• Dave Shanahan

Simplicity is the ultimate sophistication

Protecting against SARS-CoV-2. "Simplicity is the Ultimate Sophistication" - (Da Vinci).

As this excellent article attached in the link to the New York Times makes clear, scientific publication and opinion can take time to catch up with the reality of those working at the coalface of care. Silent spreading, asymptomatic transmission, pre-symptom spreading, essentially refer to the same thing - patients infected with SARS-CoV-2 spreading and shedding virus unknowingly and thereby infecting others. This is a reality borne out by data around community based transmission already in evidence. Infected individuals, can create clusters of infection. Transmission can happen easily in some cases, via innocuous contact, such as sharing a table condiment for instance, as documented here. The primary route for transmission and infection is via the mouth and nose. These are major reservoirs of the virus and the body's portal for viral entry and exit, through droplet infections creating aerosols, or touching surfaces contaminated by droplets and contact. As healthcare workers make up 30% of infected patients, the occupational hazards to healthcare workers are immense. Infection with SARS-CoV-2, is a serious challenge for many people. What is additionally worrying is the potential for long term health impacts arising from infection. Whilst illness from the infection may be short, long term lung and neurologic damage is being increasingly recognised in some people who recover from the infection. Hence SARS-CoV-2 must be considered a serious infection. Every preventative measure against infection is therefore worth significant consideration. For this reason, as Povidien recommend, there is no benefit in foregoing practical, obvious and cheap interventions to reduce potential transmission. The advice regarding PPE use, social distancing and hand hygiene, is rooted in common sense. We understand these interventions by their very nature must reduce transmission potential. It is the same logic in supporting the case to use Povidone-iodine (PVP-I) as a pre-procedural mouthwash in ENT and Dental procedures. When used, in a thoughtful manner under specialist supervision, PVP-I mouthwash and nasal treatment leverages the proven viricidal activity of POV-I against SARS-CoV-2 and assumes potential benefit for its use in the mouth and nose. It has years of established safety data when used in the mouth and nose, something not available to other treatments such as Hydrogen Peroxide which cannot be used in the nose. We cannot wait for "the final proof" from large randomised trials. Healthcare workers are being infected daily by patients who do not know they are infectious and are not suspected of being a risk......but they are! PVP-I can be an additional layer of PPE, used by patients as a pre-treatment to protect themselves, other patients and their healthcare professionals before routine procedures by rinsing and gargling as mouthwash and employing as a nasal treatment shortly before surgery. This is just leveraging common sense. Dentists and Surgeons can create the appropriate protocols to support informed patient consent and exclude patients considered inappropriate for pre-procedural rinsing. They can choose an agent suitable in the mouth and nose, one proven to be viricidal against SARS-CoV-2, with many years of established safety experience and global regulatory approvals in these indications. They can lead on improving occupational safety in their clinics. The reluctance of the professions to run ahead of proven science is understandable. There is the possibility that trials using pre-procedural rinsing with PVP-I may demonstrate little or no clinical benefit against SARS-CoV-2 in clinical practice. Patients could be asked to use a mouthwash and nasal rinse before procedures that works poorly in eliminating SARS-CoV-2 virus in the mucosa. There is the potential for very rare allergic reaction. However, just as with PPE, all barriers to infection, using agents proven to inactivate the virus, adopting new clinical practices to reduce risk should be employed, especially where the benefits they potentially confer, far outweigh any risks they present. We believe strongly with PVP-I, when used as a pre-procedural mouthwash, gargle and nasal treatment, is beneficial for patients and practice and these benefits far outweigh the very modest risks arising. We also believe PVP-I will impede asymptomatic transmission from patients to others, including care workers in the healthcare system, when used as we propose. This decision ultimately comes down to dental specialists and clinicians who operate on large numbers of patients each day. Is it realistic to think such people engaged in high risk clinical procedures around the patient's mouth and nose are not at increased risk of infection by their patients? With 30% of infections arising in healthcare workers, is it wise to ignore solutions which could contribute to prevent infection with this virus and its potentially long term consequences? Whilst waiting for clinical trials to report, does it make sense to forego, a simple additional and cheap intervention, one with compelling data to reduce the potential for transmission of this debilitating viral infection and a proven use case in viral infection treatment of the mouth and nose over years across the world? We are at war with a virus. In wartime, we accept and understand the need to make sacrifices and to take unknown risks. Using PVP-I liquid in the mouth and nose as pre-treatment in patients undergoing dental and ENT procedures hardly seems to constitute much of either.

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