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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 164-171

COVID-19 pandemic and safe dental practice: Need of the hour


1 Department of Oral and Maxillofacial Surgery, Noorul Islam College of Dental Sciences, Thiruvananthapuram, Kerala, India
2 Conservative Dentistry and Endodontics, Noorul Islam College of Dental Sciences, Thiruvananthapuram, Kerala, India
3 Department of Oral Medicine and Radiology, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India
4 Department of Oral and Maxillofacial Surgery, D A P M R V Dental College, Bangalore, Karnataka, India

Date of Submission30-Apr-2020
Date of Decision11-Jun-2020
Date of Acceptance16-Jun-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
Dr. Darshan R Prasad Hiremutt
Department of Oral Medicine and Radiology, Bharati Vidyapeeth Dental College and Hospital, Katraj - Dhankawadi, Pune - 411 043, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_80_20

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   Abstract 


The COVID-19 pandemic has spread across the globe and is the greatest challenge faced by world nations today. The first outbreak of this disease occurred in a seafood market of Wuhan City, China. The community pattern of spread was alarming and has gripped the entire international society. The dentists and other health care professionals should take stringent measures to prevent the spread of infection while providing care. In this article, we discuss the etiology, clinical manifestations, route of transmission, general and specific infection control protocols to protect the dental health care professionals as well as patients from COVID 19 disease while providing emergency dental care.

Keywords: COVID-19, dental practice, emergency dental management, pandemic, PPE, SARS-CoV-2, Wuhan


How to cite this article:
Kumar G A, Mohan R, Prasad Hiremutt DR, Vikhram K B. COVID-19 pandemic and safe dental practice: Need of the hour. J Indian Acad Oral Med Radiol 2020;32:164-71

How to cite this URL:
Kumar G A, Mohan R, Prasad Hiremutt DR, Vikhram K B. COVID-19 pandemic and safe dental practice: Need of the hour. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Jul 11];32:164-71. Available from: http://www.jiaomr.in/text.asp?2020/32/2/164/288143




   Introduction and Background Top


The novel coronavirus disease (COVID-19) pandemic has emerged as a community health crisis and is spreading exponentially across the globe. The first case was reported in Wuhan City, of China, in late December 2019.[1] On 11th February 2020, WHO named the novel viral pneumonia as “Corona Virus Disease (COVID-19)” while the International Committee on Taxonomy of Viruses (ICTV) named this novel virus as “SARS-CoV-2” following phylogenetic and taxonomic analysis.[2] Coronavirus is from a family of single-stranded RNA viruses known as Coronaviridae.[3] SARS-CoV-2 is a disease of animal origin, most probably from Chinese horseshoe bats (Rhinolophus sinicus) with Malayan pangolins as the potential intermediate host.[4],[5] However, pangolins shared only 85%–92% homology with SARS-CoV-2,[5] warranting further research. Inside the human body, this virus is present abundantly in nasopharyngeal and salivary secretions of affected patients.[6] The primary route of spread of COVID-19 is via respiratory droplet,[7] which makes it more vulnerable to dental professionals. Dental setups invariably carry the risk of COVID-19 infection due to the specificity of its procedures (aerosol production), proximity to the oropharyngeal region, and frequent exposure to saliva. Moreover, if adequate precautions are not taken, the dental office can potentially expose patients to cross-contamination.


   Mode of Transmission Top


COVID-19 infection mainly spreads via respiratory droplets or through contact. Air-borne spread occurs when the infected person coughs or sneeze (radius approximately 6 feet).[7] Another possible route of spread is through infected inanimate objects. Studies suggest that the virus can be viable at room temperature for up to 3 days on inanimate surfaces.[8] COVID-19 virus has been isolated from both saliva and feces of infected persons.[6],[9],[10] SARS-CoV-2 can bind to human angiotensin-converting enzyme 2 (ACE-2) cells of human salivary glands.[11],[12] The risk of vertical transmission (mother to fetus) is still to be confirmed.[13],[14]


   Source of Transmission Top


Symptomatic patients are the main source of transmission. But the recent studies suggest that asymptomatic patients and patients in their incubation period are also carriers of SARS-CoV-2.[15],[16] Besides, it remains to be proven if the patients in the recovering phase are incipient carriers of infections.[16]


   Incubation Period Top


The average incubation period is estimated to be around 0–14 days (generally adopted duration for quarantine and medical observation of potentially exposed persons).[17]


   High-Risk Population Top


People in close contact with patients (symptomatic/asymptomatic) and health care workers are at higher risk, yet generally, all age groups can be susceptible. In general, older age groups, existence of underlying disease conditions (diabetes, hypertension, respiratory/cardiovascular disease, immunosuppression) are associated with poorer prognosis.[18],[19]


   Clinical Manifestations Top


Most patients present with fever and dry cough, while some experience headache, sore throat, anosmia, fatigue, shortness of breath, and other atypical symptoms (muscle pain, confusion, diarrhea, and vomiting).[20],[21] Chest computed tomography of patients, revealed bilateral pneumonia, with ground-glass opacity and patchy shadows.[18],[21] The undiagnosed cases may be more in number as most patients present with mild symptoms that closely resemble seasonal allergies and common flu.[22]

Oral manifestations

A recent survey concluded that more than half of the patients suffered from dysgeusia/amblygeustia.[23],[24] The Centers for Disease Control and Preventions (CDC) included recent loss of taste sensation (ageusia/dysgeusia) as an early symptom of COVID-19 (American Centers of Disease Control and Prevention, 2020b). Other oral manifestations reported so far include oral unspecific ulcerations (affecting both keratinized and nonkeratinized epithelium), xerostomia, opportunistic fungal infections, recurrent oral herpes simplex virus-1 infection, fixed drug eruptions, and gingivitis. There is no conclusive evidence whether oral lesions associated with COVID19 are typical of direct viral invasion or occurring as a result of systemic deterioration or following adverse drug reactions.[25] However, the most likely reason could be linked to the fact that oral tissues (salivary glands and tongue) show high degree of ACE2 expression and to the presence of FURIN (an enzyme that facilitates cellular entry of SARS-CoV-2).[26]

Saliva and covid-19

SARS-CoV-2 has been found to be in high concentration in saliva of infected patients which makes it a potential route of transmission. Salivary droplets consist of droplet nuclei of microorganisms in a mixture of moisture, generated by an infected person during coughing, sneezing, talking, or exhalation. The potential risk of transmission through salivary droplets depends on (i) how long the droplets remain in air and (ii) how long the virus remains infectious in the droplet.[26]

Saliva as a potential diagnostic aid

Throat swabs are exclusively used for diagnostic confirmation of COVID-19 infection. However, throat swabs are relatively invasive, induce cough and bleeding, increasing risk of healthcare workers to this infection. Saliva stands at the entry of respiratory system. Moreover, collection of saliva is less invasive, more acceptable to patients and less hazardous to health care workers. Saliva can be collected using any of the following three approaches: coughing out (deep throat saliva), salivary swabs, and directly from salivary gland duct. A recent study concluded that deep throat saliva has the highest rate of positive virus detection. The potential diagnostic value of saliva in detecting COVID-19 virus is still under research.[26]


   Recommendations for Providing Dental Care during COVID-19 Pandemic Top


1. Dental clinic modification

A. Reception/Waiting area[27]

  1. Display visual alerts at the entrance of the clinic and reception area about respiratory hygiene, cough etiquette, social distancing, and disposal of contaminated items in trash cans.
  2. As soon as the patient enters the reception area, ask them to wash their hands using hand wash or alcohol-based hand rub. Use tissue paper or hand dryer to dry the hands instead of towels. Tissue paper dispenser and foot-operated waste bin are mandatory.
  3. Include temperature recordings as part of your routine patient assessment before performing any dental procedure. A noncontact forehead thermometer can be used to measure the patient's body temperature.[12]


  4. Note: Patients presenting with fever or respiratory disease/symptoms should be registered and referred to designated hospitals.

  5. Include screening questionnaire: 1) Any history of fever/respiratory illness, including cough or difficulty in breathing in the last 14 days? 2) Any history of contact by you or any household member with a known COVID-19 patient in the past 14 days? 3) Any history of international travel by you or any household member or to areas of suspected community spread in the last 14 days.[12]
  6. Maintain social distancing in the reception area by placing chairs, preferably 1 m apart. Instruct the patient to wear a mask while waiting in the reception area and maintain respiratory hygiene by covering their mouth and nose during coughing and sneezing.[24]
  7. Remove magazines, articles, toys, and other objects from the reception area that may be touched by others and are difficult to disinfect.
  8. Install glass/plastic barrier at the reception desk. Cashless/contactless payment methods should be encouraged.
  9. Avoid usage of commercial split/centralized/window air conditioners unless equipped with high-efficiency particulate air (HEPA) filters. It is recommended to use natural and mechanical ventilation using fans and exhaust.


B. Operatory Area

Installation of high vacuum extra oral suction devices recommended.

Maintain natural air circulation within the operatory, through frequent opening of windows and by using an exhaust blower to extract the room air into the atmosphere.

Place a table fan behind the operator and let the air flow toward the patient.

A strong exhaust fan is recommended to create a unidirectional flow of air away from the patient.

Avoid the use of a ceiling fan while performing procedure.

The window air condition system/split AC should be frequently serviced, and filters cleaned. Commercially available electrostatic air conditioner filters can be used.

Use of indoor portable air cleaning system equipped with HEPA filter and UV light may be used.

C. Changing Room

Changing room to be available for staff and all workers. Dedicated area for donning and doffing of personal protective equipment (PPE).

2. Protocols for Dental Patient Management:

A. Telescreening and triaging

The objective of triaging is to facilitate the scheduling of patients based on the level of need. Triaging helps to limit incoming patients while prioritizing emergency care. Thus, there are three categories of patients requiring 1) emergency, 2) urgent, and 3) scheduled/elective care [Figure 1].
Figure 1: Patient triaging and dental management during COVID 19 pandemic

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Pharmacological management of patients requiring urgent dental care [Figure 2]
Figure 2: Drugs recommended for pharmacological management

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*The usage of ibuprofen during the COVID-19 pandemic has not been contraindicated according to the current WHO guidelines. Because of conflicting research in this issue, the use of alternative medications to ibuprofen is suggested.

[Endodontic and Dental Practice during Covid19 Pandemic: Joint position statement by Indian Endodontic Society (IES), Indian Dental Association (IDA), and International Federation of Endodontic Associations (IFEA)]. According to recent research, the role of antibiotics in reducing pain associated with irreversible pulpitis seems questionable. But, if the patient presents with features of acute apical abscess/cellulitis, then appropriate antibiotic medications must be given.[28]

§ Classification of dental treatments based on zones of COVID-19 spread

According to updated notification by Ministry of Health and Family Welfare (MOHFW), the Dental Council of India (DCI) has recommended a zone wise classification of dental treatments [Table 1].
Table 1: Zone wise classification of dental treatment

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B. Dental Health Care Professional Guidelines

  1. Strict adherence to hand hygiene protocols should be followed.[29]
  2. The highest level of PPE, i.e., gloves, gown, goggles, face shields, and an N95 or higher-level respirator must be used during emergency dental care.[29],[30] N-95 masks by the national institute for occupational safety and health/FFP2 masks (filter facepiece) set by the European Union are recommended.[31],[32] If available FFP3 (N-99) standard mask should be used and, in COVID-19 positive patients, this would be considered essential. Recommendation of PPE for dental staff is provided in [Table 2].
Table 2: Recommended PPE for dental staff

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C. Preprocedural Modifications

  1. Drape the patient preferably with single-use, disposable plastic apron.[27]
  2. Ask the patient to remove the mask.
  3. Preprocedural mouth rinse: Effective reduction in salivary microbial load can be achieved by rinsing with 0.2% povidone-iodine or 1% hydrogen peroxide before the procedure [14],[33]. Studies conclude that chlorhexidine is ineffective against COVID-19.[12]


D. Procedural modifications

According to guidelines given by Ministry of Health and Family Welfare dated 19 May 2020, only emergency and urgent procedures to be carried out and all routine and elective dental procedures should be deferred for a later review until new policy/guidelines are issued.

Practice modifications for emergency, urgent care, and specialty wise modification to be adopted as and when regular services resume [Table 3] and [Table 4][33],[34],[35],[36],[37].
Table 3: Specialty Wise Do's and Don'ts

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Table 4: Practice modification during COVID 19 infection

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E. Emergency treatment protocol for the management of high-risk patients

The Centers for Disease Control and Prevention (CDC) as on 8th April 2020 recommends to postpone all elective procedures, surgeries, and nonurgent dental visits, while prioritizing urgent, emergency visits and procedures now and for the coming several weeks.[30]

Emergency dental treatment for a confirmed/suspected COVID-19 patient if warranted medically, it should only be provided in a hospital or dental setup with adequate airborne precautions (negative pressure or AIIR and an N95 mask).[29]

Emergency dental care for non-COVID-19 patients may be provided using appropriate engineering controls, work practices, and infection control protocols.[29]

The most common acute dental conditions and its management are outlined in [Table 5].[38] Dentists providing treatment must exercise clinical judgment based on their skill, expertise, unique patient-specific factors while following the protocols issued by the concerned regional dental and health advisories.
Table 5: Management of acute dental conditions during COVID-19 pandemic

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F. Management of resolved COVID-19 patients

The emergency dental care for resolved COVID-19 patients is decided using two strategies: a nontest-based strategy and a test-based-strategy.[30]

Nontest-Based-Strategy:

At least 3 days (72 h) have passed since recovery (resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms such as cough or shortness of breath) and at least 7 days have passed since symptoms first occurred.

Test-Based-Strategy:

Symptomatic COVID-19 patients: Resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath) and negative results from at least two consecutive nasopharyngeal swab specimens collected ≥24 h apart.

Asymptomatic laboratory-confirmed COVID-19 patients: At least 7 days have passed since the date of the first positive COVID-19 diagnostic test and have had no subsequent illness.

G. Patient discharge protocol[27]

Removal of patient drape by the assistant.

Patient to perform hand hygiene.

Guide the patient out of the clinic toward reception area.

Recording prescription, follow up instructions should only be done after doffing PPE.

3. Disinfection of the Clinic Settings[27],[39]

COVID-19 virus can potentially survive in the environment for several hours/days.

A. Floor

  1. Mop the floor with 1% sodium hypochlorite solution with a contact time of 10 min.
  2. Use separate mops for the clinical area. Unidirectional mopping technique should be followed by mopping from inner to outer area.
  3. Ideally the floor should be cleaned after every patient or after a major splash or two hourly period.
  4. Wash and disinfect the mop with clean water and 1% sodium hypochlorite and leave it for sun-drying.


B. Rest of the surfaces

Freshly prepared 1% sodium hypochlorite (contact time: 10 min) is used.

Disinfection should be done daily before starting work, after every procedure, and at the end of the day.

C. Delicate Electronic equipment

Should be wiped with alcohol-based rub/spirit (60%–90% alcohol) swab before each patient contact.

D. Fogging

This method is called “No-touch surface disinfection.” 20% (w/v) working solution of hydrogen peroxide (stabilized by 0.01% of silver nitrate) is prepared. The amount of solution required is approximately 1000 mL per 1000 cubic feet.

  1. Immediately after the procedure, exit the room and close the operatory for half hour. This allows the aerosols/droplets to settle down.
  2. A 2-step surface cleaning is performed.
  3. Fogging is done for 45 min followed by a dwell time of 1 h.
  4. The room can then be opened and fans switched on for aeration.
  5. Wet surfaces can be dried/cleaned using a sterile cloth or clean cloth.


4. Waste Management

The infectious medical and domestic waste of suspected or confirmed COVID-19 patients should be disposed of in double-layered yellow color bags with gooseneck ligation.[12] The bags should be marked and disposed of in accordance with the Biomedical Waste Management and Handling Rules, 2018.[40]


   Conclusions Top


Every patient should be considered potentially infectious. The dental practitioners should revise their infection control protocols and must keep themselves updated about this evolving disease.

In conclusion, healthcare professionals including dentists have the duty to protect the public and themselves from this novel infection while maintaining high standards of infection control.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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