐Up‐America‐Again.pdf). Early in the process, industries that allow employees to telework from home and maintain social distancing can reopen. However, reopening the service industries and health professions creates unique challenges and opportunities. Dentistry, in particular, which places patients in close proximity to their providers and potentially other patients, and where inhalation of aerosolized droplets can occur, requires carefully crafted guidelines.

One opportunity for dentistry, during this key moment in time, is to develop controls and guidelines that focus on RPM. These guidelines are dependent on the presence/absence of effective diagnostic tests, vaccines, and anti‐viral agents. Assuming some of these will not be readily available and accessible worldwide before 2021, our goal is to reduce the spread of COVID‐19 during the interim by following a logical series of steps.

Communication is the first step. All patients should be contacted before their appointment and asked whether they (a) have been tested, (b) know their test results, (c) are feeling well or not, and have COVID‐19‐related symptoms. Persons experiencing symptoms or having a positive viral load test should be rescheduled to a later date. Those with a positive antibody test can be treated in a routine manner. Patients who do not know their infectivity status should be encouraged to be tested, and then directed to complete an online screening form within 24 hr of their dental appointment. This form assesses potential risk to contagious disease and must inquire about recent (a) exposures, (b) travel in the last 4 weeks, (c) virological testing, and (d) the presence of symptoms including, “Do you have a sore throat, cough, loss/change in smell or taste, shortness of breath, fever, chills, headaches, dizziness, fatigue, muscle or body aches, stomach pains or diarrhea?” “Do you cough more than twice per hour?” and “Can you take a deep breath without coughing?” Any positive responses should result in rescheduling of the patient.

Patients determined to be low risk for COVID‐19 exposure/infection are scheduled. At the portal of entry, patients should be wearing a facemask, or given one to wear, and have their temperatures taken. Ideally, this screening is done at the entry of the facility or in an area separate from treatment rooms. During all aspects of the visit, dental healthcare workers must wear appropriate personal protective equipment including face shields/goggles to protect corneal epithelium. Febrile patients are dismissed. Afebrile patients are rescreened, and those who are negative to all screening questions should be delivered directly to the treatment room to minimize interaction with others. If a patient must wait in the reception room, they should be given a facemask to wear, if not wearing one, and appropriate environmental controls implemented. Signs should be posted in the reception area that state “Cover Your Cough,” “Wash Your Hands,” and “Please Tell the Receptionist if You Have a Cough, Fatigue, Body Aches, or Fever.” Risk reduction is enhanced by social distancing—spacing chairs at least six feet apart. Transmission may be reduced by placing plexiglass between chairs, adding air purifiers that contain HEPA filters, and spraying disinfectant and wiping down surfaces at regular intervals.

Diagnostic testing is critical for identifying infected patients, especially since more than 50% of COVID‐19‐infected patients may be asymptomatic (Chow et al., 2020). However, there are several concerns with testing. Testing assesses antibodies and viral load (Cheng et al., 2020) and requires accuracy, accessibility, affordability, and timely results. Unfortunately, this information is not readily known for many of these tests, and availability of tests may be difficult.

For those who receive antibody testing and have COVID‐19 antibody positivity, dentists can provide care, if the patient reports a history of clearance of the virus/symptoms at least 30 days prior. However, a negative test result does not prevent a person from entering a congregant setting between testing and their dental appointment, making a negative test potentially invalid. In the absence of a vaccine, repeat testing or required quarantine after testing are options. However, quarantine is difficult to guarantee and enforce.

This is where rapid testing becomes important. Chairside tests based on either nasal swabs or saliva can provide important diagnostic information. COVID‐19 is present in saliva, and salivary load has a high correlation with the presence of COVID‐19 in nasal swabs (To et al., 2020; Wyllie et al., 2020), and has been reported to be present in saliva when not detected in pharyngeal and respiratory swabs (Azzi et al., 2020). In the setting where large numbers of individuals require screening, saliva would appear to provide a practical noninvasive method for determining infectivity that could be provided easily by dental healthcare workers. COVID‐19 testing by dentists is supported by the American Dental Association during this public health emergency (Burger, 2020), and dentists must use valid and reliable screening tests.

Later when a vaccine becomes available, dentists could become key administrators of the vaccine (Miller & Greenberg, 2018). In the meanwhile, another layer of prevention could come from reducing potential infectiousness of patients through the use of an antiseptic protocol. Here, preoperative mouth rinsing and nasal spraying with disinfectants such as 0.5% povidone‐iodine or other effective ingredients may prove beneficial (Meng, Hua, & Bian, 2020).

Clearly, reopening society in the postcoronavirus world will evolve as we make scientific advances in prevention, screening, testing, and treatments. Meanwhile, our emergence from this pandemic could benefit from applying the principles of RPM. Then, we can move onto asking, “What have we learned from this pandemic and our reactive behavior?”

CONFLICT OF INTEREST

None to declare.

AUTHOR CONTRIBUTIONS

Craig S. Miller: Conceptualization; Writing‐original draft; Writing‐review & editing. Charles R. Carlson: Conceptualization; Writing‐original draft; Writing‐review & editing.