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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 23-26

Dental public health need in the midst of coronavirus disease 2019 pandemic

Department of Prosthodontics Crown and Bridge, Maulana Azad Institute of Dental Sciences, New Delhi, India

Date of Submission06-Jul-2020
Date of Decision16-Oct-2020
Date of Acceptance20-Apr-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. Amala Nancy
4/1091-A, MGR Nagar, Melavasthachavadi, Thanjavur - 613 005, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_25_20

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The coronavirus disease 2019 (COVID 19) pandemic has stilled the world, due to its highly contagious nature, lack of specific drugs, or vaccine availability. To prevent the nosocomial spread of COVID-19 infections, several countries summoned for closure of dental practice. There is increasing demands of dental public health need in the community. This article highlights on specific guidelines to prevent nosocomial infections and to meet the demands of the public dental health in the midst of the COVID 19 pandemic.

Keywords: Clinical guidelines, coronavirus disease 2019, dental public health, preventive measures

How to cite this article:
Nancy A, Satheesh R, Gupta R, Gill S. Dental public health need in the midst of coronavirus disease 2019 pandemic. Int J Oral Health Sci 2021;11:23-6

How to cite this URL:
Nancy A, Satheesh R, Gupta R, Gill S. Dental public health need in the midst of coronavirus disease 2019 pandemic. Int J Oral Health Sci [serial online] 2021 [cited 2022 Jul 1];11:23-6. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/23/323528

  Introduction Top

A global threatening viral outbreak of emerging coronavirus disease 2019 (COVID 19) is highly alarming.[1] Since lack of therapeutics and vaccine for disease control, it possesses a great threat for global public health.[2] Closing dental practices during this pandemic can reduce the spread of infection, but parallelly it might increase the suffering of the individuals in need of urgent dental care.[3] It will also incense the burden on medical emergency departments.

Dental intervention has a unique nature which includes aerosol generation, handling of sharps, and proximity of operator to oropharyngeal region. Therefore, Dental professionals are at a higher risk to be easily infected and can become a potential carrier of the disease. As the understanding of this novel disease is evolving, dental practices should be better prepared to identify a possible nosocomial spread of COVID 19 infection and refer susceptible patients to appropriate treatment centers as well as to meet the demand of dental public health need. This article demonstrates step-by-step guidelines on prevention of COVID spread and management of dental emergencies.

  Epidemiology Top

The outbreak of pneumonia of unknown cause was initially observed from Wuhan, China. This pneumonia was proven to be caused by a novel coronavirus belongs to the family of single-stranded RNA viruses known as Coronaviridae.[3] There is strong evidence that this novel coronavirus species is similar to coronavirus species found in bats and pangolins confirming the zoonotic nature of its new cross-species viral-mediated disease.

As the published genome sequence for this novel coronavirus has a close resemblance with other beta-coronavirus such as SARS-COV and MERS-COV, the coronavirus study group of the International Committee of Taxonomy of Viruses has given its scientific name SARS CoV-2, even though popularly called as the COVID-19 virus.[3]

First case of COVID 19 was reported to the World Health Organisation (WHO) Country Office in China on December 31, 2019.[14] On January 30, 2020, the WHO declared the rampant spread of this coronavirus disease as a Public health emergency.[14] On February 11, 2020, the WHO announced a name for the new COVID-19.

According to the WHO rolling updates on COVID-19 July 6, 2020, statistical data, there are around 11,604,025 confirmed cases and 537,716 deaths Globally.[14] In India, there are around 253287 active cases with 19693 deaths according to the Ministry of Health and Family Welfare, Government of India on COVID-19 July 6, 2020.[14]

  COVID 19 – Dental Concerns Top

Dentists are highly susceptible for acquiring the disease. Some clinical facts of COVID 19 infection are of dental practitioners concern as given below

  1. The incubation period of the virus is believed to be up to 14 days. Thus increased probability of transmission from asymptomatic COVID-19 carriers[4],[5],[6]
  2. The infectious droplets may travel up to 4.5 m.[7] Its effects of warm moist outbreath surrounding droplets may travel up to 8.2 m[8]
  3. It is unclear yet, but COVID-19 recusancy might be possible, some virus strains can be present in saliva for as long as 29 days[9],[10],[11]
  4. Some confirmed COVID-19 carriers might need urgent dental care at some point.

  Dental Office Considerations Top

Considering the clinical facts of aerosol spread and its survival ability on nonliving organisms, the dental setup considerations are given below

  1. The dental office should have partitions such as a pretreatment screening triage area, personal protective equipment (PPE) Donning area, nonaerosol producing treatment area, aerosol producing area, laboratory area, PPE doffing area, and waste management area
  2. The reception areas should be devoid of magazines, newspapers, display models or flyers, and furniture arrangement in such away to maintain social distancing
  3. There should not be centralized air conditioner facility
  4. Air purification system or HEPA filters can be installed for improved protection
  5. Appointing a new dental staff called Sanitization Technician/Environmental Dental Assistant. He/She is responsible for sanitizing all areas of possible infection.

  Dental Patient Management Protocols Top

According to the American Dental Association guidelines,[12] the dental practitioners should make a clinical judgment and categorize their patients according to their extent of dental need as given below.

  1. Dental emergencies
  2. Urgent dental care
  3. Nonemergency dental procedures.

Dental emergencies are potentially life-threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:

  • Uncontrolled bleeding
  • Cellulitis or a diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromises the patient's airway
  • Trauma involving facial bones, potentially compromising the patient's airway.

Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.

  • Severe dental pain from pulpal inflammation
  • Pericoronitis or third-molar pain
  • Surgical post-operative osteitis, dry socket dressing changes
  • Abscess or localized bacterial infection resulting in localized pain and swelling
  • Tooth fracture resulting in pain or causing soft tissue trauma
  • Dental trauma with avulsion/luxation
  • Dental treatment required prior to critical medical procedures
  • Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
  • Biopsy of abnormal tissue
  • Suture removal
  • Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa.

  Step-By-Step Guidelines For Dental Practice Top

The primary aim is to prevent nosocomial infections and to meet the dental public health demands

  1. Patient history should be taken through the telecommunications throgh mails and telephonic conversation
  2. All patients and their accompanying need to be screened at a pretreatment triage area with noncontact thermal scanners (forehead or ear thermometer) for temperature measurement, and a patient is asked for epidemiological contact history, travel history, have attended any gatherings recently, fever, and respiratory symptoms
  3. If patients to be found with contact history or symptoms encountered, refer the patients to go to the COVID treatment designated hospital for further management
  4. Only patients with utmost dental emergency should be considered for treatment
  5. When the patient arrives at the dental treatment set up, he/she should be directed to the hand wash station situated outside the main entrance where he/she should carry out hand washing under the supervision of a designated hand wash assistant
  6. Proper Patient protection including protective gear, mask, and gloves will be provided at the door for the patient to put on before entering the office
  7. A strict informed consent should be obtained from all the patients regarding COVID-19 and their dental treatment. Consider every patient as a potential viral carrier and follow universal precautions. It is essential to maintain the records of the patient addresses, contact details
  8. The dental practitioner and his staff should be prepared in advance to manage the patient efficiently at the treatment set up.

  Treatment Considerations Top

  1. Intraoral imaging should be restricted and extraoral radiographs should be utilized to reduce the excessive salivation and gag reflex associated with intraoral radiographs
  2. Advice pre-procedural mouth rinse using 1% hydrogen peroxide/0.2% w/v Povidone-Iodine mouth wash for at least 15 s, which can reduce the viral load in the patient's saliva (Eggers et al., 2018).[17] (Chlorhexidine mouthwash is not effective against COVID 19)[18]
  3. Patients should also be covered with a full-length drape with their hands tucked in and a head cap and goggles and the immediate extra oral area may be wiped with Betadine solution or a disposable disinfectant face wipe before commencing the procedure
  4. Disposable and single-use instruments and devices should be used whenever possible to reduce the cross-infection risks
  5. Aerosol-generating procedures should be avoided whenever possible. Procedures to be completely avoided are.

    • Full coverage crowns needing extensive reduction of teeth
    • Crown and bridge restorations
    • Scaling with ultrasonic device.

  6. Some techniques to prevent aerosol generation in dental office are listed below:

    • Clinical micro motor and a contra angled handpiece with latch type burs without water or irrigation. This can reach a maximum speed of approximately 40,000 RPM
    • Electric driven motor and speed increasing handpiece (1:5) without water with friction grip burs. This device can reach a maximum speed of approximately 200,000 RPM
    • Intermittent breaks should be given and small quantity of water in a syringe can be used to it cool down the tooth surface. Excess water should be removed with a high vacuum suction. Rinsing and spitting should be prohibited
    • The working position of the chair should be such that the clinician is operating from 11 o'clock or 12 o'clock position. This is done to avoid direct face-to-face contact with the patient. The use of magnification will help to maintain a safer distance from the patient while working
    • It is advisable to reduce the air pressure on the three-way syringe to a minimum, so as to prevent any aerosol production while drying a tooth
    • Rubber dam should be used whenever possible and High vacuum extra oral suctions used in conjunction with high-speed saliva ejectors, should be mandatory to minimize aerosol dissemination.[16]

  7. It is highly recommended to use anti-retraction high-speed dental handpiece designed with anti-retractive valves or other anti-reflux designs, as they can significantly reduce the backflow of oral bacteria and HBV into the tubes of the handpiece and dental unit as compared with the handpiece without anti-retraction function
  8. After the patient gets off the dental chair, the sanitation assistant 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. The PPE is to be disposed of as per laid down protocols on completion of the treatment of each and every patient
  9. Whenever pharmacologic management of pain is required, Ibuprofen should be avoided in suspected and confirmed COVID-19 cases (Day, 2020)[19]
  10. Encourage and educate the patients to pay the fees by digital routes. If interaction must take place then physical barriers, such as tables or chairs should be placed to ensure 6 feet of separation. Patients should also be wearing their mask as this point. All exchanges of payment should be sanitized with disinfectant spray.

  Medical-Waste Management Top

The medical and domestic waste generated by the treatment of patients regardless of suspected or confirmed 2019-nCoV infection are regarded as infectious medical waste. Double-layer yellow color medical waste package bags and “gooseneck” ligation should be used. The surface of the package bags should be marked and disposed according to the requirement for the management of medical waste.

  Conclusion Top

Dentistry is classified in the very-high-risk category of occupations involved with aerosol production. This article enriched the knowledge of dental concerns with regard COVID-19 infection and clinical guidelines to be followed while meeting dental health needs of the community.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Stein-Zamir C, Abramson N, Edelstein N, Shoob H, Zentner G, Zimmerman DR. Community-oriented epidemic preparedness and response to the Jerusalem 2018-2019 measles epidemic. Am J Public Health 2019;109:1714-6.  Back to cited text no. 1
Liu C, Zhou Q, Li Y, Garner LV, Watkins SP, Carter LJ, et al. Research and development on therapeutic agents and vaccines for COVID-19 and related human coronavirus diseases. ACS Cent Sci 2020;6:315-31.  Back to cited text no. 2
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. 3
Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020;323:1406-7.  Back to cited text no. 4
Tian S, Hu N, Lou J, Chen K, Kang X, Xiang Z, et al. Characteristics of COVID-19 infection in Beijing. J Infect 2020;80:401-6.  Back to cited text no. 5
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. 6
Loh NW, Tan Y, Taculod J, Gorospe B, Teope AS, Somani J, et al. The impact of high-flow nasal cannula (HFNC) on coughing distance: Implications on its use during the novel coronavirus disease outbreak. Can J Anaesth 2020;67:893-4.  Back to cited text no. 7
Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: Potential implications for reducing transmission of COVID-19. JAMA 2020;323:1837-8.  Back to cited text no. 8
Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig 2020;24:1619-21.  Back to cited text no. 9
Chen D, Xu W, Lei Z, Huang Z, Liu J, Gao Z, et al. Recurrence of positive SARS-CoV-2 RNA in COVID-19: A case report. Int J Infect Dis 2020;93:297-9.  Back to cited text no. 10
Zuanazzi D, Arts EJ, Jorge PK, Mulyar Y, Gibson R, Xiao Y, et al. Postnatal identification of zika virus peptides from saliva. J Dent Res 2017;96:1078-84.  Back to cited text no. 11
Marui VC, Souto ML, Rovai ES, Romito GA, Chambrone L, Pannuti CM. Efficacy of pre procedural mouth rinses in the reduction of microorganisms in aerosol: A systematic review. J Am Dent Assoc 2019;150:1015-26.  Back to cited text no. 12
Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP, et al. Ethical practice during the COVID 19 pandemic. J Am Dent Assoc. 2020 May; 151: 377-8.  Back to cited text no. 13
WHO COVID-19 Dashboard. Geneva: World Health Organization, 2020. Available from: https://covid19.who.int/. [Last accessed on 2021 May 30].  Back to cited text no. 14
American Dental Association. ADA Interim Guidance for Minimizing Risk of COVID 19 Transmission; 2020. Available from: https://www.ada.org/en/publications/ada-news/2020-archive/april/ada-releases-interim-guidance-on-minimizing-covid-19-transmission-risk-when-treating-emergencies.  Back to cited text no. 15
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.  Back to cited text no. 16
Kirk-Bayley J, Challacombe S, Sunkaraneni S, Combes J. The use of povidone iodine nasal spray and mouthwash during the current COVID-19 pandemic may protect healthcare workers and reduce cross infection. SSRN Electronic Journal 2020.  Back to cited text no. 17
Bhanderi S, Lessani M, Morgan A, Tomson P, McLean W. Diagnosis and Management of Endodontic Emergencies, a British Endodontic Society Position Paper for Primary Dental Care and other healthcare providers during the COVID-19 pandemic. Available from://britishendodonticsociety.org.uk/wp-content/uploads/2020/04/BES-Emergency-Protocol-v3-April-23-1.pdf  Back to cited text no. 18
Day M. Covid-19: European drugs agency to review safety of ibuprofen. BMJ 2020;368:m1168.  Back to cited text no. 19


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