Oral health and COVID-19 complications

Victoria Sampson shares insight into her paper exploring whether there is a link between oral hygiene and the severity of SARS-CoV-2 infections. 1 

Victoria Sampson is a general dentist and winner of three British national dental prizes for published papers, written as a dental student while studying at Barts and The London School of Medicine and Dentistry. She was also chosen to represent the UK in a special training programme at the Karolinska Institute in Sweden, recently rated the top dental/medical school in the world. Victoria's passion is in preventive dentistry and aesthetics, helping patients avoid or detect emerging problems early.

What motivated you to explore the potential connection between COVID-19 and poor oral health?

Victoria: When we stopped working, I didn't really know what to do with my time. I became obsessed with COVID research, and at first that had nothing to do with dentistry.

Then I got COVID but fortunately recovered quite easily. That made me start questioning why one person gets complications and another doesn't. I began to wonder what oral health might have to do with it all.

I started researching in that direction and joined forces with a nutritional therapist who focuses on inflammation and gut health. We started brainstorming and that's really where it started.

How did you go about it?

Victoria: From a research point of view, we are fortunate that we've had other respiratory virus outbreaks before. For example, SARS and MERS; they are about 80% similar to COVID-19.

Due to the rush to find the latest information on COVID globally, there have been a lot of papers, not all of gold standard quality. Initially, it was very hard to sift through all the masses of research that was coming out on a daily basis, but thankfully I really enjoy analysis and have a very scientific, analytical mind so it worked out well! I did much of the analysis and combining information together. My sister, on the other hand, an orthodontist, one of the co-authors, really helped to put the research into a reader-friendly, logical format, so it was a team effort from all the authors to get to where we did.

What were the top line outcomes?

Victoria: The number one outcome is that more research needs to be done! That's for sure.

But then there is the idea of bacterial superinfection, whether it's coming from the mouth or from the gastrointestinal tract. It needs to be understood that bacteria are playing a huge role in COVID-19.

I don't think people tend to pair a viral infection with bacteria, because they think, "Oh, it's a virus. So why would I be thinking about bacteria?”

What happens is that when you have a viral infection, you become immunocompromised and then you become very vulnerable to bacteria. So, if you've already got altered oral microbiome, the moment you become immunocompromised you're at a much higher chance of getting an opportunistic infection. Knowing that, the dental community can try to reduce the risk of a bacterial superinfection and therefore the risk of COVID-19 complications.

What do you think about what you found?

Victoria: It was pretty much what I was expecting, because we've seen this with other viruses. In 1918, when there was a huge influenza pandemic, although it was a virus, the majority of deaths resulted from bacterial superinfections.

How can the information you have gathered be used in everyday dental practice?

Victoria: The key for dental teams is to make sure that the oral microbiome is healthy. For example, we know that periodontal disease causes a lot of inflammation and alters the bacteria in the mouth. So, if we can make sure that all of our patients are free from periodontal disease, that's a huge advantage.

Guided biofilm therapy (GBT) is fantastic for that because it removes the biofilm using an antibacterial powder – namely, erythritol. Because of that, I’ve actually started to reduce the time between my recalls, especially for the at-risk patients.

We also need to re-emphasise to our patients the importance of their at-home care. I think that for a lot of people oral health is not the number one priority and they certainly won’t link oral health and COVID-19 without us raising awareness.

So, it's about making that link and making sure that they maintain their oral health at home: brushing twice a day with a fluoridated toothpaste, flossing or using interdental brushes, to make sure that they are reducing the bacterial overload as much as possible.

You mentioned the benefits of GBT, which is obviously an AGP. How might patients be best educated and reassured about the risks?

Victoria: We did have a few patients initially who were a little bit concerned or scared about coming in. I have reassured them that our processes are in line with the latest guidance and we are constantly reassessing what constitutes best practice.

It's important for patients to know that we've been fighting viruses and bacteria all of our careers. This isn't the first virus we've ever come across. Every year the flu comes along, and we see patients all the time who might have hepatitis, HIV, strep throat, all of those kinds of things. We have always been set up to stop cross-contamination.

In addition, I see vulnerable / high-risk patients first thing in the morning, so that means that there's literally no aerosol in that room before we enter.

What advice can you offer to fellow dental professionals worried about AGP produced?

Victoria: Our disinfection protocols have always been really good, and we've always cleaned between patients. I do accept that this virus is different, but we are all doing everything we can to make sure that the practice is as clean and as hygienic as possible for our patients and for ourselves.

There is new, evidence-based guidance to follow and every day more research is being published, some of which indicates that a very low number of dentists are contracting COVID-19, and that was the case before lockdown, too.

So, it might be that dental professionals have built an immunity, because we are constantly impacted by the flu and other viruses. Or maybe it’s because of our disinfection protocols, we actually do not have that much exposure to viruses.

In terms of GBT, as long as you're following the guidance, creating a fallow period between patients, wearing the correct protective equipment, using your Airflow in the right way, angulated correctly, and you've got high flow suction, you're not at an increased risk at all.

In addition, our hygienists are now practising four-handed GBT, which allows optimal suction and I strongly recommend that way of working.

I'm very comfortable continuing to practise under those circumstances.



1. Sampson V, Kamona N, Sampson A. Could there be a link between oral hygiene and the severity of SARS-CoV-2 infections? Brit Dent J. 2020; 228: 971–975.

Photo by SJ Objio on  Unsplash



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