How to practice veterinary medicine in a COVID-19 world is causing a lot of angst. Questions about dental procedures often top the list. Rightly so, since those are perhaps the highest risk type of procedure for SARS-CoV-2 exposure from animals. Dentistry involves close contact with the face and respiratory secretions, and the potential generation of aerosols.
Routine procedures of all kinds have largely been postponed in most areas because of the need to restrict in-clinic care to urgent cases due to potential COVID-19 risks. As we learn more about the likelihood of human-to-pet transmission (our surveillance study is moving along nicely now) and the dynamics of transmission in people, it will get easier to make informed decisions about how to control the risks. Ultimately, patient-side testing might be a useful approach, but it’s hard to say whether that’s going to be needed or even an option, and that doesn’t help us right now.
In times of uncertainly, I’d always rather be over-prepared, within reason. That means erring on the side of protection, rather than being a case report. We have very little data to work with, so we have to base our recommendations on common sense and reasonable guesses. As with pretty much all of our other advice, things may change. But, since I get asked about this so often, here are my thoughts and considerations around SARS-CoV-2 and veterinary dental procedures. (Remember I’m an internist, not a dentist! Dental colleagues should feel free to chime in and correct my blatant non-dentist errors and provide their thoughts.)
Is the patient at high risk for SARS-CoV-2 exposure?
Querying the pet’s likely exposure risk is a good first step. The potential presence of asymptomatic (human) infections in household contacts means that a lack of known exposure it not 100% protective, but if the pet does come from a household where COVID-19 is present, we know there’s some degree of increased risk. My concerns are also greater with cats vs dogs, since cats are likely at greater risk of infection, and infected cats maybe would have more virus present in respiratory secretions compared to infected dogs.
How long should a patient be considered high risk?
This is yet another area where we have very limited information. However, based on what we do know, it’s reasonable to estimate that the risk of a pet shedding the virus would be very low by 14 days after its last potential exposure. That means 14 days after the last infected person in the household is deemed non-infectious (often 10-14 days after the start of their illness) .
Does the patient have signs suggestive of SARS-CoV-2 infection?
Any acute unexplained onset of respiratory or GI disease in an exposed animal needs to be considered high risk. Lots of things can cause these problems but if there’s plausible exposure, we need to be wary of SARS-CoV-2. That would mean the risk to veterinary personnel would be even higher, and the threshold of urgency for doing any procedure would have to be quite high.
Can the patient be managed by telemedicine and medication?
No, we can’t extract a tooth over the phone. However, some patients might be manageable in the short term (a couple weeks) with analgesics and/or antibiotics (that’s the recommended approach in human dentistry in some regions). We don’t want to throw those drugs around unnecessarily (the demise of antimicrobial stewardship is a concern in human medicine with the focus on COVID-19), but there may be some cases in which we can delay the definitive treatment long enough that the patient is no longer a high risk to staff.
The patient is high risk and the procedure has to be done. How can we reduce the risk?
The first question is probably “should I handle the case?” If a clinic or clinician are not adequately equipped with PPE and are not comfortable handling the case, referral to a colleague or specialist who is is reasonable.
If the case will proceed, here are some considerations for reducing the risk of SARS-CoV-2 exposure:
- Minimize aerosol generating procedures. This might involve use of older techniques and manual instruments over instruments (e.g. burrs) that will aerosolize respiratory secretions. Think about every step, whether it’s needed and how it can be done the most efficiently.
- Consider staging the procedure. If the urgent aspect of the patient’s problem can be managed quicker and/or with less use of aerosol-generating techniques, consider taking care of that part to control pain and limit disease, with a plan to finish the job later. Yes, that requires another anesthesia and more cost, but if the best way to fix things involves lots of aerosol generation and that can be delayed, it may reduce the risks.
- Wear proper PPE. For an animal from a high-risk household, that means a gown, gloves, N95 respirator and eye protection. A surgical mask plus a face shield is probably an acceptable alternative to the respirator and eye protection, unless the animal has signs consistent with SARS-CoV-2 infection. However, the lower the level of PPE available, the more I’d want to limit the procedure and reduce aerosolization.
- Consider where the procedure will be performed. It’s ideally done in a closed area where aerosols are confined, and where potentially contaminated surfaces are easy to identify and disinfect. Movement into and out of the room should be minimized to limit airflow disruption. The area should be as free of other items as possible, so that there are fewer potentially contaminated surfaces to address when the procedure is done.
- Limit people in the area to essential personnel only. Make sure no other patients are in the aerosolization zone.
Hopefully we’ll learn more about the risks and the best ways to control them, and hopefully the risks are actually exceptionally low. We need to balance practicality, patient care and occupational health, and we’re trying to do that largely blindfolded at this time. A little common sense and basic infection control knowledge can go a long way, though.