Precautions and recommendations for orthodontic settings during the COVID-19 outbreak: A review

  • Khadijah A. Turkistani
    Address correspondence to: Khadijah A. Turkistani, Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, PO Box 80209, Jeddah 21589, Saudi Arabia.
    Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
    Search for articles by this author


      • Coronavirus disease 2019 is a highly contagious global pandemic.
      • It could transmit by asymptomatic carriers via person-to-person contact, aerosol, and droplets.
      • Strict infection control and aerosol containment are required in orthodontic settings.


      Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2). It emerged as a global pandemic in early 2020, affecting more than 200 countries and territories. The infection is highly contagious, with disease transmission reported from asymptomatic carriers, including children. It spreads through person-to-person contact via aerosol and droplets. The practice of social distancing—maintaining a distance of 1-2 m or 6 ft—between people has been recommended widely to slow or halt the spread. In orthodontics, this distance is difficult to maintain, which places orthodontists at a high risk of acquiring and transmitting the infection. The objective of this review is to report to orthodontists on the emergence, epidemiology, risks, and precautions during the disease crisis. This review should help increase awareness, reinforce infection control, and prevent cross-transmission within the orthodontic facility.


      A comprehensive literature review of English and non-English articles was performed in March 2020 using COVID-19 Open Research Dataset (CORD-19 2020), PubMed, MEDLINE, Scopus, and Google Scholar to search for infection control and disease transmission in orthodontics.


      This review emphasizes minimizing aerosol production and reinforcing strict infection control measures. Compliance with the highest level of personal protection and restriction of treatment to emergency cases is recommended during the outbreak. Surface disinfection, adequate ventilation, and decontamination of instruments and supplies following the guidelines are required.


      Reinforcing strict infection control measures and minimizing personal contact and aerosol production are keys to prevent contamination within orthodontic settings. Although no cases of COVID-19 cross-transmission within a dental facility have been reported, the risk exists, and the disease is still emerging. Further studies are required.
      To read this article in full you will need to make a payment


        • Zhou P.
        • Yang X.L.
        • Wang X.G.
        • Hu B.
        • Zhang L.
        • Zhang W.
        • et al.
        A pneumonia outbreak associated with a new coronavirus of probable bat origin.
        Nature. 2020; 579: 270-273
        • Peng X.
        • Xu X.
        • Li Y.
        • Cheng L.
        • Zhou X.
        • Ren B.
        Transmission routes of 2019-nCoV and controls in dental practice.
        Int J Oral Sci. 2020; 12: 9
        • Gorbalenya A.E.
        • Baker S.C.
        • Baric R.S.
        • de Groot R.J.
        • Drosten C.
        • Gulyaeva A.A.
        • et al.
        The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2.
        Nat Microbiol. 2020; 5: 536-544
        • World Health Organization
        Novel coronavirus (2019-nCoV): situation report-11.
        (Available at:)
        • Chan J.F.W.
        • Yuan S.
        • Kok K.H.
        • To K.K.W.
        • Chu H.
        • Yang J.
        • et al.
        A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.
        Lancet. 2020; 395: 514-523
        • Ge Z.Y.
        • Yang L.M.
        • Xia J.J.
        • Fu X.H.
        • Zhang Y.Z.
        Possible aerosol transmission of COVID-19 and special precautions in dentistry.
        J Zhejiang Univ Sci B. 2020; : 1-8
        • World Health Organization
        Coronavirus disease 2019 (COVID-19): situation report-51.
        (Available at:)
        • World Health Organization
        Coronavirus disease 2019 (COVID-19): situation report-70.
        (Available at:)
        • World Health Organization
        Coronavirus disease 2019 (COVID-19): situation report-65.
        (Available at:)
        • Guan W.J.
        • Ni Z.Y.
        • Hu Y.
        • Liang W.H.
        • Ou C.Q.
        • He J.X.
        • et al.
        Clinical characteristics of coronavirus disease 2019 in China.
        N Engl J Med. 2020; 382: 1708-1720
        • Chen N.
        • Zhou M.
        • Dong X.
        • Qu J.
        • Gong F.
        • Han Y.
        • et al.
        Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.
        Lancet. 2020; 395: 507-513
        • Hassan S.A.
        • Sheikh F.N.
        • Jamal S.
        • Ezeh J.K.
        • Akhtar A.
        Coronavirus (COVID-19): a review of clinical features, diagnosis, and treatment.
        Cureus. 2020; 12: e7355
        • Wang J.
        • Zhou M.
        • Liu F.
        Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China.
        J Hosp Infect. 2020; 105: 100-101
        • Rothe C.
        • Schunk M.
        • Sothmann P.
        • Bretzel G.
        • Froeschl G.
        • Wallrauch C.
        • et al.
        Transmission of 2019-nCoV infection from an asymptomatic contact in Germany.
        N Engl J Med. 2020; 382: 970-971
        • Lu X.
        • Zhang L.
        • Du H.
        • Zhang J.
        • Li Y.Y.
        • Qu J.
        • et al.
        SARS-CoV-2 infection in children.
        N Engl J Med. 2020; 382: 1663-1665
        • Jin Y.H.
        • Cai L.
        • Cheng Z.S.
        • Cheng H.
        • Deng T.
        • Fan Y.P.
        • et al.
        A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).
        Mil Med Res. 2020; 7: 4
      1. COVID-19 open research dataset (CORD-19).
        (Available at:)
        • Leggat P.A.
        • Kedjarune U.
        • Smith D.R.
        Occupational health problems in modern dentistry: a review.
        Ind Health. 2007; 45: 611-621
        • Oshagh M.
        • Hematiyan M.R.
        • Mohandes Y.
        • Oshagh M.R.
        • Pishbin L.
        Autoclaving and clinical recycling: effects on mechanical properties of orthodontic wires.
        Indian J Dent Res. 2012; 23: 638-642
        • Klevens R.M.
        • Moorman A.C.
        Hepatitis C virus: an overview for dental health care providers.
        J Am Dent Assoc. 2013; 144: 1340-1347
        • Radcliffe R.A.
        • Bixler D.
        • Moorman A.
        • Hogan V.A.
        • Greenfield V.S.
        • Gaviria D.M.
        • et al.
        Hepatitis B virus transmissions associated with a portable dental clinic, West Virginia, 2009.
        J Am Dent Assoc. 2013; 144: 1110-1118
        • Redd J.T.
        • Baumbach J.
        • Kohn W.
        • Nainan O.
        • Khristova M.
        • Williams I.
        Patient-to-patient transmission of hepatitis B virus associated with oral surgery.
        J Infect Dis. 2007; 195: 1311-1314
        • Younai F.S.
        Health care-associated transmission of hepatitis B & C viruses in dental care (dentistry).
        Clin Liver Dis. 2010; 14 (ix): 93-104
        • Feldman R.E.
        • Schiff E.R.
        Hepatitis in dental professionals.
        JAMA. 1975; 232: 1228-1230
        • Starnbach H.
        • Biddle P.
        A pragmatic approach to asepsis in the orthodontic office.
        Angle Orthod. 1980; 50: 63-66
        • Lawrence A.J.
        • Mordecai R.M.
        Health and safety at work in orthodontic practice—part II.
        Br J Orthod. 1994; 21: 216-220
        • Meng L.
        • Hua F.
        • Bian Z.
        Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine.
        J Dent Res. 2020; 99: 481-487
        • To K.K.W.
        • Tsang O.T.Y.
        • Yip C.C.Y.
        • Chan K.H.
        • Wu T.C.
        • Chan J.M.C.
        • et al.
        Consistent detection of 2019 novel coronavirus in saliva.
        Clin Infect Dis. 2020; 149: 1-3
        • Gu J.
        • Han B.
        • Wang J.
        COVID-19: gastrointestinal manifestations and potential fecal-oral transmission.
        Gastroenterology. 2020; 158: 1518-1519
        • Xu H.
        • Zhong L.
        • Deng J.
        • Peng J.
        • Dan H.
        • Zeng X.
        • et al.
        High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa.
        Int J Oral Sci. 2020; 12: 8
        • Micik R.E.
        • Miller R.L.
        • Mazzarella M.A.
        • Ryge G.
        Studies on dental aerobiology. I. Bacterial aerosols generated during dental procedures.
        J Dent Res. 1969; 48: 49-56
        • Holloman J.L.
        • Mauriello S.M.
        • Pimenta L.
        • Arnold R.R.
        Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling.
        J Am Dent Assoc. 2015; 146: 27-33
        • Barnes J.B.
        • Harrel S.K.
        • Rivera-Hidalgo F.
        Blood contamination of the aerosols produced by in vivo use of ultrasonic scalers.
        J Periodontol. 1998; 69: 434-438
        • Rautemaa R.
        • Nordberg A.
        • Wuolijoki-Saaristo K.
        • Meurman J.H.
        Bacterial aerosols in dental practice - a potential hospital infection problem?.
        J Hosp Infect. 2006; 64: 76-81
        • Bentley C.D.
        • Burkhart N.W.
        • Crawford J.J.
        Evaluating spatter and aerosol contamination during dental procedures.
        J Am Dent Assoc. 1994; 125: 579-584
        • Huntley D.E.
        • Campbell J.
        Bacterial contamination of scrub jackets during dental hygiene procedures.
        J Dent Hyg. 1998; 72: 19-23
        • Ricci M.L.
        • Fontana S.
        • Pinci F.
        • Fiumana E.
        • Pedna M.F.
        • Farolfi P.
        • et al.
        Pneumonia associated with a dental unit waterline.
        Lancet. 2012; 379: 684
        • Harrel S.K.
        • Molinari J.
        Aerosols and splatter in dentistry: a brief review of the literature and infection control implications.
        J Am Dent Assoc. 2004; 135: 429-437
        • Crotty O.P.
        • Davies E.H.
        • Jones S.P.
        The effects of cross-infection control procedures on the tensile and flextural properties of superelastic nickel-titanium wires.
        Br J Orthod. 1996; 23: 37-41
        • Pernier C.
        • Grosgogeat B.
        • Ponsonnet L.
        • Benay G.
        • Lissac M.
        Influence of autoclave sterilization on the surface parameters and mechanical properties of six orthodontic wires.
        Eur J Orthod. 2005; 27: 72-81
        • Irfan S.
        • Irfan S.
        • Fida M.
        • Ahmad I.
        Contamination assessment of orthodontic bands after different pre-cleaning methods at a tertiary care hospital.
        J Orthod. 2019; 46: 220-224
        • Pithon M.M.
        • Ferraz C.S.
        • Rosa F.C.S.
        • Rosa L.P.
        Sterilizing elastomeric chains without losing mechanical properties. Is it possible?.
        Dental Press J Orthod. 2015; 20: 96-100
        • Omidkhoda M.
        • Rashed R.
        • Bagheri Z.
        • Ghazvini K.
        • Shafaee H.
        Comparison of three different sterilization and disinfection methods on orthodontic markers.
        J Orthod Sci. 2016; 5: 14-17
        • Coley-Smith A.
        • Rock W.P.
        Bracket recycling–who does what?.
        Br J Orthod. 1997; 24: 172-174
        • Machen D.E.
        Orthodontic bracket recycling.
        Am J Orthod Dentofacial Orthop. 1993; 104: 618-619
        • Guo H.
        • Zhou Y.
        • Liu X.
        • Tan J.
        The impact of the COVID-19 epidemic on the utilization of emergency dental services.
        J Dent Sci. 2020; ([Epub ahead of print])
        • Li Z.Y.
        • Meng L.Y.
        The prevention and control of a new coronavirus infection in department of stomatology [in Chinese].
        Zhonghua Kou Qiang Yi Xue Za Zhi. 2020; 55: E001
        • Zhang W.
        • Jiang X.
        Measures and suggestions for the prevention and control of the novel coronavirus in dental institutions.
        Front Oral Maxillofac Med. 2020; 2: 4
        • Marui V.C.
        • Souto M.L.S.
        • Rovai E.S.
        • Romito G.A.
        • Chambrone L.
        • Pannuti C.M.
        Efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review.
        J Am Dent Assoc. 2019; 150: 1015-10126.e1
        • Tang H.S.
        • Yao Z.Q.
        • Wang W.M.
        Emergency management of prevention and control of the novel coronavirus infection in departments of stomatology.
        Zhonghua Kou Qiang Yi Xue Za Zhi. 2020; 55 ([in Chinese]): 246-248
        • Lu C.W.
        • Liu X.F.
        • Jia Z.F.
        2019-nCoV transmission through the ocular surface must not be ignored.
        Lancet. 2020; 395: e39
        • Chang D.
        • Xu H.
        • Rebaza A.
        • Sharma L.
        • Cruz C.S.D.
        Protecting health-care workers from subclinical coronavirus infection.
        Lancet Respir Med. 2020; 8: e13
        • World Health Organization
        WHO guidelines on hand hygiene in health care.
        (Available at:)
        • Dutil S.
        • Meriaux A.
        • de Latremoille M.C.
        • Lazure L.
        • Barbeau J.
        • Duchaine C.
        Measurement of airborne bacteria and endotoxin generated during dental cleaning.
        J Occup Environ Hyg. 2009; 6: 121-130
        • van Doremalen N.
        • Bushmaker T.
        • Morris D.H.
        • Holbrook M.G.
        • Gamble A.
        • Williamson B.N.
        • et al.
        Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.
        N Engl J Med. 2020; 382: 1564-1567
        • Shah R.
        • Collins J.M.
        • Hodge T.M.
        • Laing E.R.
        A national study of cross infection control: ‘are we clean enough?.
        Br Dent J. 2009; 207: 267-274
        • World Health Organization
        Safe management of wastes from health-care activities: a summary.
        (Available at:)
        • Carvalho M.R.
        • dos Santos da Silva M.A.
        • de Sousa Brito C.A.
        • Campelo V.
        • Kuga M.C.
        • Tonetto M.R.
        • et al.
        Comparison of antimicrobial activity between chemical disinfectants on contaminated orthodontic pliers.
        J Contemp Dent Pract. 2015; 16: 619-623
        • Papaioannou A.
        A review of sterilization, packaging and storage considerations for orthodontic pliers.
        Int J Orthod Milwaukee. 2013; 24: 19-21
        • Vendrell R.J.
        • Hayden C.L.
        • Taloumis L.J.
        Effect of steam versus dry-heat sterilization on the wear of orthodontic ligature-cutting pliers.
        Am J Orthod Dentofacial Orthop. 2002; 121: 467-471
        • Hohlt W.F.
        • Miller C.H.
        • Neeb J.M.
        • Sheldrake M.A.
        Sterilization of orthodontic instruments and bands in cassettes.
        Am J Orthod Dentofacial Orthop. 1990; 98: 411-416
        • Lall R.
        • Sahu A.
        • Jaiswal A.
        • Kite S.
        • Sowmya A.R.
        • Sainath M.C.
        Evaluation of various sterilization processes of orthodontic instruments using biological indicators and conventional swab test method: a comparative study.
        J Contemp Dent Pract. 2018; 19: 698-703
        • Wichelhaus A.
        • Bader F.
        • Sander F.G.
        • Krieger D.
        • Mertens T.
        Effective disinfection of orthodontic pliers.
        J Orofac Orthop. 2006; 67: 316-336
        • Mousavi S.M.
        • Hormozi E.
        • Moradi M.
        • Shamohammadi M.
        • Rakhshan V.
        Effects of autoclaving versus cold chemical (glutaraldehyde) sterilization on load-deflection characteristics of aesthetic coated archwires.
        Int Orthod. 2018; 16: 281-293
        • Brindha M.
        • Kumaran N.K.
        • Rajasigamani K.
        Evaluation of tensile strength and surface topography of orthodontic wires after infection control procedures: an in vitro study.
        J Pharm Bioallied Sci. 2014; 6: S44-S48
        • Ascencio F.
        • Langkamp H.H.
        • Agarwal S.
        • Petrone J.A.
        • Piesco N.P.
        Orthodontic marking pencils: a potential source of cross-contamination.
        J Clin Orthod. 1998; 32: 307-310
        • Benson P.E.
        • Ebhohimen A.
        • Douglas I.
        The cleaning of photographic retractors; a survey, clinical and laboratory study.
        Br Dent J. 2010; 208 (discussion 306-307): E14
        • Sheriteh Z.
        • Hassan T.
        • Sherriff M.
        • Cobourne M.
        • Riley P.
        Decontamination of viable Streptococcus mutans from orthodontic tungsten carbide debonding burs. An in vitro microbiological study.
        J Orthod. 2010; 37: 181-187
        • Rerhrhaye W.
        • Ouaki B.
        • Zaoui F.
        • Aalloula E.
        The effect of autoclave sterilization on the surface properties of orthodontic brackets after fitting in the mouth.
        Odontostomatol Trop. 2011; 34: 29-34
        • Fulford M.R.
        • Ireland A.J.
        • Main B.G.
        Decontamination of tried - in orthodontic molar bands.
        Eur J Orthod. 2003; 25: 621-622
        • Akyalcin S.
        • McIver H.P.
        • English J.D.
        • Ontiveros J.C.
        • Gallerano R.L.
        Effects of repeated sterilization cycles on primary stability of orthodontic mini-screws.
        Angle Orthod. 2013; 83: 674-679
        • Chate R.A.
        An audit improves the quality of water within the dental unit water lines of general dental practices across the East of England.
        Br Dent J. 2010; 209: E11
        • Chate R.A.
        An audit improves the quality of water within the dental unit water lines of three separate facilities of a United Kingdom NHS trust.
        Br Dent J. 2006; 201: 565-569

      Linked Article

      • COVID-19 precautions and recommendations
        American Journal of Orthodontics and Dentofacial OrthopedicsVol. 158Issue 3
        • Preview
          We read with great interest the recent article by Turkistani (Turkistani KA. Precautions and recommendations for orthodontic settings during the COVID-19 outbreak. Am J Orthod Dentofacial Orthop 2020;158:175-81). Because of challenges imposed by the current coronavirus disease 2019 (COVID-19) pandemic on the world, we are all trying to maintain balance in a clinical and academic environment of unpredictability and uncertainty. We would like to emphasize and discuss the possible approaches for clinical care in the extended period of COVID-19 crisis and beyond:This will be done by the development of low cost intraoral scanner to take a digital impression, development of freely available robust software for 3D treatment planning for aligner therapy, and low cost 3D printers with accuracy to print sequential treatment model for thermoforming to integrate aligner orthodontic therapy not only in university-based teaching institutions but also in small to medium size orthodontic offices.
        • Full-Text
        • PDF
      • Virucidal mouth rinses for patients during the coronavirus disease 2019 outbreak
        American Journal of Orthodontics and Dentofacial OrthopedicsVol. 159Issue 6
        • Preview
          We congratulate Dr Turkistani for the well-elucidated precautions and recommendations for orthodontic settings during the coronavirus disease 2019 pandemic (Turkistani KA. Precautions and recommendations for orthodontic settings during the COVID-19 outbreak: a review. Am J Orthod Dentofacial Orthop 2020;158:175-81). Representing a second layer of defense, prophylactic preprocedural use of oxidative mouth rinse and throat spray formulations have been suggested as an indispensable risk reduction measure for decreasing the number of viable microorganisms in dental aerosols during the current outbreak.
        • Full-Text
        • PDF
      • Supplementary precautions
        American Journal of Orthodontics and Dentofacial OrthopedicsVol. 158Issue 5
        • Preview
          We read with great interest the recent article by Khadijah A. Turkistani published online in May 2020 (Turkistani KA. Precautions and recommendations for orthodontic settings during the COVID-19 outbreak: a review. Am J Orthod Dentofacial Orthop 2020;158:175-81). The author aimed to help increase awareness and control cross-contamination among orthodontists, assistants, office staff, and patients during the coronavirus disease 2019 crisis.
        • Full-Text
        • PDF