Abstract
Healthcare workers are the frontliners in the fight against COVID-19, where they are risking their lives every now and then to treat their patients. Dental practitioners are among the healthcare service providers who are at the top when it comes to the risk of exposure to the lethal virus. This short review article discusses the background of this pandemic and the potential risks and challenges that dentists face due to the peculiar nature of the profession and some infection control measures to cope with the same.
Keywords: COVID-19, pandemic, dental practitioners
Introduction
The Novel Coronavirus (COVID-19) outbreak is a bolt from the blue for mankind. It has brought the planet to a standstill- way beyond humans could have ever imagined. To cope with the virus and prevent its transmission, countries are locked down, movements restricted and professional life has been shattered, suspended, cancelled and come to a halt. The shocking and surprising outburst has posed a significant threat to Health resulting in a global public health emergency 1. Interestingly, while the whole world is on one side isolating and maintaining social distancing, healthcare providers are the one and only who are coming in close contact with their patients day in and day out.
As a part of the healthcare industry, dental practitioners have always faced a great challenge for both providing dental care and at the same time protecting themselves from coming in contact with such deadly infections. Dental practitioners work in one of the most dangerous infection prone areas in the body- the mouth 2. Saliva in the mouth is home to a wide range of pathogenic micro-organisms such as viruses and bacteria and thus, the risk involved of getting infected through it is very likely 3. Dental procedures involve face-to-face communication, and with the emergence of such communicable diseases such as COVID-19, dentists have to be extra cautious while adopting infection control protocols in their clinics, it has to be more effective and efficient in addition to the existing setting to minimize cross-contamination 4.
The World Health Organization (WHO) announced the 2019 novel coronavirus as pandemic on 11th March, 2020 and declared the official name as Coronavirus disease 2019: COVID-19. The disease is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)(5). Wuhan city- the capital of Hubei province in Central China is the epicentre of the COVID-19 pandemic, from where it spread worldwide 6. The global death toll from the outbreak nears more than 228 thousand & more than 3.21 million people have been affected from more than 190 countries as of 30th April, 2020.
Coronaviruses - Origin & history
The 2019-nCoV is a newly discovered strain of coronavirus, formerly not recognized in human beings. Coronoviruses belong from the virus family which are common in animals. These are RNA viruses that are enveloped and single stranded 7. They can cause mild infections such as the common cold to severe infections such as SARS (Severe Acute Respiratory Syndrome), MERS (Middle East Respiratory Syndrome), and COVID-19 with symptoms ranging from severe respiratory, hepatic, enteric to neurological 8. These viruses are zoonotic in nature (can be transmitted from animals to humans). A possible transmission of the 2019-nCov is believed to be from the seafood and wildlife market in Wuhan, China, following which it spread by human-to-human close contact. Vaccines or antiviral drugs have not yet been discovered to treat human coronavirus infections 9.
Modes of Transmission of 2019-nCov in The Dental Clinic - The Challenge
According to reports published in the New York Times, dentists are among the top healthcare workers who face the greatest coronavirus risk, as shown in Figure 1 10. The nature of work in dentistry involves frequent exposure to saliva, blood, and other body fluids including exposure to sharp equipments 11. As mentioned earlier, the confronting direct face-to-face communication with the patient while performing dental procedure in the clinic carries the greatest risk of exposure to the virus. In the dental clinic, transmission can be direct, contact, indirect or through aerosol as given in Table 1 12.
Figure 1: Dental Professionals among the top workers facing the greatest coronavirus risk (Adapted from The New York Times)10
The most significant transmission route of SARS-CoV-2 in the dental clinic is droplet and production of aerosol. Large quantities of aerosol and droplet mixed with saliva and blood are generated during dental procedures 13. The virus can suspend in the aerosol as long as three hours after the procedure and can persistently remain on surfaces for prolonged periods. Studies have found that on copper surfaces it can remain up to four hours, on cardboard up to one day, on stainless steel and plastic up to two to three days, making the environment more vulnerable to exposure 14. It must be taken into account that an asymptomatic patient with the infection carries equal risk of spreading the virus similar to a symptomatic patient 15.
Clinical Manifestations of COVID-19
Duration from exposure to the start of symptoms is mostly between 2 to 14 days. Generally, the incubation period is between 5 to 6 days 16. The typical symptoms include:
- Fever
- Cough, usually dry
- Dyspnea (laboured breathing)
They may be accompanied by 17
- Fatigue
- Muscle aches
- Runny nose
- Sore throat
- Headaches
- Diarrhoea and
- Vomiting.
In severe cases, complications may arise like -
- Pneumonia
- Acute respiratory distress syndrome
- Viral sepsis
- Renal failure &
- Death.
Significant risk-factors of COVID-19 involve the presence of co-morbidities 18 such as
- Diabetes
- Hypertension
- Cardiovascular diseases and
- Respiratory diseases
A positive travel history with risk of viral exposure is another major risk factor. Males are generally more affected (60%) than females and people aged above 70 years are at highest risk for COVID-19 19. All these risk factors lead to poorer prognosis.
Diagnosis and Management
Standard diagnostic method involves reverse transcription polymerase chain reaction (rRT-PCR) testing from a nasopharyngeal swab. CT (Computed Tomography) scan mostly shows characteristics of bilateral pneumonia. It is important to note that the disease can only be properly diagnosed by accessing the symptoms, risk factors and investigations with detailed history taking 20.
The management is enumerated in Figure 2.
Figure 2: General Management of COVID-19
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