Coronavirus Disease (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine
The first case of COVID-19 was reported in Wuhan, China in December 2019 and since then, has become a global health problem around the world.
On the 8th of January 2020, The Chinese Center for Disease Control and Prevention made an official statement that the novel coronavirus was the causative pathogen of COVID-19. On January 30, 2020, the World Health Organization (WHO) announced that the epidemic had instigated a public health emergency of international concern.
As of February 26, COVID-19 had been diagnosed in 34 different countries, with a total of 80,239 laboratory-confirmed cases and 2,700 fatalities.
In a Dental practice, the risk of transmitting Covid-19 is highly likely between dental practitioners and patients. For areas where there are outbreaks, extremely strict, and effective infection control protocols are urgently needed. This article looks at relevant guidelines and research, introduces the essential knowledge about COVID-19 and nosocomial infection in dental settings, and aims to provide management protocols for dental practitioners and students in (potentially) affected areas.
What Is COVID-19?
According to recent research, similar to SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), SARS-CoV-2 is zoonotic, with Chinese horseshoe bats (Rhinolophus sinicus) being the most probable origin and pangolins as the most likely intermediate host.
Mode of Transmission
Findings from genetic and epidemiologic research, suggests that the COVID-19 outbreak was initiated with a single animal-to-human transmission, followed by sustained human-to-human spread.
It is now believed that its interpersonal transmission occurs mainly via respiratory droplets and contact transmission. In addition, there may be risk of fecal-oral transmission, as researchers have identified SARS-CoV-2 in the stool of patients from China and the United States. However, whether SARS-CoV-2 can be spread through aerosols or vertical transmission (from mothers to their newborns) is yet to be confirmed.
Source of Transmission
Symptomatic COVID-19 patients have been the main source of transmission, however more recent data has revealed that asymptomatic patients and patients in their incubation period are also carriers of SARS-CoV-2.
This epidemiologic feature of the disease has made its control extremely difficult and hard to manage, as it is difficult to identify and quarantine these patients in time, which can result in the quick transmission of SARS-CoV-2 in communities. Also, it is unclear whether patients in the recovering phase are a potential source of transmission.
The incubation period of patients with COVID-19 has been estimated at 5 to 6 days on average, but there is evidence that it could be as long as 14 days, which is now the commonly adopted duration for medical observation and quarantine of (potentially) exposed persons.
Current data suggests the fatality rate (cumulative deaths divided by cumulative cases) of COVID-19 is 0.39% to 4.05%, depending on different regions of China. This is lower than that of SARS (severe acute respiratory syndrome; ≈10%) and MERS (Middle East respiratory syndrome; ≈34% and higher than that of seasonal influenza (0.01% to 0.17%) according to data for 2010 to 2017 from the US.
People at High Risk of Infection
Current trends suggest that people of all ages are generally susceptible to this new infectious disease. However, it has been shown that those who are in close contact with patients with symptomatic and asymptomatic COVID-19, including health care workers and other patients in the hospital, are at higher risk of SARS-CoV-2 infection. In the early stage of the epidemic, in an analysis of 138 hospitalized patients with COVID-19 in Wuhan, 57 (41%) were presumed to have been infected in hospital, including 40 (29%) health care workers and 17 (12%) patients hospitalized for other reasons. As of February 14, 2020, a total of 1,716 health care workers in China were infected with SARS-CoV-2, consisting of 3.8% affected patients nationally, 6 of that group who have died.
Most patients with COVID-19 present with relatively mild symptoms. Recent studies and data from the have found the proportion of severe cases among all patients with COVID-19 in China was around 15% to 25%.
The majority of patients experienced fever and dry cough, while some also had shortness of breath, fatigue, and other atypical symptoms, such as muscle pain, confusion, headache, sore throat, diarrhea, and vomiting. Among patients who underwent chest computed tomography (CT), most showed bilateral pneumonia, with ground-glass opacity and bilateral patchy shadows being the most common patterns.
Among hospitalized patients in Wuhan, around one-fourth to one-third developed serious complications, such as acute respiratory distress syndrome, arrhythmia, and shock, and were therefore transferred to the intensive care unit. Broadly speaking, the elder population and the existence of underlying conditions (e.g., diabetes, hypertension, and cardiovascular disease) were linked with poorer prognosis.
Diagnosis and Treatment
The diagnosis of COVID-19 can be based on a combination of epidemiologic information (e.g., a history of travel to or residence in affected region 14 days prior to symptom onset), clinical symptoms, CT imaging findings, and laboratory tests (e.g., reverse transcriptase-polymerase chain reaction [RT-PCR] tests on respiratory tract specimens) according to standards of either the or the. It should be mentioned that a single negative RT-PCR test result from suspected patients does not exclude infection. Clinically, we should be alert of patients with an epidemiologic history, COVID-19–related symptoms, and/or positive CT imaging results.
So far, there has been no evidence from randomized controlled trials to recommend any specific anti-nCoV treatment, so the management of COVID-19 has been largely supportive. Currently, the approach to COVID-19 is to control the source of infection; use infection prevention and control measures to lower the risk of transmission; and provide early diagnosis, isolation, and supportive care for affected patients. A series of clinical trials are being carried out to investigate interventions that are potentially more effective (e.g., lopinavir, remdesivir).
Infection Control in Dental Settings
Risk of Nosocomial Infection in Dental Settings
Dental patients who cough, sneeze, or receive dental treatment including the use of a high-speed handpiece or ultrasonic instruments make their secretions, saliva, or blood aerosolize to the surroundings. Dental apparatus could be contaminated with various pathogenic microorganisms after use or become exposed to a contaminated clinic environment. Thereafter, infections can occur through the puncture of sharp instruments or direct contact between mucous membranes and contaminated hands.
Due to the unique characteristics 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 asymptomatic carriers, or choose to conceal their infection.
Effective Infection Control Protocols
Frequent hand washing and good hand hygiene is the most critical measure for reducing the risk of transmitting microorganism to patients. SARS-CoV-2 can persist on surfaces for a few hours or up to several days, depending on the type of surface, the temperature, or the humidity of the environment. This reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within the dental clinic. The use of personal protective equipment, including masks, gloves, gowns, and goggles or face shields, is recommended to protect skin and mucosa from (potentially) infected blood or secretion.
As respiratory droplets are the main route of SARS-CoV-2 transmission, particulate respirators (e.g., N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union) are recommended for the routine dental practice.
Recommended Measures during the COVID-19 Outbreak
Recommendations for Management
In January 2020, the National Health Commission of China added COVID-19 to the category of group B infectious diseases, which includes SARS and highly pathogenic avian influenza. However, it also suggested that all health care workers use protection measures similar to those indicated for group A infections—a category reserved for extremely infectious pathogens, such as cholera and plague.
Since then, in most cities of the mainland of China, only dental emergency cases have been treated when the strict implementation of infection prevention and control measures are recommended. Routine dental practices have been suspended until further notification according to the situation of epidemics.
Additionally, dentistry-related quality control centers and professional societies in many provinces and cities have put forward their recommendations for dental services during the COVID-19 outbreak, which, as supplementary measures, should be helpful in ensuring the quality of infection control.
Recommendations for Dental Practice
Interim guidance on infection prevention and control during health care is recommended when COVID-19 infection is suspected. Up to now, there has been no consensus on the provision of dental services during the epidemic of COVID-19. On the basis of our experience and relevant guidelines and research, dentists should take strict personal protection measures and avoid or Aerosol generating procedures. The 4-handed technique is beneficial for controlling the infection. The use of saliva ejectors with low or high volume can reduce the production of droplets and aerosols.
Evaluation of Patients
During the outbreak of COVID-19, dental clinics are recommended to establish precheck triages to measure and record the temperature of every staff and patient as a routine procedure. Precheck staff should ask patients questions about the health status and history of contact or travel. Patients and their accompanying persons are provided with medical masks and temperature measurements once they enter our hospital. Patients with fever should be registered and referred to designated hospitals. If a patient has been to epidemic regions within the last 2 weeks, quarantine for at least 14 days is required. In areas where COVID-19 spreads, non-urgent dental practices should be postponed.
It was reported that dental practice should be postponed at least 1 month for convalescing patients with SARS. It is unknown yet whether the same suggestion should be recommended for patients with COVID-19.
Preoperative antimicrobial mouth rinse could reduce the number of microbes in the oral cavity. Procedures that are likely to induce coughing should be avoided (if possible) or performed cautiously. Aerosol-generating procedures, such as the use of a 3-way syringe, should be minimized as much as possible. Intraoral x-ray examination is the most common radiographic technique in dental imaging; however, it can stimulate saliva secretion and coughing. Therefore, extraoral dental radiographs, such as panoramic radiography and cone-beam CT, are appropriate alternatives during the outbreak of COVID-19.
Treatment of Emergency Cases
Dental emergencies can occur and exacerbate in a short period and therefore need immediate treatment. Rubber dams and high-volume saliva ejectors can help minimize aerosol or spatter in dental procedures. Furthermore, face shields and goggles are essential with use of high- or low-speed drilling with water spray. According to our clinic experience during the outbreak, if a carious tooth is diagnosed with symptomatic irreversible pulpitis, pulp exposure could be made with chemomechanical caries removal under rubber dam isolation and a high-volume saliva ejector after local anesthesia; then, pulp devitalization can be performed to reduce the pain. The filling material can be replaced gently without a devitalizing agent later according to the manufacturer’s recommendation. We also met a patient who had a spontaneous toothache because of a cracked tooth without dental decay, and a high-speed handpiece had to be used to access cavity preparation. Given that the patient wanted to retain the tooth, she was scheduled as the last patient in the day to decrease the risk of nosocomial infection. After treatment, environmental cleaning and disinfection procedures were followed. Alternatively, patients could be treated in an isolated and well-ventilated room or negatively pressured rooms if available for suspected cases with COVID-19.
The treatment planning of tooth fracture, luxation, or avulsion is dependent on the age, the traumatic severity of dental tissue, the development of the apex, and the duration of tooth avulsion. If the tooth needs to be extracted, an absorbable suture is preferred. 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 because the RT-PCR test, besides time-consuming, needs a laboratory with pan-coronavirus or specific SARS-CoV-2 detection capacity.
Impact on Dental Education
Education-related challenges for medical and dental schools, as well as their affiliated hospitals, are significant. It was reported that open communication among students, clinical teachers, and administrative staff would enhance mutual trust and facilitate adequate cooperation.
On the basis of our experience with SARS and relevant highly pathogenic infectious disease, we provide a few basic recommendations for dental education during an outbreak: First, during the outbreak period, online lectures, case studies, and problem-based learning tutorials should be adopted to avoid unnecessary aggregation of people and associated risk of infection. Existing smart devices and applications have already made it possible for students to listen to and review lectures whenever and wherever possible. Second, it is worth advocating to encourage students to engage in self-learning, make full use of online resources, and learn about the latest academic developments. Third, during this period, it is easy for students to be affected by disease-associated fear and pressure, and dental schools should be prepared to provide psychological services to those who need them.
With the increased knowledge of viral features, epidemiologic characteristics, clinical spectrum, and treatment, efficient strategies have been taken to prevent, control, and stop the spread of COVID-19. The infection prevention and control strategies that we have adopted are determined by the fact that we are in the center of COVID-19. Other regions should follow the recommendations from the disease control centers for infection prevention and control according to the local epidemic situation.
What should we do to improve the current infection prevention and control strategies after the epidemic? How should we respond to similar contagious diseases in the future? These are open questions in need of further discussion and research.
We must be constantly aware of infectious threats that may challenge the current infection control regimen, especially in dental practices and schools of dental medicine.