Dental setup in the covid-ified era – A review

Introduction: The infectious agent of this viral pneumonia happening in Wuhan was finally identified as a novel coronavirus (2019-nCOV), the 7th member of the family of coronaviruses that infect humans widely known as Covid-19. The common transmission routes of novel coronavirus include direct transmission like cough, sneeze, and droplet inhalation transmission and contact transmission contact with oral, nasal, and eye mucous membranes. Live viruses (COVID-19) were isolated from the saliva. Hence, healthcare workers particularly the dental professionals are at more risk. Objective: An overview of how-to setup the dental office so as to minimize the risk of transmission while simultaneously carrying out the necessary treatment procedures. Conclusion: A proper management and setup of the dental office and treatment planning along with strict categorisation of patients is necessary for a successful and safe practice during Covid times. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
"The measure of intelligence is the ability to change"this famous quote by Albert Einstein is the rule for the present era. With the emergence of the COVID-19, dentists face a herculean task of upgrading their dental office by means of incorporating a wide range of measures to enhance the hygiene of the dental office, thereby creating a better clean and safe environment for dental practice. Coronaviruses belong to the family of Coronaviridae, of the order Nidovirales, comprising large, single, plus-stranded RNA as their genome. Coronaviruses have traditionally been associated with mild upper respiratory tract infections throughout the world. In the fall of 2002, a new coronavirus emerged in in Asia causing severe viral pneumonia, i.e., severe acute respiratory syndrome (SARS). 1 Middle East respiratory syndrome (MERS) is a new human disease first reported from Saudi Arabia in September, 2012, after identification of a novel coronavirus (CoV) from a male Saudi Arabian patient who died from severe respiratory illness. The virus was designated MERS-CoV. 2 Last year, in late December a pneumonia outbreak emerged in the city of Wuhan, China which spread very rapidly through the city following which WHO declared a public emergency worldwide on January 30, 2020. The typical clinical symptoms of the patients who suffered from the novel viral pneumonia were fever, cough, and myalgia or fatigue with abnormal chest CT, and the less common symptoms were sputum production, headache, hemoptysis, and diarrhea. 3 The infectious agent of this viral pneumonia happening in Wuhan was finally identified as a novel coronavirus (2019-nCOV), the 7 th member of the family of coronaviruses that infect humans. 4

Mode of Transmission
The common transmission routes of novel coronavirus include direct transmission like cough, sneeze, and droplet inhalation transmission and contact transmission contact with oral, nasal, and eye mucous membranes. 6 In addition, studies have shown that respiratory viruses can be transmitted from person to person through direct or indirect contact, or through coarse or small droplets, and 2019-nCoV can also be transmitted directly or indirectly through saliva.
Notably, a report of one case of 2019-nCoV infection in Germany indicates that transmission of the virus may also occur through contact with asymptomatic patients. 7 It has been reported by King et al. that after ultrasonic scaling, bacteria could be recovered 6 inches from the mouth of the patient and that the number of colony forming units was significantly reduced when an aerosol reduction device was used during scaling. 8 Live viruses (COVID-19) were isolated from the saliva. 9 Hence, healthcare workers particularly the dental professionals are at more risk. Considering that numerous kinds of dental equipments that are used in the clinical practice in the form of handpieces, air-water syringes and ultrasonic scalers considerable amounts of aerosols are produced. Hence, the potential for the spread of infections from patients to dentists or dental assistants is high. 10 Consequently, the air in dental clinics is likely to be contaminated with several microorganisms to which workers are potentially exposed. Because of the high concentration of bacteria in the oral cavity (nearly of 1.0 E+07-1.0 E+08 colony forming units (CFU)/mL of saliva) and due to concerns of cross contamination between dentists and patients, oral bacteria have been identified as components of dental bioaerosols. 11

Setup of Dental Office
Patient awareness, education and co-operation play a major role in effective implementation of any control measures in a dental clinic. Hence in the wake of the Covid-19 pandemic, the role of the front office and the reception staff assumes a very significant place and forms the first line of defence. This is also the stage where the patient screening is done.

Note on appoinment and scheduling of patients
Patient should be instructed to take an appointment over the phone, if possible, through video calling, which helps in tele-screening. Patients shall be advised to install the "Aarogya Setu" app in their phones to track their contact history with Covid positive individuals. People who have a travel history or relevant respiratory symptoms should be urged to stay at home and do tele-consultation till the stipulated period or symptoms subside. Similarly, tele-consultations should be done for elderly people and vulnerable group. There should be a policy for walk-in patients in case of an emergency, based on the needs and capabilities of the clinic. There should be a minimum of 15 minutes scheduled between appointments to allow proper disinfection measures. Patients should be requested to wait in their vehicles or any appropriate area for observing social distancing norms in case they arrive early.

Immunisation to the personnel
Ideally every clinical staff should be adequately immunised. The vaccines recommended are BCG, DT, HBV. 3  The waiting area should be mopped and disinfected, every two hours, using 1% NaOCl solution. 6. Audio/visual alerts can also be used in addition to educate and motivate the patients.  (Figure 3) 1. 3-ply masks and a pair of gloves should be worn by dental practitioners always inside the clinic. 3 Tests to check the quality of 3 ply-masks before purchasing -this is necessary because of the duplicate products that are released over this period of time. (Figure 4) 1. Cut open the mask and you should see a very obvious 3-layers. 2. Translucent piece (top), White piece (middle), and the coloured piece (Green, Blue, or even White).

Water test
1. The outer layer is designed to be waterproof. 2. Fold the mask such that the outer side forms a funnel and pour some water into it. The mask should be holding up the water properly.

Fire test
1. The middle layer is a filter, not a piece of paper. Therefore, if you were to light it with a flame, it WILL NOT catch fire.

Sequence of wearing PPE -Centre of Disease
Control Guidelines (Figure 5) 3.6.   Waste containing radioactive substances; e.g., unused liquids from radiotherapy or laboratory research, contaminated glassware, packages or absorbent paper, urine and excreta from patients treated or tested with unsealed radionuclides, sealed sources

Conclusion
The working area of a dentist, the dental office, is different from other health proffessionals in that there is a closer doctor patient interaction and the chances of infection spread is high. In these dark times, especially with every patient being a potential carrier for the novel coronavirus, proper precautions if not taken can result in cross contamination. So a proper maintanance of hygiene, a strict protocol along with great caution is the way to go forward in this proffession.

Source of Funding
None.

Conflict of Interest
None.