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 Table of Contents  
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 77-82

Changing paradigm of dentistry: Innovations and management in INHS Sanjivani during pandemic crisis

Dental Centre, INHS Sanjivani, Kochi, Kerala, India

Date of Submission12-Nov-2020
Date of Acceptance22-Jan-2021
Date of Web Publication09-Mar-2021

Correspondence Address:
M M Dempsy Chengappa
Dental Centre, INHS Sanjivani, Southern Naval Command, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodd.jodd_64_20

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Introduction: March 11, 2020, when the WHO announced the COVID-19 as a pandemic, the whole world went into a panic. This was more so among the health workers and even higher among the dental health-care providers as we are at the highest risk of infection inherently as we are in close proximity with the patients' fluids and have multiple procedures which cause aerosol generation. However, as time passed and more understanding of the disease was obtained, guidelines were devised based on these findings.
Objective: To emphasise the protocols and procedures required to be followed to safely carry out the procedures in the background of COVID 19 pandemic. This article looks at how the dental center at INHS Sanjivani has managed to keep the outpatient department (OPD) running and at the same time has successfully prevented patient to patient and patient to health worker spread of COVID-19.
Conclusion: The precautionary procedures and procedures instituted resulted in reducing the chances of spread of the pandemic. These protocols may be useful for application in future with an aim to reduce spread through the dental operatory while providing quality care.

Keywords: Changing paradigms, COVID-19, dental care, innovations, Kerala

How to cite this article:
Dempsy Chengappa M M, Anand A N, Ray S, Sharma D, Kumar A N. Changing paradigm of dentistry: Innovations and management in INHS Sanjivani during pandemic crisis. J Dent Def Sect. 2021;15:77-82

How to cite this URL:
Dempsy Chengappa M M, Anand A N, Ray S, Sharma D, Kumar A N. Changing paradigm of dentistry: Innovations and management in INHS Sanjivani during pandemic crisis. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:77-82. Available from: http://www.journaldds.org/text.asp?2021/15/1/77/310971

  Introduction Top

COVID-19 or SARS-CoV-2 is a public health emergency which has ravaged the entire world ever since the first case was reported in Wuhan, Hubei province in central China in December 2019.[1] The primary hosts for coronaviruses are animals such as pangolins, snakes, and bats; infection in humans occurs when the animal–human barrier is crossed as is speculated in this instance possibly from a seafood market.[2] The infection subsequently spread worldwide through human hosts due to travel, followed by local and community transmission through infected persons.[3] As per current data available, there are approximately 3 crore 67 lakh confirmed cases and 10 lakh 64 thousand deaths worldwide (available at coronavirus.jhu.edu). India too has been severely affected by this pandemic with the total number of cases at 70 lakhs 53 thousand and no of deaths at one lakh eight thousand as on October 10, 2020 (available at mohfw.gov.in). The state of Kerala was a model for the rest of the country during the initial stages of the pandemic and drew a lot of praise for its proactive handling of the crisis.[4] However, this initial success story came undone with the numbers of COVID-positive cases quickly starting to rise by June. There were various factors which were attributed to this turn of events such as the return of expatriates and subsequent transmission through the local communities.[5] The number of daily positive cases steadily rose from zero on some days of May 20 when it was declared that Kerala had achieved a “viral miracle” to the present day when up to 11,000 fresh cases have been detected per day.[6] The Indian Navy which played a crucial role in the evacuation of Indian nationals from various foreign lands was not immune to the virus in spite of stringent measures which were instituted. This necessitated the adoption of treatment protocols to prevent transmission of the disease in the community during the delivery of dental care. The guidelines issued by the office of Director General Dental Services and Ministry of Health and Family Welfare served as the mainstay for all dental care delivered at the Naval Hospital.[7] The Dental fraternity at the Naval Hospital had to adapt to these guidelines and make necessary changes to incorporate identification, prevention, decontamination, disinfection, and sterilization protocols.[8] There was a need to triage the cases and classify them into emergency, urgent and routine cases, and also changes in reception and screening protocols were put up in place.[9] The need to reduce the footfall in the dental outpatient department by the contactless screening of patients and classifying them into emergency and nonemergency cases led to the introduction of teledentistry.[10] This article aims to present the various treatment protocols used to deliver dental care at Dental Centre, INHS Sanjivani by applying and modifying existing guidelines to fulfill the local needs.

  Management of Dental Patients During the Pandemic Top

The treatment protocol adopted by the Dental Centre, INHS SANJIVANI has evolved continuously to suit the prevailing local situation, the directives of the organization, IDA, and adoption of successful strategies from other Armed Forces Dental Centres. The main salient features have revolved around, triaging at every stage and on the factors mentioned below:

  1. Mode of transmission
  2. Recording thorough travel and contact history
  3. Signs and symptoms
  4. Investigation and diagnosis of suspect cases
  5. Management protocols and procedures in the dental office.

In keeping with these points, the dental treatment procedure was categorized into three steps:

1. Preappointment procedures

  • Teledentistry was introduced to conduct teletriage; this enabled contactless first point screening. This was done using a smartphone which was procured solely for the purpose through unit resources with due approval from higher formations. This enabled the recording of medical history including symptoms of fever, cough, sore throat, running nose, diarrhea, and loss of taste and smell.[11] This modality also helped to give access to photographs of the affected site assisting in the evaluation of the treatment needs [Figure 1]
  • In keeping with the requirement to reduce the footfall in the Dental Centre, the routine cases which did not require emergency or urgent care were suspended till further guidelines were issued by relevant authorities. Those cases which could be managed using medications were prescribed accordingly, which were collected from the nearest service dispensary negating the need for a dental center visit
  • In case of patients needing emergency or urgent treatment, appointments were given to visit the dental center. A log for all the patients visiting the dental center was maintained separately along with a list of the questionnaire being answered by the patients. This was done to keep the contact and travel history of all the patients
  • The procedure at the reception was modified to cater for COVID-19 transmission prevention. All surfaces were disinfected routinely using 70% isopropyl alcohol. A glass separator was placed to prevent aerosol contact during registration. The receptionist mandatorily wore protective gear including N95 mask and face shield [Figure 2]. The recording of temperature using a contactless infrared thermometer was done for all patients. A patient information questionnaire was also given to be filled by the patient to record medical and travel history [Figure 3]
  • The patient was then sent to the screening zone where he/she was examined by a dental surgeon in personal protective equipment (PPE) including N95 mask, face shield, double gloves, spill proof gowns, and shoe covers. And if the treatment need of the patient was not of an emergency or urgent nature, he/she was counseled or prescribed medication as per need and disposed [Figure 4]
  • The patients requiring management were then directed to the waiting area where social distancing norms as suggested by the WHO and Government of India were maintained [Figure 5][12]
  • Pretreatment protocols were also instituted for all the dental and paradental staff. Every staff changed into scrubs in the treatment area and wore PPE when in contact with the patients. A demarcated area was established for donning and doffing of PPE kits and biomedical disposal of waste was instituted as per guidelines in place. Periodic cleaning and disinfection of reception, waiting area, donning/doffing area including doorknobs (using 1% sodium hypochlorite), and working surfaces were ensured [Figure 6],[Figure 7],[Figure 8]
  • Patient education posters and guidelines on COVID-19 were well displayed at reception and patient waiting areas.
Figure 1: Photo sent by the patient for teledentistry consultation

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Figure 2: Reception area, receptionist uses the personal protective equipment kit with N95 mask and face shield

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Figure 3: Self-assessment questionnaire given to patients at the time of outpatient department registration

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Figure 4: Patient being screened by operator and assistant in personal protective equipment, in a well-ventilated surgery

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Figure 5: Patients seated in waiting are following strict social distancing protocols

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Figure 6: Designated personal protective equipment donning area

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Figure 7: Designated doffing area

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Figure 8: Door knobs being sterilized with sodium hypochlorite 1.2% solution

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2. Procedure during dental treatment

  • The patients who were screened and selected to undergo treatment are called to the surgery in a staggered manner to allow for disinfection of all surfaces
  • Accompanying persons were discouraged except in case of children and persons with special health-care needs. In case of female patients, a service employed lady attendant was allowed into the surgery with the necessary protective gear[13]
  • The surgeries were isolated from the central air conditioning to reduce the chances of transmission. The patients were asked to sanitize their hands with hand sanitizer containing 70% isopropyl alcohol, followed by preprocedural mouth rinse with 1% povidone-iodine mouth rinse[14],[15]
  • To reduce the generation of aerosols, micromotor was used for most procedures, however during procedures requiring the use of air rotor, a high power extra oral suction with highly efficient particulate air filter was used (procured through COVID 19 emergency fund). The antiretraction air rotor handpiece or electric friction grip handpiece was also procured (through the Director General Local Purchase (DGLP) fund) to reduce the generation of aerosols. Rubber dam isolation was done in some cases requiring extensive management[16]
  • All cases treated were considered with a high degree of suspicion keeping in mind the asymptomatic carriers. Hence, PPE kits were used for all patients with face shields, N95 masks, and shoe covers (through DGLP fund) [Figure 9]. As per the data of cases treated, cases requiring extensive aerosol-generating procedures were sent for a True Nat COVID diagnostic test (originally designed to detect cases of tuberculosis) before the procedure [Table 1][17]
  • In cases requiring minor surgeries, i.e., trauma, impactions, etc., resorbable sutures were preferred over nonresorbable ones to reduce visits. Use of ultrasonic scaler was completely stopped and hand scaling was done for emergency cases[18]
  • Elective orthodontic treatment was suspended, and only emergency cases were being taken up. The emergency cases were selected as per the O/o DGDS guidelines on the subject [Table 2]
  • All procedures requiring management under general anesthesia including oral maxillofacial and pedodontic procedures were done with all protective precautions after two negative True Nat test results on day 1 and day 7 of admission [Figure 10].
Figure 9: All patients are treated in full personal protective equipment kit with N95 masks and face shield with use of intraoral suction and extraoral hepa filter suction

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Figure 10: Emergency surgeries were conducted under proper OT protocols and in full personal protective equipment suits

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Table 1: Cases managed in dental center INHS Sanjivani from March 1, 2020 till date

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Table 2: Emergency severity index as per Office of Director General Dental Services DGDS

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3. Procedure posttreatment

  • On completion of the procedures, the PPE kits were doffed in the designated area and disposed as per biomedical waste disposal protocols. The face shields were sanitized with 70% isopropyl alcohol
  • The patients were asked to inform about any COVID-19 like symptoms within the completion of 7 days' posttreatment
  • A logbook was maintained to record the number of PPE kits and other protective consumables used and their present stock, so as to raise an indent to procure the same on time
  • All instruments used were autoclaved. The red surfaces were disinfected after each patient [Figure 11]. The paradental staff was instructed to carry out this procedure with all necessary protective wear
  • The surgeries were then fumigated before closure using sterisol solution (hypochlorous acid and peroxide anion) produced in the Operation theatre OT using a Sterigen disinfectant generating system [Figure 12].
Figure 11: Patient contact surfaces being wiped with 70% isopropyl alcohol after each patient

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Figure 12: Surgery fumigation using sterisol solution

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  Conclusion Top

During this unprecedented pandemic, it is imperative that all dental treatment facilities follow the latest guidelines to prevent vertical transmission of the disease. It is essential to incorporate best practices from other centers to improve and fine-tune procedures in place. Toward this end, Dental Centre, INHS Sanjivani, has continuously liaised with Army Dental Centre R and R and Department of Dental Surgery and Oral Health Sciences, AFMC Pune, to constantly update its protocols keeping the O/o DGDS guidelines as the base. The protocols so far have helped to reduce chances of transmission as the data in this article reveal and proper implementation of these guidelines will help in the safe delivery of dental care during the time of COVID-19.


The authors of this manuscript would like to thank and acknowledge the contribution of Command Medical Officer, Southern Naval Command, Surg RAdm Arti Sarin and Commanding Officer, INHS Sanjivani, Surg Cmde Anupam Kapur, NM, for all the proactive measures and providing us with the required infrastructure and materials to combat COVID-19 in a safe and secure manner. Also, the authors would like to thank Brig B Jayan, Commandant, ADC R, and R for constant guidance and support during the pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – An update on the status. Mil Med Res 2020;7:11.  Back to cited text no. 1
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 2
Coronavirus Situation Report -83; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/>. [Last accessed on 2020 Oct 10].  Back to cited text no. 3
Responding to COVID-19-Learnings from Kerala. WHO South East Asia (India). Available from: https://www.who.int/india/news/feature-stories/detail/responding-to-covid-19-learnings-from-kerala: 1-5. [Last accessed on 2020 Jul 02].  Back to cited text no. 4
Soutik B. India coronavirus: How Kerala's Covid 'success story' came undone. BBC News 2020 p. 5; https://www.bbc.com/news/world-asia-india-53431672. [last accesed on 2020 Jul 20].   Back to cited text no. 5
COVID 19 INDIA. Ministry of Health and Family Welfare. Government of India as on : 15 Sep 2020.  Back to cited text no. 6
Ali A, Saad A, Shahad A. Guidelines for dental care provision during the COVID-19 pandemic. The Saudi Dental Journal 2020; 32:1016.  Back to cited text no. 7
Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 outbreak: An overview on dentistry. Int J Environ Res Public Health 2020;17:2094.  Back to cited text no. 8
Center for Disease Control and Prevention (CDC). Interim infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) pandemic. Available Online : https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html [Last assessed on 15 May 2020].   Back to cited text no. 9
Chopra SS, Sahoo NK. Protocol for teledentistry during COVID-19 in armed forces dental establishments. Med J Armed Forces India 2020;76:356-9.  Back to cited text no. 10
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-95.  Back to cited text no. 11
Fiorillo L, Cervino G, Matarese M, D'Amico C, Surace G, Paduano V, et al. COVID-19 Surface persistence: A recent data summary and its importance for medical and dental settings. Int J Environ Res Public Health 2020;17:3132.  Back to cited text no. 12
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Golin AP, Choi D, Ghahary A. Hand sanitizers: A review of ingredients, mechanisms of action, modes of delivery, and efficacy against coronaviruses. Am J Infect Control 2020;48:1062-7.  Back to cited text no. 14
Moosavi MS, Aminishakib P, Ansari M. Antiviral mouthwashes: Possible benefit for COVID-19 with evidence-based approach. J Oral Microbiol 2020;12:1-8.  Back to cited text no. 15
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

  [Table 1], [Table 2]


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