SARS-CoV-2, a virus causing severe acute respiratory syndrome, has inundated the whole world, generating global health concerns. There is a wildfire-like effect, despite the extensive range of efforts exercised by the affected countries to restrain the expanse of this pandemic, owing to its community spread pattern. Dental specialists in the upcoming days will likely come across patients with presumed or confirmed COVID-19 and will have to ensure stringent infection prevention and control to prevent its nosocomial spread. This paper strives to provide a brief overview of the etiology, incubation, symptoms, and transmission paradigms of this novel infection and how to minimize the spread in a dental healthcare setting. This review presents evidence-based patient management practice and protocols from the available literature to help formulate a contingency plan with recommendations, for the dental practices prior to patients’ visit, during in-office dental treatment, and post-treatment, during the pandemic and after.
A public health emergency intimidated the world in 2019, soon with a pandemic announced by the WHO with the emergence of an abstruse virus [
As of June 5, 2020, according to the World Health Organization (WHO), 2019-nCoV has involved 216 countries, over 6 million confirmed cases, and 387,155 confirmed deaths [
Relevant and swiftly evolving information regarding the SARS-CoV-2 and COVID-19 pandemic and any dental insinuations was obtained from electronic databases such as PubMed, PubMed Central, Medline, Scopus, and Google Scholar using the following search terms: “Coronavirus,” or “COVID-19,” or “SARS-CoV-2,” or “2019-nCoV,” separately combined with “incubation,” “transmission,” “symptoms,” “oral symptoms,” “dentistry,” “infection control,” “treatment,” “teledentistry,” and “protocol.” Peer-reviewed publications were given priority. Latest reports and guidelines from major health bodies such as the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and major national dental associations and health regulatory bodies were also referred.
Most recent peer-reviewed studies were given priority. However, most studies available were descriptive, small investigational studies, and narrative reviews due to the rapidly evolving information about the disease. A narrative synthesis was undertaken to provide a summary of the important aspects relevant to dental practitioners during and after the COVID-19 pandemic.
Initially, COVID-19 started as a zoonotic infection, followed by human-to-human transmission. SARS-CoV-2 uses angiotensin-converting enzyme-2 (ACE-2) which is found in the lower respiratory tract as its entry receptor. It is transmitted through both Flügge microdroplets due to direct proximity (a distance less than 2 metres and an exposure duration greater than 15 minutes) and core droplets that remain suspended in aerosol through coughing or sneezing by an infected person and possible transmission through fomites [
Transmission of SARS-CoV-2 has been mainly described through inhalation/ingestion/direct mucous contact with saliva droplets [
COVID-19 may manifest as flu-like symptoms, ranging from dry cough, fever, sore throat, headache, lethargy, and diarrhea in few to troubled breathing, persistent pain or pressure in the chest, and bluish lips or face, which are emergency warning signs and necessitate immediate attention [
A confirmed case is one which is positive for the 2019-nCoV by the real-time PCR test [
Sound knowledge of the spread of SARS-CoV-2 is required to prevent its transmission in the dental practice. Aerosols are a predominant route for transmission of pathogens including SARS-CoV-2; therefore, stringent infection control measures are imperative [
Interdigitation of teledentistry which includes telescreening, teletriage, and teleconsulting is highly encouraged with telephone screening aimed to be the first point of contact between the patient and the dentist. Detailed medical history regarding the symptoms of COVID-19 (fever, cough and/or shortness of breath, sore throat, runny nose, diarrhea, lethargy discolouration of fingers or toes, rash of skin, and loss of taste and smell) must be investigated, and in case of any positive replies, in-office dental care should be delayed for 3 weeks except in case of dental emergencies [ If needed, patients can be prescribed analgesics or topical agents via a teledentistry appointment itself. In lieu of the fomite spread, every surface in the reception area must be presumed to be a potential risk. All nonessential items such as dental display models, brochures, and magazines should be removed, and chairs in the waiting area should be placed 6 feet apart [ All staff should change into different office clothing once they reach the office. Dentists, staff, and patients should be asked to hold-off on accessories such as bracelets, necklaces, and watches. Cleaning and disinfection and sterilization of the reception, waiting area, and equipment must be ensured [
Patients should be called/texted about their appointment and informed about the details of screening and in-office protocol [ Operatory preparation: a negative pressure/airborne infection isolation room should be allocated for treatment of any suspected COVID-19 patients to minimize the exposure of patients and staff [ Hand hygiene: 80% ethanol or 75% 2-propanol as an Alcohol-Based Hand Rub (ABHR), against SARS-CoV and MERS-CoV, were found to be efficient. Hence, in dental practice, their use should be highly encouraged, and hands must be washed whenever visibly soiled [ Personal Protective Equipment (PPE): Ti et al. advised the use of fit-tested N95 masks, gloves, overgown, and face/eye protection during aerosol-generating procedures on confirmed or suspected COVID-19 patients [ Pre-procedural mouthrinse with oxidative agents such as 1% hydrogen peroxide or 1% povidone iodine is considered to minimize the viral load [ Xu et al. have shown that, in some cases of asymptomatic COVID-19 carriers, the virus may be residing in the salivary gland; hence, all patients should be considered carriers, and aerosol production must be reduced for all patients [
Doffing of PPE: an appropriate doffing sequence and disposal in designated bags should be followed as per local biomedical waste protocols. Glasses and face-shields must be washed and disinfected after each procedure. ABHR must be used after each patient. Follow-up: all patients must be followed up after 7 days for any flu-like symptoms. Employee care: daily log for employees’ temperature and symptoms must be made and reviewed periodically. An in/out daily log book needs to be maintained as to who all entered and left the office along with the date and time. Post-procedure disinfection and decontamination: all sterilizable instruments should be cleaned, disinfected, and sterilized expediently, while all disposables, whether used or not, should be presumed to be infected and discarded appropriately [ Patients previously suffering from COVID-19 who have completed home isolation clearance can receive emergency dental care after fulfilling the latest CDC guidelines [
In this unprecedented time, events are unfolding rapidly, and hence, all dental practitioners should be abreast with the latest news and guidelines in accordance with the regulatory bodies and IPAC protocol Asking patients about symptoms during reminder calls and rescheduling nonurgent appointments should be incorporated till the situation stabilizes The dental operatory should be well prepared, and stringent infection control and waste management protocols should be followed to reduce nosocomial infection Although currently catastrophic, even after the critical peak of the outbreak has been contained, management is needed as cases might still exist in the community for months and, perhaps, years
The authors declare that there are no conflicts of interest regarding the publication of this article.