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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 121-125

Prevention of SARS-CoV-2 Spread in Dental Clinic: The Future Challenge in Resuming Clinical Practice


1 Department of Oral and Maxillofacial Surgery, JSS Dental College and Hospital, JSSAHER, Mysore, Karnataka, India
2 Department of Forensic Medicine & Toxicology, Mysore Medical College and Research Institute, Mysore, Karnataka, India

Date of Submission10-Jun-2020
Date of Decision15-Jul-2020
Date of Acceptance27-Jul-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Chandan S N
Reader, Dept. of Oral & Maxillofacial Surgery, JSS Dental College & Hospital, JSSAHER, SS Nagar, Mysuru 570015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/denthyp.denthyp_70_20

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  Abstract 


In the present scenario, the pandemic of coronavirus disease 2019 (COVID-19), which is responsible for simple upper respiratory infection to fatal pneumonia and multi-organ failure has become a major public health challenge and a public health emergency of international concern. Apart from secondary and tertiary care, it is very much essential to provide primary care, prevention, and early detection. To prevent the virus from the human-human transmission and to control the situation, the protocols vary at various setups. Due to the uniqueness of dental settings and practice, the risk of cross-infection can be high between patients and dental practitioners. Establishment of strict and effective infection control protocol is necessary owing to the varying sustainability of the virus on different surfaces. The area of concern for a dental professional is the oral cavity and upper respiratory region where the host recipient cell receptor, angiotensin-converting enzyme receptor 2, is present abundantly acts as the host cell entry route for the coronavirus. Dental professionals play an important role in preventing the transmission of SARS-CoV-2; we aim to review the infection control measures in dental practice.

Keywords: Coronavirus, dental health, infection control, SARS-CoV-2, transmission in dental practice


How to cite this article:
Manjula, Prasad DM, S N C, Shetty SK, ShyamS, Shivananda. Prevention of SARS-CoV-2 Spread in Dental Clinic: The Future Challenge in Resuming Clinical Practice. Dent Hypotheses 2020;11:121-5

How to cite this URL:
Manjula, Prasad DM, S N C, Shetty SK, ShyamS, Shivananda. Prevention of SARS-CoV-2 Spread in Dental Clinic: The Future Challenge in Resuming Clinical Practice. Dent Hypotheses [serial online] 2020 [cited 2020 Dec 5];11:121-5. Available from: http://www.dentalhypotheses.com/text.asp?2020/11/4/121/300868




  Introduction Top


The outbreak incidence of a new coronavirus China, in December 2019 has set a new pandemic. In few months, the virus has infected more than 36,164,596 people and killed more than 1,055,815.[1] The virus was originally named “new Coronavirus 2019 (n-CoV-19)” and then WHO established the correct name as “SARS-CoV-2”.[2] The Chinese horseshoe bat (Rhinolophus sinicus) being the host of SARS-CoV-2, zoonotic in origin[3],[4],[5] and pangolins are the likely intermediate host.[6] The spread is through the respiratory droplets, aerosols and contact spread.[7],[8] The Chinese Center for Disease Control and Prevention officially announced the etiologic factor of COVID-19 is SARS-CoV-2 on January 8, 2020.[9]

It is the viral transmission and the incubation period that plays a dominant role in the pandemic state. Apart from the symptomatic cases, the asymptomatic cases and cases in the incubation period may also be a potent threat in SARS-CoV-2 transmission.[7] The incubation period of SARS-CoV-2 has been estimated at 5 to 6 days, but there is evidence that it could be as long as 14–21 days, which is now the commonly adopted duration for medical observation and quarantine of exposed persons.[10],[11] According to current data, the mortality rate of COVID-19 is 0.39% to 4.05%, depending on different regions of China, which is lower than that of SARS (≈10%) and higher than that of seasonal influenza (0.01% to 0.17%).[12]

In the present scenario, in developing countries like India, there are a large number of people at high risk of infection because of higher population density. The health care providers, health workers, and the community are always at risk of getting the infection. However, the geriatric group with immune-compromised status, diabetes, history of lung infections like tuberculosis, pneumonia, chronic obstructive pulmonary disorder are at high risk. Wang et al.[13] revealed that in the early stage of the epidemic, in an analysis of 138 hospitalized patients with COVID-19 in Wuhan, 57 (41%) were presumed to have been infected in hospital, including 40 (29%) health care workers and 17 (12%) patients hospitalized for other reasons. As of February 14, 2020, a total of 1,716 health care workers in China were infected with SARS-CoV-2, consisting of 3.8% affected patients nationally, among them six have died. Thus the risk of nosocomial infections is a major possibility in a pandemic. It is difficult to prevent the transmission among the cases who receive dental treatment, including the use of a high-speed hand-piece or ultrasonic instruments which can spread secretions like saliva or blood aerosolized to the surroundings. So it is a challenge for a dental practitioner to decontaminate. Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily work are not effective enough to prevent the spread of SARS-CoV-2, especially when patients are in the incubation period or asymptomatic carriers or choose to conceal their infection.

Dental practice demands the practitioner to be in close vicinity to the patient with the aerosol generation, so the risk of cross-infection may be high. Therefore a strict and effective infection control protocol is the need of the hour along with the psychological boost for both dental practitioners. This article, based on our experience and relevant guidelines, explains the essential knowledge about SARS-CoV-2 and nosocomial infection in dental settings, and provides recommended management protocols for dental professionals.

Transmission of SARS-CoV-2 in Dental Clinics

The transmission of SARS-CoV-2 depends on the aerosol formed during clinical procedures and surface stability of SARS-CoV-2.[14] The possible transmission routes of SARS-CoV-2 include direct transmission (cough, sneeze, and droplet inhalation transmission) and indirectly, contact transmission (contact with oral, nasal, and eye mucous membranes).[15] However viral transmission can also occur through contact with asymptomatic patients.[16] Notably, the recent data suggests that nearly half of patients present with predominant digestive tract symptoms as their primary complaint.[17] Apart from nasal and respiratory secretions coronavirus will be shed in stools[18] and continue to be potentially infectious until 5 weeks even after the respiratory features have reduced. Thus to prevent the transmission it is mandatory to practice good hygiene and toilet care. The release of bio-aerosols and its spread has to be taken care of during the flush. Studies have shown that the virus was detected after 7days in stool sample.[18]

The coronavirus uses the angiotensin-converting enzyme receptor 2 (ACE2), the receptor for SARS-CoV-2, was expressed in human airway epithelium and lung parenchyma. ACE2 is a type I transmembrane metallo-carboxypeptidase with homology to ACE, an enzyme in the renin-angiotensin system involved in the management of hypertension which is expressed in vascular endothelial cells, the renal tubular epithelium, and in Leydig cells in the testes. PCR analysis revealed that ACE2 is also expressed in the lung, kidney, and gastrointestinal tract, tissues shown to harbor SARS-CoV-2.[17],[19]

Coronavirus enters the cell through the ACE2 cell receptor and invades cells, which may promote human-human transmission.[5] ACE2 cells are present throughout the respiratory tract. The basic ACE2 cell morphology is compatible with the salivary gland duct epithelium in the oral cavity. ACE2 epithelial cells of salivary gland ducts were demonstrated to be early targets of SARS-CoV-2 infection.[20] Therefore the dental professionals and patients are at risk of adopting and/or the transmission of the virus that infects the oral cavity and respiratory tract. The dental clinical settings, papers, instruments, prosthesis, airborne organisms that can remain suspended in the air for long periods, generated from an infected individual and propelled a short distance by coughing and talking without a mask and/or environmental surfaces invariably carry the risk of SARS-CoV-2 infection.[21],[22],[23]

Effective infection control strategies are needed to prevent the spread of SARS-CoV-2 through droplets and aerosols, as they are small particles that stay airborne for an extended period before they settle on environmental surfaces or enter the respiratory tract. Studies reveal that the SARS-CoV-2 was stable long-lasting decay rates in five different conditions like aerosols and on surfaces like plastic, stainless steel, copper, and cardboard. The aerosols obtained from the upper and lower respiratory tract in humans of size <5 µm contain SARS-CoV-2 (105.25 50% tissue-culture infectious dose [TCID50] per milliliter).[24]

These results indicated that aerosol and fomite transmission of SARS-CoV-2 is possible, since the virus remains viable and infectious in aerosols for hours up to days, however with a minimal decrease in the infectious titer [Table 1]. These findings infer the association of nosocomial spread and latent-spreading events.[24],[25]
Table 1 Duration of the viability of SARS-CoV-2 on different surfaces[24]

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Infection Control Protocol in Dental Setting

Dental professionals should be familiar with the mode of virus spread and to identify patients with SARS-CoV-2. The personal protection equipment has to be used with extra-protective measures during the practice [Table 2]. Every surface in the clinic and waiting area carries the risk of infection. Hand and surface hygiene with water, soap, and other detergents has been considered the most effective critical measure for reducing the risk of transmission. The staff should work at an adequate distance from patients. Adequate periodic air exchange on all surfaces, furniture, magazines, and doors that come into contact must be disinfected. The masks should be provided for the patients. It is essential to have the knowledge of viability of the virus on different surfaces [Table 1]. In the case of an air conditioning system, it must be sanitized very frequently or it is better to close.
Table 2 Plan for use of personal protective equipment[27]

Click here to view


As often as possible, the hand-piece must be equipped with anti-reflux devices to avoid contamination. The dentist should prefer procedures reducing the quantity of aerosol produced in the environment. The stability with long-lasting decay rates of the virus depends on the surface material [Table 1], thus the instruments should be appropriately disinfected and sterilized.[26]

Selection of patients

The American Dental Association (ADA) has published a guidance on dental emergency and nonemergency care called: What constitutes a Dental Emergency? [Table 3].[28],[29]
Table 3 Speciality wise selection of patients during SARS-CoV-2 pandemic

Click here to view


Cases with uncontrolled bleeding, cellulitis, diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling, facial bones fracture that compromises the patient’s airway, should be considered as dental emergencies. Dental urgencies being severe dental pain from pulpal inflammation, pericoronitis, third-molar pain, surgical post-operative osteitis, dry socket dressing changes, abscess, 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 before critical medical procedures, final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation, a biopsy of abnormal tissue.

Mandatory patient evaluation

A comprehensive evaluation of a patient for COVID-19 infection state is recommended as an initial step. Tele-consult or tele-screening of the patient is encouraged before the first point of contact between the patient and receptionist or dentist, where current and past medical history pertaining to severe acute respiratory illness (SARI) type symptoms can be analysed. A questionnaire has to be prepared regarding the health status, previous quarantine, traveling and contact history, as 85% of transmission occurs among family members. Any case of febrile state, cough, sneeze, running nose should be registered in designated fever clinics and should be very careful as the viral shed in the initial 3–4 days is to a very maximum extent. If a patient has been to epidemic regions within the past 14 days, quarantine for at least 14 days is suggested. In areas where SARS-CoV-2 spreads, non-emergency dental practices should be postponed. European guidelines require that patients undergo another questionnaire (similar to the first one) once they come to dental clinic.[26] The oral cavity of the patient has to be rinsed with antimicrobial mouth rinse so that it could reduce the number of microbes in the oral cavity. Procedures that are likely to induce coughing or gag reflex should be avoided or performed cautiously. Aerosol-generating procedures, such as the use of a 3-way syringe, should be minimized as much as possible. Intraoral x-ray examination should be avoided as for as possible and extraoral dental radiographs, such as panoramic radiography and cone-beam CT should be considered during the outbreak of SARS-CoV-2.

Disinfection of the dental setting

To ensure quality dental practice and standard of dental care the dental setting should be effectively and strictly disinfected. The clinic settings should be cleaned and disinfected in accordance with the Protocol for the Management of Surface Cleaning and Disinfection of Medical Environment.[30] Between each patients, sufficient time should be allotted for disinfection. Surfaces like the dental chair, light handle, trays, suction, and equipment should be disinfected. All things, switches, boards, doors, handles, the elevator should be disinfected regularly. People taking elevators should wear masks correctly and avoid direct contact with switches and other objects.

Management of dental setting waste

The waste generated in a dental set up should be segregated at the generation level as per the bio-waste management protocol using color-coded bins. It should be transported to the temporary storage area. The reusable instrument and items should be pre-treated, cleaned, sterilized, and properly stored in accordance with the Protocol for the Disinfection and Sterilization of Dental Instrument. The waste generated by the treatment of patients is regarded as infectious medical waste. The surface of the package bags should be marked and disposed of according to the requirement for the management of bio-medical waste.[29]

Psychological care of dental professionals, dental students, and staff

In the present pandemic era, it is essential to care for the psychological status and mental health of well-being. They will be associated with fear of acquiring infection and they will be working under pressure and stress. People should stop unnecessary work and limit the medical and surgical practice in dentistry which may increase the risk of exposure and spread. Work in shift basis with all personal protective equipment in the triage system should be practiced. Hospital quarantine with psychology counselling should be considered rather than home quarantine.


  Conclusion Top


The newly emerged virus, SARS-CoV-2 has caused the pandemic outbreak resulting in upper and lower respiratory infection and complications like myocarditis, arrhythmias, acute respiratory distress, shock with acute renal failure, hypotension, bradycardia, and multi-organ dysfunction syndrome which enters the human cell through receptor ACE2 and forms multiple copies of RNA strands under the influence of r- reverse transcriptase. This virus is more contagious, stable, and sustainable for different time duration on different surfaces and in the atmosphere, with evidence of rapid human-human transmission. As the patients frequently visit dental clinics, it is mandatory to understand the pathogenicity, clinical features, complications, and preventive measures to restrict the spread of SARS-CoV-2 and protect mankind from mortality and morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3]



 

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