In the Coronavirus outbreak worldwide, we indeed are talking about how this pandemic has affected the economy, education and even the basic medical practice. But what we have completely ignored is how the very important day-to-day life dental treatments will be affected in this situation.
To address this issue, Dr. Neeraj Sahni talks about his opinion on the situation and how exactly is dentistry getting affected by Covid-19.
How is the dental profession at risk with the advent of COVID 1?
Dr. Neeraj Sahni: The coronavirus (COVID-19) has challenged health professions and systems and has evoked different speeds of reaction and types of response around the world. On the other hand, healthcare facilities are necessarily required for any society and are rarely closed under such pandemic conditions. Healthcare professionals are exposed to a higher risk of getting infected due to their close contact with infected patients.
The dental profession is particularly at risk, due to the possibility of aerosols produced by saliva droplets. The covid-19 transmission via contact with droplets and aerosols generated during the dental clinical procedures is expected. These droplets can be inhaled, come into contact with skin or mucous membranes or lodge on the surfaces of the dental office or other materials used during the dental appointment where hands can then be contaminated.
For safe and COVID-free dental practices all over the world, strict and effective infection control protocols are urgently needed.
How dentistry will face its impact in the current pandemic?
Dr. Neeraj Sahni: The COVID-19 virus was recently identified in saliva of infected patients. Saliva can have a pivotal role in the human-to-human transmission. Dentists and other healthcare professionals that perform aerosol-generating procedures may be unknowingly providing direct care for infected but not yet diagnosed COVID-19 patients. Due to the characteristics of dental settings, the risk of cross infections may be high between dental practitioners and patients. Owing to the unique physiognomies of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection. Therefore, dentists have a high risk of getting infected from patients and potentially spreading it to their peers, families, and other patients.
What circumstances lead to the risk?
Neeraj Sahni: Under these circumstances, it may be natural for dentists to develop a fear of being infected by their patients. Despite having high standards of knowledge and practices, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the COVID-19 pandemic impact on humanity. Currently, the effects of COVID-19 around the globe are worsening day by day. Several dental practices have either modified their services according to recommended guidelines to emergency treatment only, or closed down practices for an uncertain period.
Given developing evidence, many are nervous that the virus could be transmitted from asymptomatic patients needing urgent treatment. In these circumstances, continuing to advise that standard personal protective equipment is sufficient does not feel adequate and more clarity and support from the Health Ministry is needed.
To stabilize the future of Dentistry, specific protocols are needed and should be verified.
How ‘COVID-ified FUTURE OF DENTISTRY is the only solution to the present day dentistry crisis?
Dr. Neeraj Sahni: No one can predict the future. But there is a lot of speculation about what the future holds for dentistry when the pandemic is behind us.
In all probabilities, the virus will stay with us. There will be changes in the lifestyle and behavior of the people such as less travel, reduced smoking, increased use of pneumococcal vaccines, higher online sales and food ordering, higher interest in online courses, social distancing, etc.
The pre-defined, existing models of major human activities and practices are on the verge of experiencing a radical change and Dentistry is one of them!
As Dentists would consider re-opening their practices, the following could be the new guidelines and measures that need to be taken to ensure the safety of the doctors, health-care staff and the patients.
What are the Infrastructural modifications to be included for the solution?
- Strict adherence of social distancing by providing large waiting/reception areas with separate/single seats
- Sanitary gel stations at entry/exit points of the clinic
- Installing physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact with potentially infectious patients.
- Creating separate and distant cabins or working operatory for diverse tasks
- Post visual alerts (e.g., signs, posters, guides, videos) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette.
- Provide clear signage to guide new patients about the waiting area, consultation room, etc. to avoid gatherings
- Providing the pick and drop facility for patients with special needs or severe conditions.
- Creating isolation rooms for the suspected or infected Covid-19 patients.
- Using disposable door handle covers and door mats
What are the other factors to be considered for the same?
Dr. Neeraj Sahni: Negative-pressure treatment rooms/airborne infection isolation rooms (AIIRs): Patients with suspected or confirmed COVID-19 infection should not be treated in a routine dental practice setting. Instead, this subset of patients should only be treated in negative-pressure rooms or AIIRs. Therefore, anticipatory knowledge of health care centers with provision for AIIRs would help dentists to provide emergency dental care if the need arises.
- Only one attendant should be allowed with the patient in the clinic
- Extraoral suction systems should be implemented to suck any aerosol in the operatory or waiting area
- Clinic should be well-sanitized at regular intervals every day
- Centralized air conditioning must be avoided giving preference to individual air conditioning units
- Alterations in Working and Management
- Temperature screening upon arrival of patients and staff
- Face masks for 100% of medical/dental staff at all times during work shifts
- Requiring staff exhibiting any symptoms of COVID-19 to stay at home and self-quarantine for 14 days
- Requiring patients to complete questionnaires prior to treatment certifying that they have not travelled to/from specific countries nor have they exhibited flu-like-symptoms
- Detailed medical history of the patient should be noted along with travel and social history
- Lesser appointments to be given and more time to be allotted while working on a patient
- A decent time gap should be maintained between two consecutive patients for sanitization
- Antibody titres should be assessed before any dental treatment in a previously treated COVID-19 dental patient
- Every patient and their attendant need to undergo COVID-19 test before commencing dental treatment
What are the Clinical Measures to be taken in this regard?
Dr. Neeraj Sahni:
- Disposable PPE to be worn by Dentists, dental nurses and patients which includes N95 respiratory, head cap and eye gear
- Our existing examination gloves should be replaced with surgical gloves
- Usage of disposable hand pieces
- Usage of Autoclave and well sterilized instruments
- Usage of preprocedural mouth rinse: previous studies have shown that SARS-CoV and MERS-CoV were highly susceptible to povidone mouth rinse. Therefore, preprocedural mouth rinse with 0.2% povidone-iodine might reduce the load of corona viruses in saliva. Another alternative would be to use 0.5-1% hydrogen peroxide mouth rinse, as it has nonspecific virucidal activity against corona viruses
- Usage of disposable (single-use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross contamination should be encouraged
What are the other precautionary measures to be adopted?
- Dentists should use a rubber dam to minimize splatter generation. Treatment with rubber dam insertion should be a common practice
- Dentists should minimize the use of ultrasonic instruments, high-speed handpieces, and 3-way syringes to reduce the risk of generating contaminated aerosols.
- clinic staff should make sure to disinfect inanimate surfaces using chemicals recently approved for COVID-19 as the virus can remain viable in aerosol and survive up to 3 days on inanimate surfaces at room temperature and maintain a dry environment to curb the spread of COVID-19
- Extraoral imaging such as panoramic radiography or cone-beam computed tomographic imaging should be used to avoid gag or cough reflex that may occur with intraoral imaging. When intraoral imaging is mandated, sensors should be double barriered to prevent perforation and cross contamination
- Laser cutting tools should be encourages as dental hand pieces are prone to create more aerosols
Why tread a digital path?
Dr. Neeraj Sahni:
- Dentistry should go more DIGITAL: E-prescriptions, digital X-rays and post-operative videos should replace the longstanding procedures
- No attendant should be allowed in Dental Operatory
- Strict NO PHONE policy should be implemented in an operatory (answering calls by doctors and patients should be strictly prohibited during treatment)
- Emergency drugs should be a part of the new Dental Infrastructure as majority of dental clinics do not have any emergency medication to handle unforeseen situations
- Keeping oxygen and nitrogen cylinders should be mandatory in all dental offices
- Dental staff can call and remind the patients for the follow-ups and to check on the patients if in case, the patient demonstrates any COVID-19 symptom
- Recycling of clinical waste material should be better regulated by government
- Advanced Technology
- Digital scanners
- Automatic sanitizers
- Advanced air purifiers
- Digital X-rays
- Better Air-conditioning system
- High power extraoral suction machines
- Laser cutting tools
- Rubber dams
How should the Dentists be getting the Staff Training?
Dr. Neeraj Sahni:
- Dentists should be given basic training on CPR (it should be mandatory and dentist must have a certificate from a certified body)
- Dentists should have a training on oxygen saturation or he should know how to administer oxygen in case of pulmonary distress
- Dentists should be quick and competent to handle medical emergencies in dental clinics
- Nearby ambulance or associated hospital’s phone number should be listed in the waiting or reception area of a dental clinic
What will be the Post-operative Measures?
Dr. Neeraj Sahni:
- Regular follow-ups with the patients and their attendants by the staff to check if they developed any signs or symptoms of COVID-19
- Consistently reminding the patients of their medications and treatment regimes
- Testing for coronavirus disease 2019 (COVID-19) in dental professionals should be undertaken with the same high priority as that of medical health-care workers in hospitals. The risk of a dental practitioner being positive for COVID-19 and potentially infecting patients attending emergency dental services should not be underestimated.
Disclaimer: The views, ideas and opinions proposed in this interview are solely belong to Mr. Sahni and do not necessarily reflect those of any other doctor, dental practitioner or Medical Association. The primary purpose of this interview is to demonstrate the practice of Dentistry in the light of COVID-19 and does not meant for imposition.