|Year : 2021 | Volume
| Issue : 1 | Page : 54-59
Containing the contagion-dental practice management post-COVID-19
Padma K Bhat, MM Nayana, MY Jayachandra
Department of Public Health Dentistry, Rajarajeswari Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||03-May-2020|
|Date of Decision||17-May-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||31-Dec-2020|
M M Nayana
Department of Public Health Dentistry, Rajarajeswari Dental College and Hospital, Bengaluru - 560 074, Karnataka
Source of Support: None, Conflict of Interest: None
The coronavirus disease 2019 (COVID-19) pandemic, which originated in Wuhan, China, has now affected more than 100 countries around the world. In the light of the WHO declaring COVID-19 as a public health emergency of international concern, despite global efforts to contain the killer disease, the cases are still increasing due to community spread. Coronavirus or the severe acute respiratory syndrome coronavirus 2 is present abundantly in the infected person's salivary and nasopharyngeal secretions. The contagion occurs very easily through these droplets, which are very evident in any dental clinic. However, the dental clinics are open for emergency treatments. The aim of this article is to give a glance into the impact of COVID-19 on dentistry in India.
Keywords: Corona, coronavirus disease 2019, dentistry, pandemic, practice management
|How to cite this article:|
Bhat PK, Nayana M M, Jayachandra M Y. Containing the contagion-dental practice management post-COVID-19. Indian J Dent Sci 2021;13:54-9
|How to cite this URL:|
Bhat PK, Nayana M M, Jayachandra M Y. Containing the contagion-dental practice management post-COVID-19. Indian J Dent Sci [serial online] 2021 [cited 2021 Jan 16];13:54-9. Available from: http://www.ijds.in/text.asp?2021/13/1/54/305975
| Introduction|| |
”The Workers Who Face the Greatest Corona virus Risk,” is an article published in The New York Times, where a remarkable schematic representation showed that dentists were at the highest risk of contact with the virus as they encounter diseases and infections daily and typically work in proximity with one another and the patients. As mentioned earlier, the transmission is through droplets. The literature shows that many dental procedures produce aerosols and droplets that are contaminated with bacteria, viruses, and blood and have the potential to spread infections to dental personnel and other people in the dental office. A retrospective study by Guo et al. showed that in spite of authorities' recommendations and fearing of epidemics, people were reluctant to go outside but stay in houses, with less willing to go to dental institutions. Apart from taking care of themselves, dental care providers face another challenge of protecting the patients from community transmission and at the same time ensuring patients continue to have access to urgent/emergency dental care.
The usage of dental devices produces a large amount of aerosols and droplets which are mixed with the patient's saliva and blood. Any dental apparatus will be contaminated when exposed to such an environment. Nosocomial infections in the health-care facilities did happen and stress the importance of good infection control. 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 coronavirus disease 2019 (COVID-19), especially when patients are in the incubation period, are unaware that they are infected, or choose to conceal their infection. Thus, dentists have not only the highest risk of contact with the virus but also can reduce the spread if proper preventive measures are followed. Dentists have been recommended to take several personal protection measures and avoid or minimize operations that can produce droplets or aerosols; moreover, the use of saliva ejectors with a low volume or high volume can reduce the production of droplets and aerosols. The pathogenic microorganisms can be transmitted in dental settings through inhalation of airborne microorganisms that can remain suspended in the air for long periods; direct contact with blood, oral fluids, or other patient materials; contact of conjunctival, nasal, or oral mucosa with droplets and aerosols containing microorganisms generated from an infected individual and propel at a short distance by coughing and talking without a mask; and indirect contact with contaminated instruments and/or environmental surfaces. Taking into account the severity of COVID-19, and all in all the wholesome devotion of several dental associations and dental journals, it is essential to give clear and easy guidelines to manage dental patients and to make working dentists safe from any risk. Testing for COVID-19 in dental professionals should be undertaken with the same high priority as that of medical health-care workers in hospitals.
| Indian Scenario|| |
In India, the Indian Dental Association and the Dental Council of India recommend preventative measures for dental professionals to minimize transmission through contact and dental procedures which consist of numerous ways to minimize the chance exposure and guides on the proper usage of personnel protective equipment (PPE), actual hand hygiene techniques, etiquette for cough and respiratory hygiene, waste disposal, disinfection and cleaning of patient care equipment, and importantly training and education of the personnel. The hand hygiene technique recommended by the WHO is advised as per the standard precautions. If soap and water are unavailable, usage of at least 60% alcohol-based hand sanitizer is advised after contact with the patient. The Joint Position Statement from the Indian Endodontic Society, Indian Dental Association, and International Federation of Endodontic Associations states that “whilst it is recognized that practitioners from different countries will be subject to the governing authorities and directives of their country, nevertheless this general position statement is for the benefit of endodontists and dentists and provides an objective method of streamlining their dental practices based on need and evidence based disease containment protocols.” [Figure 1] shows the recommended drugs for emergency care patients reporting with severe dental pain during COVID-19 Pandemic:
|Figure 1: The recommended drugs for emergency care patients reporting with severe dental pain during coronavirus disease 2019 pandemic|
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- The pain felt by patients diagnosed with symptomatic irreversible pulpitis may also be alleviated by administering 4 mg dexamethasone either orally or through intraligamentary and mainly supraperiosteal injections
- A Cochrane review illustrates that there is not enough evidence to recommend the use of antibiotics to reduce pain in cases with irreversible pulpitis. (Note that if patient reports with signs and symptoms of acute apical abscess/cellulites, appropriate antibiotic medications have to be given)
- The current WHO guideline has not contraindicated the usage of ibuprofen during COVID-19 pandemic as on March 27, 2020. However, with conflicting research in this issue, this position statement would recommend the usage of alternative medications to ibuprofen given above.
The same bodies recommend something called as triaging and tele-screening, keeping in mind the standard guidelines to prevent the symptoms from worsening. Triaging is the process of determining the priority of patients' treatment needs based on the severity of their condition. Even when not using aerosol generating procedures, it is important that robust infection control measures are employed. In nonclinical areas such as reception and waiting areas, thorough cleaning should take place. Ideally, all nonessential items should be removed from these areas and surfaces free of clutter[Figure 2].
|Figure 2: Checklist for dental centers before treating patients during coronavirus disease 2019 pandemic. *Adapted from the National guidelines for infection prevention and control in healthcare facilities, National Centre for Disease Control, Directorate General of Health Services. Ministry of Health and Family Welfare, Government of India. January 2020. *https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.htmlGuidelines for Environmental Infection Control in Health-Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)|
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In dentistry, with the principle of universal precautions for cross-infection control, based on an understanding, we may not know whether a patient has the potential for disease transmission or not. As more advanced PPE is advocated for health-care professionals caring for COVID-19 patients, this level of protection should be used for all patients considering the transmission from asymptomatic patients also. All treatments must be done keeping in mind the safety of patients, the staff, and the dentist himself. India has over half a million registered dentists. It is also alarming that the virus can survive on surfaces or objects that are exposed to the aerosol splatter with saliva. Thus, it is highly advocated to follow and implement the precautionary guidelines to prevent themselves from being the epicenter of the disease.
| The Reception or Patient Waiting Area|| |
The reception is the first area of encountering a patient. Any patient might directly walk in into the clinic, which must be discouraged during this time. The staff must be well informed about the protocol that has to be followed. The dentist has the whole right of educating and informing the patients through tele-screening with the help of applications available on the digital platform. These may prove effective tools for the same. The patient as well as the staff must maintain social distancing from others, which means escorting the patients to the treatment area is unnecessary at the present. As mentioned, the patient can be provided with a surgical mask and an alcohol-based rub before consultation [Figure 2]. A disinfection and sterilization protocol has been recommended:,
- Avoid sweeping with broom
- Use wet moping with warm water and detergent or hospital disinfectant (e.g., 1% sodium hypochlorite)
- High-touch surfaces must be cleaned more frequently with detergent/disinfectant (including door handles, chairs, and desks).
| Dentists Prior to Treatment|| |
The WHO guidelines on hand hygiene in health care (2009) suggest that hand hygiene is the single most important measure for the prevention of infection.
Hand hygiene is a simple but very effective measure in preventing any contamination. When soiled with any dirt (blood or after using washroom), hands must be washed using soap and water. An alcohol-based hand rub is just effective when hands are not visibly soiled or when soap and water are not necessary.
Dental professionals should avoid touching their own eyes, mouth, and nose.,
The essential use of PPE stands as a highly reliable method for preventing further contamination. These are strongly recommended for all health-care providers and support staff in the clinic/hospital settings.,, Before meeting the patient, the dentist must be fully geared with all the PPE.
The use of PPE, including protective eyewear, masks, gloves, caps, face shields, and protective outerwear, is strongly recommended for all health-care givers in the clinic/hospital settings during the COVID-19 pandemic,
- A triple-layered surgical mask can be worn by all health-care providers when within 1–2 m of the patient
- Particulate respirators (N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union) are recommended for routine dental practice
- If available, an FFP3-standard mask should be used, and in COVID-19-positive patients, this would be considered essential.
The IES, IDA, and IFEA recommend a preparedness checklist to verify before treating a patient. The dental practitioner is recommended to not to treat the patient unless he/she complies with all the above points in the checklist; if not, the patient must be referred to a well-equipped dental center or local medical authorities [Figure 3].,
|Figure 3: The list of personnel protective equipment that must be used as recommended by the DCI|
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The DCI not only emphasizes on the usage of the PPE but also gives important guidelines on how to put them on and to remove them, which has to be followed in a sequence [Figure 4].,
|Figure 4: The sequence of steps to be followed while putting the personnel protective equipment|
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| Preprocedural Mouthwash|| |
The established safety profile of PVP-I (povidone iodine) from over 60 years of use provides a strong rationale for the use of PVP-I oral solution for protective oropharyngeal hygiene management for individuals at high risk of exposure to oral and respiratory pathogens. Application of PVP-I products with concentrations of 0.23%–1% for 1–2 min reduced severe acute respiratory syndrome coronavirus (SARS-CoV) virus infectivity. Iodine is effective in inactivating both enveloped and nonenveloped viruses.
An oral rinse with 1% hydrogen peroxide or 0.2% povidone iodine is highly efficient in reducing the infectivity of SARS-CoV virus by reducing the salivary load of oral microbes.,, Chlorhexidine gluconate (CHG) is a very commonly used mouthwash, which has wide antimicrobial action and is considered the gold standard. However, CHG is found to be ineffective against SARS-Cov-2.
| During Treatment|| |
If gloves are torn or compromised during the procedure, it is recommended to perform hand hygiene technique again to contain the contagion.
| Dental Treatments and Aerosol Splatter|| |
One of the most evident things during dental procedures is the production of aerosols be it tooth preparation with a rotary instrument or air abrasion, use of 3 way air-water syringe, use of an ultrasonic scaler or during polishing. Air polishing incorporates slurry made up of air, water, and sodium bicarbonate in a commercial device [Figure 5].,
It is recommended that any aerosol-producing procedures are to be avoided. Dental imaging like intraoral radiography is also to be minimized as it tends to stimulate saliva secretion and induce coughing.,
Essentially, if any procedure involve aerosol production,it should only be done in dental/medical set ups equipped with negative pressure or (airborne infection isolation room) treatment rooms which allow for complete disinfection to prevent cross-contamination
| Posttreatment|| |
The whole clinical setting has to be disinfected as mentioned before. Reusable instruments should be pretreated, cleaned, sterilized, and properly stored. Disinfectants containing isopropyl alcohol and 0.5% sodium hypochlorite must be used [Figure 6].,
|Figure 6: The sequence of steps to be followed when removing the personnel protective equipment|
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| Waste Disposal|| |
Medical and domestic waste should be marked and disposed in accordance with the Biomedical Waste Management and Handing Rules 2016, 2018, [Figure 7].
|Figure 7: Medical and domestic waste should be marked and disposed in accordance with the biomedical Waste Management and Handing Rules 2016, 2018|
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| Other Important Aspects|| |
India is finishing almost 2 months of lockdown due to COVID-19. No chosen representative of dental fraternity has yet raised a voice on national level about the disaster that dentistry is going to face. There are few aspects wherein the field of dentistry can expect a crisis in the future: financial aspect, disinfection and sterilization aspects and patient traffic aspect.
| Financial Aspect|| |
Almost cent percentage of dentists have been forced to shut down their practice as a preventive measure. The additional scarce of patients not visiting will have led many of the dentists into a financial catastrophe. With such a less number of treatments happening, it would be unlikely that a dentist could bear to pay the salaries of helping staff. The first person to lose the job would be the associate dentist as there would be no clinical overwork to be handled. This will increase the unemployment in the fraternity. Private practitioners specially will be hit hard as they have to pay the rent of the clinics, salary of the employees, pending bills, and loans from the bank.
For years, dental treatments have been considered costly; in addition, majority of public are aware that the highest risk groups among health personnel are dentists, leading to less and less patients being ready to actually meet with a dentist and more resolving to a pharmacy for analgesics. In addition, the usage of recommended PPE extensively will catapult the dental expenses further.
With little or no earning, private dental practitioners are forced to resort to drastic measures. The government can pitch in and save the dental professionals by granting an economic package.
| Disinfection and Sterilization Aspect|| |
As per the report published in EClinicalMedicine, April 2020, 100% of patients treated for dental problems in Wuhan, China, were found to be corona positive within days of getting the dental treatment. The COVID-19 virus spread across in no time, with Kerala reporting the first positive case in India. Most practicing dentists are unaware of the sterilization guidelines. What can such vulnerable majority of dentists do during such an outbreak? With the present outbreak, a separate dedicated area is required for step-wise decontamination and sterilization.
The dentists need to be properly trained and also be prepared to work under rigid disinfection and sterilization protocols.
| Patient Traffic Aspect|| |
The drastic loss of patients would force close a huge number of dental centers across the country once the country starts getting back to the normality. Unless a high level program to educate and inform the public about oral health awareness is started today, a good number of dentists will be forced to leave the profession by this yearend. As in other countries, a dental insurance can help cope up with the finance of dentists. School Dental Health Program must be immediately and strictly implemented engaging one dentist per 2000 students.
| Conclusion|| |
In an article published in JKNewsline titled, “Corona virus in India: Package for private dentists sought” even after lockdown, Jammu and Kashmir dentists will not be able to work on patients for at least 2–3 months. At present, the treatment of COVID-19 is based on containment measures, which have to an extent reduced the new cases from emerging. As in India, the ICMR has approved the usage of plasma therapy for COVID patients in the southern state of Kerala, the state which has effectively flattened the curve to a significant mark. High amount of limitation to the surgical and clinical activities in dental and medical sector will have an adverse effect on the country's economy, which is inevitable at this point of time. The citizens can also take responsibility and practice social distancing and hand hygiene and follow other healthy habits including maintenance of good oral hygiene to prevent any emergency from happening. To conclude, “Not all heroes wear capes, some wear gloves and masks.” This too shall pass.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]