The “day after” in Periodontology

EDITORIAL - July 02, 2020

Life has changed. Full stop.

Will we ever go back to our (old) lives?

Well, it is clear: “We’re living in unprecedented times” - the words we’ve thrown around and repeated so often in the recent months that they’ve become sort of a buzzword, a mantra, a kind of a repetitive conversational banality... However, the past months were everything but a banality…

As the founder of the Herald, what has riddled me was to understand in which way I could support the (increasing and lovely) community of our readers in these dire times. For the time being, I would like to share my thoughts on some specific milestones.

Milestone # 1. The pandemic frenzy

After a swift escalation, on the 9th of January 2020 the WHO declared the discovery of a new CoV, (first 2019-nCoV and then officially named SARS-CoV-2) which had never been identified in humans before. On the 11th of February, the respiratory disease deriving from SARS-CoV-2 infection was named COVID-19 (Lu et al. 2020, Mahase 2020). In the period of just a few weeks, a rapid and exponential growth of the virus diffusion brought the WHO to declare the status of a pandemic (with everyone searching their memory, trying to remember the last time the World had to face one?) Many, if not most, European countries at the time found themselves in lockdowns of different levels of restrictions, and the same was happening outside of the Old continent. And while living in the times of a pandemic sounds like a scenario from a movie, it was, and still is, our reality. Today, the general outlook surely seems brighter than just a few weeks ago, but does any of us feel comfortable enough to think or even dare to say that we are finally out of harm’s way?

Milestone #2. Living a risk: a new profession?

To say that in March an unexpected publication by The New York Times caused a commotion is an understatement. Ever since they declared that dentistry is the most dangerous profession due to the high risk of exposure to bioaerosol, all of the focus has been turned to us. 

No discussion: SARS-CoV-2 transmission mostly occurs through inhalation of airborne particles, which has undoubtedly been a favouring factor for the virus’ spread and subsequent global outbreak (del Rio & Malani, 2020). 

And yes: aerosol and airborne particles are indeed generated during dental procedures, so I must say that it comes as no surprise that Periodontology, in particular, is put right into the spotlight. Ultrasonic scaling, the basis of contemporary periodontology, is considered to be the main generator of dental aerosol. This is due to the contact between the ultrasonic tip with blood and saliva and the water used to avoid the heating of the tip and the ultrasonic handpiece, also favoured by the ultrasonic tip vibration (Rivera-Hidalgo, Barnes, & Harrel, 1999). Technologies such as air polishers are also capable of generating a significant amount of aerosol. Even though its reduction can be significantly achieved with aerosol reducing devices, the risk for virus diffusion cannot be eliminated (Muzzin, King, & Berry, 1999). This has led me, on behalf of the European project committee of the European Federation of Periodontology, to produce important safety protocol infographics with critical suggestions.

We need to limit aerosol. We have been told this a gazillion of times in the last two months. Given all of this, the elephant in the room is clear: can we go fully manual? Do we swap our machine-driven instruments with hand instruments? Our Neshat Zolekhapur gave this issue a delightful and fresh perspective in her column “Did you know that…?”, to which I would like you to give a look and your comment.


Milestone #3. The “new normal” in dentistry

Dentistry is not only about mastery and dexterity. In fact, what you do with your hands is just a specific element within the entire process which should be led by stringent (in the best of the cases...) organisation. 

Our group has tried from the very beginning to define some possible actions that should serve as the base for practising dentistry in complex times like these - and what an experiential whirlwind that was… amid Italy’s lockdown, all of my research group members separated, working day and night, meeting on Zoom at unholy hours... 

The results of this fantastic rush determined firstly a paper on measures of professional prevention in the dental setting, the first one authored outside of China, produced and published in the matter of a mere few weeks. 

Most importantly, we tried to encapsulate all the available knowledge on COVID-19 and dentistry in an ebook, available for free, dedicated to the dental community, which I would love for you to download and give feedback on (

Among all the good practices that we can put in place, one has a particular relevance as both patients and professionals share it: hand washing. Hand hygiene, the most effective method of decreasing the risk of the transmission of COVID-19, has been scrutinised by Larisa Musić in the A Periodontist’s Notebook column: a fascinating piece on this practice that, as you will find out, does not have a very long history.

Milestone #4. Our periodontal patients and the lockdown 

The pandemic has not been easy for any of us, nor our patients. In fact, one phenomenon we are witnessing in some of our patients is a significant deterioration in their periodontal status 

This might be due to several factors related to both the higher bacterial burden and the alteration of our defence mechanisms. 

Let me focus on the bacteriological aspect first. Supportive phase is a fundamental part of periodontal treatment care and as such, cannot be excluded. For nearly two months, we haven’t been able to provide support and maintenance, and this, especially in patients at high risk, could prove to be detrimental. Very much related to this is, indeed, a paper that my Cristiano, Prof Tomasi, deconstructed in this issue’s of Periocampus Journal Club. Another fundamental perio study for all studious perio minds!

But the problem does not only lie in the amount of plaque. Life routines have been entirely messed up, and thus smokers have smoked more, and the fridge has been opened too frequently. 

Moreover, the lack of physical activity and the social isolation determined a higher level of general inflammation which may be associated with a higher tendency of alteration of the oral health.

This is why it is so crucial to restore that bond among us, the professionals, and our perio patients. Therefore communication is at the forefront of this comeback. A modality of care we need to provide to our patients is remotivation and reinforcement of healthy behaviours. You may thus find the article of Sofia Drivas focused on Motivational Interviewing for behaviour changes in the dental practice particularly insightful - make sure to check her column Changing the patient. 

I would also care to mention the article by Victoria Wilson, the mind behind the “Exploring communication”. Victoria tackled the issue of the importance of oral health promotion, seeing this as an opportunity to both incorporate it in the dental practice, but also extend it wider, beyond it.

Milestone #5. Today and tomorrow 

We need to move on. We need to readjust, rethink and most importantly, we need to act. Being myself a glass-half-full-ist, I see this challenge as an opportunity to design a better Periodontology and dentistry, but most importantly, as an opportunity for redefining the human connection. And bearing in mind the importance of human connection, I’m pleased to announce the new collaborative column, starting in this issue: Women Implantology Network, presenting the exciting new idea of creating an essential network of talent and solidarity.

We should not allow the fear of the uncertainties and the unknown to repress the atmosphere that is buzzing with excitement. Instead, we should accept the change and the transformation of our life and work to the new situation. 

Give it a thought, when have in recent times human beings had the chance and the opportunity to rethink and reimagine how to connect, to work and to be a caring society?

Life has changed. Full stop.

How good is that?

Literature and suggested reads:

del Rio, C., & Malani, P. N. (2020). 2019 Novel Coronavirus—Important Information for Clinicians. JAMA, 323(11), 1039. 

Izzetti, R., Nisi, M., Gabriele, M., & Graziani, F. (2020). COVID-19 Transmission in Dental Practice: Brief Review of Preventive Measures in Italy. Journal of Dental Research. 

Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, Wang W, Song H, Huang B, Zhu N, et al. (2020) Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 395(10224):565–574. 

Mahase E (2020) China coronavirus: WHO declares international emergency as death toll exceeds 200. British Medical Journal, 368:m408. 

Muzzin, K. B., King, T. B., & Berry, C. W. (1999). Assessing the clinical effectiveness of an aerosol reduction device for the air polisher. Journal of the American Dental Association, 130(9), 1354–1359. 

Rivera-Hidalgo, F., Barnes, J. B., & Harrel, S. K. (1999). Aerosol and Splatter Production by Focused Spray and Standard Ultrasonic Inserts. Journal of Periodontology, 70(5), 473–477. 

van Doremalen, N., Bushmaker, T., Morris, D. H., Holbrook, M. G., Gamble, A., Williamson, B. N., … Munster, V. J. (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine, NEJMc2004973.