|COVID SPECIAL SECTION: ORIGINAL ARTICLE
|Year : 2021 | Volume
| Issue : 1 | Page : 83-91
Covid-19 and delivery of dental health care services at Army Dental centre Research & Referral: A holistic assessment
Dinesh Chander Chaudhary, B Jayan, Manish Mukherjee, Rajat Mitra, Vivek Saxena, Dinesh Kumar, Sudip Indu, Amit Khatak, Mohit Sharma, K Megala, Twinkle Rathore, V Jackson
ADC (R&R), New Delhi, India
|Date of Submission||23-Dec-2020|
|Date of Acceptance||22-Jan-2021|
|Date of Web Publication||09-Mar-2021|
Dinesh Chander Chaudhary
Army Dental Centre (R&R), New Delhi
Source of Support: None, Conflict of Interest: None
Background: The practice of dentistry has been worst affected in Covid-19 pandemic due to its non-emergency nature and fear of rapid spread of disease through aerosol generating procedures. But, multiple dental problems can severely compromise function. This assumes even greater significance when it concerns the health of Armed Forces. ADC (R&R) was always at the forefront providing essential, urgent and scheduled dental care at various stages of pandemic with stringent management protocols.
Aims and Objectives: To evaluate challenges, measures and the outcome in delivery of dental services based on observational assessment from 20 Mar-30 Nov 2020. The objectives were to assess patient attendance trends, reason for availing dental services, loss of manhours, antibiotic usage, Covid protection measures and resources, aerosol generating procedures, Knowledge/Attitude/Perception (KAP) studies, Covid-19 casualties, management of quarantine periods.
Materials and Methods: Patients and staff data based on attendance, treatment instituted, patient screening procedures, additional expenses on Covid related resources, infrastructural changes etc.
Results and Conclusion: The total of 13,046 patients were treated. There has been a considerable loss of manhours and more than 65% of the allocated budget was used in managing patients which otherwise were less than 25-30% of the pre-covid attendance. The manpower requirements tripled and the housekeeping services were heavily taxed. The staff Covid-19 casualties were considerably low and no patient reported acquiring Covid-19 infection post dental treatment at this centre. If the condition persisted, the ability to provide dental health care services will be an uphill administrative and financial challenge.
Keywords: Challenges, COVID-19, dental care delivery, observational assessment, outcome
|How to cite this article:|
Chaudhary DC, Jayan B, Mukherjee M, Mitra R, Saxena V, Kumar D, Indu S, Khatak A, Sharma M, Megala K, Rathore T, Jackson V. Covid-19 and delivery of dental health care services at Army Dental centre Research & Referral: A holistic assessment. J Dent Def Sect. 2021;15:83-91
|How to cite this URL:|
Chaudhary DC, Jayan B, Mukherjee M, Mitra R, Saxena V, Kumar D, Indu S, Khatak A, Sharma M, Megala K, Rathore T, Jackson V. Covid-19 and delivery of dental health care services at Army Dental centre Research & Referral: A holistic assessment. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:83-91. Available from: http://www.journaldds.org/text.asp?2021/15/1/83/310973
| Introduction|| |
COVID-19 pandemic has emerged as the biggest bane in the global social network in the 21st century breaking all the human personal, professional, and geographical barriers. The health sector is working round the clock to spread awareness, provide treatment, and search a viable cure for this disease, and the administration is toiling to provide congenial working environment and optimize the need of basic necessities, but the end does not seem near. In this pandemic, COVID has taken a center stage, and most other emergent, essential, and routine medical conditions and services have been relegated., The practice of dentistry has also been worst affected mainly due to two reasons: not an emergency lifesaving service and fear of rapid spread of COVID-19 among patients and staff due to its aerosol-generating procedures., Nonetheless, the importance of dental procedures and their efficient delivery cannot be denied to those in need in any scenario: pandemic or no pandemic. Pain is the biggest emergency and severity of dental pain in compromising physical/mental health and seeking treatment cannot be understated. Besides, there are various appliances and prostheses which need regular maintenance and can severely compromise function if not attended to. The Army Dental Centre (ADC) (R and R) has been at the forefront during this testing time to deliver efficient emergent, essential, and routine dental care to its dependent clientele, during various stages of pandemic in compliance with directives of reputed professional bodies such as the Centers for Disease Control and Prevention, Ministry of Health and Family Welfare, World Health Organization, Armed Forces Medical Services, and Dental Council of India.,,,, The stringent patient manaegement protocols were formulated and followed in letter and spirit to prevent any untoward incident. However, the journey to provide these services was full of challenges at professional, administrative, financial, and spiritual levels.
The aim of this article, based on observational assessment, is to evaluate these challenges, measures undertaken, and the outcome based on our experience from March 20 to November 30, 2020.
The objectives of this observational assessment were to:
- Assess the patient attendance trends
- Reasons for availing dental services
- Antibiotic usage
- Loss of manhour
- Resource usage for COVID protection measures
- Aerosol-producing procedures
- Knowledge attitude and perception (KAP) of dental officers, paradental, housekeeping staff, and patients
- COVID-19 infection and staff casualties
- Compare it with other health-care organizations committed to health-care delivery.
| Patient Attendance Trends|| |
Although the news of COVID-19 spread had started making headlines in different parts of the world in January, India was unaffected and so were the regular health services which continued till mid-March, when India felt the heat. Dental treatment was considered to be one of the riskiest situations to contract and spread the disease due to the very nature of the procedures involved. Since the disease is spread by contact with infected droplets,, dental procedures were discouraged by the dental fraternity and the patients alike.
A look at the graphical representation in [Figure 1] throws light on the patient attendance trends from January to November 2020. Thus, from an average daily attendance of 250–300 patients in January–February, the outpatient department (OPD) services shrank significantly followed by steady rise as the provisions and infrastructure to work safely in new environment were put in place. The total patient attendance during this observational time (March 20–November 30, 2020) was 13,046, which is highly significant. [Figure 2] gives insight into the treatment procedures in terms of emergency, urgent, and scheduled care during the same period. The total patient attendance in initial 2.5 months (till 31 May 2020) was 488; of which scheduled treatment attendance was only 52 patients. This was followed by steady increase in scheduled treatment attendance. In a scenario, where most of the dental establishments almost abandoned their functioning and medical establishments exercised extreme caution in extending health-care services, ADC (R and R) continued to provide required services. In addition, postgraduate training could not be abandoned indefinitely as loss of each day has great significance. There were various positive factors involved in extending these services: large manpower of about 24 dental professionals and 30 postgraduate trainees, strong administrative management team, proximity of staff residential areas to work place, efficient support staff, and dedicated housekeeping staff.
|Figure 2: Emergency, urgent, and scheduled procedures during COVID pandemic|
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| Reasons for Availing Dental Services|| |
The protocol compromising emergency, urgent, and scheduled care was formulated as per [Table 1]. The scheduled care was discouraged and priority was given to emergency and urgent care in the initial 2 months. Teledentistry was promoted to an extent that the patient could at least get his concerns evaluated before stepping-out for any management. If deemed necessary, physical appointment was scheduled and attended to. The details of emergency and urgent output from lockdown to November 2020 is illustrated in [Table 2] and [Table 3], and [Table 4] provides the details of the emergency and urgent procedures undertaken. The protocol to evaluate emergency and urgent procedures was revised after May 31, 2020, and is reflected in [Table 4]. One clinic in each department was dedicated to patient care considering the strict protocol to contain infection and ensure disinfection after each procedure. The manpower requirement to manage each surgery tripled considering the protocols.
| Use of Antibiotics|| |
This dental facility was never completely shut down and all the emergency/urgent dental procedures were cautiously carried out routinely. Thus, the indiscriminate use of antibiotics and other medicines related to telemedicine practice for symptomatic relief was limited. The self-medication by patients may have been an issue, especially in the initial 2 months of lockdown due to inability of the patients to attend the OPD facilities for various lockdown-related restrictions, but indiscriminate use of antibiotic as part of treatment schedule was avoided. The use of antibiotics and analgesics during first four months of Covid-19 pandemic is as per [Table 5] and its co-relation with OPD is reflected in [Table 6] and [Figure 3]. Thus, considering the type of patients who attended and treatment instituted especially during the initial 2.5 months, when treatment procedures were restricted, the antibiotic use was highly judicious. At the same time, the patients were educated on the importance of good oral hygiene and preventive measures. The use of adjunctive measures such as use of mouthwash and flossing where required was reinforced.
|Table 5: Antibiotic and analgesic use in COVID-19 pandemic (April-August)|
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| Loss of Manhours|| |
The pandemic resulted in significant manhour loss. The manhour loss can be simply calculated as hours in a day multiplied by days of absence from duty due to various reasons. However, keeping in view the productive workhours involved in patient care and training in a day, the total manhour loss was calculated based on this logic. The manhour loss can be divided into three parts:
- Manhour loss due to inability of personnel on leave to join back on time due to lockdown travel restrictions
- Manhour loss due to compulsory quarantine schedule for staff on rotation basis
- Manhour loss due to quarantine after rejoining from postlockdown leave (August–November).
Manhour loss due to inability to join back
There were 20 staff members on leave during lockdown when restrictions on travel were imposed and the delay in joining duty ranged from 12 to 82 days with an average of 59.55 days. In addition, on rejoining, every personnel was put on 14 days of compulsory quarantine, which amounts to loss of another 280 days combined. As per our normal working schedule (workhours – 4 days: 0800 h–1700 h and 2 days: 0800–1400 h), every person works 48 hours/week in a 6 day work week. Even, if productive workhours by most conservative means are taken to be 40 h/week, the total workhour loss due to this single factor was 8400 h or 210 work weeks or 4 work years.
Manhour loss due to staff rotation schedule
Due to lockdown and considering the nature of services that were to be provided to the patients, the staff was divided into two teams: red and orange, optimizing manpower of each department to reduce congestion at workplace, to ensure mandatory social distancing, and to have adequate reserve staff in case of any eventuality of contracting disease during active service phase. Strict anti-COVID protocols were followed by both teams. This quarantine schedule was adhered to from 01 April to 31 July. Thus, the total manhour loss due to Covid-19 pandemic as per [Table 7] in this tertiary dental care centre was staggering 46,000 hrs; 1150 work weeks or 22 work years till Nov 2020.
Manhour loss due to quarantine on return from leave from August to November
From mid-July, working resumed on full strength, but with the resumption of travel services and fresh scheduled leaves, necessary quarantine on return from leave continued as per the guidelines. The quarantine period in August/September and October/November was reduced to 7 and 3 days, respectively, with appropriate COVID-19 testing where deemed necessary before resuming active service. On an average, 5–6 personnel returned from leave every week and were subjected to quarantine. Thus, assuming 40 hours (hrs) of productive work hour loss/ week and an average five personnel rejoining from leave every week; this translates to 2400 hrs/ 60 work weeks/ 1 work year (approx).
Thus, the total manhour loss due to COVID-19 pandemic in this tertiary dental care center was staggering 46,000 h: 1150 work weeks or 22 work years till November 2020.
| Expenses Due to COVID|| |
Dentistry is the one of the most feared professions during COVID-19 due to the nature of procedures involving aerosol generation as well as proximity to all the sources releasing and harboring pathogenic SARS Cov-2. Thus, specific guidelines have been issued for control of this infection and one focus of such guidelines is enhanced infection control protocols including personal protection equipment (PPE). In addition, the equipment which can provide noncontact sanitization and limit the spread of aerosols are valuable additions. Although ADC (R and R) has managed to offer treatment to dependent clientele, it has come at heavy financial burden. All treatment to dependent clientele is provided free of cost. The medical store purchases to deal with Covid-19 pandemic are as per [Table 8]. The expense on COVID-related stores till November was close to Rs. 12.5 million. This is about 65% of the sanctioned budget for the FY 2020–2021.
| Knowledge, Attitude, and Perception of Staff|| |
In the atmosphere of fear, uncertainty and lack of definitive management surrounding the nature of pandemic, it was equally important to assess the KAP of the staff and patients toward this disease. This step was equally important to get the real time preparedness professionally, psychologically, and spiritually and to reinforce necessary measures to ensure preparedness and allay apprehensions. Thus, after initial training and education on anti-COVID precautions from the information/guidelines available from sources,,,,, KAP survey was carried out for dental professionals, assisting staff, and housekeeping staff. All these feedbacks were obtained on survey instrument directly. The results of the knowledge survey of Dental and paradental staff are illustrated in [Table 9] and [Table 10]. Since the survey was in-house and response could be obtained directly, we could obtain true response and overcome some of the short-coming of online surveys.
|Table 9: Dental officers' knowledge (officers surveyed: 51 average knowledge score: 66%)|
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|Table 10: Paradental staff knowledge (surveyed: 40, average knowledge score: 58%)|
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Attitude and perception of dental and paradental staff was a mixed reaction with the following observations:
- Majority of respondents agreed to be in high-risk category in dental hospital and treatment setting
- Majority had faith in preparedness of the institution in managing situation without much adverse affects
- Majority had faith in ability to handle patients despite COVID-19 threat
- Majority felt that it is difficult to work with elaborate PPE kit
- Majority agreed with a need to continuously provide essential dental treatment services
- Fear of transmitting infection to family was the biggest concern
- Few felt that the situation has been blown out of proportion.
| Knowledge, Attitude, and Perception of the Patients Attending Outpatient Department|| |
Patients attending OPD were subjected to KAP regarding coronavirus pandemic, its implication on dental treatment, how they feel about our preparedness in providing treatment, and general measures on COVID management. Approximately 100 patients were surveyed randomly in OPD over a period of 1 week in June, and the results were recorded on the survey instrument along with educational, professional, and demographic details. The highlights of the survey are as follows:
- Fifty percent of the patients reported for emergency and urgent dental care, while 44% reported for review appointment of their emergency, urgent, or scheduled appointment and only 6% respondents visited for regular check-up
- Seventy-three percent of the respondents viewed COVID-19 as a serious threat while remaining considered it either as mild problem, blown out of proportion, or like any other normal disease
- Seventy-seven percent of the respondents felt safe seeking dental treatment and 85% confided in ADC (R and R) being safe place to seek dental treatment. They also felt that adequate and essential preventive measures were being adopted in patient management
- Seventy-five percent of the responders did not face any problem in seeking treatment and the major problem illustrated was long waiting time which is justified keeping in view the adopted checks and balances in anti-COVID measures
- The verdict was highly split on question of acquiring corona infection while seeking dental treatment; 21% yes, 29% no, 32% maybe, and 11% don't know. About 31% and 28% of responders, respectively, felt dental treatment to be a high-risk or maybe high-risk treatment, for the spread of corona infection
- Majority of responders (72%) felt that dentists are at greater risk or may be at greater risk of acquiring COVID-19 infection
- Sixty-seven percent of the responders were satisfied with the general measures adopted by the administration in tackling COVID-19.
| COVID-19 Staff Casualties|| |
The initial phase of lockdown from March to May was without any COVID-19 staff casualty though there was significant emergency and urgent work output considering a situation when most of the dental health services were totally shut down. This can be attributed to execution of stringent anti-COVID measures at all levels ranging from patient screening, history, demographic assessment, treatment, and posttreatment disinfection/sterilization protocols. The first staff casualty, a dental officer, was reported in June. This can be a result of acquiring COVID-19 infection from asymptomatic patient or from sources outside hospital premises. However, considering the expansion of services and resumption of work in full strength from mid-July onward, the proportion of COVID-19 positive cases in staff was significantly low. This also initiated the process of acquiring permission from the Indian Council of Medical Research [Figure 4] for setting up COVID-19 antigen testing facility to enhance patients and staff screening potential as per requirement to prevent spread of infection. The COVID-19-positive cases diagnosed from staff when working in the hospital setting were only 6. The contact tracing of all positive cases was carried out and necessary quarantine and hospitalization as per requirement was followed. All the cases recovered uneventfully. There has been no reported incident of any patient/ attendant contracting Covid-19 infection after treatment at this tertiary care dental centre.
|Figure 4: Indian Council of Medical Research permission for COVID antigen testing|
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| Aerosol-Producing Procedures and Necessary Preparations|| |
Modern dentistry is synonymous with aerosol generation due to use of high speed, high efficiency cutting, and drilling equipment associated with air and water spray. Aerosol generation was the biggest concern during the pandemic because of risk of spreading infection. To overcome this limitation, many infrastructural changes and equipment upgradations were introduced. These changes can be grouped into two types:
- Infrastructural changes limiting spread of aerosols: Changes in the surgeries with addition of exhaust and pedestal fans preventing spread of aerosol in surgery, converting few open surgeries into closed chambers with exhaust fans, procurement of high-volume suction apparatus, use of nonretraction valve handpieces, etc.
- Proactive screening of patients undergoing such procedures: Any patient scheduled for long aerosol-producing procedures such as surgical extraction, crown cutting, randomized controlled trial, or debonding of orthodontic appliances was subjected to COVID-19 antigen screening. The screening of dental and paradental staff was also carried out as and when required.
In addition, the COVID-19 antibody test facility was also established. This test was carried out for entire staff and patients on discretion for two reasons: first to identify asymptomatic carriers and second to establish a database for plasma donation therapy when required.
The details of COVID-19 antigen and antibody tests carried out from July to November 20 and the outcome of the results are illustrated in [Table 11]. Although the number of antigen positive cases was only 3% of the total tested, instituting treatment in such cases would have exposed the entire hospital and the patients to risk of acquiring this serious infection and its after effects.
| Management of Housekeeping Staff|| |
Housekeeping staff was the backbone of our response ensuring provision of dental services to the clientele during this testing time. The requirement of housekeeping services tripled as there was a need to sanitize operational areas as well as patient seating areas frequently. The housekeeping staff was the most taxed staff as rotational quarantine reduced their strength to half and the quantum of required services almost tripled. Additional training in handling biomedical waste as per the latest guidelines,,,, on COVID-19 was given. Their high susceptibility to contract infection and spread to family/other staff was reinforced regularly to keep them motivated to work with all precautions. Their KAP of COVID-19 was also recorded in the survey and reflected that they have acquired adequate knowledge and were well informed about the threat posed by this pandemic. As a result, no housekeeper has tested positive for coronavirus infection till date and they continue to observe strict protocols despite discomfort involved.
| Management of Quarantined Staff|| |
In Armed Forces significant number of personnel stay away from families due to various personal or service restrictions and thus have susceptibility to develop stress. During this pandemic, the importance of family to help live a balanced life and manage stressful situations came to forefront., On one hand, pandemic further increased the stress levels; the separation of personnel from families added exponentially to it, especially during quarantine. Hence, it was very important to ensure that their stress levels are adequately addressed. The individuals were encouraged to make best use of this time indoors to raise their education standards and strengthen their immune system through dietary changes and practice of yoga, as most of the outdoor activities were suspended during initial phase. They were encouraged to undertake online courses on computer education, language skills, or pursue any hobby to stay gainfully engaged.
| Discussion|| |
This observational assessment endeavored to holistically evaluate challenges and measures posed by COVID-19 infection at this flagship tertiary dental care institute of Indian Army. Although there are no direct studies available for comparison, these observations warrant discussion based on available data from limited COVID-related studies and pre-COVID observations.
There was significant reduction in patient load due to number of reasons such as imposition of lockdown and limited mobility, increasing patient awareness of sinister effects by coronavirus infection, limited availability of dental services, treatment prioritization for emergency, and urgent conditions. The guidelines issued placed dental treatment in high-risk category for the spread of infection and routine dental procedures in nonessential treatment category. This trend was seen throughout the world ranging from China, Italy, UK, USA, etc., affecting the dental care delivery.,,
Though the patient load reduced the requirements to attend them increased significantly in terms of manpower requirement, financial burden due to enhanced need for sanitisation/sterilization, need for PPE and special equipment for containment/ prevention of spread of aerosol generated. This contrasted with the expenses and the patient load of the last year. These requirements and the expenses are the additional burden, and if normal services are to be resumed along with anti-COVID measures, which obviously cannot be done away with at present, the budget requirement for the next financial year will almost triple.
COVID resulted in significant manhour loss and fear of dental procedures severely crippled the dental professionals and allied industries. In one of the reports, the outbreak of corona shut down approximately 198,000 active dentists and dental specialists in the USA. As per one of the reports on Indian dental professionals, the dentistry is facing its darkest hour with dental clinics shut throughout the country for 2 months and little hope for revival soon compounded by zero earning., In a country with over 3 lakh registered dental practitioners and where approximately 270,00 dentists joining the workforce every year, this shutdown amounts to staggering loss of manhours and the associated financial crunch.
The International Labour Organization (ILO) census states that the work places are affected in 94% of the countries due to COVID. About 70% of the workers in middle-income countries with strict lockdown are affected, while in low-income countries, though the earlier strict restrictions have been relaxed, the COVID-19 cases continue to increase considerably. As per ILO monitor, the estimated workhour loss due to COVID is 17.3%, and in low-income countries, this share is about 23.3%.
Considering the staggering workhour loss, 46,000 h equivalent to 1150 work weeks or 22 work years till November 2020, in our institute, COVID-19 pandemic has severely compromised the delivery of dental health-care services to the Indian Army personnel in our area of responsibility. This assumes even greater significance in terms of the crucial role Army plays in the defense of the country and its preparedness. The amount of loss of workhours in these 7 months is approximately equivalent to working life span of one individual in an average life.
Although the primary care dental triage in COVID-19 pandemic focused on the provision of the three A's: Advice, Analgesia, and Antimicrobials (if needed), the exclusive reliance on these can have adverse ramifications if continued over a long period of time. COVID-19 pandemic has seen a significant rise in the prescription of antibiotics as access to dental care was restricted. In one of the studies across England, the overall antibiotic prescription witnessed 25% rise in April–July 2020 compared to the data of 2019 with a range of 10%–60% increase. It further states that patients have been remotely prescribed with antibiotics but have returned with pain or swelling, as the cause of their dental problem has not been properly addressed. This confirms the adage that 'antibiotics don't cure toothache'. However, the illogical prescription certainly adds to the developing antibiotic resistance. This also downplays the role of teledentistry, unlike telemedicine, in managing dental problems where physical evaluation and intervention has higher relevance.
The antibiotic usage in our institute during this pandemic was highly judicious as the facility was never shut completely and provision was made for physical intervention, coupled with the use of PPE as per the recommendations, to deal with emergency and urgent dental problems. This can be appreciated from the evaluation of Tables 5 and 6 in conjunction with the patient output.
| Conclusion|| |
COVID-19 pandemic has thrown serious challenges for the practice of dentistry and dentistry has become synonymous with one of the most feared professions. ADC (R and R) has been at the forefront in providing essential and scheduled dental care to its dependent clientele even under the harshest threat of COVID. The challenges posed by the pandemic were overcome with the observation of strict anti-COVID protocols, continuous training, enhancement of infrastructure, large trained manpower at hand, and financial support. The total of 13,046 patients have been treated in COVID-19 pandemic till November 30, 2020, which is highly significant. Despite providing significant dental treatment and continuous postgraduate training, the staff of COVID-19 casualties were considerably low and no patient or attendant has reported acquiring this infection postdental treatment at this center. There has been a considerable loss of manhours and more than 65% of the allocated budget was used in patient management during this period with patient attendance 25-30% of the pre-Covid times. The manpower requirement in patient management tripled and the housekeeping services were heavily taxed. Thus, considering the continuous threat and safety of staff/patients, resumption of normal patient care services is still a serious administrative, financial, and human resource challenge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]