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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 57-63

Dental practice in COVID times: A review


1 Department of Diagnostic and Surgical Dental Sciences, College of Dentistry, Gulf Medical University, Ajman, UAE
2 Department of Oral and Caraniofacial Health Sciences, College of Dentistry, University of Sharjah, Sharjah, UAE
3 Department of Restorative Dental Sciences, College of Dentistry, Gulf Medical University, Ajman, UAE
4 Department of Preventive Dental Sciences, College of Dentistry, Gulf Medical University, Ajman, UAE

Date of Submission18-Jun-2020
Date of Decision03-Sep-2020
Date of Acceptance23-Sep-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Sesha Manchala Reddy
Department of Diagnostic and Surgical Dental Sciences, College of Dentistry, Gulf Medical University, Al Jurf 4184, Ajman.
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_212_20

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  Abstract 

Coronavirus originated from Wuhan, China in December 2019 was designated initially as an epidemic but later in a short period it was declared as a pandemic. Currently, this pandemic has spread to 210 countries. There is a steady increase in the number of people getting infected with COVID and a surge in mortality as well. It is an alarming situation for health-care professionals. Dental professionals, by the very nature of treatment (direct contact with the patient’s mouth, saliva, aerosols, and droplets), carry a potential risk of getting infected or transmitting infection. Various associations have developed guidelines for an approach to the dental treatment in COVID crisis. With current knowledge, prevention and isolation seem to be the best method reiterating the old-age saying “Prevention is better than cure.” In this review, we will discuss with the help of flowcharts various preventive measures to decrease the spread of infection and precautions for the dental practice.

Keywords: Coronavirus, COVID-19, Dental Practice


How to cite this article:
Reddy SM, Shetty SR, Marei HF, Abdelmagyd HA, Khazi SS, Vannala V. Dental practice in COVID times: A review. J Int Oral Health 2020;12, Suppl S2:57-63

How to cite this URL:
Reddy SM, Shetty SR, Marei HF, Abdelmagyd HA, Khazi SS, Vannala V. Dental practice in COVID times: A review. J Int Oral Health [serial online] 2020 [cited 2021 Jan 27];12, Suppl S2:57-63. Available from: https://www.jioh.org/text.asp?2020/12/8/57/301861


  Introduction Top


The COVID pandemic brought the entire world to a standstill. It is speculated to have supposedly originated from Wuhan in South China and later spread like wildfire around the globe[1],[2] [Figure 1]. The route of spread of this infection remains mysterious even though droplet inhalation and airborne spread are the most speculated mode. No continent has been left untouched by this alarming infection. The World Health Organization (WHO) initially labeled it as an epidemic but later declared it as a pandemic. The International Committee on Taxonomy of Viruses (ICTV) named the disease as coronavirus disease-2019 (COVID-19) and named the virus as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Even though the two viruses are different, this name is given based on the genetic relationship to coronavirus that was responsible for the SARS epidemic in the year 2003.[3],[4],[5],[6] Its appearance is like a crown, which in Latin means corona; that is how it got its name.
Figure 1: Global COVID-19 pandemic in real time as of September 21, 2020

Click here to view


At present, the WHO has declared that COVID-19 disease is a public health emergency in combination with the currently known mortality rate.[7],[8],[9] A general increase in fatality rate with a steady rise in the number of new cases has necessitated prevention, detection, and control measures. Due to the increased number of reports of the spread of infection to health-care providers (HCPs) in close contact with the infected patients, dentists, in particular, maybe at a higher risk.[10],[11] Currently, dentists are familiar with occupational hazards such as hepatitis B, C, and other risk factors. However, with the recent outburst of this new deadly virus, dental practitioners not only are at increased risk of infection but could also be a possible carrier of this virus.[12]

The higher magnitude of risk involved may be attributed to the distinctive nature of dental treatment procedures such as scaling, restorative and endodontic procedures, and tooth preparation, which lead to aerosol production. A recent study on the lookout for receptors of this virus in humans stated that angiotensin-converting enzyme II (ACE2) is likely the cell receptor of COVID-19, which was also the receptor for SARS-CoV and HCoV-NL63. It plays a pivotal role in the entry of a virus within the cell to induce the final infection.[13] Unfortunately, epithelial cells of the tongue are highly enriched with these receptors, probably explaining the possible role of the oral cavity as a reservoir of viral infection.[14] This places the dentists at high risk to COVID-19 infectious, further emphasizing the need for preventive strategies in day-to-day dental practice [Figure 2].
Figure 2: Ways to prevent COVID-19 spread in dental clinics

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  Symptoms Top


Patients with COVID-19 are divided into three categories. The first group is COVID-19 positive but asymptomatic and the second group has mild symptoms such as fever, dry cough, nausea, malaise, reduced sense of smell, and diarrhea. In third group, there is pneumonia, respiratory distress, septic shock, ground-glass opacities displayed by chest radiograph, and lastly multiorgan failure. A large percentage of the populations (80%) have mild symptoms that resemble a common cold. However, these patients could be potential carriers of the disease even before they get diagnosed, as the incubation period of this infection varies from 14 to 24 days.[15],[16]


  Management of This Pandemic Disease Top


Early detection followed by surveillance limits the spread of this infection to some extent, thus minimizing the impact of a community outbreak. Lapses in following preventive protocols often result in dire health, economic, and social consequences. An excellent synchronization among national and international authorities is essential in combating the further spread of this disease. Although the HCP is responsible for managing these situations, support from all sectors of the community is needed to prevent its further spread.


  Role of the Dental Profession in the Management of Patients with COVID-19 Top


Dentists are at a higher risk of being infected or transmitting this COVID-19 as they come in close contact with the patient’s saliva and blood. Each dental procedure will result in direct contact with body fluids, leading to aerosol production.[17] As a result, it is mandatory to screen every individual patient as a potential candidate for COVID-19 infection. Patients use the mobile to answer the questions such as travel history, cough, cold fever, any contact with a COVID-19 patient, and tooth pain. Although these phone-based questionnaires are not confirmative, they can avoid unnecessary patient–dentist interaction, thus reducing the scope of transmission. Aerosols are biological particles that float and drift in the air, thus posing a threat for either transmission or spread of this disease to another patient/HCPs. Studies on SARS-CoV-2 in aerosols have reported that viral particles have been detected up to 3h and could travel 4 m in the wards. Survival time of SARS-CoV-2 varied from hours to days based on the surfaces its been isolated from. The virus has been found until 4h on copper, 24h on cardboard, and 2–3 days on plastic and stainless steel.[18],[19] These findings furnish crucial data regarding the stability of SARS-CoV-2 and the necessary precautions that are needed in preventing its transmission through aerosols. Hence, efforts should be made to identify potential individuals such as doctors, nurses, HCPs, and other auxiliary staff and provide them with these guidelines.


  Specific Dental Conditions that Need Intervention Top


Various international dental associations’ guidelines have recommended performing only emergency procedures in negative pressure rooms or airborne infection isolation rooms. All other procedures were postponed for at least 3–4 weeks. It is recommended that emergency dental conditions require to be managed by pharmacological modalities (antibiotics and analgesics). This practice relieves patients’ pain and buys time to treat the patient in inappropriate time and settings. Dental professionals should keep themselves updated with developments in practice protocols. The protocols keep changing rapidly as new and more information of this novel disease is discovered. We have provided some useful weblinks for the dentist to access periodicals so that they can keep themselves abreast with attested guidelines and information [Table 1].
Table 1: Online resources about global COVID pandemic

Click here to view


It is a consensus among all guidelines to reduce aerosols. All personal protective equipment (PPE) was disposed of as per the Center for Disease Control and Prevention (CDC) guidelines. The use of telemedicine is essential in these situations. Telemedicine facilities are used to prescribe analgesics and antibiotics to reduce any pain or infection. It is desirable to follow necessary precautions such as the use of rubber dam, high-volume suctions, extraoral imaging, and preprocedural mouth rinse to perform any dental procedure. [Table 2] describes the common problems and solution to COVID-19 challenges according to each dental speciality. Almost every clinical speciality of dentistry faces an imminent risk of spread of the infection, although the level of risk may vary depending on the speciality.[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32]
Table 2: List of emergency dental procedures and management during COVID-19 pandemic

Click here to view



  Innovations for the Clinical Practice Top


The high-risk profession in this COVID-19 pandemic is dentistry as all its procedures release some aerosol and HCPs come in contact with patient blood and saliva. These lead dentists to undertake innovative methods not only to protect themselves but also to prevent cross infection. Here in this review, an attempt is made to highlight some of the newer techniques or devices used to prevent coronavirus risk. These are categorized as testing techniques, improved PPE’s devices and equipment to neutralize Coronavirus. As more clinics reopen, dental practices are considering enhanced measures for early detection, clean their facilities and equipment, as well as protect their patients and staff from this deadly virus. In early detection, newer methods include Scent Check, Diffractive Phase Interferometry (DPI), PPE, Scalene Hypercharge Corona Canon (SHYCOCAN), and ultraviolet (UV) sterilization. The currently used techniques are polymerase chain reaction (PCR) and loop-mediated isothermal amplification tests, which are used for detecting patients with COVID-19; in addition to this, we now have new techniques that are noninvasive and rapid.

DPI test uses a laser technique to scan a blood sample for signs of surging red blood cells, which is said to be an early sign that the body is fighting off a virus. Results are obtained within 5min. This technique detects inflammation markers pressingly caused by COVID-19 infection. It differs from PCR that is based on antibody detection. It is incredibly reliable and innovative. It uses a biosensor that is nano-photonic and supported by a specialized complementary metal-oxide semiconductor (CMOS), which is capable of detecting virus antigens with the help of strips. Nanosensors detect ribonucleic acid (RNA) strands that identify SARS-CoV-2. If the results are positive, patients need to have a conformity PCR test.[33],[34]

Scent check

This noninvasive and rapid test was revolutionized by using exhaled air to detect suspected cases of COVID-19 by using volatile organic compounds (VOC) from patients with SARS-CoV-2. Samples were collected with the help of an air trap, which is a small bag consisting of straws into which the patient needs to blow air. Analyzing, diagnosing, and labeling the VOC signature were done through a machine-learning system that provides test results in approximately 30–60s.[35]

Personal protective equipment

PPE is worn to protect HCPs from bioaerosols generated during dental procedures. Regular surgical masks are not effective against influenza and SARS during these pandemic times. They were, thus, stressing the need for newer respirators that protect against droplets, aerosols, and fluid penetration. Common respirators used by health-care workers are N95 filtering face piece respirators (FFRs), surgical N95 FFRs, and Powered Air-Purifying Respirators (PAPRs). However, HCPs are least acquainted with PAPRs. These types of respirators use cartridges or canisters filter to force air through blowers into the wearer’s zone of breathing. Airflow is created in either snug-fit or loose-fit helmets, thus rendering a high assigned protection factor (APF) than the conventional masks or respirators. PAPR has the advantage of protecting high-risk dental HCP from dental aerosols.[36],[37],[38],[39]

Equipment to neutralize coronavirus

Newer device, such as SHYCOCAN, is developed to neutralize coronavirus. It claims to neutralize coronavirus drifting in the air or closed areas up to 99.9%. It had received clearance and license to manufacture from the US Food and Drug Administration (USFDA) as well as the European Union. It works by emitting photons, which, in turn, collide with air particles, thereby releasing electors that neutralize the spike-protein or S-protein in coronavirus. The process is instant as it uses light as an energy source. The device is said to be effective in almost all closed spaces such as patient waiting areas as well as in office.[40],[41],[42],[43]

Ultraviolet sanitation

UV-C disinfection has gained popularity in comparison to other techniques due to its wide range of action against microorganisms and virus. As compared with UV-A and UV-B, the UV-C gets absorbed readily by atmospheric ozone. It works by the photodimerization process, leading to structural damage of molecular RNA and deoxyribonucleic acid (DNA), thus inactivating the virus and making them incapable of replicating.[44],[45]

The UV spectrum is subdivided into three bands by using the CIE classification:

  • UV-A (long wave) from 315 to 400 nm


  • UV-B (medium wave) from 280 to 315 nm


  • UV-C (short wave) from 100 to 280 nm



  •   Conclusion Top


    An unprecedented global public health crisis has been initiated with the COVID-19 pandemic. Oral health-care professionals are required to have up-to-date information as well as follow respective national guidance in dealing with a current viral infection caused by COVID-19. The dentist is at high risk owing to constant exposure to aerosols, as they could be inhaled, attached to the skin, or suspended in the air. Asymptomatic or undiagnosed COVID-19-infected patients may visit dental clinics for regular checkup or emergency dental procedures. During such visits, the dentist must be familiar with local and international norms while treating patients. Universal precaution in infection control while dealing with the patient should be followed, as some patients may be potential sources of transmitting disease.

    Simple precautions by WHO during COVID-19 pandemic

  • Wash hands regularly as recommended by the WHO.


  • Keep the social distance of 1 m between individuals.


  • Evade contacting eyes, nose, and mouth.


  • Follow respiratory hygiene.


  • Stay home if you feel unwell.


  • Be updated on COVID-19 hotspots.


  • Recommendations for dental health-care professionals

  • Postpone elective procedures, surgeries, and nonurgent dental visits.


  • Emergency dental treatment should be performed as minimally invasive as possible.


  • Stay at home if sick.


  • Contact patients before emergency dental treatment


  • Acknowledgement

    Not applicable.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Author contributions

    Manchala Sesha Reddy: Final draft and conceptualization; Shishir Ram Shetty: First draft, revision, and final approval; Prof Hesham Fathi Ahmed Marei: Revision and plagiarism check; Prof. Hossam Abdelatty Eid Abdelmagyd: Article writing and first draft; Shakeel SK: Advisor, first draft, revision, and final approval; Venkataramana Vannala: Advisor, first draft, and revision. Finally, all authors approved the article.

    Ethical policy and institutional review board statement

    Not applicable.

    Declaration of patient consent

    Not applicable.

    Data availability statement

    Not applicable.

     
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        Figures

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        Tables

      [Table 1], [Table 2]



     

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