COVID-19: PRESENT AND FUTURE CHALLENGES IN THE DENTAL PRACTICE
By: Mary Maiko Jane N. Hopida
The Coronavirus disease 2019 (COVID-19) or SARS-CoV-2, a virus causing severe acute respiratory syndrome, has inundated the whole world, generating global health concerns. It was characterized by rapid spread, causing a pandemic. Multiple public health interventions have been implemented worldwide to decrease the transmission of the 2019 novel coronavirus disease (COVID-19)
The spectrum of clinical manifestations can be seen in COVID-19 patients ranging from asymptomatic infections to severe disease resulting in mortality. The standard laboratory test to detect current SARS-CoV-2 infection is the real-time reverse transcription-polymerase chain reaction (RRT-PCR) test. Many countries have implemented different public health measures to control the spread of SARS-CoV-2. Traditional measures such as quarantine of confirmed cases and close contacts, isolation, treatment of confirmed cases, social distancing, and community containment in the form of lockdowns and restricted travel are being implemented in various degrees worldwide. After the World Health Organization (WHO) declared it a pandemic, the emphasis has been on early testing, prevention by meticulous sanitation, social distancing, cough hygiene, and lockdown to flatten the disease curve. The WHO has warned that the defiance of these primary but effective measures will worsen the pandemic.
Dental health care workers are at the highest risk of contracting COVID-19 because of their occupational exposure to patients and exposure to respiratory secretions and aerosols produced during procedures like ultrasonic scaling and cavity/access preparation using high-speed air rotor with waterjet cooling systems. Dental procedures causing splatters, fomites, and aerosols can propel a high viral load in the procedure room, thereby increasing the risk of cross-infection between dental practitioners, patients, consecutive in-between patients, as well as dental staff.
Though dentistry is familiar with the principle of standard precautions to prevent cross-infections, in the present times, it is difficult to ascertain if the patient has disease transmission potential or not. To take significant actions against this harmful disease, the Philippine Dental Association instructed dentists not to perform any procedures other than emergency procedures. However, with the passage of time and the pandemic not showing any significant signs of control and patients having dental problems, it became essential to perform dental treatment.
Dentists have been recommended to take several protection measures. Some of the measures which need to be followed to have a ‘new normal’ dental practice are mentioned below. Before any appointment is given to the patient, the dental office institutes a pre-appointment screening regarding health, which includes eliciting any current symptoms and risk factors for COVID-19 or any travel history. On arrival at the dental office, outside the dental operatory, the patient is advised to perform hand sanitization and is provided with the mouth mask and head cap. The patient must undergo a body temperature check using an infra-red thermometer to rule out fever. The office assistant fills out a screening form to rule out any changes since the pre-appointment phone call. When the patient presents with negative history and fever <37.3ºC, then only should be allowed to enter the dental operatory with shoe covers. In the operatory, the patient may undergo treatment as decided by the dentist with all the personal protective gear. Patients should be discouraged from bringing anyone along. In the waiting room, it is recommended to have hand sanitizer, cleaning wipes, and provision for the proper disposal. Chairs should be placed at an adequate distance to maintain social distancing. The waiting room, along with the operatory, should be cleaned regularly. No reading materials should be placed. Appointments should be spaced out to reduce waiting time and reduce the number of people in the waiting room at any given time. Cleaning with a broom should be avoided; wet mopping with detergent and disinfectant (1% sodium hypochlorite) is preferable. Every hour, including door handles, the surface should be cleaned with 70% ethanol.
The dental operatory should be well ventilated with open windows, and adequate airflow should be maintained. During the procedure, the dentist should provide necessary treatment in the minimum number of appointments to reduce the contagion spread. N95 mask, face shield or goggles, and water repellent PPE are mandatory for the dentist and the assistant to perform any dental procedure with the aerosol generation, which should be ‘donned’ and ‘duffed’ in dedicated rooms and disposed of with care. The use of a high-power aspirator is indispensable. The use of air-water spray must be minimized. After every dental procedure, careful disinfection of the surface with 1% sodium hypochlorite or 70% ethyl alcohol and 5% sodium hypochlorite should be performed for the disinfection of visible biological fluid stains. The saliva aspirator and spittoon tubing should be flushed first with water, then with 0.1% sodium hypochlorite after each patient. Not more than 0.01% NaOCl is advisable in the dental waterline as higher concentrations may corrode and cause a smell.
Mouth rinse before a dental procedure is mandatory to reduce the salivary load of oral microbes. The use of preprocedural mouth rinse containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone-iodine for one minute should be mandatory as SARS-CoV-2 is vulnerable to these oxidizing agents. Reinforcing good hand hygiene, the dentists should wash hands before the patient examination, before dental procedures, after touching the patient, after touching the surroundings and equipment without disinfection, and after touching the oral mucosa, damaged skin, or wound, blood, body fluid, and secretion. Dental office staff also should be screened every day at the entry for symptoms and risk factors of COVID-19 and should not be allowed in the office if they present with any of the symptoms.
In conclusion, clear guidelines for preventing and controlling SARS-CoV-2 infection in dental practice should be available until a vaccine, or a drug becomes available. It is a fact that things are unlikely to get back to the ‘old’ normal soon, if ever. This may lead to the resumption of dental practices at the ‘new’ normal level, accompanied by changes in products, technologies, and treatment patterns. Dentists have to be patient, and they may need to acquire new skills to combat this pandemic situation.