Searches were performed in the PubMed/Medline, Web of Science, Science Direct, Scopus, Embase and Cochrane Collaboration Library databases (last update in March 2021) using the following search terms: (i) (“oral surgery” * OR “maxillofacial surgery” *) AND (“COVID-19” OR coronavirus OR “SARS-CoV-2” OR “2019-nCoV” OR “corona virus” OR “COVID”); (ii) ((“Oral surgery” * OR “maxillofacial surgery” *) AND (“COVID-19” OR coronavirus OR “SARS-CoV-2” OR “2019-nCoV” OR “corona virus” OR “COVID” AND ) AND Clinical practice).

In addition, the reference lists of eligible articles were hand searched. Duplicates were identified and removed. The search was performed without time or language restrictions. Manuscripts not originally published in English were translated for subsequent assessment.

The following eligibility criteria were applied according to the PICO framework for selection of the studies: (1) Patients: maxillofacial professionals and patients attending oral and maxillofacial surgery services during the COVID-19 pandemic; (2) Intervention: analysis of the risk of contamination with COVID-19 in oral and maxillofacial surgery settings and methods used to prevent this risk; (3) Control: group of COVID-19-negative patients/professionals; (4) Outcome: rate of cases diagnosed with COVID-19. The articles were considered eligible if they met the following inclusion criteria: observational studies that provided recommendations regarding maxillofacial surgery measures during the COVID-19 pandemic and that analyzed the risk of contamination of patients/professionals with SARS-CoV-2. Review articles, conference abstracts, editorials, or letters were excluded from the systematic review.

The titles and abstracts of studies were retrieved using the search strategy and then selected independently by two authors. The complete content of the extracted studies was independently assessed for eligibility by the same two authors. Any situations that resulted in disagreement were resolved through a consensus meeting with a third reviewer. The following data were extracted: first author; time of publication; country of origin; study design; age, sex and number of patients; type of maxillofacial surgery performed; protocol used to prevent COVID-19; result of screening for COVID-19 (COVID-19/no COVID-19) before and after the surgical procedure; number of cases diagnosed with COVID-19 among patients and maxillofacial surgeons; complication (yes/no) of cases diagnosed with COVID-19, and type of complications.

The system for classifying evidence of the Oxford Centre for Evidence-Based Medicine (CEBM) was used to evaluate the level of evidence of each recommendation. The CEBM system categorizes the level of evidence from level 1 (highest level) to level 5 (lowest level).9 The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to assess the quality of the selected studies.10

The search strategy developed for the different databases and the hand search identified a total of 102 articles. Twenty-two articles were pre-selected after initial screening through analysis of the titles and abstracts. Seven studies met the inclusion criteria and were selected for the present systematic review (Fig. 1).11–17

Figure 1.

PRISMA flow diagram of screened studies.

(0.34MB).

These studies included data from 709 oral and maxillofacial surgeons, 562 patients, 174 oral and maxillofacial surgery and traumatology residents, and 95 residency program directors (Table 1). The quality of the selected studies was analyzed.

All included studies reported a decrease in the number of surgical procedures through the cancellation/postponement of elective surgeries, with priority being given to urgency/emergency cases. In the study of Barca et al.12 the main surgeries performed during the emergency period caused by COVID-19 were those related to traumas and different oncological diseases. At the time of the pandemic, Blackhall et al.13 reported 255 cases related to trauma, 221 infections, and 48 cases of postoperative complications during the study period. Maffia et al.15 found traumatology to be the least affected area, which was maintained in 83.2% of all services of the interviewed professionals.

An important finding was the adaptation of consultations and patient screening. Barca et al.12 used a questionnaire for patient screening by telephone and on admission to the clinic, which consisted of the following topics: (1) Presence of fever in the last 14 days; (2) Possible respiratory problems; (3) Travel to risk areas with high COVID-19 spread; (4) Contact with COVID-19-positive patients, and (5) Participation in agglomerations. All patients underwent an RT-PCR test before the surgical procedure and were hospitalized in individual rooms.

Blackhall et al.13 attended 134 patients remotely by phone or video for initial screening on the risk of COVID-19 and the need for face-to-face health care. Huntley et al.14 reported that almost all programs (95.7%) in which residents participated had screened patients for symptoms of COVID-19. This was done more frequently by hospital screening (65.2%) or by the reception staff (62.2%). Among the respondents, 83.6% indicated that their program was using laboratory tests for patients with COVID-19.

Barca et al.12 reported that the healthcare team implemented preventive measures during the surgical procedure, as recommended by the provisional guidelines of the World Health Organization (WHO). The healthcare team used personal protective equipment: N95 or FFP2 masks, eye protection, fluid-resistant gowns, and surgical gloves. Blood pressure, body temperature, heart rate, and oxygen saturation were monitored periodically. No cases of COVID-19 were detected in the study. In an international multicenter study, Maffia et al.15 found that more than half (57.1%) of the maxillofacial surgery centers that reported not to have received any instructions on COVID-19 management did also not receive adequate personal protective equipment.

In the study of Brar et al.,17 16 of the 33 programs (48.5%) did not report the lack of personal protective equipment, while 51.5% did. The most common missing devices were N95 respirators (94.1%) and surgical masks with face shield (35.3%). In a global study conducted by van der Tas et al.,16 the perception of the availability of personal protective equipment for health professional and surgeons differed significantly between the countries analyzed. The best protection offered to maxillofacial surgeons was observed in Australia, where surgeons could work with N95/FFP2 masks in 60.0% of services, followed by North America (47.7%).

In the study of Huntley et al.,14 all respondents indicated that their programs made changes to the scheduling of elective cases, with 97.7% of the interviewed residents reporting that their program had stopped elective procedures. Urgency or emergency cases were also affected, with 83.6% of respondents indicating changes in the scheduling of these cases. Regarding personal protective equipment, 95.3% of the respondents stated that their programs made changes in the use of this equipment. Most residents reported good (32.7%) or excellent (32.1%) access to masks with eye protection; however, 36.8% indicated limited access to N95 masks.

The study of Brar et al.17 found that all residency programs continued to provide limited services to patients during the COVID-19 pandemic. These included emergency dental treatment (93.9%); emergency and urgent surgical procedures such as the correction of facial fractures or oncological resection and reconstruction (93.9%); postoperative follow-up visits (75.8%); dental consultations with hospitalization (72.7%), and new outpatient appointments (36.4%).

Residents were strongly concerned about the possible practical effects of the pandemic on surgical teaching and training. Huntley et al.14 reported that residents were more concerned about their experience in orthognathic surgery (55.1%), ambulatory anesthesia and deep sedation (43.6%) and reconstructive and esthetic surgery (42.3%), as well as general experience in anesthesia (32.1%). Most residents (88.8%) indicated that their surgical experience was affected, with a mean reduction in surgical experience of 67%. The majority of respondents (94.2%) reported that their program used virtual didactics (online) and that the frequency of didactics had generally increased.

The COVID-19 pandemic has physically, mentally, and emotionally challenged residents, teachers, and staff. The study of Brar et al.17 indicates that different techniques for wellbeing were particularly important to maintain the health and safety of residents during this period, including meditation seminars, yoga routines and physical exercises, free or reduced fare transit passes, food delivery services, counseling services, and free hotel accommodation.