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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 172-179

Dealing with dental patients during and after coronavirus disease 2019 outbreak


1 Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, India
2 Consultant Periodontist, Uttar Pradesh, India

Date of Submission16-Apr-2020
Date of Decision14-Jul-2020
Date of Acceptance25-Jun-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Priyanka Tandon
Zest Dental and Implant Centre, Greenfield Colony, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_54_20

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  Abstract 


The coronavirus disease 2019 (COVID-19) outbreak was declared a pandemic on March 11, 2020. Several dental care facilities in affected countries have been completely closed or have been only providing minimal treatment for emergency cases. However, several facilities in some affected countries are still providing regular dental treatment. This can, in part, be a result of the lack of universal protocol or guidelines regulating the dental care provision during such a pandemic. This lack of guidelines can, on the one hand, increase the nosocomial COVID-19 spread through dental health care facilities, and on the other hand, deprive patients' in need of the required urgent dental care. Moreover, ceasing dental care provision during such a period will incense the burden on hospital emergency departments already struggle with the pandemic. This review article is aimed to develop guidelines for dental patients' management during and after the COVID-19 pandemic.

Keywords: Coronavirus disease 2019, dental emergency management, infection control, severe acute respiratory syndrome coronavirus-2


How to cite this article:
Srivastava S, Tandon P. Dealing with dental patients during and after coronavirus disease 2019 outbreak. Indian J Dent Sci 2020;12:172-9

How to cite this URL:
Srivastava S, Tandon P. Dealing with dental patients during and after coronavirus disease 2019 outbreak. Indian J Dent Sci [serial online] 2020 [cited 2020 Sep 23];12:172-9. Available from: http://www.ijds.in/text.asp?2020/12/3/172/292279




  Introduction Top


The coronavirus outbreak is a global concern. With each passing day, the situation seems to change for the worst. More and more people are confirmed as infected, the mortality rate goes up slightly with each fatal case, and the virus is making its way outside the Chinese borders.

The Wuhan virus is the first major health threat of 2020, but its far from being the first or the worst health crisis that humanity faced. Before we had the Ebola virus, Avian influenza, and severe acute respiratory syndrome (SARS), with the last on this list actually being a type of coronavirus. All were highly contagious and potentially deadly, but none caused such a visceral reaction from the population. The epidemics of coronavirus disease 2019 (COVID-19) started in Wuhan, China, last December and have become a major challenging public health problem for not only China but also countries worldwide.[1]

On January 30, 2020, the World Health Organization (WHO) announced that this outbreak had constituted a public health emergency of international concern.[2]

The novel coronavirus was initially named 2019-nCoV and officially as SARS-coronavirus 2 (CoV-2). As of February 26, COVID-19 has been recognized in 34 countries, with a total of 80,239 laboratory-confirmed cases and 2700 deaths.[3]

In the field of dentistry, the risk of cross infection high between dental practitioners and patients. COVID-19 affected countries/or regions made dental practices and hospitals potentially at high risk, in which strict and effective requirements of infection prevention protocols urgently needed. This article is based on the relevant guidelines and research about the COVID-19 and providing the recommended management protocols for dental practitioners in affected areas.


  Origin of the Coronavirus Top


According to recent research, similar to SARS-CoV and the Middle East respiratory syndrome (MERS)-CoV, SARS CoV-2 is zoonotic, with Chinese horseshoe bats (Rhinolophus sinicus) being the most probable origin and pangolins as the most likely intermediate host.[4],[5]

2019-nCoV possessed the typical coronavirus structure with the “spike protein” in the membrane envelope,[6] and also expressed other polyproteins, nucleoproteins, and membrane proteins, such as RNA polymerase, 3-chymotrypsin-like protease, papain-like protease, helicase, glycoprotein, and accessory proteins.[6],[7],[8] The S protein from coronavirus can bind to the receptors of the host to facilitate viral entry into target cells.[9],[10] Although there are four amino acid variations of S protein between 2019-nCoV and SARS CoV, 2019-nCoV can also bind to the human angiotensin-converting enzyme 2 (ACE2), the same host receptor for SARS CoV, as 2019-nCoV can bind to the ACE2 receptor from the cells from the human, bat, civet cat, and pig, but it cannot bind to the cells without ACE2.[8],[11],[12],[13]

A recombinant ACE2-immunoglobulin antibody, a SARS CoV-specific human monoclonal antibody, and the serum from a convalescent SARS-CoV-infected patient, which can neutralize 2019-nCoV, confirmed ACE2 as the host receptor for 2019-nCoV.[14],[15],[16],[17] The high affinity between ACE2 and 2019-nCoV S protein also suggested that the population with higher expression of ACE2 might be more susceptible to 2019-nCoV.[18],[19]

Coronaviruses belong to the family of Coronaviridae, of the order Nidovirales, comprising large, single, plus-stranded RNA as their genome.[20],[21] Currently, there are four genera of coronaviruses: α-CoV, β-CoV, γ-CoV, and δ-CoV.[22],[23] Most of the coronavirus can cause infectious diseases in human and vertebrates. The α-CoV and β-CoV mainly infect the respiratory, gastrointestinal, and central nervous system of humans and mammals, while γ-CoV and δ-CoV mainly infect the birds.[20],[24],[25],[26] The SARS-CoV and MERS-CoV belong to the β-CoV.[27],[28] 2019-nCoV explored in Wuhan also belongs to the β-CoV according to the phylogenetic analysis based on the viral genome.[7],[8]


  Mode of Transmission Top


Based on findings of genetic and epidemiologic research, it appears that the COVID-19 outbreak started with a single animal-to-human transmission, followed by the sustained human-to-human spread.[4],[29] It is now believed that its interpersonal transmission occurs mainly via respiratory droplets and contact transmission.

There may be a risk of fecal-oral transmission, as researchers have identified SARS-CoV-2 in the stool of patients from China and the United States.[30] Studies have suggested that 2019-nCoV may be airborne through aerosols formed during medical procedures.[31] It is notable that 2019-nCoV RNA could also be detected by real-time reverse transcription-polymerase chain reaction testing in a stool specimen collected on day 7 of the patient's illness.[30]


  Stages of Spread of Coronavirus Top


Patients with symptomatic COVID-19 have been the main source of transmission, recent observations suggest that asymptomatic patients and patients in their incubation period are also carriers of SARS-CoV-2.[4],[32] This epidemiologic feature of COVID-19 has made its control extremely challenging, as it is difficult to identify and quarantine these patients in time, which can result in an accumulation of SARS-CoV-2 in communities. Hence, whether the patients in the recovering phase are a potential source of transmission.[32]

Stages of the spread of coronaviruses[2]

  • Stage 1: Getting the imported case – People getting infected outside the country having infection
  • Stage 2: Local transmission – the infected case came from outside the country, spreading infection to those who came in contact with them
  • Stage 3: Community transmission – If the people having infection don't restrict their movement (quarantine) they might spread infection to people whom they don't even know through infected surfaces
  • Stage 4: Turning into an epidemic – This chain reaction of the spread of infection leads to huge explosion of the cases.



  Incubation Period Top


Based on the current epidemiological investigation, the incubation period is 1–14 days, mostly 3–7 days and the COVID 19 is contagious during the latency period. It is highly transmissible in humans, especially in the elderly and people with underlying diseases.[33]

How long can SARS CoV-2 remain viable on surface/airborne?

  • Up to 72 h on plastic, stainless steel and other metal surfaces
  • Up to 24 h on cardboard surfaces
  • 6–12 h on soft surfaces
  • 4–9 h on copper surfaces
  • Up to 3 h in suspended aerosols.



  People at High Risk of Infection Top


Most patients had a good prognosis, while a few patients were in critical condition, especially the elderly and those with chronic underlying diseases. As of March 1, 2020, a total of 79,968 confirmed cases, including 14,475 (18.1%) with severe illness, and 2873 deaths (3.5%) in mainland China had been reported by WHO.[34]

Acute respiratory distress syndrome (ARDS), arrhythmia, shock, acute kidney injury, acute cardiac injury, liver dysfunction, and secondary infection patients are the complications.[35] The disease tends to progress faster in elderly people, with the median number of days from the occurrence of the first symptoms to death shorter among people aged 65 years or more.[36],[37] Neonates and the elderly need more attention and care due to their immature or weak immune system.


  Clinical Symptoms Top


A recent study led by Prof. Nan-Shan Zhong's team, by sampling 1099 laboratory-confirmed cases, found that the common clinical manifestations included fever (88.7%), cough (67.8%), fatigue (38.1%), sputum production (33.4%), shortness of breath (18.6%), sore throat (13.9%), and headache (13.6%).[38] Patients manifested gastrointestinal symptoms, with diarrhea (3.8%) and vomiting (5.0%). Fever and cough were the dominant symptoms, whereas upper respiratory symptoms and gastrointestinal symptoms were rare, suggesting the differences in viral tropism as compared with SARS-CoV, MERS-CoV, and influenza. The elderly and those with underlying disorders (i.e., hypertension, chronic obstructive pulmonary disease, diabetes, cardiovascular disease), developed rapidly into ARDS, septic shock, metabolic acidosis hard to correct and coagulation dysfunction, even leading to the death.[35]

Most patients had normal or decreased white blood cell counts and lymphocytopenia. In severe patients, the neutrophil count, D-dimer, blood urea, and creatinine levels were higher significantly, and the lymphocyte counts continued to decrease. Inflammatory factors interleukin (IL)-6, IL-10, tumor necrosis factor-α (TNF-α) increase, indicating the immune status of patients. The data showed that ICU patients had higher plasma levels of IL-2, IL-7, IL-10, granulocyte colony-stimulating factor, 10 kD interferongamma.

Induced protein-10, monocyte chemoattractant protein-1, macrophage inflammatory protein 1-α, and TNF-α.[35]


  Effects of Outbreak of Coronavirus Disease 2019 on Dentistry Top


Risk of nosocomial infection in dental settings

Dental patients who cough, sneeze, or receive dental treatment, including the use of a high-speed handpiece or ultrasonic instruments, make their secretions, saliva, or blood aerosolize to the surroundings. Dental apparatus could be contaminated with various pathogenic microorganisms after use or become exposed to a contaminated clinic environment. Thereafter, infections can occur through the puncture of sharp instruments or direct contact between mucous membranes and contaminated hands.[39]

Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection.

Recommendation for dental practice during the outbreak of coronavirus disease 2019

Given the novelty of the disease, no cases of SARS-CoV-2 transmission in a dental setting are identified yet. However, given the high transmissibility of the disease and considering that routine dental procedures usually generate aerosols; during this pandemic, alterations to dental treatment should be considered to maintain a healthy environment for the patients and the dental team.

SARS-CoV-2 has been isolated from the saliva of COVID-19 patients.[40] Salivary gland epithelial cells can potentially be infected by SARS-CoV and become a major source of the virus in saliva.[41] Even after patient recovery, recusancy during the convalescence period was reported. This is plausible since the presence of some virus strains in saliva for as long as 29 days have been reported in the literature.[42],[43]

In addition to blood and salivary contamination, the majority of routine rental treatments generate significant amounts of droplets and aerosols. This is usually related to the utilization of devices and equipment such as ultrasonic scalers, air-water syringes, and air turbine handpieces.

Closing dental practices during the pandemic can reduce the number of affected individuals, but will increase the suffering of the individuals in need of urgent dental care. It will also incense the burden on hospital emergency departments.

This calls for the creation of standard guidelines for dental care provision during the worldwide spread of the pandemic and/or local epidemic outbreaks.

Patient management and prevention of nosocomial infection

Based on the experience gained from the previous outbreak of SARS-CoV and the data available on SARS-CoV-2 and its associated disease (COVID-19), certain specific measures are discussed for dental patient management in this pandemic period of COVID-19 [Flowchart 1].[44]



Telescreening and triaging

Initial screening through telephone to identify patients with suspected or possible COVID-19 infection can be performed remotely at the time of scheduling appointments [Flowchart 1]. The three most pertinent questions for initial screening should include any exposure to a person with known or suspected COVID-19 presentation, any recent travel history to an area with a high incidence of COVID-19, or presence of any symptoms of febrile respiratory illness such as fever or cough.

A positive response to either of the three questions should raise initial concern, and elective dental care should be deferred for at least 2 weeks (Note: the incubation period for SARS-CoV-2 can range from 0 to 24 days). These patients should be encouraged to engage in self-quarantine and contact their primary care physician by telephone or E-mail.[45]

Patient evaluation

On patient arrival in dental practice, patients should complete a detailed medical history form, COVID-19 screening questionnaire, and the assessment of a true emergency questionnaire [Table 1]. Dental professionals should measure the patient's body temperature using a noncontact forehead thermometer or with cameras having infrared thermal sensors.[46] Patients who present with fever (>100.4°F = 38°C) and/or respiratory disease symptoms should have elective dental care deferred for at least 2 weeks. As per the Centers for Disease Control (CDC) and Prevention guidelines, individuals with suspected COVID-19 infection should be seated in a separate, well-ventilated waiting area at least 6 ft from unaffected patients seeking care.[24] Patients should be requested to wear a surgical mask and follow proper respiratory hygiene, such as covering the mouth and nose with a tissue before coughing and sneezing and then discarding the tissue.[47] After informing the patients to self-quarantine themselves, dentists should instruct the patients to contact their physician to rule out the possibility of COVID-19.
Table 1: Coronavirus disease 2019 screening questions

Click here to view


Pharmacologic management

In suspected or confirmed cases of COVID-19 infections requiring urgent dental care for conditions such as tooth pain and/or swelling, pharmacologic management in the form of antibiotics and/or analgesics is an alternative. This approach may offer symptomatic relief and will provide dentists sufficient time to either refer the patient to a specialist or deliver dental care with all appropriate measures in place to prevent the spread of infection [Table 2].
Table 2: Recommendations for dental emergency management during coronavirus disease 2019 outbreak

Click here to view


Standard and transmission-based precautions and personal protective equipment

  • Dental health care personal (DHCP) should adhere to standard precautions, which are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered.
  • Standard precautions include hand hygiene, use of personal protective equipment, respiratory hygiene/etiquette, sharps safety, safe injection practices, sterile instruments, and devices, clean and disinfected environmental surfaces. If available, DHCP should implement transmission-based precautions. “Necessary transmission-based precautions might include patient placement (e.g., isolation), adequate room ventilation, respiratory protection (e.g., N-95 masks) for DHCP, or postponement of nonemergency dental procedures“
  • ”Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering ([large droplets]) of blood or other body fluids.” Mask are classified into three types: triple-layered surgical mask, N95 mask, and FFP3 mask
  • Supplies of N95 respirators can become depleted during an influenza pandemic wide-spread outbreaks of other infectious respiratory illness.[48]


Existing CDC guidelines recommend a combination of approaches to conserve supplies while safeguarding health care workers in such circumstances:

  • Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls
  • Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators [FFRs], elastomeric half-mask and full facepiece air-purifying respirators, powered air-purifying respirators) where feasible
  • Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable.


Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use may be implemented when multiple patients are infected with the same respiratory pathogen, and patients are placed together in dedicated waiting rooms or hospital wards. Extended use has been recommended as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.[49]

Reuse refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it (“doffing”) after each encounter. The respirator is stored in between encounters to be put on again (“donned”) before the next encounter with a patient. For pathogens, in which contact transmission (e.g., fomites) is not a concern, nonemergency reuse has been practiced for decades. For example, for tuberculosis prevention, CDC recommends that a respirator classified as disposable can be reused by the same worker as long as it remains functional and is used in accordance with local infection control procedures. Even when N95 respirator reuse is practiced or recommended, restrictions are in place, which limits the number of times the same FFR is reused. Thus, N95 respirator reuse is often referred to as “limited reuse.” Limited reuse has been recommended and widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.[50]

  • Surgical masks are one use only, and one mask should be used per patient
  • “If your mask is damaged or soiled, or if breathing through the mask becomes difficult, you should remove the face mask, discard it safely, and replace it with a new one.”


In response to this potential shortage of N95FFR, the CDC and the Institute of Medicine have suggested that use of a surgical mask as an external cover over the N95FFR could serve as a barrier to pathogens and thereby extend the useful life of the respirator, and this suggestion has been carried over to the CDC's recently released guidance on the use of respiratory protective equipment and community mitigation efforts during pandemic influenza. Although this seems reasonable, it has the potential to be cost-effective (surgical masks cost a fraction of the price of N95FFRs) and would be easy to implement[51] [Figure 1].
Figure 1:N95 filtering facepiece respirator (with exhaust valve) with a surgical mask overlay

Click here to view


Hand hygiene

Wash hands with soap and water for at least 20 s after contact with patients or use an alcohol-based hand sanitizer with at least 60% alcohol if soap and water are not available (these recommendations already are part of standard precautions).

  • Before and after any direct patient contact and between patients, whether or not gloves are worn
  • Immediately after gloves are removed
  • Before handling an invasive device
  • After touching blood, body fluids, secretions, excretions, nonintact skin, and contaminated items, even if gloves are worn
  • During patient care, when moving from a contaminated to a clean body site of the patient
  • After contact with inanimate objects in the immediate vicinity of the patient.



  Specific Dental Treatment Recommendations Top


In the unlikely event of providing dental care to suspected or confirmed cases of COVID-19 infection, dentists should be cognizant of the following recommendation:[44]

  • Preprocedural mouth rinse: previous studies have shown that SARS-CoV and MERS-CoV were highly susceptible to povidone mouth rinse.[52] Preprocedural mouth rinse with 0.2% povidone-iodine might reduce the load of coronaviruses in saliva.[53] Another alternative would be to use 0.5%–1% hydrogen peroxide mouth rinse, as it has nonspecific virucidal activity against corona viruses[54]
  • Use of disposable (single-use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross contamination are encouraged
  • Radiographs: extraoral imaging such as panoramic radiography or cone-beam computed tomographic imaging should be used to avoid gag or cough reflex that may occur with intraoral imaging. When intraoral imaging is mandated, sensors should be double barrier to prevent perforation and cross-contamination
  • Dentists should use a rubber dam to minimize splatter generation (of course, this is the standard of care for nonsurgical endodontic treatment). It may be advantageous to place the rubber dam so that it covers the nose
  • Dentists should minimize the use of ultrasonic instruments, high-speed hand-pieces, and three-way syringes to reduce the risk of generating contaminated aerosols
  • In this time of public health crisis, endodontic practices can dilute the sodium hypochlorite irrigant solution to 1% concentration, to extend the supplies without compromising on treatment outcome
  • Negative-pressure treatment rooms airborne infection isolation rooms (AIIRs): it is worth noting that patients with suspected or confirmed COVID-19 infection should not be treated in a routine dental practice setting. Instead, this subset of patients should only be treated in negative-pressure rooms or AIIRs. Therefore, anticipatory knowledge of health care centers with provision for AIIRs would help dentists to provide emergent dental care if the need arises
  • SARS CoV-2 can remain viable in aerosol and survive up to 3 days on inanimate surfaces at room temperature, with a greater preference for humid conditions. Therefore, clinic staff should make sure to disinfect inanimate surfaces using chemicals recently approved for COVID-19 and maintain a dry environment to curb the spread of SARS-CoV-2
  • Another adjunctive measures, which we all can use in our daily clinical practices during this outbreak of COVID-19 i.e.,:


    • 0.01 percent to 0.02 percent NaOCl could effectively inactivate a variety of infectious agents that might be aspirated into water lines, then dispersed in the water spray or those dispersed directly from the patient's mouth[55]
    • Filtration or decontamination - Through high-efficiency particulate arrestor Filters [Figure 2].[56]


  • Ultraviolet germicidal irradiation (UVGI) is a sterilization method commonly used in hospitals and medical settings to destroy airborne microorganisms. UVGI is most often utilized as a lamp in the operating room for air purification or a lighted box for toothbrush sterilization. This method of sterilization has increased due to its efficacy and ease of use–only lasting a 15-min duration [Figure 3].[57]



  Recommendation for Empiric Use of Hydroxy-Chloroquine for Prophylaxis of Severe Acute Respiratory Syndrome Coronavirus-2 Infection by Indian Council of Medical Research Top


Hydroxy-chloroquine is found to be effective against coronavirus in laboratory studies andin vivo studies. The following recommendation for the use of hydroxy-chloroquine as a prophylactic agent against SARS-CoV-2 infection is based on these considerations, as well as risk-benefit consideration, under exceptional circumstances that call for the protection of high-risk individuals.[58]
Figure 2: High-efficiency particulate arrestor filters

Click here to view
Figure 3: Ultraviolet germicidal irradiation

Click here to view


The National Taskforce for COVID-19 recommends the use of hydroxy-chloroquine for prophylaxis of SARS-CoV-2 infection for selected individuals as follows:

Eligible individuals

  • Asymptomatic health-care workers involved in the care of suspected or confirmed cases of COVID-19
  • Asymptomatic household contacts of laboratory-confirmed cases.[58]


Dose

  • Asymptomatic health-care workers involved in the care of suspected or confirmed cases of COVID-19: 400 mg twice a day on day 1, followed by 400 mg once weekly for next 7 weeks; to be taken with meals
  • Asymptomatic household contacts of laboratory-confirmed cases: 400 mg twice a day on day 1, followed by 400 mg once weekly for the next 3 weeks; to be taken with meals.[58]


Exclusion/contraindications

  • The drug is not recommended for prophylaxis in children under 15 years of age
  • The drug is contraindicated in persons with a known case of retinopathy, known hypersensitivity to hydroxychloroquine, 4-aminoquinoline compounds.[58]



  Conclusion Top


Health-care professionals have the duty to protect the public and maintain high standards of care and infection control. This new emerging SARS-CoV-2 threat could become a less pathogenic and more common infection in the worldwide population. It is important to make informed clinical decisions and educate the public to prevent panic while promoting the health and well-being of our patients during these challenging times. The prudent practitioner will use this review as a starting point and continue to update themselves with useful online information as this outbreak continues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Origin of the Co...
Mode of Transmission
Stages of Spread...
Incubation Period
People at High R...
Clinical Symptoms
Effects of Outbr...
Specific Dental ...
Recommendation f...
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