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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 110-114

Management of Coronavirus disease 2019 in dentistry


1 Department of Orthodontics and Dentofacial Orthopedics, MGM Dental College and Hospital, Kamothe, Navi Mumbai, Maharashtra, India
2 Private Practice, DentisTree Multispeciality Dental Clinic and Implant Center, Ulhasnagar, Maharashtra, India

Date of Submission18-Apr-2020
Date of Decision16-May-2020
Date of Acceptance01-Jan-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
Neetha Pious
10C - Dhavalgiri, Anushakti Nagar, Mumbai - 400 094, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_13_20

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  Abstract 


Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the most recently discovered severe acute respiratory syndrome coronavirus 2. The outbreak of COVID-19 which was first detected in Wuhan, China, has evolved swiftly into a worldwide health crisis. The disease started spreading globally from 2019 and has resulted in the 2019–2020 coronavirus pandemic. Being a recently discovered disease, several aspects about it are unknown. Infection control measures are needed to control this pandemic situation. The characteristics of dental settings may give rise to the risk of cross-infection for both patients and dentists. Thus, certain guidelines should be followed by dental practitioners, and infection control protocols are urgently needed. Literature review was performed in PubMed, PubMed Central, EBSCO, and Google Scholar using keywords to identify and gather data. This article can serve as a guidance for dentists to deal with coronavirus disease.

Keywords: Coronavirus, coronavirus disease 2019, dentistry, infection control, severe acute respiratory syndrome coronavirus 2


How to cite this article:
Pious N, Mhatre A, Ingole SD. Management of Coronavirus disease 2019 in dentistry. J Oral Res Rev 2020;12:110-4

How to cite this URL:
Pious N, Mhatre A, Ingole SD. Management of Coronavirus disease 2019 in dentistry. J Oral Res Rev [serial online] 2020 [cited 2020 Aug 10];12:110-4. Available from: http://www.jorr.org/text.asp?2020/12/2/110/290501




  Introduction Top


Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the most recently discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] COVID-19 is a beta coronavirus, a part of the Coronaviridae family.[2] It belongs to one of the four different groups of coronaviruses categorized by the Centers for Disease Control and Prevention (CDC) and is in the same family of virus which caused severe acute respiratory syndrome and Middle East respiratory syndrome.[3] The outbreak of COVID-19 which was first detected in Wuhan, China, has evolved swiftly into a worldwide health crisis. The disease started spreading globally from 2019 and has resulted in the 2019–2020 coronavirus pandemic. Being a recently discovered disease, several aspects about it are unknown to the general public, including how it spreads. Health-care professionals are on the front lines of taking care of patients with confirmed cases as well as suspected cases of coronavirus disease, thus making them prone to the risk of exposure to this new disease.[4]


  Methodology Top


Literature review was performed in PubMed, PubMed Central, EBSCO, and Google Scholar database. Data were gathered using the keywords “Coronavirus,” “COVID-19,” “SARS-CoV-2” “infection control,” and “dentistry.” The title, abstract, and reference list of acquired articles were analyzed and data were extracted by the three authors on the basis of its relevance to dentistry. A total of 26 articles were selected from which data were extracted, reviewed, and compiled in a correct manner.


  Severe Acute Respiratory Syndrome Coronavirus 2 Top


SARS-CoV-2, the source of COVID-19, is a betacoronavirus on the basis of its viral genome.[2] It has a typical coronavirus structure with spike protein in the membrane envelope. They exhibit other polyproteins, nucleoproteins, and membrane proteins, such as ribonucleic acid (RNA) polymerase, 3-chymotrypsin-like protease, papain-like protease, helicase, glycoprotein, and accessory proteins. The entry of the coronaviruses SARS-CoV-2 into cells depends on the binding of the viral spike (S) glycoproteins to cellular human angiotensin-converting enzyme 2 (ACE-2), which the virus uses as its entry receptor. In addition, S proteins are primed by host cell proteases.[5] This subsequently leads to the fusion of the viral envelope and the plasma membrane or the endosome membrane of the host. It has been indicated that the SARS-CoV-2 S protein binds to ACE2 with 10–20-fold higher affinity than the S protein of SARS-CoV which could be the reason for the rapid spread of SARS-CoV-2 in humans.[6] Human coronaviruses can remain infectious on inanimate surfaces at room temperature for up to 9 days. At a temperature of 30°C or more, the duration of persistence is shorter. Veterinary coronaviruses have been shown to persist even longer for 28 days.[7]


  Risk Top


Dentists are at high risk of getting infected by this disease [Figure 1].[8] With increasing knowledge of this novel disease, dental practices should be better prepared to detect a possible COVID-19 infection. Furthermore, patients with suspected, confirmed, or a history of COVID-19 infection should be referred to appropriate treatment centers.[9]
Figure 1: Dentists are at high risk of getting infected by coronavirus disease 2019.[8] Credit Note: Image has been taken from article titled “The Workers Who Face the Greatest Coronavirus Risk” by Lazaro Gamio published on March 15, 2020 in The New York Times

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  Symptoms Associated Top


The most common symptoms of COVID-19 are pyrexia, myalgia, tiredness, and dry cough.[10] Few patients reported with nasal congestion, runny nose, sore throat, or diarrhea. These symptoms are usually mild and begin gradually. Some people become infected but remain asymptomatic and do not feel sick.[11],[12] Most people recover from this disease without needing any special treatment. It is noteworthy that the incubation period can range from 0 to 14 days; therefore, transmission can occur before any symptoms are apparent. Some of the patients who contracted COVID-19 became seriously ill and had difficulty breathing. Older people, immunocompromised, and those with underlying medical problems such as high blood pressure, heart problems, or diabetes, are more likely to develop serious symptoms such as pneumonia or acute respiratory distress syndrome.[13]


  Mode of Transmission Top


COVID-19 disease is typically spread by direct transmission (cough, sneeze, and droplet inhalation transmission) and contact transmission.[14] Coughing or sneezing by an infected person can render the virus airborne, increasing chances of infecting individuals in close contact (within approximately 6 feet). Dental setting invariably carries a high risk of infection as it requires direct person-to-person communication. Research shows that SARS-CoV-2 binds to human ACE-2-positive cells, which are highly concentrated in the salivary glands, thus indicating the presence of SARS-CoV-2 in secretory saliva.[15] Most of the dental procedures involve frequent exposure to saliva, blood, and other body fluids. The virus can be transmitted in clinical settings through inhalation of airborne microorganisms that can remain suspended in the air for long periods and also due to contact with blood, oral fluids, conjunctival, nasal, oral mucosa with droplets, and other patient materials.[16],[17] Aerosols containing microorganisms may be generated from an infected individual during dental procedures. The dimension of the dental aerosol particles is usually less than 50 μm. The smaller particles with a size between 0.5 μm and 10 μm can get suspended in air, inhaled, and has the potential to transmit the infections. Transmission may also be through indirect contact with contaminated instruments and/or environmental surfaces. Dentists are among professionals who are at the highest risk of exposure to COVID-19. Furthermore, if sufficient precautions are not undertaken, the dental setting can potentially expose healthy patients to cross-infection. In addition, studies have shown the presence of SARS-CoV-2 in feces of the affected patients, thus indicating fecal–oral route of transmission.[18]


  Vaccine and Treatment Top


As of date, no concrete treatment or vaccine has been found for tackling coronavirus disease. The pandemic has catalyzed the development of coronavirus vaccines by several pharmaceutical companies and research organizations such as the National Institutes of Health, US. Recent publications have suggested a possible benefit of chloroquine and hydroxychloroquine, a common antimalarial drug along with azithromycin (antibiotic), in the treatment of patients infected by this novel virus.[19] Gilead's remdesivir has shown efficacy in treating the coronavirus infection according to the WHO officials.[20] Favilavir, an antiviral drug, has been approved by the National Medical Products Administration of China as a treatment for coronavirus.[21],[22] The drug has reportedly shown efficacy in treating the disease with minimal side effects in a clinical trial. The clinical trial is being conducted in Shenzhen, Guangdong province. Several coronavirus vaccines are in various stages of development, across the world, and are competing to develop the prophylactic vaccine using several platforms including mRNA, DNA, adenoviral vector, and recombinant protein.[23]


  Infection Control in Dental Settings Top


The CDC has given its Interim Infection Prevention and Control Recommendation for health-care practitioners to tackle COVID-19.[24]

Awareness and prevention

Measures should be taken to minimize exposure to the virus in the office to protect both patients and staff. Dentists should update their patient reminder scripts. Reminder voicemails, texts, emails, or calls should be done to advise patients that if they have symptoms of a respiratory infection (e.g., cough, sore throat, fever, sneezing, or shortness of breath); they should not come in and refer them to a physician. The travel history of the patient should be taken in detail. Patients with suspected symptoms and with travel history to virus-infected countries should be referred to appropriate treatment centers. Patients should be encouraged to be in self-quarantine as a preventive method. Signs or posters should be posted in the reception area advising patients on good hygiene and cough etiquette. Signs may be put up instructing patients to tell staff if they are experiencing any flu-like symptoms. Most dentists have been advised by most organizations to conduct only emergency procedures and avoid elective procedures.

Self-protection

Everyone should follow standard safety precautions.

Basic hygiene

Good hand hygiene is of utmost importance as is proper personal protective equipment (PPE) standards. The CDC recommends the usage of health care grade alcohol-based hand sanitizer before and after all patient contact, contact with potentially infectious material or surface, and before putting on or removing PPE, including gloves. Furthermore, hands should be washed with soap and water for at least 20 sec after contact with patients. Touching eyes, nose, and mouth with unwashed hands should be avoided.

Face protection

Surgical or procedure mask and eye protection gears like face shield or goggles should be worn to protect mucous membranes of the eyes, nose, and mouth during activities that are likely to generate splashes or sprays of blood, body fluids, and other secretions. N95 respirators or respirators that offer a higher level of protection should be used by dental personnel instead of a facemask when performing or present for an aerosol-generating procedure. pulling the mask under the chin should be avoided, as when it is pulled under the chin, contamination on the neck transfers to the inside of the mask. Replacing the mask on the face exposes the mouth and nose to those contaminants. Either keep the mask on or get a new one.

Body protection

It is recommended to wear a gown to protect skin and prevent soiling of clothing during procedures that are likely to generate splashes or sprays of blood or body fluids. Discard soiled gown as soon as possible. Dental personnel should preferably wear buttoned clinic jackets rather than scrub tops that must be pulled over the head, bringing the soiled garment in contact with the eyes, nose, and mouth.

Handling, transport, and processing of linen should be done such that it prevents skin and mucous membrane exposures and contamination of clothing. Transmission of infectious agents to other patients or the environment should be avoided.

Basic precautions to be taken with the patients entering the clinic

Take a detailed travel and health history. Take temperature readings as part of the routine assessment of patients before performing dental procedures. It would be better if noncontact or disposable thermometers are available at the front desk, with a trash can available on the patient side of the desk for disposal. Patients who present with fever (>100.4°F = 38°C) and/or respiratory disease symptoms should have elective dental care deferred for at least 2–3 weeks. Hand sanitizers and tissues should be available in the waiting area also. Provisions for respiratory hygiene and cough etiquette should be provided including alcohol-based hand rub with 60%–95% alcohol and tissues and no-touch waste bin for disposal in waiting rooms.

Patients with suspected and confirmed symptoms requiring emergency care like toothache and/or swelling may be given antibiotics and/or analgesics. This approach may offer symptomatic relief and will provide dental professionals some time to develop a plan to deliver dental care with appropriate measures in place to prevent the spread of infection. It is recommended to prescribe acetaminophen for analgesia instead of ibuprofen in treating COVID-19-infected patients, as ibuprofen may interfere with immune function.[25]

Precautions during dental treatment

Certain instances such as dentoalveolar trauma, swelling, extreme dental pain, or progressive fascial space infection will definitely warrant emergency dental intervention for which extra precautions will be required.

  • Patients can be taken for emergency dental procedures, after getting COVID-19 test
  • Negative and written clearance from the physician
  • Before performing any dental procedure, one should take informed consent and signature on the declaration form to avoid any medicolegal disputes
  • Make sure the PPE being used is appropriate for the procedures being performed
  • Have patients rinse with a 0.2% povidone-iodine solution before each appointment[26]
  • Four-handed dentistry will allow the procedure to be performed efficiently
  • Use a rubber dam when appropriate to decrease possible exposure to infectious agents
  • Use high-speed evacuation for dental procedures producing an aerosol. Treatment should preferably be performed in negative pressure treatment room/airborne infection isolation rooms
  • Use of disposable (single use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross-contamination
  • Extraoral imaging such as panoramic radiograph or cone-beam computed tomography should be preferred to avoid the gag reflex or cough that may occur with intraoral imaging. When intraoral imaging is required, sensors should be double barriered to prevent perforation and cross-contamination.[27] Impervious-backed paper, aluminum foil, or clear plastic wrap may be used to cover surfaces (e.g., light handles or X-ray unit heads) that may be contaminated by blood or saliva and that are difficult or impossible to disinfect. The cover should be removed (while gloved), discarded, and then replaced (after ungloving) with new material after each patient.


Waste disposal

Ensure safe waste management. Waste contaminated with blood, body fluids, secretions, and excretions should be treated as clinical waste and they should be disposed in accordance with local regulations. Discard single-use items properly.

Additional precautions

  • All blood- or saliva-contaminated instruments should be considered potentially infectious. They should initially be disinfected, autoclaved, or chemically sterilized, then cleaned and heat- sterilized once again. Gloves and protective clothing should be worn while dealing with contaminated materials
  • Spills of blood and other infected materials should be covered with a disinfectant solution before washing thoroughly. Used cloths and mops must be sterilized before being disposed. Avoid reusing them
  • At the completion of work activities, countertops and surfaces that may have become contaminated with blood or saliva should be decontaminated. Virus can persist on inanimate surfaces such as metal, glass, and plastic and can be inactivated by surface disinfection procedures using 62%–71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 min[7]
  • Autoclave handpieces after each patient
  • Clothing worn during treatment and cleanup should be removed only when all cleaning and sterilizing are complete. Such clothing should be regarded as infectious and collected and disinfected prior to normal laundering to clinical standards. Clothing should be removed in the clinical area
  • Frequently clean and disinfect public areas including door handles, chairs, and bathrooms.



  Discussion Top


Coronavirus disease has spread across almost all countries in the world. With the high rate of transmission and the rate of mortality increasing, it has become a great concern for all health-care professionals all over the world. All dental personnel should keep themselves updated about this evolving pandemic. To contain the infection, dentists have been advised to stop all elective procedures and only treat patients requiring emergency care. Each patient should be treated as a potentially infected person. The dentists must ensure all protective measures if undertaking any such emergency procedure to protect themselves, the patients, and others from acquiring or spreading this novel contagious disease. As of date, specific treatment drugs and vaccines for this disease are yet to be formalized, which will further dictate the future management of coronavirus disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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