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Table of Contents
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 107-110

Dental practice and COVID-19: A review

1 Reader, Department of Oral Medicine and Radiology, Subbaiah Institute of Dental Sciences, Purle, Shivamogga, India
2 Professor and Head, Department of Conservative Dentistry and Endodontics, Subbaiah Institute of Dental Sciences, Purle, Shivamogga, India
3 Senior Lecturer, Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, India
4 Senior Radiologist, Department of Oral Medicine and Radiology, Oral D Diagnostics, Bengaluru, Karnataka, India

Date of Submission20-Nov-2021
Date of Acceptance08-Dec-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. D Shanthala
Department of Oral Medicine and Radiology, Subbaiah Institute of Dental Sciences, Purle, Shivamogga, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpcdr.ijpcdr_39_21

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The outburst of the coronavirus strain 2019 (COVID-19) represents a public health emergency of global distress. Because of the community spread outline of this infection, the outburst is still on the rise despite global efforts to control the disease spread. The appearance of coronavirus in today's life brought so many restrictions in daily life. It appears as life has stuck and limited. Dentistry is the field of medicine which has suffered a lot. The present article highlighted various challenges and effects of coronavirus on oral health and its implications.

Keywords: Coronavirus, coronavirus disease 2019, dentistry, oral health, severe acute respiratory syndrome coronavirus 2

How to cite this article:
Shanthala D, Pradeep K, Adappa N D, Rupa K R. Dental practice and COVID-19: A review. Int J Prev Clin Dent Res 2021;8:107-10

How to cite this URL:
Shanthala D, Pradeep K, Adappa N D, Rupa K R. Dental practice and COVID-19: A review. Int J Prev Clin Dent Res [serial online] 2021 [cited 2022 Jul 5];8:107-10. Available from: https://www.ijpcdr.org/text.asp?2021/8/4/107/333549

  Introduction Top

Coronavirus disease 2019 (COVID-19) (coronavirus) is a global concern since it is spreading fast as a droplet infection, leading to fever, cough, and acute respiratory disease, in severe cases, leading to pneumonia, kidney failure, and even death.[1] This epidemic disease has involved more than 212 countries in a span of 3–4 months. The outburst of COVID-19 started from Wuhan, China, in December 2019. It has emerged as one of the swift health emergencies and has extended significantly, affecting more than 90% of countries worldwide. Chinese Centers for Disease Control and Prevention declared a novel coronavirus as a causative agent of COVID-19 on January 8, 2020. World Health Organization declared this outbreak as a public health crisis of international concern on January 30, 2020. The overall mortality rate was found to be 3.4%.[2],[3],[4],[5]

  Mode of Transmission Top

Mode of transmission found to be single animal-to-human transmission, followed by sustained human-to-human spread. Now, it is ascertained that spread usually occurs through respiratory droplets and contact transmission. Sneezing and coughing by infected symptomatic or asymptomatic patients may disperse droplets in the air. If a person inhales that air, he or she can be infected. Similarly, shaking hands with the infected person can be the mode of transmission. Contact with a surface or object that has the virus and then touching the nose, eyes, or mouth is the potential mode of transmission.[1],[3],[4],[6],[7],[8]

  Source of Transmission Top

Symptomatic patients are potential source of transmission. However, recent studies advocate that asymptomatic patients are also carriers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This has been matter of concern as it is very difficult to diagnose and isolate such patients to prevent community transmission. Moreover, it is yet to be confirmed that whether patients in the recovering phase are a potential source of transmission.[9],[10],[11],[12],[13] Earlier, it was thought that there is 5–6 days of incubation period of COVID-19; however, now, there is proof that it could be as long as 14 days.

  Risk Groups Top

It has been found that healthcare worker, doctors, nurses, ward persons, sweepers, dentists, and ENT specialist are at higher risk. Those in close contact to with the patients, such as family members of any age are also at risk. It is found that older people with underlying co-morbidities such as diabetes, cardiovascular diseases, immunocompromised patients, pregnant women, hypertension, and subjects with organ transplants, lung diseases, etc., are potential risk individuals.[5],[9],[10],[11]

  Clinical Symptoms Top

Most patients with COVID-19 present with mild symptoms. Patients experience cold or flu-like symptoms mostly that start 2–4 days after a coronavirus infection. However, symptoms vary from person to person.[3],[4] The most common symptoms are high-grade fever, dry cough, shortness of breath or dyspnea, and fatigue or tiredness. Some patients may experience myalgia or muscle pain, headache, sore throat, vomiting, and diarrhea. There can be hyposmia (diminished sense of smell) and dysguesia (abnormal taste sensation). Computed tomography scan shows ground-glass opacities, bilateral patchy shadows, and bilateral pneumonia in the chest. In severe cases, patients may develop arrhythmia and shock, which need ventilator support.[2],[3],[4],[5],[9],[10],[11],[12] Changes in olfactory and gustatory sensations and frequent formation of oral ulcerations have been reported.[6],[7],[8],[14],[15] Some patients may be asymptomatic without any signs or symptoms, which can be diagnosed with blood examination.

  Sample Collection and Diagnosis Top

Preferred sample is throat and nasal swab in viral transport medium (VTM) and transported on ice. The alternate sample is nasopharyngeal swab, bronchoalveolar lavage, or endotracheal aspirate, which must be mixed with the VTM and transported on ice. It is suggested that trained healthcare professionals wear appropriate personal protective equipment (PPE) and latexfree purple nitrile gloves during collecting patient samples. One has to maintain proper infection control. Proper disposal of all waste generated. Real-time reverse transcription polymerase chain reaction (rRT-PCR) test is used for the qualitative detection of nucleic acid. Saliva can have an essential function in human-to-human transmission, and noninvasive salivary diagnostics may offer a suitable and cost-effective point-of-care stage for the quick and initial identification of COVID-19 infection.[2],[3],[4],[5],[9],[10],[11],[12]

  Dental Practice and COVID-19 Top

Dentists are those who deal with the oral cavity. Dentists are directly and closely exposed to coronavirus inhaling aerosols, patient saliva contamination, and airborne particles formed during dental procedures from COVID-19–infected or asymptomatic patients, making dental procedure as a high-risk procedure and risk to dentist and dental staff.[1],[13] As we are aware that oral cavity is a reservoir of a plenty of microorganisms, they are high risk of getting infected. The viral load contained in the human saliva and blood is very high. It has been observed form studies that smoking is most likely connected with the pessimistic succession and undesirable upshot of COVID-19. Awareness and education of dentists should be made to prevent from the spread of COVID.

  Management of Patients in Dental Clinics Top

Initial screening is advisable via telephone to recognize patients with suspected or possible COVID-19 infection. A case of COVID-19 is suspected when he/she had undertaken international flight in the last 14 days or all symptomatic contacts of laboratory-confirmed cases or all symptomatic healthcare personnel or all hospitalized patients with severe acute respiratory illness or asymptomatic straight and high-risk associates of a confirmed case.[9],[10],[11],[12],[13] There is no common practice or guideline for dental care conditions to active or suspected COVID-19 belongings. Hence, because of deficiency of standard guidelines and instructions, dental care provision has completely stopped or significantly decreased in several affected countries, including India. In adding to emergent affected populations suffering, this will also enrage the trouble on hospitals emergency departments previously struggle with the pandemic. Indian Dental Association has recommendations on COVID-19.[5],[6],[7],[8],[13],[14],[15] All patients visiting dental clinics should be given a medical form to fill it, such as history of recent travel, contact with COVID-19 patients, or presence of symptoms. Infrared thermal sensors are to be used to assess patient's temperature without touching him/her at the desired distance. Symptomatic patients should be referred to the COVID care center. Appointments should be rearranged if the patient has traveled outside India in the last 2 weeks to an area such as China, Italy, Iran, Hong Kong, France, Germany, Japan, Spain, South Korea, Singapore, Thailand, Taiwan, Vietnam, or any other COVID-19–exaggerated country. Before each appointment, all routine patients should be subjected to rinse with a 1% hydrogen peroxide or 1% betadine solution before each appointment. This is to reduce viral load in the saliva. Autoclave-used instruments after each patient are necessary along with disinfection and cleaning of public places repeatedly, including chairs, bathrooms, and door handles.[1],[4],[5],[9],[10],[11],[12],[13],[14],[15] Disposable and single-use instruments and devices should be used whenever possible to reduce the cross-infection risks. Patient appointment cards should be avoided. All payments should be done digitally. Strict waste disposal protocol is necessary with training and education for assistants. All procedures should be done under rubber dam, caries excavation using spoon excavator, or chemomechanical method. All unwanted posters and consumable and nonconsumable materials should be kept away. Dental treatment should be based on patient category. It is advisable to categorized dental treatment into emergency, urgent, nonurgent, and elective. Guo et al. concluded from their study that there is a strong influence of COVID-19 on the consumption of emergency dental services. Under emergency, cases such as fractures, Ludwig's angina, and postoperative bleeding should be considered. Under urgent, cases such as acute pulpitis, pain of fractured vital tooth, avulsed or luxated tooth, dry socket and pericoronitis, and extraoral swelling should be included. Under nonurgent, cases such as asymptomatic fractured or defective restoration, removable partial denture, correction of complete denture, fixed partial denture, esthetic dentistry, scaling, esthetic, and orthodontic treatment should come. Extraoral radiographs such as panoramic radiographs should be made compulsory to reduce the excessive salivation and gag reflex with IOPAR. Home oral hygiene instruction should be given to each dental patient. Once the consultation/procedure is over, then the whole treatment chamber should be fumigated (patient, dentist, and assistants with PPE and the instruments used for the procedure) as it is. After the fumigation, the patient, dentist, and assistants with PPE should leave the treatment chamber. Then, the treatment chamber, including the instruments used for the procedure, should be UV irradiated for 15 min. Treatment area should be a negative-pressure chamber so the air-conditioner should be off.[3],[5] Frequent hand washing and use hand sanitizer should be followed. After every patient, the whole chamber, including walls, roofs, and knobs, everything should be wiped with 1% sodium hypochlorite (NaoCl) solution.[6],[7],[8],[15] One dentist should do once in 3 days' consultation/procedures. This is to prevent viral loading. Doctors who are 50 years and above having hypertension, diabetes, lung disease, and any other systemic diseases should avoid seeing the patients. In between patients, a minimum of 30 min to 60 min' gap should be given. Call up all the cases seen/treated every 7 days for 4 weeks to know about their health condition. Dentist and dental assistants should use PPE to prevent spread of infection, and it should be changed for each patient. Single-piece PPE should be preferable so that there will not be any gaps. Before wearing the PPE, regular dress should be removed and wear only PPE in a separate-designated room for wearing them (donning room). After the procedures, PPE should be discarded very carefully in a separate-designated room (doffing room). Everyone should take bath and go home. There are certain challenges for dentists. The use of PPE in each patient is not possible. The high cost of the PPE kit and the heavy burden of dress make it quite hectic. There should be separate entry/exit for the patients and a separate entry/exit for the doctors and assistants. N95/FFP3 masks can be treated in plasma sterilizer (hydrogen peroxide gas) and reused for five times. Housekeeping and group D employees should also be provided protective gear. Dental aerosol during many dental procedures, aerosols, and droplets are produced; this causes spread of droplet spread of diseases such as COVID-19, tuberculosis, and SARS. Hence, it is advised for regular use of standard barriers such as masks and gloves, PPE kit, the universal use of preprocedural rinses, and high-volume evacuation. Dental drill (airotor handpiece) creates the formation of splatter, droplets, and aerosol generally contaminated with viruses, bacteria, fungi, and blood. Oral surgery drills also cause aerosol in addition to splatter. Periodontal procedures such as ultrasonic scaling have to be avoided. Endodontics cannot use 3-way syringes and airotor as there is high production of aerosols. The usual protective procedures in daily clinical work are not effective adequate to prevent the COVID-19 spread. All dental treatments which require drills or ultrasonic devices that cause aerosol release, oral surgery procedures, and routine dentistry (orthodontic, radiograph, esthetic corrections, etc.) should be postponed until the recession of COVID-19 outbreak.

  Pharmacological Management Top

Professional authoritarian bodies advised in opposition to prerequisite dental treatment except for emergency cases, since the recognition of the pandemic COVID-19, but supportive therapy for the control of dental symptoms of pain, such as analgesics and nonsteroidal anti-inflammatory drugs, can be recommended. There is no definite treatment method for COVID yet, and vaccine development is under process. Plasma therapy and hydroxychloroquine (dose 400 mg BD for 1 day followed by 200 mg BD for 4 days) in combination with azithromycin (500 mg OD for 5 days) drug has been suggested. Topical and systemic steroids are usually not advised. In suspected or confirmed cases of COVID-19 infections requiring urgent dental care for conditions such as tooth pain and/or swelling, antibiotics and/or analgesics are an alternative. This approach may offer symptomatic relief and will provide dentists sufficient time to either refer the patient to a specialist or deliver dental care with all. In case of symptomatic irreversible pulpitis or apical periodontitis, first line of management is ibuprofen 600 mg plus acetaminophen 500 mg and second line of management is dexamethasone 0.07–0.09 mg/Kg. Secondary management includes full pulpotomy. In case of acute apical abscess, primary management includes incision and drainage along with antibiotic augmentin 500 mg twice for 5 days or clindamycin 300 mg thrice for 5 days. Local anesthetic 0.5% bupivacaine may be useful as an immediate pain reliever. Patients with tooth fracture and vital pulp therapy are recommended. Patients with cellulitis or fractures should be managed surgically. Social distancing with use of personal protection measures and frequent hand sanitization helps prevent exposure to the COVID-19 droplet infection. Further studies are required to prevent and manage the spread of COVID-19.

  Conclusion Top

Commencing dentistry again after this pandemic is over needs assessment of all above-said points. Failure of adherence to all these may land up the dental surgeon in trouble. One should be hopeful of lockdown and pray for downward flow of graph of COVID-19–positive cases.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Kamate SK, Sharma S, Thakar S, Srivastava D, Sengupta K, Hadi AJ, et al. Assessing Knowledge, Attitudes and Practices of dental practitioners regarding the COVID-19 pandemic: A multinational study. Dent Med Probl 2020;57:11-7.  Back to cited text no. 12
Unhale SS, Ansar QB, Sanap S, Thakhre S, Wadatkar S, Bairagi R, et al. A review on corona virus (COVID-19). World J Pharm Life Sci 2020;6:109-15.  Back to cited text no. 13
Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc 2004;135:429-37.  Back to cited text no. 14
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