The global emergency in a nutshell
COVID-19, which is now deemed a pandemic by the World Health Organization has infected 181 countries & territories out of 197 countries (Fig 1), and 1 international conveyance (the Diamond Princess cruise ship harboured in Yokohama, Japan)1. The number of cases are rising by the hour and the numbers are huge. However, getting the virus does not mean inevitable death as the case fatality rate is estimated to be 0.25-3% 2.
Worldwide common appeal to dentists
In the light of the COVID‐19 outbreak, the Indian Dental Association (IDA) has issued an advisory wherein they strongly recommend all the dentists practicing in the country to voluntarily suspend non‐essential or non‐urgent dental care up to at least 31st March 2020. The Govt. of India has advised the same, and so have all Indian state dental councils.
Globally, most national dental associations, including US & Europe is recommending that dentists must postpone elective procedures until further notice.
To work or not to work?
Dentists worldwide are facing this unique question and arguments are being put forth.
Reasons cited to not work 3 –
1. Risk of nosocomial infection in dental settings –
- Dental patients who cough or sneeze on the chair or in waiting area
- The use of a high-speed handpiece or ultrasonic instruments makes patients’ secretions, saliva, or blood aerosolize to the surroundings – large number of droplets and aerosols are generated
- Dental apparatus could be contaminated with various pathogenic microorganisms after use.
- Infections can occur through the puncture of sharp instruments or direct contact between mucous membranes and contaminated hands.
2. Compliance with higher authorities who have issued these guidelines and directives.
Reasons cited to continue work 4 –
1. Ethics –
A. “Hospitals are open and medical doctors are working even when they are at a high risk. If they can show courage to treat infected patients, why not us?”
B. “ I’ve already given appointments to patients living in faraway towns.”
2. Finances –
A. “Most of us depend on our clinic revenue for a living. We have monthly rents and EMI’s to pay, monthly salaries to give.”
B. “I’ve already given appointments to my implant/FMR/ortho cases.”
3. Need of a global lockdown –
“If I shut down for 2 weeks but if everything else is still open, the virus will still progress. Then I’ll be asked close down for another 2 weeks. There must be a national or global 2 week quarantine. Everything shuts down for 2 weeks, everyone stays home and anyone with symptoms goes to a mobile testing station.”
I understand that it breaks our heart to not treat our patients. But sometimes, it is wiser to not work in order to safeguard those very same patients. My opinion is – barring emergency procedures, avoid any other treatments, even if lucrative, as this risks the patient, your team, your other patients, your family and yourself.
Remember that this is a temporary state and not a permanent decision. You may open your clinic for an hour or two daily for dental emergency patients only with strict infection protocol.
Taking care of dental emergency during a global emergency
Let us understand this in detail. This has specially been written keeping the COVID-19 pandemic in mind, however it can be used for any other such event in the future too. There are 2 main parts to this –
1. Who is a dental emergency patient? A patient with –
- Severe toothache/ pain (not just a twinge)
- Swelling of gums, face, or neck
- Bleeding in mouth that does not stop
- Infection or a substantial risk of it
- Trauma (such as a broken tooth)
2. What is a strict infection protocol?
We can simply adopt the dental clinic infection protocol straight from Wuhan, China 5. Even though this was the birthplace of the novel coronavirus, they continued emergency dental treatments and reported no new cases from their dental clinic. For this, you have to alter the design of your dental clinic like the dental department of Wuhan University did (Fig. 2). You may use temporary partitions for this.
1. Waiting cum Triage area – In the yellow area, establish precheck triages. Your triage staff in this area should wear disposable surgical mask, cap, and work clothes. While patients and their accompanying persons should be given medical masks. Triage staff should ask patients questions about the health status and history of contact or travel.6 They should measure and record the temperature of every staff and patient as a routine procedure.
Patients with fever should be registered and referred to designated hospitals. If a patient has been to epidemic regions within the past 14 days, a quarantine for at least 14 days should be suggested to him.
2. Dental clinic – In the orange area, all the emergency patients without a suspicious history should be treated. Your dental staff in this area must wear Personal Protective Equipment (PPE), i.e. disposable N95 masks, gloves, gowns, cap, shoe cover, and goggles or face shield. This must be changed after every patient. The area should be disinfected once every half day.
3. Isolation clinic – The red area is designed for those emergency patients –
- who are suspected with COVID-19,
- who are recovering from COVID-19 (but <1 mo after they are discharged from hospital) or
- who need dental procedures producing droplets and/or aerosols.
Separate entrances for patients (red arrow) and staff (blue arrow) should be provided in this area. Your dental staff should wear protective clothing besides the aforementioned PPE. In addition, the entire isolation area must be disinfected immediately after the treatment is over and the patient has left.
(If you have a single chair practice, then treat your treatment area as the isolation clinic/red area).
4. Staff area – The green area must be restricted for your staff only. Staff can have a rest here. The grid area behind the red line is also for staff only. They are recommended to enter the room by one by one and to keep wearing medical masks unless they are eating or drinking.
(If your clinic has space constraints, make temporary partitions in the waiting area for this or limit working time & staff socializing)
Treatment guidelines in the orange & red area
- If the patient is not an emergency patient, or if you/your clinic is not equipped as above to handle the dental emergency, then DO NOT TREAT.
- Good hand hygiene and thorough disinfection of all surfaces within the dental clinic is of critical importance.
- Use of Personal Protective Equipment (PPE) during treatment is a must. Follow proper sequence of putting it on & removing it to prevent contamination.(Fig 3)
- Preoperative antimicrobial mouth rinse can reduce microbes in oral cavity. 7
- Aerosol-generating procedures, such as the use of a 3-way syringe, should be minimized as much as possible.
- Taking intraoral radiographs can stimulate saliva secretion and coughing 8. Extraoral dental radiography like OPG or CBCT are appropriate alternatives.
- Red area patients should be scheduled as the last patient of the day to decrease the risk of nosocomial infection.
Emergency RCT protocol amidst COVID- 19 scare
1. Establish the pulp exposure under rubber dam isolation and a high-volume saliva ejector after local anesthesia. 4 handed dentistry is preferred.
2. Face shields and goggles are essential whether you are using high- or low-speed drilling with water spray.
3. Complete pulp devitalization & cleaning – shaping should be performed to reduce the pain.
4. The filling material should be placed gently without a devitalizing agent later according to the manufacturer’s recommendation.
Emergency surgery protocol amidst COVID- 19 scare
- If the tooth needs to be extracted, give suturing with absorbable suture.
- For patients with facial soft tissue contusion, debridement and suturing should be performed.
- It is recommended to rinse the wound slowly and use the saliva ejector to avoid spraying.
- Life-threatening cases with oral and maxillofacial compound injuries should be admitted to the hospital immediately, and chest CT should be prescribed if available to exclude suspected infection.
Recommendations for dental colleges
- During the outbreak period, online lectures, case studies and problem-based learning (PBL) tutorials should be adopted to avoid unnecessary aggregation of students and associated risk of infection.
- Schools should encourage students to engage in self-learning, make full use of online resources and learn about the latest academic developments.
To sum it up
Due to the characteristics of dental settings, the risk of cross infection between patients and dental practitioners is high. For dental practices and hospitals in areas that are (potentially) affected with COVID-19, strict and effective infection control protocols are urgently needed. They are elaborated in detail above. In case they cannot be implemented, it is wiser to avoid ‘herodontics’ and shut practice temporarily.
- Wilson N, Kvalsvig A, Telfar Barnard L, Baker MG. Case-fatality estimates for COVID-19 calculated by using a lag time for fatality. Emerg Infect Dis. 2020
- Kohn, WG, Collins, AS, Cleveland, JL, Harte, JA, Eklund, KJ, Malvitz, DM; Centers for Disease Control and Prevention . 2003. Guidelines for infection control in dental health-care settings—2003.
- Written public conversations with dentists all over the world through social media.
- Meng, L., Hua, F. and Bian, Z. (2020) ‘Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine’, Journal of Dental Research
- World Health Organization . 2020a. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: interim guidance [accessed 2020 Feb 17]
- Marui, VC, Souto, MLS, Rovai, ES, Romito, GA, Chambrone, L, Pannuti, CM. 2019. Efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review. J Am Dent Assoc. 150(12):1015–1026.
- Vandenberghe, B, Jacobs, R, Bosmans, H. 2010. Modern dental imaging: a review of the current technology and clinical applications in dental practice. Eur Radiol. 20(11):2637–2655.