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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 79-85

Practicing prosthetic dentistry in the COVID era


Department of Prosthodontics, Crown and Bridge and Implantology, Manav Rachna Dental College, Faridabad, Haryana, India

Date of Submission24-Sep-2020
Date of Acceptance27-Oct-2020
Date of Web Publication16-Feb-2021

Correspondence Address:
Dr. Navdha Gupta
Department of Prosthodontics, Crown and Bridge and Implantology, Manav Rachna Dental College, Faridabad, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_31_20

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  Abstract 


The article entails an in-depth study on general and self-protection of dentists to be followed in the prosthodontic clinics and laboratories. A research was conducted using keywords such as “Covid-19,” “epidemiology,” “risk factors,” “guidelines for dentists,” “guidelines on infection control in prosthodontic department,” “dental unit water lines,” and “water quality in dental units” in the databases of PubMed/Medline, Google Scholar, and textbooks on public health community dentistry between 1990 and 2020. Articles and texts without reliable source of publication were excluded, and articles focusing on the well-being of dentists along with sterilization norms during this pandemic time were only included. In the field of prosthodontics, the prosthodontists were constrained to curtail their scale of operations as dentists were always at a higher exposure of saliva and bodily fluids. The tasks/procedures exposing the prosthodontists to their patients' bodily fluids had to be curtailed to a larger extent, and they ought to be extra cautious while performing the procedures. The emphasis is not only on sterilization protocols which are to be strictly followed in the clinics but also on a personal level whereby the dentists too have to go an extra mile to safeguard themselves as well as their patients. There is a humongous fear psychosis prevalent in the mindsets of both patients and doctors owing to the fear factor arising out of the airborne infection.

Keywords: COVID-19, prosthetic dentistry, disinfection, sterilization, aerosols


How to cite this article:
Gupta N, Dhawan P, Nautiyal M. Practicing prosthetic dentistry in the COVID era. Int J Oral Health Sci 2020;10:79-85

How to cite this URL:
Gupta N, Dhawan P, Nautiyal M. Practicing prosthetic dentistry in the COVID era. Int J Oral Health Sci [serial online] 2020 [cited 2021 Feb 27];10:79-85. Available from: https://www.ijohsjournal.org/text.asp?2020/10/2/79/309449




  Introduction Top


Pandemic is an epidemic that affects a large proportion of population, occurring over a wide geographic area such as a nation, a continent, or the world.[1] Pandemics have been part and parcel of humankind. Even before the outbreak of coronavirus disease 2019 (COVID-19), we have braved Antonine Plague, Plague of Justinian, Black Death, cholera, flu, HIV/AIDS, Ebola, H1N1 virus, severe acute respiratory syndrome (SARS), etc., The latest in the list is COVID-19. Wuhan in China was the first to outbreak the impact of the deadly coronavirus in their city.[2],[3] Till now, it is believed that the source of the virus is related to bat-origin SARS-like coronavirus which only infects the humans and shows human-to-human transmission.[4],[5],[6],[7] Like the rest, this disease has not only affected the physical health but also the mental and economic security and the well-being of the entire community.

Health ministries had categorized dentists at the highest risk along with ear, nose, and throat specialists because of the direct exposure to saliva droplets and aerosols. Dentists should endorse themselves into self-protection along with the utilization of low-volume saliva ejectors that decrease the splashing of droplets and aerosols. According to the guidelines, patients above 60 years of age are more prone to the exposure of coronavirus. Therefore, it is the responsibility of the prosthodontist to not to entertain elderly patients, without any dental emergency who are negative to coronavirus.[8]


  Study Design and Methods Top


A research was done electronically using databases such as PubMed/Medline, Google Scholar, Web of Science, EBSCO, Scopus, and textbooks on public health community dentistry focusing on COVID-19 and its epidemiology, causes, signs and symptoms, route of transmission, risk factors in dental clinics, dental unit water lines, biofilm, water quality, sterilization protocols, disinfection norms, and importance of self-protection of the prosthodontist in the department of prosthodontics. The aim of this investigation was to find the best possible ways to understand the current scenario and to protect oneself from all the myths.


  Discussion Top


The motive behind this review article was to understand the impact of COVID-19 on the field of dentistry and prosthodontics. During these times, there has been a multifold increase in the number of measures of safety being adopted by dentists for themselves and for their patients.

Epidemiology

The first approved reported case was witnessed in December 2019 in Wuhan, China. Studies have revealed that it was due to their resident market named Huanan Seafood market where almost 41 people were found positive.[3],[5] By the end of December, this virus had spread as a wildfire among the residents of China and hence, it was announced as an epidemic by the Health-Care Ministry.[3] Gradually, this virus was also seen in parts of countries such as Thailand, Italy, the USA, Spain, Germany, Iran, France, the Republic of Korea, and Switzerland.[3],[4] According to WHO report, India got its first case on January 30, 2020, in Thrissur district, Kerala, in a disciple who had returned from China. In no time, many people were affected in different places of India such as New Delhi, Ladakh, Jammu and Kashmir, Punjab, and Tamil Nadu. Hence, on March 11, 2020, the WHO announced this epidemic to be a pandemic.[3],[4],[5],[9]

Cause

Coronaviruses are a large family of enveloped, RNA viruses. There are four groups of coronaviruses: alpha and beta originated from bats and rodents, and gamma and delta originated from avian species.[3],[5],[10],[11] Coronaviruses are responsible for a wide range of diseases in many animals, including livestock and pets. In humans, they were thought to cause mild, self-limiting respiratory infections until 2002, when a beta-coronavirus crossed species barriers from bats to mammalian host, before jumping to humans, causing the SARS epidemic.[3],[9],[10] The novel coronavirus is responsible for the COVID-19 pandemic. COVID-19 is also a beta-coronavirus. The genome of the virus is fully sequenced and appears to be most similar to a strain in bats, suggesting that it also originated from bats. The virus is also very similar to the SARS-coronavirus and therefore named SARS-coronavirus-2. At the moment, it is not clear if the virus transmitted directly from bats to humans, or if there is a mammalian intermediate host.[3],[5],[9],[10],[11]

Signs and symptoms

The Ministry of Health and Family Welfare reported fever, cough, fatigue, shortness of breath, expectoration, myalgia, rhinorrhea, sore throat, diarrhea, loss of smell, loss of taste, persistent pain or pressure in the chest, new confusion, inability to awake or stay awake, and bluish lips or face to be the most critical respiratory symptoms. In the case of elderly people and immunocompromised patients, the symptoms are fatigue, reduced alertness, reduced mobility, diarrhea, loss of appetite, delirium, and absence of fever.[3],[12]

Route of transmission

Forty thousand droplets can be produced through sneezing ranging between 0.5 and 12 μm in diameter and can spread up to 100 m/s. Coughing and talking can produce almost 3000 droplets, and the latency stage of the airborne virus spans between 2 and 14 days.[13],[14],[15] Hence, it is proven that saliva is a pool of microorganisms such as Streptococcus pyogenes, Haemophilus influenza, Staphylococcus spp., Pseudomonas spp., and Acinetobacter spp. that can also spread the infection.[16],[17],[18] If physical distancing is not maintained, the droplets can easily spread through talking, coughing, and sneezing.

Considering the environment in dental clinics, it can be said that the probability of cross-contamination increases two folds between dentists and patients. Hospitals and dental clinics that are in red and orange zones due to the effect of the ongoing COVID-19 pandemic, as categorized by the Health Ministry, should follow stern and virtual regulations even in emergencies.[19]


  Risk Factors in Dental Clinics Top


It has been reported that some patients within 14 days of acquiring the COVID-19 infection were asymptomatic, but after 24 days, these individuals could spread the virus. On viral culture test, it has been found that microbes which reside in the saliva of the infected person can eventually infect dental practitioners when they perform treatment.[3],[20],[21]

Dentists and patients are quite likely to be prone to infective agents, comprising of virus and bacteria, which affect rima oris as well as olfactory organs because of the close contact and manifestation of saliva, blood, and other biofluids during the dental process and communication with patients along with maneuvering sharp instruments.[20],[21]

Infective agents can spread in the dental environment directly from the ingestion of aerial bacterium, which endures suspension in the environment for a prolonged haul; immediate engagement with blood, saliva, and patients' stuff; and exposure of conjunctional, rhinal, or mucous membrane with droplets and aerosols containing microbes produced by the affected person.[20],[21]

The outbreak of COVID-19 is an alarm that all health-care providers must be cautious in safeguarding against a contagious disease, and it may permit determination of whether intrusive saliva in indicative of coronavirus that might aid in determining symptoms and can reduce the outspread of these kinds of arboviruses. Some strains of the virus have been recognized in saliva even after 29 days of contamination.[20],[21]


  Asymptomatic PatientS do They RinG a Bell? Top


Communicable Disease Network Australia recommendations state that verified coronavirus patients can be from confined areas and can pursue dental emergency while adhering to the safety norms. As per the criteria stated by the CDNA for the confirmed cases who were asymptomatic and have recovered, ten days should have crossed since the first respiratory sample confirmed for SARS-CoV-2 by polymerase chain reaction assay was collected and no manifestations have occurred during this time.[21],[22] The treatment can be extended if the minimum of ten days have crossed since the beginning of symptoms; and there has been a resolution of all symptoms of acute infection for seventy-two hours; and the patient has had two successive respiratory samples negative for SARS-CoV by PCR collected not less than twenty-four hours aside at the minimum seven days from symptom on set.[21]

[TAG:2]General Precautions for Frontline Workers[3],[15],[20],[22],[23],[24],[25],[26],[27],[28],[29],[30][/TAG:2]

  • • Thermal scanners should be used whenever the patient or the dentist enters the institution or the clinic
  • • Online registrations and telecommunications should be done for all patients to record the detailed clinical, travel, and contact history
  • • Patients should practice hand hygiene before entering the hospital and clinics. Therefore, sanitizers should be put outside elevators, outpatient departments, screening areas, and wards
  • • Social distancing should be maintained at all times among patients, staff, and students. Even the waiting area should be adequately prepared for proper queue maintenance to ensure social distancing
  • • All personnel and patients entering the premises should strictly wear masks. Mask should be carefully worn to cover the mouth and nose. Once the mask is worn, it should not be touched. Due to the tight seal in N95 mask, there are less chances of virus entering the respiratory tract and also there is a reduction in bacterial colonization in the clinics. Face shield provides protection to an extent of 96% and goggles prevents the irritation of eyes at the time of exposure to the aerosol production.
  • • All personnel should wear personal protective equipment as per the procedure
  • • Aerosol-generating treatment should be replaced by nonaerosol-generating alternatives for the same procedure as far as possible
  • • The use of airotors and ultrasonic scalers should be avoided altogether. In addition, the use of a three-way syringe should be limited as it generates aerosols
  • • High evacuation suctions should be used for aerosol-generating procedures
  • • No patients should be referred for intraoral periapical X-rays and only extraoral dental radiographs should be preferred till the outbreak of COVID-19 subsides
  • • Prerinsing using povidone-iodine, chlorhexidine, cetylpyridinium chloride, and essential oils should be done by the patient before undergoing any procedure including examination as it reduces approximately 68.4% of the bacterial load in the oral cavity
  • • Patients should be scrubbed with isopropyl alcohol extraorally before undergoing any dental procedure followed by preoperative germicidal mouth wash to decrease the number of microorganisms in the mouth
  • • Attend 4–5 patients only per day and try completing the maximum amount of work to reduce patient visits. In addition, patients must be educated as much as possible
  • • In between the interval of two patients, 62%–71% ethanol, 0.5% hydrogen peroxide, and 0.1% sodium hypochlorite should be used to clean the surface around the working area
  • • Strict fumigation or sanitization of operatory should be done postsplatter treatment. Preferably, fumigation with a quaternary ammonium compound should be performed every day
  • • Medical staff should use an alcohol-based hand sanitizer for a minimum of 20 s or by washing with detergent and water for about a minimum of 40 s
  • • When a confirmed case has visited, the area should be sealed before carrying out cleaning and disinfection of the contaminated environmental surfaces. This is done so as to prevent the unsuspected person from being exposed to those surfaces
  • • Mop floor with routinely available disinfectant
  • • Ultraviolet rays can also be used to disinfect the air
  • • Wipe all frequently touched areas and toilet surfaces with chemical disinfectants and allow to air dry. One percent sodium hypochlorite solution can be used. Alcohol can be used for surfaces, where the use of bleach is not suitable
  • • It is advisable to remove all the potential source of fomites such as blinds, upholstery, or any other clutter near the operatory
  • • Buckets should be disinfected by soaking in disinfectant or bleach solution or rinsed thoroughly in hot water before filling
  • • Cleaning methods that might aerosolize infectious material, such as the use of compressed air, must not be used
  • • Two layers of biohazardous bags should be used; they should be properly labeled and tied before disposing off, upon completion of the disinfection work.



  Precautions for Prosthodontists Top


In true sense, prosthodontic treatment does not fall in emergency treatments.[6],[9] However, according to Australian Dental Association guidelines, dental trauma due to denture fracture, repair of broken dentures, need for temporary or immediate dentures, final crown or bridge repair or rehabilitation of interim crowns, the problem with implants or implant prosthesis, and ulceration due to sharp edges of tooth or prosthesis require urgent treatment so that the patient can carry his/her daily chores without any difficulty.[12],[15],[22]

Managing COVID-19 patients in a dire need of treatment is of utmost importance for dentists. However, for the clinician, it is very important to know the status of the patient; whether the patient is under the mild, moderate, or severe category.[31]

Level 1 restrictions

Only urgent treatment should be carried out if the patient shows clinical symptoms.

Level 2 restrictions

Patients who are COVID positive should be only treated if they have ulcerations due to sharp edges of tooth or prosthesis, any temporomandibular dysfunction management, and denture problems. No elective implants should be done.

Level 3 restrictions

No patient should be entertained in the dental clinic till the time he/she is agitated with his/her final crown or bridge repair or cementation is lost or broken.


  Teleconsultation Top


Teleconsultation can be described as “synchronous or asynchronous consultation using information and communication technology to omit geographical and functional distance.” It can be utilized for diagnostic and treatment purposes between two or more dentists and patients.[32],[33],[34]

With this technology, the clinician can easily comfort the psychology of the patient and guide him/her through his/her hapless circumstances with his/her prosthesis. Furthermore, he/she can decide that whether it is an emergency or not.[33]


  Guidelines on Infection Control in Prosthodontics Department and Laboratory Top


The guidelines mentioned in [Table 1] can be followed in prosthetic clinics and laboratories.[22],[24],[25],[26],[35],[36],[37],[38],[39],[40],[41]
Table 1: Guidelines on Infection control in Prosthodontics Department and Laboratory

Click here to view



  Dental Unit Water Lines, Biofilm, and Water QualitY Top


Along with dental instruments, dental chair is the most important item in our practice which is nearly overlooked in our sterilization protocols.[39],[42] Dental chair consists of water lines that supply water, air, suction, and electric power to our handpieces, air/water syringe, and ultrasonic scalers.[39],[42],[43] According to research, dental unit waterline promotes the growth of bacterium and evolution of biofilm within 5 days of installing new dental unit waterlines. Bacillus, Acinetobacter, Staphylococcus, and Pseudomonas species can easily be found in the dental unit water lines.[44],[45] Some studies revealed that Legionella causes pneumonia, high fever, chills, cough, muscle aches, headaches, and diarrhea.[36],[43]

A negative force is caused whenever a handpiece is suddenly brought to a halt while working on the patient, which further leads to the formation of bacterial biofilm growth within the untreated water lines, in the bottled supply of water, and from the patient's mouth.[43] If the microbial count reaches < 200,000 colony-forming unit/mL, it can even cause septic shock and hinder wound healing. To reduce the microbial load, the Centers for Disease Control and Prevention in 2020 and the University of Minnesota School of Dentistry's Infection Control recommended that dental waterlines should be

  1. Flushed every morning before the appointments and at the end of the day.[42],[43] Therefore, after seeing every patient, water and air should be discharged for at least 20–30 s
  2. Reservoir bottles used in this process should be cleaned and sterilized frequently before filling the bottle[43],[44]
  3. Dental water quality can be scanned by observing its physical changes that alter its nasty taste or stink and haziness present in the water[43]
  4. Filtered water should always be used in the sterilized bottles because it eliminates microorganisms due to the in-built ultraviolet light in the filter or the electrolyzed water.[43],[45]


With the increased marketing strategies, there is a diversity in disinfectants available in the market such as alkaline or hydrogen peroxide, hydrogen peroxide/silver ions, peracetic acid formulations, tetrasodium ethylenediaminetetraacetic acid, chlorhexidine formulations, iodine, quaternary ammoniums and chlorine dioxide, hydrogen peroxide, Listerine® mouthwash, povidone-iodine, and electrochemically activated water.[43],[46]


  Factors Leading to COVID-19 Among Prosthodontists Top


With the ongoing studies, it has been found that coronavirus can infect not only through exposures from close contacts between health-care workers and patients but also due to other major reasons that lead to deadly conditions from which we should be totally unaware or do not give an eye. Some of the reasons are:[47],[48]

  • • Decreased supply of protective personal equipment
  • • No training programs being conducted for housekeeping staff
  • • No social distancing followed by the fellow colleagues
  • • The associations that take place outside the hospital or clinic premises between the dentists and lab technicians
  • • Circumstances where dentists surrender their case or the patient models to other staff members or technicians
  • • While consuming lunch together in their free time which can also lead to the easy spread of the infection
  • • As dentists or lab technicians are working in enclosed areas where social distancing cannot be maintained.


Hence, it is essential that all the norms that have been implemented by the government should be followed not only by patients but also by other professionals.[47],[48]


  Conclusion Top


The progressive spread of the COVID-19 pandemic is associated with an increased possibility that dental clinicians will be exposed to COVID-19-infected patients during their treatment. Therefore, it has become all the way more important for dental professionals to incorporate all precautions in their routine practice and additional safety measures in the treatment of patients with COVID-19. Each patient must be regarded as probably affected by this virus, and all dentists need to analyze their infection control policies.[23] As they say, “Prevention is the best cure.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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   General Precauti...
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  Teleconsultation
   Guidelines on In...
   Dental Unit Wate...
   Factors Leading ...
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