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Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 313-318  

Findings in COVID-19 cases and protocols to be followed in dental operatories

1 Department of Dentistry (Periodontics), Maharaja Suhel Dev Autonomous State Medical College and Mahrishi Balark Hospital, Bahraich, Uttar Pradesh, India
2 Department of Pathology, Maharaja Suhel Dev Autonomous State Medical College and Mahrishi Balark Hospital, Bahraich, Uttar Pradesh, India
3 Department of Dentistry (Oral Surgery), Government Medical College, Saharanpur, Uttar Pradesh, India
4 Department of Periodontics, Career Dental College, Lucknow, Uttar Pradesh, India

Date of Submission08-Jun-2020
Date of Decision01-Dec-2020
Date of Acceptance21-Sep-2021
Date of Web Publication26-Feb-2022

Correspondence Address:
Anshul Sawhney
Department of Dentistry (Periodontics), Maharaja Suhel Dev Autonomous State Medical College and Mahrishi Balark Hospital, Bahraich - 271 801, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_323_20

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Coronavirus-causing pandemic flu known as COVID-19 originated in Wuhan, China, in December 2019 and since then has spread worldwide. It is a single-stranded RNA virus of betacoronavirus family ranging from 60 to 140 nm in diameter. Its genome is similar to that of SARS and MERS. Patients present with fever, cough, malaise, headache, etc., Various tests such as nucleic acid testing, reverse transcription-polymerase chain reaction, and antibody testing are available. Laboratory tests show leukocytosis with lymphopenia and occasionally thrombocytopenia. Few biomarkers such as ferritin, C-reactive protein, procalcitonin, lactate dehydrogenase, and interleukin-6 are under study to predict the outcome of patients. Mainly, the virus is seen affecting the lungs with hyaline membrane formation, resulting in acute respiratory distress syndrome. Cases affecting kidney and gastrointestinal system are also seen. Self-quarantine and social distancing are effective measures to prevent the spread of this disease. The spread of coronavirus has posed significant challenges for dentistry and medicine. Most of the dental procedures are aerosol producing called as bioaerosols which consist of particles from saliva, blood, dental plaque, calculus, gingival fluid, oronasal secretions and microparticles from tooth preparation. This review gives an insight on the ways to reduce aerosols, standard measures and protocols to be followed to maintain the hygiene levels in the operatory, and the ways to reduce the viral load in this COVID era to prevent the spread of SARS-CoV-2 via human-to-human transmissions.

Keywords: Acute respiratory distress syndrome, biomarkers, coronavirus, lymphophenia, pandemic

How to cite this article:
Sawhney A, Ralli M, Dhar S, Saimbi CS. Findings in COVID-19 cases and protocols to be followed in dental operatories. Med J DY Patil Vidyapeeth 2022;15:313-8

How to cite this URL:
Sawhney A, Ralli M, Dhar S, Saimbi CS. Findings in COVID-19 cases and protocols to be followed in dental operatories. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:313-8. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/313/338623

  Introduction Top

COVID-19, i.e., coronavirus disease 2019, is a pandemic disease which first appeared in the Wuhan city of China, and it was named SARS-CoV-2.[1],[2] In India, the index case was reported on January 30, 2020, in Thrissur, Kerala, and till April 27, 2020, the Ministry of Health and Family Welfare has confirmed a total of 28,380 cases in the country.[3] Coronavirus belongs to betacoronavirus genus.[4] It has a single-stranded RNA genome (26–32 kb).[5] Coronavirus virions are spherical and own their name corona due to the crown-like spikes on their surface. Coronavirus has four different genera, namely, α, β, σ, and ϒ.[6]

The present SARS-CoV-2 is the seventh coronavirus to infect humans, while SARS-CoV-1, MERS-CoV, OC43, HKU1, 229E, and NL63 have produced symptoms although mild and were previous types. Novel β-CoV has shown to resemble the sequence of two bat-derived SARS and MERS-CoV.[7] Another evidence is the high degree of homology of receptor angiotensin-converting enzyme 2 from various species of animals.[8]

  Pathogenesis Top

It has a spike-like protein which binds to cellular receptor[9] responsible for the membrane fusion and viral infectivity.[10] Clinical manifestations of COVID-19 include leukocytosis, lymphopenia, abnormal respiratory findings, and increased levels of plasma pro-inflammatory cytokines.[11] Apart from blood counts, patients show high C-reactive protein (CRP), high erythrocyte sedimentation rate, high ferritin, procalcitonin, and D-dimer values. All these parameters indicate poor outcome in patients.[12]

  Clinical Presentation Top

The clinical signs and symptoms of patients infected include cough, fever, fatigue, dyspnea, viral pneumonia, blood-tinged sputum, dry cough, loss of taste or smell, hemoptysis, diarrhea, conjunctivitis, exertion, breathing difficulty, and lymphophenia.[13],[14]

  Incubation, Latency, and Contagious Period Top

The incubation period ranges from 1 to 14 days, with an average of 3–7 days.[12] The percentage of mortality is more from 6 to 41 days of the onset of symptoms.

  Clinical Manifestations of Covid-19 Top

Patients can be a symptomatic or can present with symptoms. Atypical symptoms include sore throat, severe headache, confusion, and muscle pain. Most patients experience a dry cough, fatigue, and fever. Shortness of breath and gastrointestinal symptoms (diarrhea and vomiting), as well may occur. Patients with severe complications have multiorgan dysfunction, septic shock, and systematic failure. Individuals of all ages are susceptible to being infected with COVID-19.

Certain patients are at more risk of developing COVID disease and include:

  1. Patients more than 65 years of age
  2. Individuals with comorbidities such as chronic lung disease, heart diseases, diabetes, renal failure, liver disease, and immunocompromised patients
  3. Those with close contact with individuals diagnosed with COVID-19
  4. Infants.

Chest computed tomography (CT) scan shows features of pneumonia along with ground-glass opacities. The causes of death in most cases have been acute respiratory distress syndrome (ARDS) and acute cardiac injury. Targeting of lower airways is evident.

  Diagnosis of COVID-19 Top

Clinical diagnosis of COVID-19 can be done by:

  1. Nucleic acid detection by using polymerase chain reaction
  2. Immunological detection kits which target viral antigens or antibodies. Commercial ELISA kits are available
  3. CT scans.

Reverse transcription-polymerase chain reaction (RT-PCR) is the gold standard test for the diagnosis of COVID-19. Various open and closed RT-PCR platforms (open-system RT-PCR machines, TrueNat™, and CBNAAT) are currently being used for diagnosis in India.

According to the Indian Council of Medical Research guidelines on the use of rapid antigen detection test, one nasopharyngeal swab needs to be collected using a customized sample collection swab provided with the kit. After collection of the sample, the swab is gently immersed in a viral extraction buffer, provided in the kit which causes inactivation of the virus. However, it is stable only for 1 h, so antigen testing should be conducted at the site of sample collected. Once the sample is transferred to the buffer and is mixed with it, the buffer tube cap is replaced with a nozzle present in the kit, and 2–3 drops of sample with buffer is added into the well of the test strip. After 15 min, the test can be interpreted as positive or negative, by the appearance of test and control lines in the well, which can be evaluated with naked eye. The kit should be stored at a temperature between 2°C and 30°C. Each kit comes with an in-built COVID antigen test device, a viral extraction tube with viral lysis buffer, and a sterile swab for collection of sample.

  Treatment Top

Due to droplet transmission from one person to another, self quarantine and social distancing are important steps to prevent disease spread. Research is ongoing on the use of remdesivir and chloroquine in the treatment of coronavirus.[15] Use of antibody and plasma therapy is made after obtaining plasma from recovered patients.[16]

  Protocols to be Followed in Dental Operatories Top

The dental professional and his/her team are at increased risk while working because of close contact with the patient and the risk of saliva, blood, and droplet exposure.[17] To et al. recognized saliva as a reservoir of SARS-CoV-2 in patients already infected.[18] Hence, dentists come under very high exposure-risk jobs. This necessitates screening of every patient meticulously, considering every patient to be an asymptomatic COVID-19 carrier. It is important to classify patients according to the urgency of dental treatment required and its risks and benefits. Usage of personal protective equipment (PPEs) for every procedure and airborne precaution should be made mandotory. Most dental procedures performed by a dentist and his/her team have the potential of contaminated aerosol generation and splatter. These are tiny droplets which remain suspended in the air and can cause infection due to their contamination with microorganisms such as bacteria, viruses, fungi, and blood. They are about 50 μ or less in diameter. Instruments such as ultrasonic scalers, high-speed dental turbines, micromotor hand pieces, air polishers, and air water syringes produce aerosols. Minimal use of aerosol-generating procedures (AGPs) should be done. The protocols followed can be grouped into various steps or stages, as follows:

  1. Step I: Telephonic prescreening protocol: Initial screening via telephone. Most important details to be asked include any chief complaint of the patient and since how long is he/she having the same and presence of any symptoms of fever, cough, and difficulty in breathing. The details to be asked include any exposure to a person with known or suspected COVID-19 presentation, any travel history to an area with high incidence of COVID-19, and the place where he/she is residing. Telephonically appoint patients and triage them according to their level of dental care, i.e., emergency, urgent, and elective care. Scheduling of patient appointment is essential, and one should avoid interaction of medically compromised or elderly patients with general patients
  2. Step II: Waiting area protocol: Schedule minimum appointments during the day after tele-triaging. Put a sign at the entrance which instructs patients having any symptoms of cough, sore throat, fever, and shortness of breath for >48 h to please reschedule their appointments and meet their physician. Record patient temperature using a digital noncontact thermometer. Patients who present with fever (>100.4°F) and/or respiratory disease symptoms should have elective dental care deferred for at least 2 weeks.[19] Use of foot cover and face mask is mandatory. Provide alcohol-based hand rub and ask the patient to fill a COVID-19 screening questionnaire and patient response form [Questionnaire 1]. Seating arrangement with a minimum of 3 feet physical distancing should be done. Primary care should focus on three As: advice, analgesia, and antimicrobials, where needed. Patients should be instructed on hand and cough hygiene before they enter the operatory. Remove tables, magazines, and newspapers to reduce cross-infections. Patient bags and other stuffs are encouraged to be left in the operating area. Dentists are encouraged to organize patient flux to not have >1 patient in the waiting area. Those who are accompanying the patients should be requested to wait outside the dental office. Various signages indicating proper hand hygiene technique, donning and doffing of PPEs, use of shoe covers before entering clinical area, and treatment categorization should be put up for patient's knowledge.
  3. Step III: Dental operatory protocol: Before patient enters, it is the duty of the staff to disinfect inanimate surfaces using chemicals approved, i.e., 0.1% sodium hypochlorite and 70% isopropyl alcohol 0.1% NaOCl for disinfection of dental water lines. Cover parts of dental chair with one-time use plastic sheets, for example, light handles, chair arms, light switches, chair backs, and head rests. Improve air circulation, at least a 5-min air change is advised. Disposable protection should be placed on working surfaces, dental chairs, and devices. Use of high-volume suction is required in AGPs. Rooms should be equipped with high-efficiency particulate air (HEPA) 13 or 14 filters and if surfaces are dirty, they should be cleaned using detergent or soap water prior to disinfection. All chairs should be 3–6 feet apart. Patients are instructed to do a preoperative 1-min mouth rinse at the sink area with already-prepared 1% povidone or 0.2% chlorhexidine mouth wash, which helps in reducing aerosol count,[20] 0.05%–0.1% cetylpyridinium chloride or use of 1% hydrogen peroxide can also be done depending on the availability before starting any procedure, especially AGP. Disposable and single-use instruments and devices should be used. Rubber dams and extraoral X-rays should be used to reduce the risk of saliva stimulation.[21] Dentists and his/her assistant (one) should follow the appropriate usage of PPE and hand hygiene practices[22] as they are at risk of inhaling droplets which have the chances of carrying microorganisms. Treatment should focus on reducing droplets, aerosols, and contact, if these procedures are required. Air sterilization can be done with the help of ultraviolet radiation, which damages or ruptures the DNA of bacteria and viruses. Use of high-volume extraoral suctions and preprocedural mouth rinses such as 0.2% chlorhexidine (1:1) dilution with water for 30 s should be made mandatory before initiating AGP.[20] The dental unit water lines should be flushed regularly with 0.5% sodium hypochlorite and hydrogen peroxide. Both donning and doffing should be done in separate isolated rooms. For AGPs, use of isolated rooms with HEPA filters should be done. Dentists should make use of four-handed dentistry, and his/her team should refrain from touching their face. Before starting the procedure, extraoral scrubbing of patient's face with an antiseptic wipe is must.

    Sequence for donning PPE:

    A. Wear a head cap

    B. Hand hygiene

    C. Put-on gown

    D. Put-on face mask

    E. Put-on goggles

    F. Put-on gloves
  4. Step IV: Patient discharge: Patients are requested to wash their hands for 60 s with soap water and again put their face mask as they go to the reception area. Card method for payment should be followed.
  5. Step V: Chairside disinfection and cleaning of operatory: Remove all the barriers, plastic sheets. All water outlets, handpiece pipelines, and 3-in-1 syringes should be flushed with water and disinfectant solution for at least 1 min. Back flush the suction pipe with 1% sodium hypochlorite. Disinfect 3 feet area around the chair with 0.5%–1% sodium hypochlorite or 70% alcohol for sensitive surfaces. Mop heads and clothes used for cleaning should be decontaminated regularly with hot water detergent and 1:1000 dilution of sodium hypochlorite and then should be dried at least till 80°C and changed weekly. The dental assistant should remove his/her gloves and wear heavy-duty nitrile rubber gloves. All instruments should be collected in a tray and rinsed under running water for removing organic matter. Discard needles and any disposable sharp instruments. All instruments should be immersed in 1% sodium hypochlorite and detergent solution for 24 h and then transferred to a ultrasonic cleaner. Instruments should be packed in pouches along with handpieces, contra angles, etc., and autoclaved at 15 psi pressure, 121°C temperature for 30 min.
  6. Step VI: Surface disinfection: All hard surfaces should be disinfected by sodium hypochlorite (1000 ppm or 0.1% for surfaces and 10,000 ppm for 1% blood spills), 0.5% hydrogen peroxide, and 62%–71% ethanol. 10% diluted bleaching powder can also be prepared by mixing 5 tsp of bleach per gallon of water, which consists of 3%–6% sodium hypochlorite, and small amounts of sodium hydroxide, hydrogen peroxide, and calcium hypochlorite. The prepared bleach should be allowed to dry after mopping. All windows and door knobs should be mopped before leaving the operatory area. Check all electrical connections and remove those necessary. Drain the compressor cylinder until gauge is 0. At the end of day, fumigation needs to be done. For every 1000 cu.ft, 500 ml of formaldehyde add 1000 ml of water in the fumigation machine and place at one corner of the room. After 45 min, switch off the machine without entering the room and seal that entrance door.

  7. Doffing by the dentist and the assistant should be done in separate isolated room. Dental waste resulting from suspected or confirmed COVID patients must be strictly disposed off in accordance with the official instructions using double-layered yellow medical waste package bags and gooseneck ligations.

    Prepare a checklist at the end of the day:

  8. Once the dentist and staff reach their homes, it is their duty to leave all their stuff's inside a box at the entrance of the house. Sanitize your phones and keys. Shower and wash your hands with soap water for at least 60 s.

  Conclusion Top

Social distancing and self quarantine are two effective measures in the prevention of spread of COVID-19. Proper handwashing with soap and water for 30 s is essential. Spraying of sodium hypochlorite solution is recommended for disinfecting surfaces. Effective SARS-CoV-2 vaccines are essential for reducing the disease severity and stoppage of disease transmission, hence leading to ultimate control. Research and studies related to vaccine generation are under progress. Guidelines have been published for health-care providers, medical staff, and public health individuals. Apart from complete blood count, levels of few biomarkers such as CRP, procalcitonin, ferritin, and lactate dehydrogenase (LDH) are also being studied to predict patient outcome. Studies by Guan et al. and Zhou et al. emphasized on increased CRP, procalcitonin, LDH, ferritin, and interleukin-6 associated with poor outcome.[23],[24] Many studies have linked high CRP and high LDH levels with higher risk of ARDS and myocardial injury development.[25],[26]

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Conflicts of interest

There are no conflicts of interest.


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