|Year : 2021 | Volume
| Issue : 1 | Page : 27-33
Coronavirus disease 2019 outbreak: Roles and responsibilities of dental health-care providers
Himani Sharma1, Umang Tripathi2
1 Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
2 Clover Dental Solutions, Greater Noida, Uttar Pradesh, India
|Date of Submission||18-Mar-2021|
|Date of Acceptance||17-May-2021|
|Date of Web Publication||9-Aug-2021|
Dr. Himani Sharma
Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida - 201 306, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
With the recent spread of coronavirus disease 2019 (COVID-19), human race is observing tough times. COVID-19 is a potentially severe respiratory disease which was first observed in Wuhan, China. Now, this disease is widely spreading in other countries around the world including India. It is claimed to be a zoonosis, which has found its way to humans through bats and pangolins. Despite the global efforts to curb the disease spread, the outbreak remains rising, causing serious widespread public health concerns. This virus features a tendency to be abundantly present within the nasopharyngeal and salivary secretions of the patients suffering from this disease. Therefore, dental health-care professionals, including periodontists and endodontists, are at a higher risk of contracting this disease due to aerosol spread during the procedures. Thus, the aim of this article is to provide a brief overview about the epidemiology, symptoms, and routes of transmission alongside specific recommendations for clinical practice which may help a dental health-care provider for efficiently managing a patient affected by this disease. This review was last updated on February 18, 2021.
Keywords: Coronavirus, coronavirus disease 2019, dental professionals, severe acute respiratory syndrome coronavirus-2
|How to cite this article:|
Sharma H, Tripathi U. Coronavirus disease 2019 outbreak: Roles and responsibilities of dental health-care providers. Int J Oral Health Sci 2021;11:27-33
Highlights of the Review
Dental health-care procedures warrant additional infection control measures considering close face-to-face contact and aerosol production.
Dental professionals need to be aware and prepared for tackling the outbreak of SARS-CoV-2 transmission and its associated coronavirus disease (COVID-19), which can be life threatening to themselves and their patients.
| Introduction|| |
First reported in Wuhan, China (December 31, 2019), the coronavirus disease-2019 (COVID-19) has been declared a pandemic by the WHO on March 11, 2020. Currently, this disease (May 10, 2021) has affected more 215 countries and territories including India. With >15.8 Cr cases and >32.9 L deaths worldwide; and 2.23 Cr confirmed cases and 2.42 L deaths in India, this ongoing COVID-19 has rapidly evolved as a public health crisis.,
COVID-19 has become a major challenge in health-care services including dental care. Although all the elective procedures have been suspended, the need to treat dental emergency situations cannot be denied. Therefore, the role of dental health-care providers in preventing the transmission of COVID-19 becomes critically important. Amidst the explosion of information that is available online and through social media, this review attempts to identify reliable research evidence and guidance, and discusses certain specific measures which can be helpful for dental patient management during the COVID-19 pandemic.
| Search Strategy|| |
MEDLINE, PubMed (using medical subject headings), WHO database, CDC database, MHA database (India), and Google Scholar were searched using the following terms in different combinations: “COVID-19,” “Dental health care,” “SARS-CoV-2,” and “zoonosis.” This was supplemented by hand-searching in peer-reviewed journals, databases, and cross-referenced with the articles accessed.
| Background|| |
The causative agent of this disease is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (as named by-Coronavirus Study Group, International Committee on Taxonomy of Viruses, February 11, 2020) which was earlier known as 2019 novel coronavirus. This Wuhan strain of SARS-CoV-2, belongs to Coronaviridae family which has been identified as a new strain of βcoronavirus of 2B group, sharing ~70% genetic similarity to SARS-CoV. It is an enveloped virus containing positive-sense single-stranded RNA with a characteristic feature of having club-shaped spikes projecting out from its surface resembling solar corona, thus deriving its name [Figure 1]. These viruses possess Zoonotic nature and are spilled over to humans through animals, which in this case are suspected to be bats, pangolins linked with Huanan Seafood Wholesale Market (Jianghan District, Wuhan, Hubei, China). The mean incubation period of this virus is observed to be 6.4 days (95% credible interval: 5.6–7.7), ranging from 2.1 to 11.1 days (2.5th to 97.5th percentile).
|Figure 1: Structure of severe acute respiratory syndrome coronavirus-19|
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In animals and birds, coronaviruses primarily infect the upper respiratory tract and the gastrointestinal tract. In similar way, when SARS-CoV-2 virus enters the human body, it is seen to be present abundantly in the salivary and nasopharyngeal secretions of affected patients. The patients affected with this virus show relatively nonspecific symptoms and many times they may be asymptomatic (up to 44%) with only mild flu-like symptoms. However, if these asymptomatic patients tests positive for the virus, then they can act as a carrier for the disease by becoming a reservoir for the SARS-CoV-19, for further reemergence of the diseased condition. These affected persons can transmit the disease even before any apparent symptom appears, with a predilection for patients with a mean age of 56 years and compromised health condition or presence of a comorbidity including cardiovascular disease, diabetes mellitus, or immunosuppression. The most common symptoms of COVID-19 are fever, dry cough and myalgia. Less common symptoms (<15% affected population) include nausea, diarrhea, chills, hemoptysis, hyposmia, and dysguesia. According to the WHO, one out of five persons become seriously ill requiring emergency treatment and faces difficulty in breathing and other emergency symptoms including persistent chest pain/pressure, buish lips/face, sudden confusion, and difficulty waking. These patients if not treated effectively may develop potentially fatal complications which may include acute respiratory distress syndrome, pneumonia, septic shock, sepsis, and kidney failure.
SARS-CoV-2 infections primarily spread via respiratory droplets or during contact. The small droplets which are produced during coughing, sneezing, or talking by an infected person can result in the spread of this infection in another individual with a close contact of up to 3–6 feet. The virus can survive from a few hours to days on various more specifically on polypropylene and stainless steel (up to 3 days), cardboard (up to 1 day), and copper (up to 4 h) with a variation according to temperature and humidity. Therefore, another route of transmission includes touching of contaminated surface which includes the objects located nearby an infected individual which leads to the contamination of the skin on an individual and then this individual can get contracted by touching its eyes, nose, or mouth. According to a study, an individual on an average touches its face 23 times an hour and out of which 44% contact is around their nose and mouth. This virus has a tendency to bind to human angiotensin-converting enzyme 2 receptors, and due to the plentiful presence of this receptor in salivary glands, SARS-CoV-2 is found abundantly in secretory saliva. Dental procedures involve face-to-face communication with patients, and frequent exposure to saliva, blood, and other body fluids. Thus, putting the dental office setting in the risk of contributing to its nosocomial spread; also, dentists can become potential carriers of the disease through fomites, aerosol spread during dental procedures or through feco-oral route., Therefore, the awareness of the dental practitioners becomes crucial for minimizing the disease transmission through improvements in infection control, risk assessment, and disease management methods. Stages of the spread of coronaviruses:
- Stage 1: Getting the imported case – People getting infected outside the country having infection
- Stage 2: Local transmission – the infected case came from outside the country, spreading infection to those who came in contact with them
- Stage 3: Community transmission – If the people having infection do not restrict their movement (quarantine) they might spread infection to people whom they do not even know through infected surfaces
- Stage 4: Turning into an epidemic – This chain reaction of the spread of infection leads to huge explosion of the cases.
| Prescreening and Prevention of Viral Contraction in Dental Office Setting|| |
Dental professionals are at a higher risk of COVID-19 infection, therefore, dentists should suspend all the routine health-care procedures. This will save them from unnecessary risk of disease transmission and will also help in preserving the patient care supplies and personal protective equipment (PPE). The use of teleconferencing or teledentistry options should be done to assess the need of in office treatment and if dental treatment is delayed, then patients should be provided with detailed home care instructions and appropriate pharmaceuticals including analgesics, antibiotics, and other relevant drugs [Table 1]. The emergency procedures; [Table 2] should be treated as minimally invasive as possible, and for such procedures specific guidelines which have been issued by state dental boards or other regulating health agencies should be followed.,
|Table 1: Provision of emergency care during coronavirus disease 2019 pandemic|
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|Table 2: Conditions which require emergency dental healthcare procedures|
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Guidelines for prescreening prior to dental health care
Sick leave policies for employees
Sick leave policies should be implemented in the dental office, which should allow the employees to stay at home if they have any symptom of respiratory infection. All the staff should be screened at the beginning of their shift for fever and respiratory symptoms and those who develop symptoms while at work should be sent home to curb contraction. As appealed by central government of India, these leaves should be flexible, consistent with the public health guidance and the employers should not cut the wages or terminate the employees.
Contact and screening of the patients prior to emergency dental treatment
All the patients should be contacted and detailed medical history should be recorded for all patients telephonically, prior to their appointment; also, questions about onset of signs or symptoms of respiratory illness including fever, cough, and shortness of breath should be incorporated into daily assessments of all patients. If the patient reports any of these signs or symptoms, then avoid dental care and in case of emergency, dental care should be delayed until the patient recovers from the respiratory infection.
If the patient reports positive travelling history outside India in the past 2 weeks, especially, China, Hong Kong, Iran, Italy, France, Spain, Germany, Japan, Singapore, South Korea, Taiwan, Thailand, Vietnam, or any other COVID-19-affected country, then the dental appointment should be rescheduled. Their medical history should be updated timely in the records and such patients should be reported to the health department immediately.
| Guidelines To Be Followed During Emergency Treatment|| |
If emergency dental care is medically necessary for a patient who has, or is suspected of having COVID-19 following measures should be taken.,,
Dental office setting
Emergency dental treatment should be provided in a hospital or other clinical facility which can treat the patient using the necessary precautions.
Patients should be treated in an isolation room with negative pressure relative to the surrounding area. Use of an N95 filtering disposable respirator should be done by all the persons entering that room to prevent airborne transmission.
Measures should be taken to minimize aerosol production. Use of dental handpieces, ultrasonic scalers, and air water syringe should be avoided and treatment using hand instruments should be preferred. However, if aerosol generating procedures are necessary for emergency care, the use of four-handed dentistry with high evacuation suction and dental rubber dams should be done to minimize droplet spatter and aerosols production.
Visual alerts signs/posters can also be placed at the entrance and in strategic places including waiting areas, elevators, and cafeterias to provide patients with instructions about hand hygiene, respiratory hygiene, and cough etiquette. Furthermore, supplies for respiratory hygiene and cough etiquette including alcohol-based hand rub (with 60%–95% alcohol), tissues can be provided, and measures for no-touch receptacles for disposal, at entrances, waiting rooms, and patient check-ins should be taken.
Personal protective equipment, hand hygiene, cleaning and disinfection
The patients should be asked to perform preprocedural mouth rinses using 0.2% povidone-iodine or 0.5%–1% hydrogen peroxide to decrease the bacterial load before the treatment.,
Judicious use of the PPE (consisting of gloves, a gown, eye protection which includes goggles, or a disposable/reusable face shield that covers the front and sides of the face, and an N95 or higher-level respirator) depending upon the risk of contamination, should be done by clinicians and patients with confirmed or possible SARS-CoV-2 infection during evaluation and emergency dental care. The clinicians and their staff should be properly trained in donning and doffing of PPE. Suggested steps for donnig and doffing PPE gear [Figure 2]a and [Figure 2]b.
|Figure 2: (a) Suggested steps for donning of the personal protective equipment gear. (b) Suggested steps for doffing of the personal protective equipment gear|
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Strict hand hygiene should be performed before and after the patients, after touching any contaminated surface/equipment and after removing PPE.
After every patient, the workplace should be cleaned and disinfected according to the issued guidelines [Figure 3]. Disposable instruments should be used for all the patients and these should then be discarded along with other supplies and equipment located within 6 feet (1.83 m) of symptomatic patients. The reusable items must be cleaned and disinfected after each use according to the manufacturer's guidelines.
|Figure 3: Suggested steps for posttreatment disinfection of the dental setting|
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Fumigation of clinics and other areas should be done daily at the end of the day as per manufacturer's instructions in clinical and high-contact areas and for nonclinical or low-contact areas it can be done on a biweekly basis. Various chemical agents which are used for fumigation includes formaldehyde, ethylene oxide, methyl bromide, hydrogen peroxide vapor, and chlorine dioxide. Steps for fumigation of the dental setting: 
- Step 1: Seal the area/room completely using newspaper or adhesive tapes
- Step 2: Prepare the fumigation solution by adding 7.5 ml of fumigation chemical (Standard as available in market) in 1 L of water
- Step 3: Place the fumigation machine at one corner of the room after filling the fumigation solution in it and switch on the machine
- Step 4: Leave the room for the process for 30 min after complete sealing
- Step 5: Switch off the machine after the process time and remove the machine.
However, one should keep in mind that the chemicals and procedures used for fumigation as well as disinfection are potentially hazardous to human health if handled incorrectly. Therefore, precautions should be taken while handling them and all measure should be taken to avoid their expose to bare skin eyes or inhalation and fumigation work should only be carried out by trained professionals with appropriate protective clothing and breathing apparatus.
After the completion of the dental procedure, proper disposal of generated bio-medical waste (BMW) is imperative to minimize its ill-effects. Any improper disposal of medical waste can lead to an environmental crisis and risk of spreading of infection during this pandemic. Therefore, all the generated BMW during the dental procedure including the PPE, should then be disposed properly according to the guidelines issued by Central Pollution Control Board, Ministry of Environment, Forest and Climate, India. According to these guidelines, proper segregation and safe storage of the waste should be done also, the use of double layered bags (using two bags), mandatory labeling of bags, and containers as “COVID-19 waste,” is advocated.
Potential exposure guidance
All the treated patients should be contacted after 48 h of the treatment to inquire about the new onset of signs and symptoms of respiratory illness. If found to be positive then all the health-care providers should seek medical healthcare for assessment and testing for COVID-19 according to CDC's guidelines.
| Discussion|| |
After, (SARS-CoV, in 2002), and the Middle East respiratory syndrome coronavirus (MERS-CoV, in 2012), due to the uncontrolled spread of COVID-19, humanity is again observing a hard time. Fighting with an invisible army of SARS-CoV-2 has increased the likely hood of rampant spread of this disease among health-care providers including, dental professionals. Therefore, measures for prevention, diagnosis, and management for COVID-19 must be in place for appropriate reduction of further spread.
As described in this review, the use of appropriate PPE along with universal precautions and proper waste disposal is crucial to minimize the nosocomial spread of virus and disease contraction. Various health-care governing bodies have issued guidelines which should be followed for every patient.,,
To reduce the load of corona virus in saliva, preprocedural mouth rinsing with 0.5%–1% hydrogen peroxide 0r 0.2% povidone-iodine should be practiced. For radiolographs, extraoral radiographic techniques including panoramic radiographs and cone-beam computed tomography is recommended as intraoral radiographs can stimulate salivary secretion and coughing by the patient.
Any aerosol-generating procedure should be avoided and use of hand instruments such as hand scalers, spoon excavators should be practiced. If necessary aerosol-generating procedures should be scheduled at the end of the day with rubber dam application, practice of four handed dentistry, and high volume suction to avoid much of the aerosol production. All the prostheses and prosthodontic materials, for example, impressions, bite registrations, extracted teeth should be cleaned and disinfected before handling it to the laboratory. In case of biopsy specimens, they should be transported in leak-proof containers labeled with biohazard symbol.
Clinicians should assess the emergencies and should use their best clinical judgment to judge whether the condition of the patient falls into emergency and if the patient should be treated or rescheduled. Teledentistry should be incorporated for prescreening of the patient and for taking detailed medical and travelling history of every patient prior to the treatment.
Government along with Health agencies all over the world is taking measures to curb COVID-19 [Table 3]. The information and the guidelines issued by Indian government on COVID-19 can be viewed on https://www.mygov.in/covid-19/. With the introduction of various vaccines that are now available, a ray of hope is clearly visible helping us ending this pandemic but, until all the individuals are vaccinated its the duty of the health-care providers to be up-to-date and aware of their role and responsibilities during this crucial time. All patients should be considered as potentially infected with this virus and should be treated with utmost care; keeping in mind the asymptomatic presentation of the patients during incubation period.
|Table 3: COVID-19 Useful links providing information regarding COVID-19 pandemic, and guidelines for emergency treatment for dental health care practitioners|
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| Conclusion|| |
In the light of the WHO declaring the COVID-19 virus to be a pandemic, it has now become the duty of health-care providers including dental practitioners to guard themselves along with their patients from the transmission of this SARS-CoV-2. The dental practices need to review their infection control policies; they must keep themselves up-to-date about this evolving disease and provide adequate training to their staff to assist many levels of screening and preventive measures, allowing dental health care to be provided while limiting spread of this novel infection.
All papers must contain the following statements after the main body of the text and before the reference list.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gorbalenya AE, Baker SC, Baric RS, Groot RJ, Drosten C, Gulyaeva AA, et al
. Severe acute respiratory syndrome-related coronavirus: The species and its viruses – A statement of the Coronavirus Study Group. bioRxiv 2020.
Cascella M, Rajnik M, Cuomo A. Features, evaluation and treatment coronavirus (COVID-19). In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
. [Last updated on 2020 Apr 06].
Graham R, Donaldson E, Baric R. A decade after SARS: Strategies for controlling emerging coronaviruses. Nat Rev Microbiol 2013;11:836-48.
Hu D, Zhu C, Ai L, He T, Wang Y, Ye F, et al
. Genomic characterization and infectivity of a novel SARS-like coronavirus in Chinese bats. Emerg Microbes Infect 2018;7:154.
Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20–28 January 2020. Euro Surveill 2020;25:2000062.
Wang W, Xu Y, Ruqin G, Lu R, Han K, Wu G, et al
. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA 2020;323:1843-4.
Josephine M, Linda L, Lee J. A third of coronavirus cases may be' silent carriers', classified Chinese data suggests. S China Morning Post 2020.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Giacomelli A, Laura Pezzati L, Conti F, Bernacchia D, Siano M, Oreni L, et al
. Self-reported olfactory and taste disorders in SARS- CoV-2 patients: A cross-sectional study. Clin Infect Dis 2020;71:889-90.
Pan X, Chen D, Xia Y, Wu X, Li T, Ou X, et al
. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis 2020;20:410-1.
Coronavirus Disease 2019 (COVID-19) – Transmission. Centers for Disease Control and Prevention; March 17, 2020. Available from: http://???
. [Last assessed on 2021 May 10].
Moriyama M, Hugentobler WJ, Iwasaki A. Seasonality of respiratory viral infections. Annu Rev Virol 2020;7:83-101.
Kwok YL, Gralton J, McLaws ML. Face touching: A frequent habit that has implications for hand hygiene. Am J Infect Control 2015;43:112-4.
Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al
. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell 2020;181:271-80.
Sabino-Silva R, Jardim AC, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Investig 2020;24:1619-21.
Kariwa H, Fujii N, Takashima I. Inactivation of SARS coronavirus by means of povidone-iodine, physical conditions, and chemical reagents. Jpn J Vet Res 2004;52:105-12.
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.
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.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]