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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 84-89

Coronavirus infection in India: A dental surgeon's perspective


Department of Periodontology and Oral Implantology, Institute of Dental Sciences, Sehora, Jammu, Jammu and Kashmir, India

Date of Submission05-Nov-2020
Date of Acceptance15-May-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Malvika Singh
Department of Periodontology and Oral Implantology, Institute of Dental Sciences, Sehora, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_31_20

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  Abstract 


Of what was identified by the Chinese government in China's Wuhan district on January 7, 2020, and declared as a pandemic by the World Health Organization on March 11, 2020, severe acute respiratory syndrome-coronavirus 2 (CoV-2), most commonly known as 2019 novel CoV infection, has become a major challenge not only for India but also for the whole world. As on April 26, 2020, this viral infection has been recognized in over 200 countries, claiming 169,006 lives and infecting 2,471,136 people worldwide. The infection travels via respiratory droplets and clinical signs, and the symptoms include dry cough, fatigue, coughing sputum, and shortness of breath. Dental clinics are most susceptible to such infection since there is continuous production of aerosol making dental professionals highly vulnerable to the same and since there has not been a definitive pharmaceutical treatment for this infection, the whole situation makes it even more scary. This article is an attempt to throw light on CoV infection and enumerates certain preventive measures that can be taken in dental clinics while treating emergency cases along with preventing the spread to this deadly viral infection.

Keywords: Aerosol production, dental clinic, emergency treatment, novel coronavirus infection, prevention


How to cite this article:
Singh M. Coronavirus infection in India: A dental surgeon's perspective. Apollo Med 2020;17:84-9

How to cite this URL:
Singh M. Coronavirus infection in India: A dental surgeon's perspective. Apollo Med [serial online] 2020 [cited 2020 Jul 8];17:84-9. Available from: http://www.apollomedicine.org/text.asp?2020/17/2/84/287090




  Introduction and Epidemiology Top


Severe acute respiratory syndrome-coronavirus 2 (CoV-2),[1-4] known by the provisional name 2019-novel CoV,[5] is a positive single-stranded RNA virus that has become center of attention and concern for world and India these days. As on April 27, 2020, in India, 20,835 people have been infected, of which 6184 have been cured/discharged while 874 have lost their life.[6] The virus primarily spreads between people via respiratory droplets from, i.e., coughing and spitting.[7] The time between exposure and symptom onset ranges from 2 to 14 days,[8] which includes fever, dry cough, and shortness of breath,[9] sometimes leading to pneumonia, acute respiratory distress syndrome, and/or death (if left untreated). Due to the characteristics of dental settings, the risk of cross-infection is high between dental practitioners and corona-positive patients. In spite of relentless pharmaceutical research being done every minute, there is currently no vaccine or specific antiviral treatment, which makes this infection even more scary and serious. However, efforts aiming toward managing symptoms and supportive therapy have been widely recommended. For writing this article, data from the World Health Organization and the Ministry of Health and Welfare, Government of India, were taken. Further, Medline and PubMed databases were searched under the following key terms: coronavirus infection, dental emergencies, dental clinics, treatment, and prevention. Only highly relevant articles from manual and electronic databases were selected for the present review. The aim of this article is to review relevant guidelines given by various reputed organizations and experts and deals with introduction of the essential knowledge about CoV infection and nosocomial infection in dental settings and also to provide the management protocols for dental practitioners in (potentially) affected areas to treat corona-positive patients.


  Clinical Manifestations Top


Signs and symptomst

The most commonly reported clinical symptoms in laboratory-confirmed cases are enumerated in [Figure 1]. In this severe form of disease, patients may experience high fever, decreased white blood count, and kidney failure.[10]
Figure 1: Clinical features of coronavirus infection

Click here to view


Incubation period

The virus has an incubation period of 5–6 days, with a range from 1 to up to 14 days.[11]

Case fatality

Studies done in China, Italy, and South Korea confirm the overall case-fatality rate to be 2.3%, 2.8%, and 0.5%, respectively. It increased with age with the highest being in people over 80 years of age (14.8%, 8.2%, and 3.7%, respectively).[12],[13],[14]

Viral shedding

The virus has been identified in the respiratory tract specimens 1–2 days before the onset of symptoms and persists for 7–12 days in moderate cases and up to 2 weeks in severe cases.[15] It has also been detected in feces from day 5 after onset and up to 4–5 weeks in moderate cases. The virus has also been detected in the whole blood,[16] serum,[17] and saliva.[18]

Vulnerable groups

People above 60 years of age, males, smokers, and persons with underlying conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease, and cancer are more vulnerable to CoV infection.[19],[20]


  People at High Risk of Infection Top


Persons in close contact with patients with symptomatic and asymptomatic CoV infections including healthcare workers are at high risk of infection.[21]

Transmission

The primary mode of transmission is via respiratory droplets, i.e., coughing, sneezing, or spitting.[7] These droplets have been found to stay suspended in the air for a short time but have also been found on metal, glass, and plastic surface.[22]

Diagnosis

Diagnosis of COVID-19 can be done through viral testing and computed tomography (CT) imaging.

Viral testing

Real-time reverse-transcription polymerase chain reaction is used as the method for viral testing of COVID-19.[23] It has a sensitivity of 71% and can be done on respiratory or blood samples, the results of which are generally available within a few hours to days.

Imaging

Imaging techniques, such as radiographs and CT, have been described in a limited case series. It is 98% sensitive but has a limited use since the images overlap with the ones of other infections, such as adenovirus.[24]


  Nosocomial Infection in Dental Settings Top


Dental procedures are known to produce aerosols and droplets that are generally contaminated with bacteria and viruses thus having COVID-19 as one of the components of these aerosols will not be much of a surprise among the members of dental professionals. In addition, while examining or performing any dental procedure, the gloves of a dentist become soiled with the patient's saliva and blood making dentists most vulnerable to this infection. Therefore, it is suggested that elective procedures, surgeries, and nonurgent dental visits should be avoided. Instead, patients should be assessed telephonically on the basis on the severity of their chief complaints while taking into account their travel, medical, and dental history. Those patients who respond affirmatively for the same should be advised to seek immediate medical help, and only those patients who require utmost care and attention should be called for emergency treatment on dental clinics/hospitals while taking following guidelines [Figure 2].
Figure 2: Guidelines for dentists

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Providing education to colleagues as well as support staff

All the staff members should be well trained and educated in the form of a refresher training program before the functioning of clinic/hospital by the head of the same so that the team becomes prepared about handling (possibly a COVID-19 positive) patients and answering their queries.

Disinfection of dental clinic, patient waiting room, and front desk

All surfaces including dental clinic, waiting room, front desk, as well as bathrooms should be kept cleaned and sanitized frequently (as the virus has been found to stay alive for 24 h on such surfaces). These should be cleaned with 0.1% sodium hypochlorite, 0.5% hydrogen peroxide, or 62%–71% ethanol. Waiting room and clinic should be properly and adequately ventilated. The use of air purifiers with ultraviolet (UV)-C lamps is recommended. Dental clinic should be an isolated room with negative pressure relative to the surrounding area and should have an N95-filtering disposable respirator for persons entering the room. It should also be well ventilated with air exchange for six times an hour during operatory hours and should be cleaned preferably with hypochlorous acid (as it evaporates from the surface without wiping).[25] Dental chair-side surfaces, chair keyboard keys, connected computers/laptops, oral cameras, dental surgery drawer handles, water taps, stationaries, working desks, telephone sets, doorknobs, and peripheral surfaces such as floor, walls, and washing sink/faucets should be disinfected in the intervals between patients using ethanol 70%.

Evaluation of risk from patients

Patients should be evaluated in following steps:

  1. Before patients' arrival: When the patient calls for an appointment, the front desk should again ask about their medical signs and symptoms, history of travel specially to endemic areas, and the possibility of coming in contact with patients diagnosed with COVID-19. The patients who answer in the affirmative should not be called immediately for dental treatment, instead they should be instructed to seek medical helpfirst. Furthermore, it should be the duty of front desk to inform the nearby health administrative authority to provide immediate medical treatment to such patients. The patients who answer front desk's questions negatively should be instructed to take their temperature before coming to dental clinic. Walk in-visits should be avoided instead, patients should be called only after giving them appointments at designated time, and they should be instructed to reach dental clinic/hospital on time to decrease the number of patients waiting in waiting area/outpatient department. The escorts of the patients should be instructed to wait in the car only to be called telephonically by front desk after patients are finished with their procedures
  2. On patient's arrival: Every attempt should be made to keep the waiting room empty, and every patient entering the waiting area should be given a surgical mask. There should be a prominent sign (display boards or charts) directing the patient to use a hand sanitizer from a nontouch dispenser stand and to vigorously rub their hands for 20 s. Waiting area should also have pictorial representation of signs and symptoms of COVID-19, indicating them to seek immediate medical help if they have or know someone who has the same kind of infection and patients should be made to be seated 3 feet (1 m) apart from each other. They should be given disposable tissues and handkerchiefs during coughs and sneezes (as a preventive measure), and the same should be immediately disposed into a garbage bin. Physical barriers such as plastic or glass windows should be installed at a designated place in the waiting area where the temperature, medical, travel, and dental history could be taken and recorded.


Personal protective measures by the dental professional and support staff

Medical, travel, clinical, and family history of all staff members working in the clinic/hospital should be recorded as a routine practice. Immunosuppressed team members should be encouraged to stay at home. Pregnant staff members should be offered a choice to work of not and those of them willing to work and are <28 weeks pregnant should practice social distancing but should be allowed only to work in patient-facing role, while women who are more than 28 weeks pregnant or have underlying health conditions should avoid direct patient contact. Personal protective equipment designed to adhere to the highest levels of sterilization protocol is given in [Figure 3]:
Figure 3: Personal protective measures

Click here to view


  1. Hand hygiene: It is one of the principal pathways for reducing the transfer of microorganisms to the patients.[26] It should be done in two ways; handwashing with water and soap and hand disinfection using alcohol-based solutions, both for 20 s. Dental professionals and personnel should follow hand hygiene protocols and prevent their hands from direct contact with eyes, nose, and mouth before examination of patients; beginning of dental treatment; after contact with patients and environmental surfaces and materials/substances contaminated with blood and body liquids/secretions; and after contact with secretions, mouth mucosa, and injured skin
  2. Gowns: Disposable or surgical cloth gowns should be worn by professionals as well as personnel. They should either be disposed or sterilized (properly UV) after treating every patient
  3. Personal protective measure: These include:


    1. Protective eyewear: Goggles and/or face shields should be recommended as ocular tissues have been shown to be susceptible to transmission of aerosols.[27] After termination of a dental treatment, the goggle/shield should be properly washed and completely disinfected. Reusable eye protection should be cleaned and disinfected according to the manufacturer's reprocessing instructions before re-use. Disposable eye protection should be discarded after use
    2. Head cap: This forms the covering of head and protects the possibility of settling down of virus in hair in the form of aerosols. Disposable or head caps made from cloth should be worn by dental professional as well as personnel. The disposable head cap should immediately be discarded and disposed after treating a patient, while the clothed head cap should be washed and sterilized before being worn in a new patient
    3. Face masks: Surgical or special masks, i.e., N95 respirator or filtering fast piece 2 masks, should be used when the operator is at a distance of <6 feet. If a respirator is not available, a combination of a surgical mask and a full-face shield should be used. If the minimally acceptable combination of a surgical mask and a full-face shield is not available, any form of procedure should not be performed instead the patient should be referred to other clinician who has adequate personal protective equipment. After termination of dental treatments, used face masks must be disposed
    4. Gloves: Dental professionals and personnel should change their protective gloves (latex, nitrile, nylon, and so forth) after the termination of each dental treatment. In addition, hand hygiene protocols should be precisely followed immediately before and after wearing gloves. Protective gloves might have unidentified or small tears, which could end in rupture of the glove during use. Therefore, the use of two pairs of gloves during dental surgical procedures is highly recommended.


Treatment of emergency cases

Before the start of dental treatment, patients should be instructed to rinse their mouth with povidone-iodine solution or mouth wash containing hydrogen peroxide [28] to reduce the number of microorganisms, which are in contact with blood during invasive dental treatments. Procedures that are likely to induce coughing should be avoided (if possible) or performed cautiously.

Use of other materials/instruments/equipment

Rubber dam should be used as it can minimize the dispersion of droplets, secretions, and aerosols, and in cases of unavailability of the same, hand instruments, e.g., hand scalers/curettes, are recommended for periodontal purposes or Carisolv for chemomechanical caries removal should be encouraged.[29]

Specific dental considerations for the reduction of aerosols

In all branches of dentistry, the following infection control principles should be carefully followed:

  1. Oral medicine and radiology: Intraoral radiographs stimulate salivary secretion and coughing; hence, it should be avoided while the use of extraoral dental radiographies, such as panoramic radiography and cone-beam CT, should be encouraged
  2. Oral and maxillofacial surgery: While performing a simple extraction, the patient should be treated in the supine position and sutured using an absorbable suture. For postextraction hemorrhage, if bleeding fails to stop after 24 h and is brisk and persistent, anticoagulant therapy should be given. Cracked, fractured, lose, or displaced fragments and restorations should be temporarily repaired along with giving optimal analgesia. Dentoalveolar injuries should be treated immediately be treated
  3. Conservative and endodontics: The application of rubber dam in endodontic treatments is highly recommended at all times along with using hand instruments instead of rotary systems. In cases of reversible pulpitis, patient should be given adequate analgesia along with instructions to prevent the same. However, in case of irreversible pulpitis, root canal treatment should be done
  4. Periodontics and oral implantology: Hand scalers/curettes should replace ultrasonic scalers in combination with high-volume suctions to reduce aerosol production and splatter. Patients having acute periodontal and periapical abscess should be prescribed analgesics and antibiotics. For patients with acute pericoronitis, curettage should be done along with prescribing analgesics and antibiotics. They should be instructed to telephonically call the doctor if problem persists to decide the further course of action (operculectomy or tooth extraction). Patients having acute necrotizing ulcerative gingivitis/periodontitis should be treated under local anesthesia and the affected site(s) should be isolated, dried, cleaned, and swabbed with cotton pellets and post-operative instructions should be given to them (rinses with 3% hydrogen peroxide and warm water solution and/or 0.12% chlorhexidine solution twice daily). They should be allowed to rinse with 3% hydrogen peroxide solution along with the prescription of medications as postoperative instructions. For patients with dentine hypersensitivity, desensitizing agents should be applied with finger over affected areas along with prescribing desensitizing dentifrice and other instructions. Patients with oral ulceration should be treated with application of topical analgesia. However, in cases of primary herpetic gingivostomatitis and herpes infection, antiviral agents should be prescribed
  5. Prosthodontics: In cases of ill-fitting/loose dentures cause pain and discomfort, patients should be encouraged to keep the same away
  6. Orthodontics: Orthodontic cases should be postponed generally. However, in cases of trauma from fractured or displaced orthodontic appliances, the same should be treated immediately
  7. Pediatric and preventive dentistry: In elective cases, high treatment priority is given to chemomechanical caries removal and atraumatic restorative techniques. Hand instrumentation for cavity preparation should be preferred to rotary preparations. However, if rotary instruments are to be considered, rubber dam isolation should pertain. Moreover, manual scaling and polishing are endorsed
  8. Patient care equipment: Offices also should follow routine cleaning and disinfection strategies used during flu season. Equipment soiled with blood, body fluids, secretions, and excretions should be discarded and disposed-off according to the sterilization protocols. All reusable equipment should be cleaned, disinfected, and reprocessed before being used in the next patients.


Disinfection of clinic, waiting area, and front desk after performing emergency procedure

The disposable protective equipment should be transferred to a temporary storage area. The medical waste from the treatment of patients suspicious to COVID-19-should be considered an infectious residue and should be packed in two-layered packages and sealed properly. All surfaces and equipment should be cleaned, disinfected, and sanitized immediately if located within 6 feet of symptomatic patients, and otherwise, they should be cleaned after doing two patients.


  Recent Trends Top


CoV infection continues to spread around the world; however, till date, the drug or vaccine to kill virus or protect against it has not been formulated. Although the research is happening at breakneck speed, there are more than 20 vaccines in development. One of them has begun human trials after unusually sipping any animal research because that would delay results by another 1 year. Other scientists are at the animal research stage and hope to get the results of human trials later in the year. According to the World Health Organization, the only antiretroviral drug right now that seems to have worked in some patients is Remdesivir.[30] There has also much interest in an old and cheap antimalarial drug called chloroquine since some laboratory tests have shown to kill viruses; however, once again, results in patients are anticipated. Recently, scientists have found the effectiveness of Food and Drug Administration approved antiviral drug called Ivermectin to inhibit 5000-fold reduction on virus in cell culture. It is the same drug that was found useful in the treatment of HIV, dengue, influenza, and Zika virus. Although it requires more clinical trials, as of now, this drug perhaps seems to be a ray of hope in treatment of this infection as well.[31]


  Conclusion Top


Since there is currently no vaccine or specific antiviral treatment; however, ongoing rigorous research is giving us a ray of hope and paving way for the development of a vaccine in the near future. Till the time we get any good news in the form of discovery of drug or vaccine, efforts should be aimed at managing symptoms, and supportive therapy including washing hands, using an alcohol-based hand sanitizer with at least 60% alcohol by volume when soap and water is not readily available when appropriate, avoiding touching the eyes, nose, or mouth with unwashed hands, coughing/sneezing into a tissue and putting the tissue directly into a dustbin, and (for those who may already have the infection) wearing a surgical mask in public. The guidelines while treating a patient in the dental set up are highly recommended so that the safety of clinician as well as patient is maintained and the infection is not spread further.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3]



 

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