JICDRO is a UGC approved journal (Journal no. 63927)

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REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 87-93

Novel Coronavirus brings a New Challenge for Oral Health-Care Professionals


1 Department of Oral Medicine and Radiology, RR Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of Oral Medicine and Radiology, Swami Devidayal Hospital and Dental College, Panchkula, Haryana, India
3 Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India

Date of Submission17-Aug-2020
Date of Decision13-Sep-2020
Date of Acceptance22-Sep-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Tarun Vyas
Department of Oral Medicine and Radiology, RR Dental College and Hospital, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_54_20

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   Abstract 


A flare-up of coronavirus disease 2019 (COVID-19) caused by the 2019 novel coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) started in the city of Wuhan in China and is viewed as another strain that has not been distinguished earlier in people. SARS-COV-2 dominatingly causes sickness that ranges from the basic virus to progressively SARS. Clinical highlights of the disease involve respiratory side effects as fever, hack, brevity of breath, and sore throat. Assessment and treatment of patients during COVID-19 pandemic is a test for the dental experts because of close face to face contact with the patients, thus implicating the requirement of prudent disease control measures. This article reviews the dental contemplations during COVID-19 flare-up in dental settings and prescribed administration conventions to dental experts in influenced territories.

Keywords: Coronavirus, dentists, examination, prevention, respiratory infection


How to cite this article:
Vyas T, Konidena A, Nagi R, Misra D. Novel Coronavirus brings a New Challenge for Oral Health-Care Professionals. J Int Clin Dent Res Organ 2020;12:87-93

How to cite this URL:
Vyas T, Konidena A, Nagi R, Misra D. Novel Coronavirus brings a New Challenge for Oral Health-Care Professionals. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Jun 19];12:87-93. Available from: https://www.jicdro.org/text.asp?2020/12/2/87/303407




   Introduction Top


Since its origin in Wuhan city of Hubei Province of China, novel coronavirus (2019-nCoV) had spread rapidly to the rest of the world.[1] Recognized as one of the major global outbreaks experienced by people across 28 countries, on February 11, 2020, the World Health Organization (WHO) proposed a new name for this outbreak as coronavirus disease (COVID-19) caused by nCoV. The International Committee on Taxonomy of Viruses has renamed the provisionally named 2019-nCoV as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), classified under the family coronaviridae.[2]

COVID-19 had been declared as the sixth public health emergency of international concern on January 30, 2020, by the WHO, (following H1N1 (2009), polio (2014), Ebola in West Africa (2014), Zika (2016), and Ebola in the Democratic Republic of Congo (2019)) and as “pandemic” by the WHO on March 11, 2020. Therefore, health-care workers, government organizations, and the public need to co-operate globally to prevent its rapid dissemination.[3]


   Structure of Coronavirus Top


SARS-CoV-2 is primarily zoonotic, i.e., transmitted from civet cats to humans, MERS-CoV from dromedary camels to humans, and SARS CoV-2 from bats to humans.[4] CoVs are 60 nm–140 nm in diameter, enveloped, positive-stranded RNA viruses, with the largest genome among RNA viruses. The genome is packed inside a helical capsid formed by the nucleocapsid protein and further surrounded by an envelope. The viral envelope consists of three structural proteins: The membrane (M) protein and the envelope (E) protein are involved in virus assembly, whereas spike protein that mediates virus entry into the host cells. S protein form large protrusions from the virus surface, giving coronaviruses the appearance of having crowns (corona in Latin means crown).[5] Studies have found that S-protein of the virus binds to angiotensin-converting enzyme (ACE 2) receptors present on the host cell membrane (ACE 2 has profound expression in the heart, gastrointestinal, and lung tissues). Therefore, CoVs cause widespread respiratory, gastrointestinal, and central nervous system diseases in humans and other animals.[4]


   Routes of Transmission Top


The normal courses of transmission for COVID-19 are immediate transmission through hack, wheezing or bead disease, or contact transmission by means of oral, nasal, and eye mucous layers. Scientists have identified nearness of ACE 2 receptors in the salivary organ tissue and transmission of infection legitimately or in approximately way through spit. The virus has been detected in stool samples suggestive of feco-oral route as the possible mode of transmission. Transmission through perinatal or vertical transmission is yet to be established, while the other mode of spread is through fomites, which are objects or surfaces that may become contaminated as virus on these surfaces can retain its infective potential for the specific period of time. For aerosol splatter, the infective potential is retained for 3–8 h, copper – 5 h, stainless steel – 12 h, and cardboard/plastic/paper – up to 24 h. A study by Meng et al. introduce essential knowledge about COVID-19 and nosocomial infection in dental settings and provide recommended management protocols for dental practitioners and students in potentially affected areas.[9]


   Sources of Transmission in Dental Clinics Top


The common transmission routes of nCoV in dental clinic or hospital include direct transmission (contact with mucous membrane and droplet inhalation transmission) and contact with contaminated surface.[12],[13] Dental care settings invariably carry the risk of 2019-nCoV infection as they involve face-to-face communication with patients along with frequent exposure to saliva, blood, and other body fluids, apart from the handling of sharp instruments. The pathogenic viral particles can also be transmitted in dental settings through the inhalation of aerosols that can remain suspended in the air for long periods.[14]

The use of high-speed hand pieces for various dental procedures such as ultrasonic scaling, tooth preparation, etc., contribute to aerosol or splatter production, and if the patient shows the symptoms of cough or fever, aerosol-generating procedures become a major source of cross-infection among patients and dentists and risk becomes even higher if patients are an asymptomatic carrier. High-speed dental hand piece may aspirate and expel the debris and fluids during the dental procedures if they do not have anti-retraction valves. Infectious viral particles or bacteria may further contaminate the air and water tubes within the dental unit, and thus can potentially cause cross-infection. A study by Peng et al.[15] had shown that the anti-retraction high-speed dental hand piece can significantly reduce the backflow of oral bacteria and hepatitis B virus into the tubes of the hand piece and dental unit as compared with the hand piece without anti-retraction function.[15]


   Incubation Period and Clinical Features Top


The incubation period of COVID-19 had been estimated to be 5–6 days on an average, but it could be as long as 14 days.[5],[6] Majority of patients’ experience fever, dry cough, shortness of breath, fatigue, while other atypical symptoms, such as muscle pain, confusion, headache, sore throat, diarrhea, nausea and vomiting, chills, nasal congestion, palpitation, and chest tightness had also been reported. Interestingly, some patients also report anosmia, hyposmia, ageusia, and dysgeusia. Severe disease accounts for 14% includes florid pneumonia that may progress to acute respiratory distress syndrome along with cardiogenic or distributive shock.[7],[8] The symptoms are usually mild initially (81%) and develop gradually depending on the host and viral organism. Few patients do not even develop any symptoms (asymptomatic cases) and are a huge threat in the spread of this virus.


   Oral Manifestations Top


This deadly virus has been studied to present few oral manifestations such as xerostomia/dry mouth, chronic sialadenitis, and taste alterations due to infection of salivary tissue that eventually leads to the damage of salivary glands. Moreover, oral ulcerations have been reported in few patients, and these oral findings need further assessment.[3],[7]


   Diagnosis of Coronavirus Top


Screening of patients before entry into dental clinic or hospital is of utmost importance, and it may be accomplished by (i) recording history, i.e., travel history within the last 14 days to COVID-19 affected area, history of a recent exposure to an infected person, and history of symptoms suggestive of respiratory infection; (ii) recording of body temperature by hand-held infrared thermometer; (iii) pulse oximeter to measure oxygen saturation of the patients, COVID-19-infected patients have been found to have low blood oxygen levels indicated by dark red color on pulse oximeter; (iv) assessment of the presence of viral RNA by its extraction by means of chemical reagents from saliva or blood sample; (v) collection of stool sample; (vi) throat and nasopharyngeal swabs found in the nasopharynx; and (vii) real-time qualitative polymerase chain reaction (RT-q PCR), which is considered to be a gold standard and is performed on rectal or respiratory tract specimens that detects viral genome and provides accurate results with reduced errors.[9]

In dental settings, collection of saliva should be encouraged as a diagnostic tool to detect viral particles, as it is noninvasive and easy to collect with less patient discomfort in comparison to throat and nasopharyngeal swabs. Moreover, studies have shown high viral loads in saliva due to the presence of ACE-2 receptors in the salivary gland tissues.[9] However, in contrary to above findings, recent study has reported lower positivity rate (63%) for saliva in the detection of coronavirus in comparison to bronchoalveolar lavage (93%), this elucidates need of further studies to prove salivary fluid sample as an complementary diagnostic tool.[10]


   Prevention and Infection Control in Dental Practice Top


Rational use of personal protective equipment (PPE) (Ministry of Health and Family Welfare [MoHFW]):[11]

PPEs are defensive riggings which are intended to defend well-being. Health-care professionals should be trained in donning and doffing of the PPE in a proper manner. The components of PPE and rationale for the use of each component of PPE as per the MoHFW[11] are detailed in [Table 1].
Table 1: Components of personal protective equipment

Click here to view



   Infection Control in Dental Practice Top


Aerosol-generating procedures become a major source of cross-infection among patients and dentists, and risk becomes even higher if patients are an asymptomatic carrier. Besides this, microbes may contaminate the air and water tubes within the dental unit, and thus can potentially cause cross-infection. A study by Peng et al.[15] showed that the anti-retraction high-speed dental hand piece can significantly reduce the backflow of oral bacteria and hepatitis-B virus into the tubes of the hand piece and dental unit as compared with the hand piece without anti-retraction function. However, if aerosol-generating procedure needs to be performed, it should be scheduled as the last appointment of the day.[15]

Various studies have reported that the disinfectants (hypochlorite and ethanol) in the hand piece and 3-in-1 syringe water supplies reduce the viral contaminants in splatter, but its action on human coronavirus is still unknown.[16] The high-speed dental hand piece without antiretraction valves may aspirate and expel the debris and fluids during the dental procedures. More importantly, the microbes, including bacteria and virus, may further contaminate the air and water tubes within the dental unit, and thus can potentially cause crossinfection.[17] Subgingival scaling for treating periodontally compromised teeth with the aid of an ultrasonic scalers produces aerosols-containing blood than a handheld curette, regardless of the scaler type employed.[17],[18] Handheld curette produces less aerosols than ultrasonic scalers containing blood. The use of dental hand pieces which have anti-retraction valves or other designs and rubber dams can significantly minimize the production of saliva- and blood-contaminated aerosol or spatter. It has been reported that the use of rubber dam could significantly reduce air-borne particles in ~3-foot diameter of the operational field by 70%.[18],[19] When rubber dam is applied, extra high-volume suction should be used during the procedures along with regular suction.[19] This is an effective way to reduce aerosol contamination and if-for some reason rubber dam cannot be used then manual scalers, manual cartes excavator, etc., should be used to minimize the aerosol contamination.[20] This is an effective way to reduce aerosol contamination. Dental extraction, minor surgical procedures such as biopsy and disimpaction surgeries should be performed with an aseptic and atraumatic technique using manual instruments rather than motorized ones.[21] Various practical strategies which can be implemented to block virus transmission during dental diagnosis and treatment include practicing hand hygiene for at least 20 s with warm water and soap and 60%–80% isopropyl alcohol or ethanol, use o1f PPE for the dental professionals, mouth rinse before dental procedures, rubber dam isolation, anti-retraction hand piece, disinfection of the clinic settings, and proper management of medical waste.[24] Good hand hygiene is one of the best ways to prevent the spread of infectious diseases. A two-before and three-after hand hygiene should be followed to reinforce the compliance of hand washing. Specifically, the dental surgeon and the dental assistant should wash their hands before examining a patient, before performing any dental procedures, after touching the patient, after touching the surroundings and equipment without disinfection, and after touching the oral mucosa, blood, damaged skin, or wound.[15] Fumigation is not practical for dental operatory; however, measures such as mopping the floor with 1% sodium hypochlorite and disinfecting waterlines with 0.01% sodium hypochlorite can help reduce the risk of cross infection.


   Challenges for Oral Medicine Specialists Top


In dental colleges or large dental hospitals, we as oral health-care professionals may be the first health-care professional to examine patients which is challenging in the current scenario. Furthermore, we may frequently encounter patients with oral potentially malignant disorders (OPMDs) in the habitual chewers of tobacco. Oral cancer screening, examination and management of OPMDs through various procedures such as vital staining of suspicious lesions, light amplification by stimulated emission of radiation ablation of white lesions, intralesional injections, punch biopsies, and lymph node fine-needle aspiration cytology can be performed using disposable kits, punch biopsy forceps, syringes, etc., under protective gear.[22] Researchers have suggested that smokers are more susceptible to develop coronavirus infections, but there is no clear cut evidence available to justify this assumption and further research should be done in this domain.[22]


   Challenges for Oral Radiologists Top


Taking radiographs, especially for urgent or emergency dental problem in the current scenario is quite a challenge for oral radiologists. Patients should be first telephone triaged to confirm if their dental condition requires radiograph. They should only be advised radiographs for severe dental pain, dental cellulitis, or space infection not relieved by prescribed antibiotics and analgesics, dental trauma with avulsion/luxation, maxillofacial trauma, and uncontrolled bleeding. Before entry into radiology section, patients should be screened in the hospital waiting area and then at radiology front desk by the appointed radiology staff.[15],[22] It should be ensured that chairs in waiting area are at 6 feet distance to avoid intimate contact and patients are wearing protective equipment such as cloth mask/face cloth covering/or surgical mask, plastic gloves, shoe covers, and head cap before commencement of radiographs.[15] Full mouth/sectional panoramic radiographs, extraoral periapical views, or oblique lateral views may be considered instead of intraoral radiographs for screening, as they induce coughing or gag reflex. Digital radiography is difficult to practice, although barrier-enveloped digital sensors provide better infection control, but they are difficult to disinfect due to the risk of damage during cleaning. Instead of full mouth series, a panoramic radiograph should be advised, and cone-beam computed tomography could also be advised in dental situations where panoramic radiograph has not provided diagnostic information.[23]

For radiographic examination of suspected or confirmed COVID-19 case with an emergency, radiographs should be taken in separate well-ventilated isolation room and proper protection protocols should be followed. Most importantly, all the radiological equipment such as X-ray tube head, film holders, dirty zones, etc., should be disinfected and cleaned after each patient. Processing should be done in the automatic processor or by manual no touch method and regular fumigation of radiology section should be practiced. PPE kit if disposable should be changed after each patient and surgical gown if worn should be cleaned and disinfected to prevent cross-infections.[23]


   Prevention and Treatment Considerations for Coronavirus Disease 2019 Top


The WHO has accelerated research in diagnostics, vaccines, and therapeutics for this nCoV. The various strategies for the prevention of transmission and infection of this respiratory pathogen include.[26]

Nonpharmacological interventions/precautionary measures

  • Isolation at home
  • Voluntary quarantine at home
  • Social distancing at least 2 m or 6 feet
  • Temporary closure of schools, universities, and workplaces.


Pharmacological interventions

Specific protection through chemoprophylaxis or immunoprophylaxis through medication is elaborated in [Table 2]. The other pharmacological interventions are as follows:[27]
Table 2: Recommended drugs in the prophylaxis as well as postexposure regimens

Click here to view


Vaccination

The most promising therapy to treat corona infection would be discovery of vaccine that will provoke an immune response on injection into a patient. Many animal-based clinical trials are going on that aim to develop protein-based vaccines using adenoviral vectors. A joint collaboration by all countries would possibly lead to the development of a vaccine in 2021 that will provide long-term protective immunity against the virus.[25]

Hyperbaric oxygen therapy

Hyperbaric oxygen (HBO) therapy allows adequate oxygen to reach the blood, inhibits inflammatory process, and promotes healing in virus-infected tissues.[25],[28],[29]

Convalescent plasma therapy

Convalescent plasma therapy is an emerging treatment option that use antibodies from recovered COVID-19 patients to treat the patients who are severely infected by the virus thus boosting their immune system. Promising results have been obtained by this therapy, with no adverse effects except the complications of blood transfusion. Therefore, collection of blood from the donor should be done after 14 days followed by screening with RT–PCR to declare them negative and safe for blood transfusion to an infected corona patient.[30] Upon patient’s arrival, the body temperature of the patient should be measured using a contact-free forehead thermometer. If the patient answers “no” to all the questions and if the patient is afebrile, the patient can be treated by the dental surgeon following the recommended protocols. The ability to test patients who need dental care for SARS-CoV-2 is to be considered to restart dentistry in a sustainable way. Tests can be a strong tool to mitigate risks for patients and oral health-care workers too.[31]

Follow-up

All patients must be followed up after 7 days for any flu-like symptoms.

Employee care

Daily log for employees’ temperature and symptoms must be made and reviewed periodically. An in/out daily logbook needs to be maintained as to who all entered and left the office along with the date and time. Postprocedure disinfection and decontamination: All sterilizable instruments should be cleaned, disinfected, and sterilized expediently, while all disposables, whether used or not, should be presumed to be infected and discarded appropriately. Appointments should be scheduled such that social distancing can be maintained in the waiting room. Another alternative is for the patient to wait outside or in their vehicle, and they can be contacted through telephone when it is their turn to be seen. It is recommended that the patients avoid bringing companions to their appointment, except for instances where the patient requires assistance.[32]. This can be communicated to the patient at the time of scheduling an appointment There is a pressing need but a narrow window of opportunity to address the gaps in global preparedness for a second wave of COVID-19. Definitive medical countermeasures are not expected to roll in the market for general public utilization for at least 1–2 years. Hence, till then, the nonpharmacological measures hold the prime importance to prevent further waves of COVID-19. Other sections that simultaneously might need attention are social harmony, political unpredictability, economic slowdown, poverty, other viral outbreaks, and food scarcity.[33] It has once again proved its relevance with the emergence of CoV disease-2019 (COVID-19) as the latest pandemic that is affecting human health and economy across the world. Hence, it is very necessary to maintain social distancing and mental distancing. Tele consultation through teledentistry can take place in either of the following ways: “Real-Time Consultation” and “Store-and Forward Method.” Real-time consultation involves a video conference in which dental professionals and their patients, at different locations, may see, hear, and communicate with one another.[34] Patience, precaution, perseverance, and peaceful mind will sail us through this bright tunnel toward our future.[35]


   Conclusion Top


As Covid-19 has altered the lifestyle globally, even we as dental professionals have to alter our protocols for the protection of our patients and ourselves by preventing the spread of COVID-19. “Physical Distancing and Hand Hygiene is the KEY.” It is essential to strengthen biomedical research, improve health-care delivery systems, establish a permanent “watch-dog” body and create an improved communication and coordination mechanism for the diverse agencies responsible for mitigating the broader adverse consequences of pandemics. Although elective nonessential procedures should be postponed, we as oral physicians can still perform our social and moral responsibility toward our needy patients in these tough times thwarting the newer challenges we face.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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    Abstract
   Introduction
    Structure of Cor...
    Routes of Transm...
    Sources of Trans...
    Incubation Perio...
   Oral Manifestations
    Diagnosis of Cor...
    Prevention and I...
    Infection Contro...
    Challenges for O...
    Challenges for O...
    Prevention and T...
   Conclusion
    References
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