Aerosol generating procedural risks and concomitant mitigation strategies in orthodontics amid COVID-19 pandemic – An updated evidence-based review

IMPORTANCE: The ongoing COVID-19 pandemic has posed unique challenges to orthodontic profession by adversely impacting provision of in-office orthodontic care due to prevailing uncertainty around risks pertaining to splatter and ‘aerosol-generating procedures’ (AGPs). This review aims to provide an insight into the prevailing and emerging evidence informing potential risks related to splatter and AGPs, and risk mitigation strategies employed for reducing the potential risk of SARS-CoV-2 transmission from dental bioaerosols. METHODS: PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, LILACS, WHO COVID-19 databases and preprint databases were searched for eligible English language publications. Citation chasing was undertaken up until the review date of 4 January 2021. Study selection, data extraction and risk of bias assessment was undertaken independently in duplicate, or else by consultation with a third author. RESULTS: Following filter application and duplicates removed, a total of 13 articles assessing procedural mitigation measures were included. Seven included studies revealed overall low-risk of bias. The overall risk varied from unclear to high for rest of the studies, with the most concerning domains being blinding of the participants and the personnel and blinding of the outcome assessors. Accumulated consensual evidence points towards the use of dental suction devices with wide bore aspirating tips as effective procedural mitigation strategies. Variations in the literature can be observed concerning aerosol transmission associated with water spray use during debonding. Emerging direct evidence consistently supports adjunctive use of pre-procedural povidone-iodine mouthrinse to mitigate direct transmission risk in the orthodontic practice. CONCLUSIONS: A thorough risk assessment concerning AGPs and implementation of consistent and evidence-based procedural mitigation strategies may play an indispensable role in navigating optimal orthodontic practice through unforeseen similar pandemic threats. High-quality robust research focussing on more biologically relevant models of dental bioaerosols in orthodontic settings is warranted.