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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 53-56

Management of special needs patients in dentistry during the SARS-CoV-2 pandemic


Department of Head, Neck and Sense Organs, School of Dentistry, Catholic University of Sacred Heart, Rome, Italy

Date of Submission26-Jun-2020
Date of Decision10-Jul-2020
Date of Acceptance31-Jul-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Romeo Patini
Department of Head, Neck and Sense Organs, School of Dentistry, Catholic University of Sacred Heart, Largo Agostino Gemelli, 8 – 00136, Rome.
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_221_20

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  Abstract 

Special needs patients and their guardians commonly encounter several difficulties due to delayed provision of oral healthcare services in private and public sectors. They are a vulnerable group and are considered highly susceptible to the repercussions of the coronavirus disease-2019 (COVID-19) pandemic. The reduction in the availability of operating rooms and the inability to manage routine visits highlight the need to redesign the doctor–patient and dentist–patient relationship for this category of patients. Diagnostic accuracy and adjustments in drug therapies are crucial elements considering that patients with COVID-19 take drugs that can interfere with those usually prescribed for the control of oral pain and infections. This review aimed to provide some guidelines for the management of patients with special needs in dentistry during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

Keywords: COVID-19, Dentistry, Pandemic, Special Needs Patients


How to cite this article:
Patini R. Management of special needs patients in dentistry during the SARS-CoV-2 pandemic. J Int Oral Health 2020;12, Suppl S2:53-6

How to cite this URL:
Patini R. Management of special needs patients in dentistry during the SARS-CoV-2 pandemic. J Int Oral Health [serial online] 2020 [cited 2021 Apr 16];12, Suppl S2:53-6. Available from: https://www.jioh.org/text.asp?2020/12/8/53/301863


  Introduction Top


Around the middle of November 2019, a new virus belonging to the coronavirus family infected the human species for the first time, infecting a 55-year-old man from the province of Hubei, China. This coronavirus, which takes the name of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a viral strain belonging to the genus Betacoronavirus (Coronaviridae family), subgenus Sarbecovirus.[1] Since the end of January 2020, SARS-CoV-2 has spread to many Asian, European, and American states, recording some infections also in Africa, Oceania, and inducing the World Health Organization (WHO) to classify the disease associated with it (coronavirus disease-2019 [COVID-19]) on March 11, 2020, a pandemic.[2] From its appearance until today, COVID-19 has infected more than 12 million people, causing over 558,000 deaths worldwide.[3]

It is believed that in most cases the spread between individuals occurs through the respiratory droplets emitted by an infected subject through coughing or sneezing. Such droplets would be then inhaled by a healthy subject who is nearby.[4] Recent evidence, however, suggests that also contact transmission (contact with oral, nasal, and eye mucous membranes) must not be ignored.[5] Moreover, studies have suggested that 2019-nCoV may be airborne through aerosols formed during medical procedures.[6] In light of this evidence it can be affirmed that in dental clinics SARS-CoV-2 can find multiple ways to be spread. In fact, in addition to the elements described above, dental care settings carry the risk of 2019-nCoV infection due to the specificity of its procedures, which involves face-to-face communication with patients, frequent exposure to saliva, blood, and other body fluids, and the handling of sharp instruments.[7],[8] To stem the widespread of SARS-CoV-2, the health authorities, together with governments around the world, have imposed strict social distancing protocols and the obligation to use personal protective equipment (PPE) for the entire population. As dentists are considered health categories at risk of being vectors for the spread of the virus, regulatory authorities and professional dental associations, including the American Dental Association (ADA), promptly issued a position paper in which they strongly advise limiting the outpatient activity to cases of urgencies and emergencies only, both in public and private structures.[9] ADA also pointed out that dental emergency treatments (dental infections that endanger the patient’s life, serious trauma, and swelling) must be performed at qualified hospital facilities, whereas other emergency treatments must be performed on an outpatient basis without referring the patient to first aid centers.[9] The progressive reduction of ordinary dental activity has caused a huge economic damage to all countries affected by the pandemic and great discomfort to many patients. Among them, the patients with special needs[10] (those suffering from particular systemic or local conditions or having an age incompatible with the compliance required by the treatments) require special care from the medical-dental staff. In some cases treatments involve a multidisciplinary approach or the use of conscious sedation methods or medical care under general anesthesia.[11],[12],[13],[14]

Special needs children

During the SARS-CoV-2 pandemic, pediatric dentists may also have to manage the oral health of their patients if they are suffering from emergencies or urgent clinical situations. Epidemiological data regarding the clinical manifestations of COVID-19 have clearly shown that infected children can frequently show only mild or moderate symptoms of their condition or be completely asymptomatic.[15] Nevertheless, it has to point out that one study reported that SARS-CoV-2 seems to be able to cause a syndrome similar to Kawasaki disease (a multisystem disorder characterized by fever and vasculitis) in children. The same study also describes that cracked lip, skin rash, conjunctivitis, and edematous hands and feet can be connected to SARS-CoV-2 infection.[16]

In light of this evidence, it is advisable that pediatric patients with special needs strictly follow national guidelines and the most recent evidence in the literature regarding the management of cross-infection both in public structures and in private clinics.[17] In addition, it is recommended that the dentist get in touch with the parents of the patients, also through a video call, to evaluate the actual urgency of the disease and to evaluate their clinical status. In fact, children (even if without systemic diseases) are not able to correctly report the symptoms they are affected from.

If the dentist deems it necessary to carry out a treatment, he will have to inform the parents that only one companion can be present during the session. The temperature will be measured both for the child and the guardian before entering the clinics and everyone will have to wash their hands thoroughly with soap and disinfect with an alcohol-based gel.[17]

In the waiting room chairs should have spacing between them and common handling objects (such as toys) should be removed to avoid surfaces exposed to contamination.[18] All environments should be ventilated for 15 minutes every hour, preferably with open windows to renew the circulating air and reduce contamination by droplets suspended in the environment.[18]

Clinicians will wear all the PPEs required to contrast the spread of the virus and triage on the patient’s health will be re-proposed before the start of the therapies.[17] Any type of intervention should not start without a 1% hydrogen peroxide mouth-rinse that has been recommended due to its oxidative potential and consequent reduction of COVID-19 viral load.[18]

In the case of pediatric patients with poor compliance, the Royal college of Surgeons of England recommends avoiding the use of hand-pieces and, in some clinical situations, preferring the extraction of the dental elements.[19] These situations are: deciduous teeth affected by pulpitis and fractures, avulsions or severe dislocations following trauma.[19]

In case of absolute lack of compliance, the dentist can evaluate the patient’s treatment under general anesthesia by administering appropriate drug therapies.

The drug prescriptions regimens for pain management in children remain the usual ones using analgesics and respecting the maximum dose according to the child’s weight. Only in the presence of systemic symptoms followed by edema and acute infection signs the antibiotic prescription could be justified.[18]

After attendance, all procedures for cleaning and disinfection of the environment and surfaces must be carried out. Cleaning surfaces with neutral detergent is recommended, followed by disinfection with solutions, such as 70% alcohol and 1% sodium hypochlorite.[4]

Special needs patients with systemic diseases

The above is to be considered valid also for patients affected by particular systemic diseases (e.g., syndrome patients) who cause a state of general disability; these conditions can also affect adolescents or adult patients.

The SARS-CoV-2 pandemic has also forced dentists to use digital platforms for teleworking to provide remote medical support.[20] In fact syndrome patients often combine with poor compliance systemic diseases that make them more at risk of fatal course in case of infection with COVID-19;[21],[22],[23],[24] for this reason the doctor should also play the role of psychological counselor and support for the relatives of these patients, severely stressed by the disability of their relatives.[25]

Patients with disabilities affected by dental emergencies that cannot be resolved remotely should be treated in conscious sedation or under general anesthesia. In the absence of these possibilities, some authors have suggested resorting to nonpharmacological pain and anxiety control techniques such as hypnotherapy.[26]

The prescription of antibiotics should be reserved for acute infections with oral involvement with or without systemic signs whereas pain-relieving drugs could be prescribed for acute or chronic painful conditions of severe intensity, paying particular attention not to interfere with any undergoing pharmacological therapy. In any case, the dentist should encourage the patient (or his family members) to continue taking the drugs previously prescribed for the control of basic systemic condition. Among antibiotics amoxicillin has good characteristics to be the drug of choice for oro-facial infections: it is readily absorbed, food does not interfere with its absorption, and it is capable of resisting damage caused by gastric acidity; in patients allergic to penicillin, researchers recommend clindamycin.[27] Antibiotics must be prescribed following in detail the appropriate posology[27] as incorrect one may cause the development of bacterial resistance, as already recently shown by the author.[28]

Regarding pain-relieving drugs WHO has decided to recommend paracetamol as a first-choice drug in pain control and to indicate ibuprofen as a second choice drug as it has recently been linked to an overexpression of the enzyme angiotensin-convertase-2, which is believed to be the target molecular receptor of the SARS-CoV-2 virus.[29] It must be considered, however, that such scientific evidence is not strong enough to endorse this hypothesis.[30] Moreover, dental pain is hardly alleviated by paracetamol which has a mild analgesic action and patients with special needs often suffer from systemic conditions that prevent them from adequately managing pain stimuli. For the aforementioned reasons it is advisable to administer NSAIDs unless other specific contraindications; among these drugs, ibuprofen should not be the first choice drug.


  Conclusion Top


It is anticipated that provision of oral healthcare services to special needs patients to be jeopardized during the COVID-19 pandemic. Health care policies should be modified to meet various challenges during these critical times. Dentists are required to introduce modifications in their practices so as to mitigate the cross-infection threats posed by the highly contagious SARS-CoV-2. They should also be sharp in identifying possibly infected patients and be well-acquainted with the appropriate referral procedures. Provision of dental treatment to special needs patients whether children or adults with systemic disease should not by postponed, and whenever it is to be done, it should take into consideration the most recent guidelines prepared by regulatory bodies and professional dental associations. Use of teledentistry should be considered especially in countries whose healthcare systems are overwhelmed by the high numbers of COVID-19 infections. Within this context, dental prescribing should take into consideration the appropriate indications and recommended guidelines for the treatment of orofacial pain and infections.

Acknowledgement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Author contributions

Not applicable.

Ethical policy and institutional review board statement

Not applicable.

Declaration of patient consent

Not applicable.

Data availability statement

Not applicable.

 
  References Top

1.
World Health Organization (WHO). Available from: who.int. [Last accessed on 2020 Feb 11].  Back to cited text no. 1
    
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Cucinotta D, Vanelli M WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.  Back to cited text no. 2
    
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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.  Back to cited text no. 5
    
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Wax RS, Christian MD Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients. Can J Anaesth 2020;67:568-76.  Back to cited text no. 6
    
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Kampf G, Todt D, Pfaender S, Steinmann E Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.  Back to cited text no. 7
    
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Cleveland JL, Gray SK, Harte JA, Robison VA, Moorman AC, Gooch BF Transmission of blood-borne pathogens in US dental health care settings: 2016 update. J Am Dent Assoc 2016;147:729-38.  Back to cited text no. 8
    
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Ettinger RL, Chalmers J, Frenkel H Dentistry for persons with special needs: How should it be recognized? J Dent Educ 2004;68:803-6.  Back to cited text no. 10
    
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Staderini E, Patini R, Guglielmi F, Camodeca A, Gallenzi P How to manage impacted third molars: Germectomy or delayed removal? A systematic literature review. Medicina (Kaunas) 2019; 55:79.  Back to cited text no. 11
    
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Patini R, Coviello V, Riminucci M, Corsi A, Cicconetti A Early-stage diffuse large B-cell lymphoma of the submental region: A case report and review of the literature. Oral Surg 2017;10:56-60.  Back to cited text no. 13
    
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Coviello V, Zareh Dehkhargani S, Patini R, Cicconetti A Surgical ciliated cyst 12 years after Le Fort I maxillary advancement osteotomy: A case report and review of the literature. Oral Surg 2017;10:165-70.  Back to cited text no. 14
    
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Licciardi F, Pruccoli G, Denina M, Parodi E, Taglietto M, Rosati S, et al. SARS-CoV-2-induced kawasaki-like hyperinflammatory syndrome: A novel COVID phenotype in children. Pediatrics 2020;2020:e20201711.  Back to cited text no. 16
    
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Patini R How to face the post-SARS-CoV-2 outbreak era in private dental practice: Current evidence for avoiding cross-infections. J Int Soc Prevent Communit Dent 2020;10:237-9.  Back to cited text no. 17
    
18.
Mund de Amorim L, Maske TT, Ferreira SH, Beraldo dos Santos R, Feldens CA, Floriani Kramer P New Post-COVID-19 biosafety protocols in pediatric dentistry. Pesquisa Brasileira em Odontopediatria e Clinica Integrada 2020;20:e0117.  Back to cited text no. 18
    
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Royal College of Surgeons of England. Recommendations for Paediatric Dentistry during COVID-19 pandemic. Available from: https://www.rcseng.ac.uk/dental-faculties/fds/coronavirus/. [Last accessed on 2020 May 6].  Back to cited text no. 19
    
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Pippi R, Pietrantoni A, Patini R, Santoro M Is telephone follow-up really effective in early diagnosis of inflammatory complications after tooth extraction? Med Oral Patol Oral Cir Bucal 2018;23: e707-15.  Back to cited text no. 20
    
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Isola G, Alibrandi A, Currò M, Matarese M, Ricca S, Matarese G, et al. Evaluation of salivary and serum ADMA levels in patients with periodontal and cardiovascular disease as subclinical marker of cardiovascular risk. J Periodontol 2020;7:1076-84.  Back to cited text no. 23
    
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Isola G, Alibrandi A, Rapisarda E, Matarese G, Williams RC, Leonardi R Association of Vitamin d in patients with periodontitis: A cross-sectional study. J Periodontal Res 2020:16. doi:10.1111/jre.12746.  Back to cited text no. 24
    
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30.
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