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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 66-74

Dental practice in a pandemic scenario: The journey from lockdown to a new reality


1 Army Dental Centre (Research and Referral), New Delhi, India
2 Dte Gen Dental Services, New Delhi, India

Date of Submission15-May-2020
Date of Acceptance20-May-2020
Date of Web Publication15-Jul-2020

Correspondence Address:
Kochiyil Chacko Jacob
Army Dental Centre (Research and Referral), New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODD.JODD_35_20

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  Abstract 


Coronavirus Disease 2019 is a rapidly progressing pandemic that has affected 12.3 million individuals while causing 5,54,061 deaths worldwide till date. In India, approx 7,94,000 individuals (including approximately 4,96,000 recovered patients) have been affected with approximately 21,604 deaths. The sheer extent of the disease makes it imperative to increase awareness among our professional peers regarding the nature of the disease and its transmissibility while formulating standard operating procedures to mitigate the same. The present article disseminates the evidence to date and is based on available literature, brief working experiences, and relevant recommendations that can be implemented at various dental centers and units at all levels.

Keywords: Armed forces, COVID-19, dentistry


How to cite this article:
Jacob KC, Gopi A, Maurya R, Jayan B, Londhe SM, Mukherjee M, Mitra R, Singla NK, Nehra K, Shaikh PH, N Babu B K, Jackson V, Bhat S, Ballabh P, Singh AK. Dental practice in a pandemic scenario: The journey from lockdown to a new reality. J Dent Def Sect. 2020;14:66-74

How to cite this URL:
Jacob KC, Gopi A, Maurya R, Jayan B, Londhe SM, Mukherjee M, Mitra R, Singla NK, Nehra K, Shaikh PH, N Babu B K, Jackson V, Bhat S, Ballabh P, Singh AK. Dental practice in a pandemic scenario: The journey from lockdown to a new reality. J Dent Def Sect. [serial online] 2020 [cited 2020 Aug 8];14:66-74. Available from: http://www.journaldds.org/text.asp?2020/14/2/66/289751




  Introduction Top


On December 31, 2019, the World Health Organization (WHO) China country office was informed of cases of “Pneumonia, unknown etiology” that were later found to be associated with exposures in a seafood market in Wuhan, China. The causal agent was identified as a novel coronavirus (2019-nCOV), on January 7, 2020,[1] and the disease was named as “Coronavirus Disease 2019” (COVID-19). Subsequently on February 11, 2020,[2] while the International Committee on Taxonomy of Viruses suggested that its name should be severe acute respiratory syndrome-corona virus-2 (SARS CoV-2) due to its phylogenetic and taxonomic analysis.[3]

SARS-CoV-2 infection has since rapidly spread from Wuhan to most other Chinese provinces and 214 countries/territories or areas worldwide.[4],[5] The WHO declared a public health emergency of international concern over this global pneumonia outbreak on January 30, 2020.[6] This disease has in last 7 months, affected 1, 22, 57, 497 individuals while claiming the lives of 5, 54, 061 worldwide.[4] In India, 7,94,000 individuals have been affected, while 21,604 deaths have occurred due to the same as on July 9, 2020.[7]

I.W. Brewer, a US Army physician, investigated several factors suspected of increasing the risk of severe flu during the influenza pandemic of 1918 that killed more than 50 million people. He reported that 'overcrowding' increased the risk of flu tenfold and the risk of flu complicated with pneumonia fivefold.[8]

In the month of April 2020, 615 crew members tested positive for the coronavirus, while one sailor died due to the disease aboard the “USS Theodore Roosevelt,” a US aircraft carrier in the Western Pacific. Similarly, a third of the sailors aboard French Navy flagship, “Charles de Gaulle,” and one of its escort vessels tested positive for the coronavirus later in the same month.[9] The above-mentioned incidents may seem isolated, however, they expose the vulnerability of the armed forces to this deadly pandemic.

An article published in the “New York Times” reported that “Dentists are the workers most exposed to the risk of being affected by COVID-19, much more than nurses and general physicians.”[10] Due to the characteristics of dental settings and operating procedures, the risk of cross-infection may be high between dental practitioners and patients. Strict and effective infection control protocols are urgently needed for dental practices and hospitals in countries/regions that may be affected by COVID-19.[11] This article, based on our experience and relevant guidelines and research, introduces the essential knowledge about COVID-19 and nosocomial infection in dental settings and provides recommended management protocols for the same.


  Etiology, Pathogenesis, Diagnosis, and Managment of Covid-19 Top


Coronaviruses belong to the family of “Coronaviridae,” of the order “Nidovirales,” comprising large, single, plus-stranded RNA as their genome.[12],[13] According to the existing literature, similar to SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), SARS CoV-2 is zoonotic, with Chinese horseshoe bats (Rhinolophus sinicus) being the most probable origin[14],[15] and pangolins as the most likely intermediate host.[16] Currently, there are four genera of coronaviruses: α-CoV, β-CoV, γ-CoV, and δ-CoV.[17],[18] 2019-nCoV explored in Wuhan belongs to the β-CoV according to the phylogenetic analysis based on the viral genome.[19],[20]

“2019-nCoV” possesses the typical coronavirus structure with the “spike protein” in the membrane envelope[21] and expresses other polyproteins, nucleoproteins, and membrane proteins, such as RNA polymerase, 3-chymotrypsin-like protease, papain-like protease, helicase, glycoprotein, and accessory proteins.[19],[20],[21] The “S” protein from coronavirus can bind to the receptors of the host to facilitate viral entry into target cells.[22],[23] 2019-nCoV binds to the human angiotensin-converting enzyme 2 (ACE-2), receptor from human, bat, civet cat, and pig cells. Furthermore, 2019-nCoV cannot bind to the cells without ACE2.[20],[24],[25] ACE2+ cells were found to be abundantly present throughout the respiratory tract and salivary gland duct epithelium in the oral cavity. ACE2+ epithelial cells of salivary gland ducts were demonstrated to be a class early targets of SARS CoV infection,[26] and 2019-nCoV is likely to be the same situation, although no research has been reported so far. Furthermore, conjunctival samples from confirmed and suspected cases of 2019-nCoV suggest that the transmission of 2019-nCoV is not limited to the respiratory tract,[27] and eye exposure may provide an effective way for the virus to enter the body.[28]


  Epidemiologic Characteristics Top


Modes of transmission: Based on findings of genetic and epidemiologic research, it has been reported that the COVID-19 outbreak started with a single animal-to-human transmission, followed by sustained human-to-human spread.[12],[29] It is now believed that its interpersonal transmission occurs mainly via respiratory droplets and contact transmission.[30] Studies have suggested that 2019-nCoV may become airborne through aerosols formed during medical procedures.[31] In addition, there may be risk of fecal–oral transmission, as researchers have identified SARS-CoV-2 in the stool of patients from China and the United States.[32]

Source of Transmission: Although patients with symptomatic COVID-19 have been the main source of transmission, recent observations suggest that asymptomatic patients including those in their incubation period are also carriers of SARS-CoV-2[12],[33] which makes it difficult to identify and quarantine these patients in time, which can result in an accumulation of SARS-CoV-2 in communities.[30] In addition, it remains to be proved whether patients in the recovering phase are a potential source of transmission.[33] The incubation period of COVID-19 has been estimated at 5–6 days on average, but there is evidence that it could be as long as 14 days, which is now the commonly adopted duration for medical observation and quarantine of (potentially) exposed persons.[34],[35]

According to the reported literature, at present, the “fatality rate” of COVID-19 is 0.39% to 4.05%, depending on different regions of China, which is lower than that of SARS (≈10%) and MERS ≈34%[36] and higher than that of seasonal influenza (0.01% to 0.17%) according to the data for 2010–2017 from the US Centers for Disease Control and Prevention (2020). In India, the fatality rate due to COVID-19 is approximately 3.35%.[7]

According to the available literature,[37],[38],[39] the proportion of severe cases among all patients with COVID-19 in China was around 15% to 25%. The majority of patients experienced fever and dry cough, while some also had shortness of breath, fatigue, and other atypical symptoms, such as muscle pain, confusion, headache, sore throat, diarrhea, and vomiting.[37],[40] Among patients who underwent chest computed tomography (CT), most showed bilateral pneumonia, with ground-glass opacity and bilateral patchy shadows.[37],[41] Among hospitalized patients in Wuhan, around one-fourth to one-third developed serious complications, such as acute respiratory distress syndrome, arrhythmia, and shock, and were therefore transferred to the intensive care unit.[27],[40],[41] In general, older age and the existence of underlying comorbidities (e. g., diabetes hypertension, and cardiovascular disease) were associated with poorer prognosis.[38],[41],[42] A similar kind of pattern has been reported in the affected Indian population as well.

The diagnosis of COVID-19 can be based on a combination of epidemiologic information (e.g., a history of travel to or residence in affected region 14 days prior to symptom onset), clinical symptoms, imaging findings, and laboratory tests (e.g., reverse transcriptase–polymerase chain reaction [RT-PCR] tests on respiratory tract specimens) as per the WHO[43] and the National Health Commission of China.[44] It should be mentioned that a single negative RT-PCR test result from suspected patients does not exclude infection. Clinically, we should be alert of patients with an epidemiologic history, COVID-19-related symptoms, and/or positive CT imaging results.[11]

Currently, the approach to COVID-19 is to control the source of infection by various measures such as use infection prevention and control methods to lower the risk of transmission and provide early diagnosis, isolation, and supportive care for affected patients.[41] “SOLIDARITY” is an International clinical trial, launched by the WHO in the management of COVID-19. As per the latest reports, over 100 countries have joined the trial to evaluate therapeutics for COVID-19. The trial is comparing four treatment options against local standard of care to assess their relative effectiveness against COVID-19 (remdesivir; chloroquine or hydroxychloroquine; lopinavir with ritonavir; lopinavir with ritonavir plus interferon beta-1a).[45] Indian Council Of Medical Research (ICMR) has been instrumental in facilitating research focused on the theme “Mission Mode-Translational Immunology” for early diagnosis, treatment, and prevention of COVID 19.[46]


  Covid-19 and Dentistry Top


Dental care settings invariably carry the risk of 2019-nCoV infection due to the specificity of its procedures, which involve face-to-face communication, generation of aerosol, frequent exposure to body fluids such as saliva, blood, and the handling of sharp instruments.

The pathogenic microorganisms can be transmitted in dental settings through inhalation of airborne microorganisms that can remain suspended in the air for long periods,[47] direct contact with blood, oral fluids, or other patient materials,[48] contact of conjunctival, nasal or oral mucosa with droplets and aerosols containing microorganisms generated from an infected individual and propelled a short distance by coughing and talking without a mask,[49],[50] and indirect contact with contaminated instruments and/or environmental surfaces.[26]

Hence, it becomes imperative that dental professionals should be familiar with how 2019-nCoV spreads, how to identify patients with 2019-nCoV infection, and what extra-protective measures should be adopted during the practice to prevent the transmission of 2019-nCoV.

To attend to the needs of armed forces personnel and their dependents requiring dental care during the period of the epidemic, certain guidelines were formulated. These guidelines were created considering the directives issued by various organizations at national and international level such as “The Ministry of Health and Family Welfare, Centers for Disease control and prevention, WHO and Occupational Safety and Health Administration” as well as procedural recommendations from various professional bodies and associations of Dentistry. The following are the guidelines that were put forward by the team at Army Dental Centre (Research and Referral) on April 11, 2020, for implementation in all dental centers of the armed forces while giving paramount importance to staff and patient safety:

  1. All dental centers were instructed to ensure distribution of their personnel into two groups designated as Team A and Team B. Both the teams would work alternately for a period of 14 days and on completion would proceed on a 14-day quarantine (home/Unit at the discretion of Unit Cdrs) as per the protocol. The unit commanders were to ensure that a subteam formed from each group comprising all functional elements would be kept ready for deployment at short notice for aid to civil or armed forces establishments. According to the directions of the Director General Dental Services, each dental center would have a designated number of surgeries functional during COVID-19 as per the number of patients that is catered to
  2. All personnel involved with patient care were instructed to change to surgical scrubs, which would be removed on completion of the duty and immediately transported to laundry services for cleaning within the unit premises
  3. All patients would first report to the nearest military hospital (MH)/Medical Inspection (MI) room for initial screening when the dental centers are colocated. If the MH was not colocated, then the patient would directly report to the dental centre. Once the patient arrives at the Dental Centre, he/she would be directed to the hand wash station [Figure 1]a and [Figure 1]b situated outside the main entrance where he/she would carry out handwashing under the supervision of a designated handwash assistant
  4. The patient would then report to the reception [Figure 2]. A minimum distance of “6 feet” would be maintained between the reception and the patient at all times. A similar distance (social distancing) would be maintained between patients in the patient waiting area [Figure 3]. The reception staff would preferably consist of an officer along with the receptionist. The telephone number of the reception would be given wide publicity. The dental officer would always attempt to perform a telephonic triage with respect to the patients prior to the patient reporting to the dental center. As far as possible, all dental visits of the patient would be appointment based. Subsequently, “Emergency Severity” [Table 1] would be ascertained verbally followed by the “COVID-19 risk level” using a questionnaire [Table 2]A and [Table 2]B. In case, the patient is found to be in “high risk” category, he/she would be referred back to the nearest medical facility. Finally, the temperature of the patient would be recorded using a non-contact thermometer. However, emergency dental procedures to alleviate pain would be considered even in COVID-19 high-risk patients[51]
  5. Based on the dental emergency index, the patient would be allocated to the following priority groups: P1 – emergency care, P2 – urgent care, and P3 – scheduled care [Table 1]. All operated cases requiring follow-up would be evaluated at the place of admission and not at the dental centre to reduce the risk of disease transmission. In the case of a patient reporting with severe pain (odontalgia) where access to the root canal system is not feasible using electric micromotor, extraction therapy would be resorted to with patient consent
  6. Details recorded at reception would include contact details of all patients for further surveillance and contact tracing if required
  7. After a patient is triaged and selected for dental treatment delivery of any nature, he/she would be directed to leave all his/her personal belongings at the entrance at a pre-designated area, wear a surgical mask, a shoe cover, disposable drape, and disposable patient cap. Following this, the patient would be instructed to perform hand sanitization using a hand sanitizer
  8. Patients would then be directed to a screening clinic where they would subsequently be directed by the Dental Operating Room Assistant (DORA) to wash their hands, face, brush their teeth (without dentifrice), and rinse their mouth with an antiseptic mouthwash at a pre-designated patient wash station
  9. The patient would then be examined by the dental officer. The dental officer ascertains the nature of the dental problem and assigns the patient to one of the dental operatories. Only disposable diagnostic instrument sets would be used
  10. The patient would then be assigned to a dental operatory. The dental officer and DORA should practice four handed dentistry while treating the patient within the dental operatory [Figure 4]. On the dental chair, the patient would be draped and made to carry out a preprocedural mouth rinse (1% hydrogen peroxide/2% w/v povidone-iodine). The dental officer would then wipe the face of the patient with a disposable disinfectant face wipe. The dental assistant would ensure that least aerosol generation occurs while the dental officer carries out treatment by the use of high-volume suction. No airotor/ultrasonics/three-way syringe would be used in the dental operatory
  11. The dental officer would strictly adhere to the principles of universal protection. Preferably, National Institute for Occupational Safety and Health (NIOSH) approved N-95 masks would be used to ensure quality control. Of the two pair of gloves worn, the inner pair would be of a different color to notice easily any inadvertent tears on the outer pair of gloves
  12. Preferably, external imaging technologies such as orthopantomogram and cone-beam computed tomography should be resorted to, as intraoral imaging may result in gag reflex activation, stimulation of saliva secretion, and coughing, resulting in salivary splatters. However, in unavoidable situations, a triple sleeve should be used on the intraoral sensor. The usage of rubber dam would be encouraged to prevent generation of splatter
  13. After the patient arises from the dental chair, the DORA must ensure that all surfaces with which the patient or aerosolized particles may have come in contact are sprayed with surface disinfectant and wiped clean
  14. The DORA would then prepare the dental operatory for the next patient. Furthermore, he/she would ensure that the biomedical waste (BMW) is disposed in the appropriate colored waste bin. Handling, treatment, and disposal of BMW would be carried out as per the standard guidelines in vogue
  15. The dental operatory would be fumigated daily at the end of working hours [Figure 5]
  16. With respect to the dental personnel, a prespecified work flow would be maintained while in the sterile zone. For efficient work flow, a separate screening, donning, and doffing room would be designated. Donning and doffing drills would be regularly practiced, as improper donning/doffing may lead to cross-contamination. Inner standard personal protective equipment (PPE) along with improvised outerwear would be donned/doffed by dental personnel using the established procedure under the supervision of an assistant assigned specifically for the purpose whereever feasible. The outer PPE donned by dental personnel can be customized at the user's end and would be changed between patients; the outer PPE would be fabricated with impermeable, biodegradable material such as the material used for BMW disposal bags. The standard inner PPE is to be worn for the entire shift period. In case the outer customized PPE is not available, then standard PPE is to be disposed of as per laid down protocols on completion of the treatment of each patient. The PPE to be used by various personnel in the dental center would be as per [Table 3]
  17. The above-mentioned procedures would be facilitated by ensuring that the dental personnel form teams that work in shifts and do not come in contact with each other
  18. Posters on the emergency dental procedures and PPEs would be displayed prominently in all dental centers
  19. All the staff members who attended work at the center would be screened for signs and symptoms of COVID 19 prior to commencement of work[52],[53],[54],[55],[56]
  20. As there is adequate evidence to suggest that there is a risk of transmission of SARS CoV-2 from dental impressions, dental casts, dental prosthesis, or appliances due to its prolonged viability on various surfaces in the laboratory including plastic, cardboard, and metals. The following guidelines were put forward for implementation in the dental laboratory of all dental centers of the armed forces.


    1. The laboratory technicians should ensure minimal direct contact with dental officer and the patient
    2. Social distancing would be practiced in the dental laboratory, and preferably, a distance of at least 6 feet should be maintained between personnel at their work stations
    3. Laboratory personnel should wear the proper working dress (scrubs), gloves, head cap, foot cover, eyewear, and a triple-layer mask. The protective garment or working dress worn in the laboratory will be left in the laboratory itself and not taken out of the laboratory. This has to be cleaned or washed, disinfected each day, and stored in the laboratory itself. Head cap, foot cover, eyewear, mask, and other items would be discarded according to the BMW disposal protocol
    4. Washing hands is critical to practicing standard precautions. Hand sanitizers are to be placed at vantage points within the laboratory and routinely used when not wearing gloves. Hands need to be washed thoroughly with soap and water after every case and the technician should avoid touching the face while in laboratory
    5. Dental laboratories should be fumigated daily before and after working hours. All surfaces including tables, chairs, trays, and slabs should be wiped clean using disinfectants containing virucidal agents like 1% sodium hypochlorite solution or 60%–90% isopropyl alcohol among others that are effective against enveloped viruses. Floors and sinks should also be cleaned using a hypochlorite-containing cleaner
    6. The laboratory must have a separate “Receipt” and “Dispatch” section. All casts, working models, prosthesis, and impressions should be thoroughly disinfected and stored in a sealed pouch at the clinic level itself before sending them to the laboratory. All laboratory forms sent should have an endorsement confirming “Disinfection protocol done.” However, on receipt of the same in the laboratory, the laboratory personnel will once again ensure the disinfection of models, casts, trays, and articulators with 70% isopropyl alcohol-based solutions. A “spray-wipe-spray” technique followed by storage in a sealed pouch or immersion in a glutaraldehyde-based disinfectant solution will be done. On completion of the laboratory work, the prosthesis will be disinfected once again and stored in a sealed pouch that is labeled
    7. While trimming and polishing the prosthesis, the plexiglass safety shield should be in place and the fumes or fragments should preferably be sucked out using a high-vacuum suction. Pumice and rag wheels or buffs and arbor bands should be changed after use. The pumice pan should be lined using foil or plastic wraps and discarded after use. Burs including acrylic trimming burs should be sterilized using dry heat
    8. All waste generated will be disposed according to the proper BMW disposal protocol
    9. CAD CAM-based prosthesis should be scaled up to minimize human interface wherever the feasibility exists.[57],[58],[59],[60],[61],[62],[63]
Figure 1: (a and b) Handwash station

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Figure 2: Patient at reception (Triage) area

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Figure 3: Social distancing in the patient waiting area

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Figure 4: Four handed dentistry with personal protective equipment

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Figure 5: Fumigation

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Table 1: Emergency severity index

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Table 3: Recommended personal protective equipment usage by personnel

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The present institution followed the above-mentioned guidelines and safely carried out dental treatment for 438 patients till date [Table 4] and [Table 5]. No COVID-19-positive cases were traced back due to the visit to the dental centre during this period. No staff member has so far been detected positive for COVID-19. Thus, it can be concluded that proper Standard Operating Procedure (SOP) and its effective implementation is the key to overcome cross-infection during deadly pandemics like COVID-19.
Table 4: Details of categories of patients who were provided dental care during Corona Virus Disease-19 lockdown period till May 31, 2020

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Table 5: Details of emergency and urgent dental procedures performed during COVID -19 lockdown period till 31 May 2020

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  Summary and Conclusion Top


The present institution continued to function during the national lockdown that was imposed by the government beginning in March 2020. Based on the existing evidence-based literature and our experiences, we have summarized the possible transmission routes of SARS-CoV-2 in dental settings and several practical strategies to block the same. Furthermore some methods have been suggested for preventing the transmission of SARS-CoV-2 during dental diagnosis and treatment procedures, including patient evaluation, hand hygiene, personal protective measures for the dental professionals and dental laboratory, mouthrinse before dental procedures, rubber dam isolation, disinfection of the clinic settings, and management of BMW.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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