Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care.

The recent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease has gripped the entire international community and caused widespread public health concerns. Despite global efforts to contain the disease spread, the outbreak is still on a rise because of the community spread pattern of this infection. This is a zoonotic infection, similar to other coronavirus infections, that is believed to have originated in bats and pangolins and later transmitted to humans. Once in the human body, this coronavirus (SARS-CoV-2) is abundantly present in nasopharyngeal and salivary secretions of affected patients, and its spread is predominantly thought to be respiratory droplet/contact in nature. Dental professionals, including endodontists, may encounter patients with suspected or confirmed SARS-CoV-2 infection and will have to act diligently not only to provide care but at the same time prevent nosocomial spread of infection. Thus, the aim of this article is to provide a brief overview of the epidemiology, symptoms, and routes of transmission of this novel infection. In addition, specific recommendations for dental practice are suggested for patient screening, infection control strategies, and patient management protocol.

The outbreak of coronavirus disease 2019 (COVID-19) in the area of Wuhan, China, has evolved rapidly into a public health crisis and has spread exponentially to other parts of the world (Fig. 1 )2. The novel coronavirus belongs to a family of single-stranded RNA viruses known as Coronaviridae . This family of viruses are known to be zoonotic or transmitted from animals to humans. These include severe acute respiratory syndrome coronavirus (SARS-CoV), first identified in 2002, and the Middle East respiratory syndrome coronavirus (MERS-CoV), first identified in 2012. There is strong evidence that this novel coronavirus has similarity to coronavirus species found in bats and potentially pangolins, confirming the zoonotic nature of this new cross-species viral-mediated disease , . As the published genome sequence for this novel coronavirus has a close resemblance with other beta-coronaviruses such as SARS-CoV and MERS-CoV, the Coronavirus Study Group of the International Committee on Taxonomy of Viruses has given it the scientific name SARS-CoV-2, even though it is popularly called the COVID-19 virus , . On January 30, 2020, the World Health Organization (WHO) declared the rampant spread of SARS-CoV-2 and its associated disease (COVID-19) a public health emergency with a currently known overall mortality rate to be as high as 3.4% , . According to the WHO situation report (March 27, 2020) update on COVID-19, there have been more than 500,000 reported cases and 23000 deaths worldwide and this number continues to increase (Fig. 1). Therefore, measures for prevention, identification, and management must be in place for appropriate mitigation of further spread.

Figure 1

A screenshot of an interactive map of the global cases of COVID-19 by the Center for Systems Science and Engineering at Johns Hopkins University. This dashboard is continually updated and can be accessed at https://coronavirus.jhu.edu/map.html. Site accessed April 9, 2020.

Figure 2

A list of online resources for COVID-19.

Dental care providers need to be aware and prepared for tackling any impending infectious disease challenge as might be the case in the current outbreak of SARS-CoV-2 transmission and its associated coronavirus disease, which can be life-threatening to susceptible patients.

Given the widespread transmission of SARS-CoV-2 and reports of its spread to health care providers , , dental professionals are at high risk for nosocomial infection and can become potential carriers of the disease. These risks can be attributed to the unique nature of dental interventions, which include aerosol generation, handling of sharps, and proximity of the provider to the patient’s oropharyngeal region. In addition, if adequate precautions are not taken, the dental office can potentially expose patients to cross contamination. As the understanding of this novel disease is evolving, dental practices should be better prepared to identify a possible COVID-19 infection, and refer patients with suspected, confirmed, or a history of COVID-19 infection to appropriate treatment centers. In this article, we summarize current recommendations for diagnosing and managing patients with COVID-19. Although this information is current up to March 2020, we anticipate that new information will emerge and have provided URLs to several useful websites (Fig. 2).

Symptoms

Patients with COVID-19 usually present with clinical symptoms of fever, dry cough, and myalgia. In addition, less obvious symptoms such as nausea, diarrhea, reduced sense of smell (hyposmia), and abnormal taste sensation (dysguesia) have also been reported. In addition, abnormal chest X-ray and computed tomographic findings such as ground-glass opacities are typically found in the chest. Notably, about 80% of these patients have only mild symptoms that resemble flulike symptoms and seasonal allergies, which might lead to an increased number of undiagnosed cases. These asymptomatic patients can act as “carriers” and also serve as reservoir for re-emergence of infection. Although SARS-CoV-2 is known to be highly transmissible when patients are most symptomatic, it is noteworthy that the incubation period can range from 0 to 24 days, therefore transmission can occur before any symptoms are apparent , . Severe forms of this disease have a predilection for men with a mean age of 56 years with preexisting chronic illnesses such as cardiovascular disease or immunosuppression. The higher-risk patient population manifests symptoms typical of pneumonia or acute respiratory distress syndrome.

Routes of Transmission

SARS-CoV-2 infections typically spread through respiratory droplets or by contact. Therefore, coughing or sneezing by an infected person can render SARS-CoV-2 airborne, potentially infecting individuals in close contact (within a radius of approximately 6 ft). This led to the recent recommendation of social distancing to minimize community spread of the disease. Another important route of transmission is if droplets of SARS-CoV-2 land on inanimate objects located nearby an infected individual and are subsequently touched by other individuals. Thus, disinfection of objects and handwashing are essential for halting the spread of this disease. This recommendation is strengthened considering that people touch their face on an average of 23 times per hour, with 44% of these occurrences involving the mucous membranes of the mouth and/or nose. In addition, studies have shown the presence of SARS-CoV-2 in both saliva and feces of the affected patients , . It is known that SARS-CoV-2 can bind to human angiotensin-converting enzyme 2 receptors, which are highly concentrated in salivary glands; this may be a possible explanation for the presence of SARS-CoV-2 in secretory saliva , . Therefore, there is a potential for transmission of COVID-19 via aerosol, fomites, or the fecal-oral route that may contribute to nosocomial spread in the dental office setting.

Patient Management and Prevention of Nosocomial Infection

Based on the experience gained from the previous outbreak of SARS-CoV and the data available on SARS-CoV-2 and its associated disease (COVID-19), certain specific measures are discussed for dental patient management in this epidemic period of COVID-19 (summarized in Fig. 3).

Figure 3

An overview of patient screening for COVID-19 and dental management.

Telescreening and Triaging

Initial screening via telephone to identify patients with suspected or possible COVID-19 infection can be performed remotely at the time of scheduling appointments (Fig. 3). The 3 most pertinent questions for initial screening should include any exposure to a person with known or suspected COVID-19 presentation, any recent travel history to an area with high incidence of COVID-19 or presence of any symptoms of febrile respiratory illness such as fever or cough. Importantly, to identify high-risk areas, live global tracking of reported cases can be done using the dashboard made accessible by the Center for Systems Science and Engineering at Johns Hopkins University . Figure 1  represents a screenshot of interactive tracking of COVID-19.

A positive response to either of the 3 questions should raise initial concern, and elective dental care should be deferred for at least 2 weeks (Note: As mentioned previously, the incubation period for SARS-CoV-2 can range from 0–24 days). These patients should be encouraged to engage in self-quarantine and contact their primary care physician by telephone or email.

Patient Evaluation and Cohorting

Upon patient arrival in dental practice, patients should complete a detailed medical history form, COVID-19 screening questionnaire and assesment of a true emergency questionnaire (Figs. 4 and Fig. 5). Dental professionals should measure the patient’s body temperature using a non-contact forehead thermometer or with cameras having infrared thermal sensors. Patients who present with fever (>100.4°F = 38°C) and/or respiratory disease symptoms should have elective dental care deferred for at least 2 weeks. As per the Centers for Disease Control and Prevention guidelines, individuals with suspected COVID-19 infection should be seated in a separate, well-ventilated waiting area at least 6 ft from unaffected patients seeking care. Patients should be requested to wear a surgical mask and follow proper respiratory hygiene, such as covering the mouth and nose with a tissue before coughing and sneezing and then discarding the tissue. After informing the patients to self-quarantine themselves, dentists should instruct the patients to contact their physician to rule out the possibility of COVID-19.

Figure 4

COVID-19 screening questionnaire.

Figure 5

Assessment of a true emergency questionnaire.

Pharmacologic Management

In suspected or confirmed cases of COVID-19 infections requiring urgent dental care for conditions such as tooth pain and/or swelling, pharmacologic management in the form of antibiotics and/or analgesics is an alternative. This approach may offer symptomatic relief and will provide dentists sufficient time to either refer the patient to a specialist or deliver dental care with all appropriate measures in place to prevent the spread of infection.

Specific Dental Treatment Recommendations

Patients with active febrile and respiratory illness will most likely not present to dental practices. Based on the assessment of emergency questionnaire (Fig. 5), clinicians can gauge the severity of the dental condition and make an informed decision to either provide or defer dental care. In order to have a clarity on what constitutes an emergency condition, dentists can refer to recent American Dental Association recommendations (Fig. 2). Certain instances such as dentoalveolar trauma and progressive fascial space infection warrant emergency dental intervention. In the unlikely event of providing dental care to suspected or confirmed cases of COVID-19 infection, dentists should be cognizant of the following recommendations:

Dentists should follow standard, contact, and airborne precautions including the appropriate use of personal protective equipment and hand hygiene practices. Figure 6 illustrates Centers for Disease Control and Prevention guidelines for putting on and removing personal protective equipment. Due to the uncertainity of this outbreak, there might be a shortage of personal protective equipment. Therefore, it is advisable to use them judiciously and follow the Centers for Disease Control and Prevention guidelines for N95 respirator use and reuse (Fig. 2).

Figure 6

Centers for Disease Control and Prevention recommendations for putting on and removing personal protective equipment for treating COVID-19 patients. From: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf. Site accessed March 17, 2020.

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 non specific virucidal activity against corona viruses.

Use of disposable (single-use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross contamination is encouraged.

Radiographs: 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.

Dentists should use a rubber dam to minimize splatter generation (of course, this is the standard of care for nonsurgical endodontic treatment). It may be advantageous to place the rubber dam so that it covers the nose.

Dentists should minimize the use of ultrasonic instruments, high-speed handpieces, and 3-way syringes to reduce the risk of generating contaminated aerosols.

In this time of public health crisis, endodontic practices can dilute the sodium hypochlorite irrigant solution to 1% concentration, to extend the supplies without compromising on treatment outcome.

Negative-pressure treatment rooms/airborne infection isolation rooms (AIIRs): it is worth noting that 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 emergent dental care if the need arises.

SARS CoV-2 can remain viable in aerosol and survive up to 3 days on inanimate surfaces at room temperature, with a greater preference for humid conditions. Therefore, clinic staff should make sure to disinfect inanimate surfaces using chemicals recently approved for COVID-19 and maintain a dry environment to curb the spread of SARS-CoV-2.

Discussion

The rampant spread of SARS-CoV-2 worldwide increases the likelihood that dental health care professionals will treat this subset of the patient population. Universal precautions are crucial to minimize the spread of this virus and its associated disease. As presented in this review, further precautions are necessary that includes careful prescreening of patients and additional measures if treatment of patients with confirmed COVID-19 is deemed necessary. The latest update (March 16, 2020) by the American Dental Association recommends dentists nationwide to defer elective dental treatment for the next three weeks and focus on emergency care32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43. As there is a surge in the number of COVID-19 cases, it is quite possible that this deferment might be extended. Therefore, in order to help dentists during this period, we have put together a set of recommendations for management of dental emergencies (Fig. 7 )33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43. It is advisable to assess the emergencies on a case-by-case basis and use clinical judgement to aid in decision making.

Figure 7

Recommendations for dental emergency management during COVID-19 outbreak.

Endodontists are in a unique situation as they may be called upon for the assessment and management of odontogenic pain, swelling, and dental alveolar trauma in suspected or known COVID-19 patients. It is worth noting that case presentations can be dynamic, and there is a good chance that dental practices might treat some of the patients with asymptomatic COVID-19 infections since the incubation period can range from 0 to 24 days and most patients only develop mild symptoms , . Thus, every patient should be considered as potentially infected by this virus, and all dental practices need to review their infection control policies, engineering controls, and supplies. Health care providers must keep themselves up-to-date about this evolving disease and provide adequate training to their staff to promote many levels of screening and preventive measures, allowing dental care to be provided while mitigating the spread of this novel infection.

In conclusion, health care professionals have the duty to protect the public and maintain high standards of care and infection control. This new emerging SARS-CoV-2 threat could become a less pathogenic and more common infection in the worldwide population. Indeed, it is predicted to persist in our population as a less virulent infection with milder symptoms, if it follows the same evolutionary pattern of the other coronavirus infections (ie, SARS-CoV and MERS-CoV). Thus, it is important to make informed clinical decisions and educate the public to prevent panic while promoting the health and well-being of our patients during these challenging times. The prudent practitioner will use this review as a starting point and continue to update themselves with useful online information as this outbreak continues (Fig. 2).