|Year : 2021 | Volume
| Issue : 1 | Page : 71-75
Consolidating facts and redesigning a novel pediatric dental practice in nCOVID-19 pandemic
Khooshbu Gayen, Supreet Shirolkar, Sauvik Galui, Subrata Saha, Subir Sarkar
Department of Pedodontics and Preventive Dentistry, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India
|Date of Submission||29-May-2020|
|Date of Acceptance||21-Nov-2020|
|Date of Web Publication||15-Feb-2021|
Village. Bagbari, PO. Baligori, P.S Tarakeshwar, Hooghly - 712 410, West Bengal
Source of Support: None, Conflict of Interest: None
The pandemic of coronavirus disease 2019 has been the most unprecedented event of our lifetimes, touching, and probably forever changing all realms of our lives and livelihoods. The field of general and speciality dental practice remains no exception. Among all health-care professionals, dentists as oral health caregivers are those who are most susceptible to contracting this infection. A never before situation like this has engaged all of humanity in studies and research for better understanding and possibly reducing the disaster that this terrible virus can inflict upon humanity. These efforts have led to a lot data, much of which is anecdotal evidence and thus a dire need to segregate facts has risen. Dentists in general and pediatric dentists in particular who routinely deal with children and managing them for dental care are at a heightened risk because of their job primarily in the oral cavity. Children routinely take longer appointments compared to adults and require more care to be exercised during this pandemic. This infection often presents asymptomatically which further complicates the problem. Thus, in a world that exists during and after this pandemic demands a reimagined dental practice that is safe for the health workers as well as effectively and efficiently delivers oral health care to all age groups. This can be achieved by rigorous and extensive study and consolidation of this knowledge which can then be adapted by health workers on the ground.
Keywords: COVID-19, gooseneck, n95, pediatric dental practice
|How to cite this article:|
Gayen K, Shirolkar S, Galui S, Saha S, Sarkar S. Consolidating facts and redesigning a novel pediatric dental practice in nCOVID-19 pandemic. J Oral Res Rev 2021;13:71-5
|How to cite this URL:|
Gayen K, Shirolkar S, Galui S, Saha S, Sarkar S. Consolidating facts and redesigning a novel pediatric dental practice in nCOVID-19 pandemic. J Oral Res Rev [serial online] 2021 [cited 2021 Mar 4];13:71-5. Available from: https://www.jorr.org/text.asp?2021/13/1/71/309430
| Introduction|| |
A novel virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the most serious challenges to health-care profession with its global pandemic outbreak. By the Chinese center for disease control and prevention, the above-mentioned coronavirus was officially declared as the causative pathogen of coronavirus disease 2019 (COVID-19) on January 8, 2020. The first case of COVID-19 was detected from Wuhan, China, in last December and soon became a major challenging health-care problem in countries worldwide. The emerging virus was declared as Public Health Emergency of International Concern by the World Health Organization (WHO) Director-General on the Recommendation of the International Health Regulations (2005) Emergency Committee on January 30, 2020.
Recently, the identification of COVID-19 was done in saliva of infected patients. During routine dental clinical procedures, there is always a potential of COVID-19 transmission through contact with the generated aerosols and droplets. Hence, there is a need of understanding the potential risk which is crucial to improve fruitful strategies for prevention, especially for dentists and health-care professionals who perform aerosol-generating procedures. The risk of cross infection is also high between the dental practitioner and patients due to these characteristics. On January 23, 2020, the first case of a dentist being tested positive for COVID-19 was reported at the department of preventive dentistry in the Wuhan university dental hospital. The rate of new case detection and along with the registered data is changing daily. As of May 20, 2020, 09:51 h (Indian Standard Time), the number of confirmed cases were 106,878 and reported deaths were 3302 with 42,326 recovered patients in India.
The clinical manifestations and the peculiarity of epidemiological spread of COVID-19 in children have not been thoroughly enlightened yet. Children are the most vulnerable part of society and the most challenging to a dental care professional to manage while providing oral health care. Hence, this article emphasizes on the importance of most relevant safety measures to prevent the cross infection between the dental care professional and the child patient while providing oral health-care delivery considering every patient can be a potential carrier. Healthcare workers, such as dentists, may be inadvertently providing direct care to them who are infected but not yet diagnosed with COVID-19 positive or those who are considered to be questionable cases for surveillance.,
| Mode of Transmission|| |
According to recent research SARS-CoV-2 is zoonotic, and the most probable origin is Chinese horseshoe bats (Rhinolophussinicus)., The transmission routes of COVID-19 are still to be narrowed upon, but human-to-human transmission has been confirmed., Interpersonal transmission is now considered to occur mainly through contact transmission and respiratory droplets (The Chinese Preventive Medicine Association 2020). There is possibility of asymptomatic infections and before the appearance of symptoms transmission may occur. This feature of COVID-19 makes it extremely challenging and difficult to control the spread. Vertical transmission (from mothers to their new-borns) occurs or not is yet to be confirmed.,
| Risk of Infection in Dental Practice|| |
The patient who come for seeking the treatment can be infectious, he/she can cough or sneeze and can spread the infection. While during the dental procedure, the use of high-speed hand piece or ultrasonic instruments can produce aerosol which may contain the saliva, secretions, or blood of the infected patient which can be a potential source of infection., The dental apparatus present in the operatory room and the dental setting such as dental chair, their handles, the spittoon can get infected also and can further spread the infection. The virus can abide on the contaminated surfaces up to 72 h. Hence, professions like dentistry involve dealing with aerosols, where there is always a high chance of getting infected or causing the spread of infection. The routine protective measures that are usually followed are not sufficient to prevent the infection.
| Risk Factors with Pediatric Patient|| |
Previous treatment pathways are common in case of treating dental patient of any age group but additional risk of transmission is there in case of pediatric patient: While dealing with auxiliary elements in fixed orthodontic therapy like intermaxillary elastic bands or removable orthodontic appliances contains risk of contamination if not handled properly with due precautions. It becomes more challenging while dealing with a child patient as it is most difficult to make them follow the commands and as they can be asymptomatic or can show mild or nonspecific symptoms. Another problem is that it is difficult for a child to endure personal protective equipment during visits. Most of the time while doing treatment the parents are allowed to be present in the operatory room. Hence, all child patients including their parents should be considered as potential source of infection and precautions should be taken accordingly [Figure 1].
| Clinical Features of COVID-19|| |
Majority of affected patients showed the following clinical symptoms:
- Dry cough
- Difficulty in breathing
- Nonrespiratory symptoms such as muscle pain, headache, confusion, sore throat, diarrhea, and vomiting.
| Features in Children|| |
Children display almost the same symptoms, but the symptoms are milder in case of them. As per health ministry update on April 4, 2020, 9% of coronavirus positive cases in India aged below 20 years. As accessed from the Ministry of Health and Family Welfare, the age wise data of first 2000 infected cases revealed 53 children were under the age of 10 years, of which 10 were <1 year old while 6 patients were 1-year old.
| Recommendations for Management During COVID-19 Outbreak|| |
According to the WHO, this pandemic has six different phases, and in different times, a country will be in different phases so it is not possible to implicate universal guidelines, rather, it is essential to follow local updated guidelines. During health-care delivery when infection of COVID-19 is suspected Interim guidance on infection prevention is recommended (WHO 2020a). On the basis of relevant guidelines and research strict personal protection measures should be taken by dentist.
- As a routine procedure, precheck triages for the measurement of temperature of every staff and patient are recommended
- Proper history from the patient and their accompanying person about health status and if any travel history, should be taken
- Minimum number of entry in the waiting room should be granted
- Avoid or minimize operative procedures which can produce droplets or aerosols
- ”Two before and three after” technique is recommended as a standard hand hygiene procedure in a Chinese study which emphasizes that oral health-care provider should wash their hands before starting examination on the patient, before the treatment procedure and after having a direct contact with the patient, after touching the equipment before the disinfection, after touching the oral mucosa of patient or coming incontact with saliva or oral secretion of the patient
- The operatory room should be well ventilated
- Before starting any dental procedure, the patient should be instructed to use antimicrobial mouth rinse to reduce oral microbial count pre operatively
- For controlling infection, four-handed dentistry can be beneficial
- High or low volume saliva ejectors and rubber dam should be used to reduce aerosol,,
- As an extra preventive measure for crossinfection anti-retraction handpiece which have special anti-retraction designs such as anti-retractive valves are strongly recommended which can significantly reduce backflow
- Regarding personal protective equipment, the use of N-95 respirator masks or filtering facepiece respirator masks are strongly indicated
- Disposable filtering facepiece such as N95s are not approved for routine decontamination but when alternatives are not available in accordance with OSHA's previous coronavirus-related enforcement memoranda Filtering Facemask Respirator decontamination and reuse may be needed. Based of the available limited research, as of April 2020, the National Institute for Occupational Safety and Health suggests the following methods that provides the most promise for decontaminating FFRs:
- Vaporous hydrogen peroxide
- Ultraviolet germicidal irradiation
- Moist heat
- If all above methods not available, microwave-generated steam or liquid hydrogen peroxide could also be suitable.
Sufficient objective data that demonstrate the safety and effectiveness are needed to consider the following methods acceptable:
- Dry heat
- Isopropyl alcohol
- Chlorine bleach
- Ethylene oxide
- Dry microwave irradiation
- Disinfectant wipes.
- While using high- or low-speed drilling with water spray face shields and goggles are essential
- While doing more severe dental procedure, give the patient the last appointment of the day to decrease the risk of spread of infection. After that environmental and disinfection processes should be followed
- Minimally invasive concept of dentistry should be in use to reduce the risk of infection such as atraumatic restorative treatment, using pit fissure sealants, silver diamine fluoride, selective caries removal, and the hall technique
- After the operatory procedure is done, PPE should be removed slowly to prevent self-contamination
- While dealing with suspected or confirmed cases of COVID-19 infection, the contaminated medical and domestic wastes are considered as infectious medical waste and they should be packed in yellow double layer package bags which are ligated by “gooseneck” ligation
- Use online advisory and telemedicine as much as possible.
It is impossible to cover all possible circumstances simply through guidance and eventually, decision to provide treatment or not can only be made by professional judgment.
| Recommendations for Pediatric Patient|| |
Implementation of specific protocol for adequate management of oral health care of children becomes of crucial importance precisely during this COVID-19 outbreak period. For the above purpose, pediatric dentists can use social digital platforms to publish and spread behavior guides for oral health-care maintenance of children.
According to recent studies, the most commonly used mouthwash, chlorhexidine is not effective against SARS-COV-2 virus. On the other side, the virus appears to be vulnerable to oxidation so to reduce the oral bacterial load oral rinse with antiseptic solutions can be instructed to child patients.
| Conclusion|| |
This global pandemic is a unique and one of the most difficult challenges to all the health-care professionals and dental professionals are in the highest risk zone. Dental team must ensure that they remain updated about the ongoing conditions and the changing guidelines to optimize safety to dental care providers and patients. Although in reported cases of infected children, the clinical manifestations found are less severe, the young children particularly infants are always vulnerable for infection and have a significant risk of transmission. Dentists who are treating children in this pandemic should follow universal infection control procedures to the highest standard and expertise this behavior through their teams. Throughout the pandemic and after that, when the practice will be undertaken, dentists will have to be more responsible, careful while taking the decisions of providing oral health care, especially procedures which create aerosols and also will have to consider every patient, including children, as a potential source of infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al
. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): Emerging and future challenges for dental and oral medicine. J Dent Res 2020;99:481-7.
Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig 2020;24:1619-21.
World Health Organization. Global Surveillance Forhuman Infection with Novel Coronavirus (COVID-19) Interim Guidance; 21 January, 2020. Available from: https://apps.who.int/iris/handle/10665/336097
. [Last accessed on 2020 Jan 28].
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al
. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.
Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al
. Genomic characterisation and epidemiology of 2019 novel coronavirus: Implications for virus origins and receptor binding. Lancet 2020;395:565-74.
Wu A, Peng Y, Huang B, Ding X, Wang X, Niu P, et al
. Genome composition and divergence of the novel coronavirus (COVID-19) originating in China. Cell Host Microbe 2020;27:325-8.
Shu Y, McCauley J. GISAID: Global initiative on sharing all influenza data – From vision to reality. Euro Surveill 2017;22:30494.
Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al
. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – An update on the status. Mil Med Res 2020;7:11.
Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al
. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9:51-60.
To KK, Tsang OT, Yip CC, Chan KH, Wu TC, Chan JM, et al
. Consistentdetection of 2019 novel coronavirus in saliva. Clin Infect Dis 2020;71:841-3.
Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al
. Perinatal transmission of COVID-19associated SARS-CoV-2: Should we worry? Clin Infect Dis 2020; Mar 17:ciaa226. [doi: 10.1093/cid/ciaa226].
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al
. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New Eng J Med 2020;382:1564-7.
Luzzi V, Ierardo G, Bossù M, Polimeni A. COVID-19: Pediatric oral health during and after the pandemics. Preprints 2020; Int J Paediatr Dent.2021;31:20-26. [doi: 10.20944/preprints202004.0002.v1].
Huang C, Wang Y, Li X, Ren L, ZhaoJ, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Mallineni S, Innes N, Raggio D, Araujo M, Robertson M, Jayaraman J. Coronavirus disease (COVID-19): Characteristics in children and considerations for dentists providing their care. Int J Paediatr Dent 2020;30:245-50.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.
Moussa SA, Mostafa NM, Arafa AF, Elbayoumi AA. The novel coronavirus (2019-nCoV) outbreakas a new challenge in the dental field. J Dent Oral Disord Ther 2020;8:6.
Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings--2003. MMWR Recomm Rep 2003;52:1-61.
Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yaskell T, Haffajee AD, et al
. Identification of early microbial colonizers in human dental biofilm. J Appl Microbiol 2004;97:1311-8.
Samaranayake LP, Peiris M. Severe acute respiratory syndrome and dentistry: A retrospective view. J Am Dent Assoc 2004;135:1292-302.
Hu T, Li G, Zuo Y, Zhou X. Risk of hepatitis B virus transmission via dental handpieces and evaluation of an anti-suction device for prevention of transmission. Infect Control Hosp Epidemiol 2007;28:80-2.
Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child 1989;56:442-4.
Smales FC, Samaranyake LP. Maintaining dental education and specialist dental care during an outbreak of a new coronavirus infection. Part 1: A deadly viral epidemic begins. Br Dent J 2003;195:557-61.
de Amorim RG, Frencken JE, Raggio DP, Chen X, Hu X, Leal SC. Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: An updated systematic review and meta-analysis. Clin Oral Investig 2018;22:2703-25.
Schwendicke F, Jäger AM, Paris S, Hsu LY, Tu YK. Treating pit-and-fissure caries: A systematic review and network meta-analysis. J Dent Res 2015;94:522-33.
Seifo N, Cassie H, Radford JR, Innes NP. Silver diamine fluoride for managing carious lesions: An umbrella review. BMC Oral Health 2019;19:145.
Li T, Zhai X, Song F, Zhu H. Selective versus non-selective removal for dental caries: A systematic review and meta-analysis. Acta Odontol Scand 2018;76:135-40.
Innes NP, Evans DJ, Stirrups DR. Sealing caries in primary molars: Randomized control trial, 5-year results. J Dent Res 2011;90:1405-10.