Challenges and opportunities for oral health care professionals in COVID-19 pandemic

Amit Tirth; Naved Alam; TL Ravishankar; Vaibhav Tandon

doi:10.4103/sjoralsci.sjoralsci_15_22

REVIEW ARTICLE

Year : 2022 | Volume : 9 | Issue : 2 | Page : 87-91

Challenges and opportunities for oral health care professionals in COVID-19 pandemic

Amit Tirth, Naved Alam, TL Ravishankar, Vaibhav Tandon
Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India

Date of Submission	30-Mar-2022
Date of Acceptance	27-Apr-2022
Date of Web Publication	31-Aug-2022

Correspondence Address:
Dr. Naved Alam
Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjoralsci.sjoralsci_15_22

Abstract

Introduction: The World Health Organization announced a pandemic crisis when the virus was isolated in all of its worldwide regions. Being highly transmissible, this novel coronavirus disease-2019, also known as COVID-19, has spread fast all over the world. The outbreak was declared a Public Health Emergency of International Concern. Human-to-human transmission happens mainly through the respiratory tract of droplets and close contact transmission. Dental practitioners are at higher risk of transmission as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has the potential to spread through droplets and aerosols from infected individuals in dental clinics and hospitals.
Aim: The aim of the study is to highlight the potential sources of COVID-19 infection in oral health-care services.
Materials and Methods: An electronic search was made of the PubMed (MEDLINE), ScienceDirect, and Google Scholar databases. Articles were identified by the searches which were checked based on title first, then by abstract or keywords with “COVID-19,” “SARS-CoV-2,” “Dentist,” and “health-care workers,” for articles involving studies and review articles published in English language only and relevant to the objectives of our review article.
Results and Discussion: The majority of the emergency cases required endodontic treatment during the COVID-19 pandemic. Atraumatic restorative treatment and interim therapeutic restoration are alternative approaches to prevent infectious aerosol during dental procedures in dental, community, or hospital settings.
Conclusion: Oral healthcare professionals are at higher risk of contracting COVID-19 infection. Risk of COVID-19 can be reduced by appropriate techniques and practice in dental settings.

Keywords: Aerosols, COVID-19, oral health care, severe acute respiratory syndrome-coronavirus-2

How to cite this article:
Tirth A, Alam N, Ravishankar T L, Tandon V. Challenges and opportunities for oral health care professionals in COVID-19 pandemic. Saudi J Oral Sci 2022;9:87-91

How to cite this URL:
Tirth A, Alam N, Ravishankar T L, Tandon V. Challenges and opportunities for oral health care professionals in COVID-19 pandemic. Saudi J Oral Sci [serial online] 2022 [cited 2023 Apr 2];9:87-91. Available from: https://www.saudijos.org/text.asp?2022/9/2/87/355221

Introduction

The HIV/AIDS pandemic in the 1980s caused an apprehensive concern in health-care workers for the spread of blood‒borne infectious diseases.^[1] Then severe acute respiratory syndrome (SARS) is the first major infectious disease to hit the international community in the 21^st century in 2003. The SARS epidemic originated from an animal market in Guangdong province of China and subsequently spread globally.^[2] In Saudi Arabia, there has been an epidemic of Middle East Respiratory Syndrome (MERS)-CoV in 2012 and later spread worldwide.^[3] In December 2019, a series of pneumonia cases of unknown cause emerged with clinical presentations greatly resembling “viral pneumonia.” It was first noted to have occurred earlier in Wuhan, China, in 2019, and the World Health Organization (WHO) reported the first case on December 31, 2019. After a rapid escalation, on January 9, 2020, the WHO declared the discovery of a new type of coronavirus. The WHO announced a pandemic crisis when the virus was isolated in all of its worldwide regions. Being highly transmissible, this novel coronavirus disease-2019, also known as COVID-19, has spread fast all over the world. The outbreak was declared a Public Health Emergency of International Concern on January 30, 2020.^[4] In India, the government announced a lockdown on March 24, 2020. Later on, the government advised maintaining social distancing, wearing a mask, maintaining hand hygiene, and avoiding crowded places to prevent transmission of SARS-CoV-2.^[5] First called novel coronavirus (2019-nCoV) and then officially named SARS-CoV-2 by the International Committee of Taxonomy of Viruses based on phylogenic and taxonomic analyses.^[6] Coronaviruses include ranges of respiratory viruses, which can present with mild-to-severe manifestations and lead to respiratory dysfunction.^[7] Globally, on December 29, 2021, there have been 281,808,270 confirmed cases of COVID-19 reported to the WHO. In India, there have been 145,582 active cases reported on January 04, 2022.^[8] With the help of COVID-19 vaccination, health-care workers succeeded by drastic reduction of transmission of SARS-CoV-2 infection globally. SARS-CoV-2 is zoonotic in origin, can cross-species barriers and spread COVID-19 disease. Human-to-human transmission happens mainly through the respiratory tract of droplets and close contact transmission. However, the health-care personnel who are in extensive and close exposure are especially vulnerable to SARS-CoV-2 infection. The risk of cross infection of SARS-CoV-2 might be elevated between dental health-care professionals (DHPs) and patients due to usual dental practice. Dental practitioners are at higher risk of transmission due to close proximity to oral cavity, for example, the exposure to saliva, other body fluids, aerosols, and face-to-face communication. The virus is transmitted through contaminated droplets, and the spread mainly occurs through coughing, sneezing, and salivary contamination.^[9] There are few studies available regarding alternative approaches to prevent aerosol during performing the treatment in dental settings.

Materials and Methods

A search was made of the PubMed (MEDLINE), ScienceDirect, and Google Scholar databases between May 2021 and January 2022. Articles identified by the searches were checked based on title first, then by abstract or keywords with “COVID-19,” “SARS-CoV-2,” “Oral health care,” and “Dental professionals” for articles involving various studies and review articles relevant to the objectives of our review article. Articles included were also assessed by other authors in this study. Articles published in the English language only were selected, and there were no publication year or publication status restrictions.

Ethics and data

Ethical approval was granted by Institutional Ethical Review Board (KDCRC/IERB/02/2022/03).

Results

The infection is known to readily spread from person to person. This occurs through liquid droplets by cough, sneeze, hand-to-mouth contact, and contaminated hard surfaces. Dental patients and professionals can be exposed to pathogenic microorganisms, including viruses and bacteria that infect the oral cavity and respiratory tract. Close human proximity accelerates SARS-CoV-2 spread. Dental care settings invariably carry the risk of infection due to the specificity of their procedures, which involves face-to-face communication with patients, frequent exposure to saliva, blood, other body fluids, and the handling of sharp instruments. A study reported that the pathogenic microorganisms can also be transmitted in dental settings through inhalation of airborne microbes that can remain suspended in the air for long periods.^[10] Liquid and solid airborne particles (aerosols) in indoor air originate from many indoor and outdoor sources. Particles may differ in size, shape, chemical composition, and biological composition. Particle size is the most important parameter affecting particle fate during transport, and it is also significant in affecting their biological properties. Primarily, particle size is a consequence of the process that led to its generation and thus it is also dependent on the source. The sizes of these different types of biological aerosols vary and can be broadly classified as follows: viruses from 0.02 to 0.3 μm, bacteria from 0.5 to 10 μm, and fungi from 0.5 to 30 μm, for example, an individual SARS coronavirus ranges from 0.075 to 0.160 μm in diameter and is a spherical virion.^[11] Thus, the 2019-nCoV has the potential to spread through droplets and aerosols from infected individuals in dental clinics and hospitals. In addition, during the pandemic, some clinicians have taken radical measures to shut down dental clinics, whereas others have allowed emergency and urgent care treatments, with some allowing elective procedures to be continued under strict protocols. Despite such unprecedented efforts in risk reduction, DHPs remain anxious and continue to search for opportunities for practice improvement. SARS-CoV-2 now seems to have a dual nature: tragically lethal in some persons and surprisingly benign in others. Heightened anxiety from DHPs stems mainly from two aspects: shortage and uncertain effectiveness of current personal protective equipment (PPE) against the SARS-CoV-2 virus and unknown risk level of transmission from a patient who might be infected with the virus but remain asymptomatic.^[12] Asymptomatic cases as a source of infection have been a potential threat for the spread in the community as well as health-care workers. There have been reports of persons who were infected with SARS-CoV-2 but did not develop symptoms of COVID-19.^[13] The viral load of such asymptomatic persons has been equal to that of symptomatic persons, suggesting a similar potential for viral transmission.^[14] Dental professionals working with the oral-pharyngeal environment determine that dental treatment poses a risk of viral transmission. Endodontic treatment is a specialized modality that is profoundly affected by COVID-19. It represents the majority of emergencies in dental practice.

A study reported that the majority of emergency cases (50.26%) of endodontic emergency patients among all dental emergency patients.^[15] Hua et al. observed that about two-thirds of dental practitioners (64.1%) were willing to treat/care for patients with confirmed or suspected COVID-19.^[16] In addition, approximately 80% of the orthodontists and nurses had resumed their orthodontic practice during the pandemic.^[16] Some preventive measures are insufficient for protection to prevent the contact of aerosols during dental treatment [Figure 1].

Figure 1: Contact of aerosol droplets during a dental drill for endodontic treatment

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Discussion

The concept of “infection control” has received considerable attention from dental professionals and organizations. Dental professionals have always been taught on protecting themselves and their patients from potential pathogens. However, the SARS-CoV-2 infection, better known as COVID-19, has brought a new, unanticipated challenge to dental professionals.^[17] The truth of the matter is that standard PPE is not enough in cases of airborne infections such as COVID-19. The next level of infection control “transmitted-base precaution” should be taken into action by upgrading the PPE with materials such as unique masks (e.g., N-95), face protection or shield, gown or coverall, head cover, and rubber boots.^{[18],[19],[20]}

Triage through teledentistry

Upon patient arrival in dental practice, patients should complete a detailed medical history form, COVID-19 screening questionnaire, and assessment of a true emergency questionnaire.^[21] Dental professionals should assess the patient's body temperature using a noncontact forehead thermometer or with cameras having infrared thermal sensors. The information regarding the previous or current symptoms of COVID-19 (fever, cough and/or shortness of breath, sore throat, runny nose, diarrhea, body ache, and loss of taste and smell) must be examined. If the treatment has to be performed in person, this includes antiseptic mouth rinse and visual and/or tactile inspection without intraoral radiography for diagnosis as (intraoral periapical) radiographs first come in contact with the patient's saliva and may cause a risk of infection. Always maintain a physical distance of six with the patient's feet while it is possible.

Prevention and management

It is known that aerosols carry an inherent risk of transmission of SARS-CoV-2 infection in closed spaces indoors such as dental settings. A study done by Benzian and Nietherman suggested that Safe Aerosol-Free Emergent Dentistry is an adaptation to a pandemic emergency, and a pandemic recovery process, by avoiding hazardous infectious aerosols.^[22] It is known that additionally, these infectious aerosols can be prevented by taking some important measures in emergency cases during treatment.

Atraumatic restorative treatment

This is an alternative approach to remove the carious lesions through hand instruments without administering local anesthesia and placing a High viscosity glass-ionomer cement (HVGIC) as fluoride-releasing restorative material to prevent the carious process. Atraumatic restorative treatment (ART) was introduced almost 30 years ago when researchers were challenged to manage cavitated dentine lesions in an environment in which rotary-driven restorative care was not possible due to the lack of electricity and/or piped water. At that time, the dentists made use of what had been available in dentistry for many years, mainly hand instruments for enlarging small cavity openings and for selective removal of carious dentine to soft (deep cavities) or firm (medium cavities) stages in vital teeth. Today, in completing this process, local anesthesia is seldom needed and used in children; the ART process causes less dental anxiety than the traditional approach of using the drill.^[23] ART is defined as a minimal intervention care approach to preventing the development of carious lesions and of stopping their progression into dentine. A second aim is to restore dentine carious lesions in a minimally invasive way. ART consists of two components: a preventive (ART sealant) and a restorative (ART restoration) component. ART sealants use an HVGIC, which is placed over carious lesion-prone pits and fissures under finger pressure. Hand instruments (such as an excavator and an applier-carver) are used for adjusting the bite and removing excess material.^[24] ART is used in cases when there are obstacles for machines and has been proven to have high success rates in primary and permanent dentitions.^[25]

Interim therapeutic restoration

Similarly, interim therapeutic restoration (ITR) is another choice of treatment for restoring carious lesions without generating aerosols through slow or high-speed dental handpieces. The difference between ART and ITR is by the purpose of their use. In ITR, the primarily temporary restoration is done, and after following up, the tooth is restored by permanent materials such as GIC. The indications for the use of ITR include young, uncooperative patients with special needs and cases when conventional dental treatment cannot be performed and needs to be postponed. ART is done in the first visit of the patient in the community or dental setting. In addition, children that are anxious and difficult to handle in the dental office are suitable candidates for ITR, which has been proven to produce satisfactory results.^[26] Teeth treated with ITR should be managed with more definitive restorations within 6 months of the placement to avoid an elevation in the number of oral microbes to pretreatment levels.^[27]

It is best to adopt this technique to avoid the aerosols and the longer duration to wait for effective local anesthesia. This study highlights the contact of SARS-CoV-2 with aerosol generation during dental procedures. The limitations of the study include that there were no publication year or publication status restrictions. Longitudinal studies are required for more observation of transmission of COVID-19 infection and aerosol retention in the air in closed spaces such as dental clinics and to find innovative ways to minimize aerosol generation during dental procedures.

Conclusion

Dentistry professionals are considered to be at high risk for contracting COVID-19. This is strongly due to COVID-19 transmission through saliva. In light of the high risk of contamination during dental care, only emergency treatment should be performed. ART and ITR could be performed to avoid infectious aerosols, and surface disinfection should be performed with 0.1% sodium hypochlorite or 62%–71% ethanol for 1 min at least. Guidance should be given to patients for maintaining oral as well as overall hygiene.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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