Impact Of Covid - 19 On Prosthodontic Practice – A Review

• Fractured prosthesis should be repaired by first disinfecting it thoroughly.
• Ulcerations or mucosal erosions can be handled through tele consultation by advising some analgesic and antiseptic gels for local application and discontinuation of the prosthesis for the time being.
• Mild smoothening of sharp borders can be advised with sandpaper if patient can't come to the clinic.
• Patients should be recalled in the clinic on strict appointment schedule if any further adjustment of the prosthesis is mandatory to restore its function.
• Denture adjustment should be done using a low speed micro motor.
• New prosthesis should be fabricated if it is affecting the systemic health of the patient.
• Primary impressions should be made in well-fitting stock trays and secondary impressions should be made in custom trays which can be discarded after obtaining the master cast.
• One step border molding can be done to minimize chair side time.

Laboratory protocol -

Record bases and wax rims should be adjusted on prior basis in order to avoid any modifications after insertion in the mouth. Care should be taken to minimize processing errors in lab and dentures should be remounted to adjust occlusion. This will ensure lesser follow up visits of the patient.

2)Fixed Prosthodontics: The fixed prosthodontics includes fabrication of crowns and bridges, inlays, onlays, smile designing, veneers, full mouth rehabilitation, post and cores etc. These are elective and aerosol generating procedures. So, adherence to strict precautions and disinfection protocols is mandatory. Digital impressions using intraoral scanners is safe alternative but the cost- benefit ratio needs to be taken care of. Papi et al. have compared digital workflow with conventional workflow and concluded that digital method reduces human contact at multiple steps thereby decreasing risk of transmission of virus, saves time and improves efficacy.16

Chair side protocol-

• Use of rubber dam and high vacuum suction are recommended during tooth preparations where supragingival margins are planned.17 This effectively wipes out most of the blood and saliva contaminants; also keeping the viral load to a minimum.
• Clinicians should avoid any undercuts and underreduction in their tooth preparations to prevent lab errors and multiple appointments.
• Shade matching should be preferably done by digital spectrophotometers and consent of patient should be taken.
• Intraoral photographs can be sent online to the laboratory to avoid any shade mismatch.
• Removal of fractured and faulty prosthesis using crown removers is advisable.
• Recementation of the dislodged prosthesis can be done, whereas adjustment of the temporary crowns should be done extra-orally using a micromotor.
• The dental tools such as air rotor and burs should be autoclaved as per manufacturer'sinstructions.
• Additional steps include working position of dentist at 11–12 o’ clock, reduced air pressure in 3-way syringes, full protection PPE for both doctor and assistant, use of anti-retraction hand pieces and disposableburs.5
• Frequent rinsing and spitting should be prohibited.

Laboratory protocol-

Crown & bridge impressions and trays need to be carefully disinfected/autoclaved.

3) Implant surgery and it’s implications in prosthodontics

Implant dentistry is the most fascinating and earning division for prosthodontists these days. Deferring patients for placement of implants can lead to big financial and mental trauma to the dental and lab personnel. But implant treatment planning involves multiple dental visits which, along with use of surgical aerosol generating hand pieces, call for extreme precaution in regard to disinfection and infection control. Following recommendations are suggested by authors though personal discretion is a must.

Chair side protocol-

• Healthy patients with no other co-morbidities can be taken up based on CBCT and virtual planning.
• During surgery, slow speed drilling with sharp drills is preferable.
• Intermittent external irrigation along with high volume suction should be done.
• Use of ultrasonic devices and piezoelectric surgery should be minimized; whereas use of osteotomes should be encouraged in order to reduce aerosol formation.18
• Immediate implants with immediate loading should be taken up wherever indicated as they require lesser time number of visits.
• It is advisable to avoid complex full mouth procedures.
• Digital impression with scan bodies is suggested as an alternative to conventional impression making.

Laboratory protocol-

Implant impressions and components need to be carefully disinfected/autoclaved before reusing them.

4)Handling dental impressions:Dental impressions are a high risk source of infection transmission and should be handled with care to minimise transmission to lab personnel - which is also the duty of the dentist.

• Autoclaved stock trays should be used and material should be loaded carefully to avoid gag reflex.
• Impression should be kept under running water avoiding direct flow over tissue surface to avoid losing surface details.
• Spray disinfectant can be used for chair side disinfection followed by packing in zip lock bags before sending the impressions to laboratory for pouring.
• Work authorization forms should be sent in separate zip lock bag. 19

Recommendations given in Table 1 should be followed in the lab for disinfection as per the material.4,6

Conclusion

In these extraordinary times, extraordinary measures need to be taken by all dental professionals. Prosthodontists, assistants, other essential supporting staff, and patients are at a potentially higher risk ofCOVID‐19 infection during prosthodontic treatments. Dental team needs to update their knowledge and learn the use of new approaches such as Tele‐dentistry whenever possible to manage patients and to avoid the risk of cross infection. The chances of contracting COVID‐19 are very low to very high while instituting holistic prosthodontic care to the patients depending on the treatment protocols adopted in the clinics.