Breathing problems and COVID-19 in patients with developmental disabilities.

In Wuhan, China, several cases of pneumonia with unknown causes were detected and spread quickly in China and the rest of the world in 2019. The patients presented with cough and fever before the onset of pneumonia. The virus was called severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) by the International Committee for Virus Taxonomy. On January 30, 2020, the World Health Organization has announced a public health emergency caused by this SARS‐CoV‐2 —the coronavirus disease 2019 (COVID‐19). The disease is highly infectious and, even asymptomatic, some individuals may have a high concentration of viral particles in the nasopharyngeal secretions. Transmission is remarkably environment dependent within indoor space with aerosol‐generating procedures ; thus, dental professionals and patients may be implicated in the pandemic scenario.

Although the current literature is not clear, special care patients may be within the high‐risk group to severe outcomes from COVID‐19. In individuals with neurological problems, difficulty in swallowing and breathing can lead to the aspiration of saliva, liquids, and solids, thus resulting in respiratory tract infections due to aspiration. The previous history of pneumonia, for example, is one of the most worrying nosological conditions in this population.

Data available are ambiguous regarding whether the history of asthma increases the risk of developing the COVID‐19 or whether it increases morbidity/mortality due to the infection. It is still unknown whether asthma medications, such as high‐dose inhaled corticosteroids or biological asthma therapies, also pose a risk in the control of COVID‐19. In truth, recent studies have shown that dexamethasone —a common and low‐cost corticosteroid—reduced deaths by one‐third in ventilated patients while one‐fifth in those receiving only oxygen. However, among individuals who did not require respiratory support, there was no significant benefit.

A potential issue in children with asthma is that COVID‐19 infection could trigger a virus‐induced asthma exacerbation. The SARS, caused by the human coronaviruses HCoV‐229E and HCoV‐OC43, did not increase asthma exacerbations in children during the 2002 epidemic, nor induced bronchial hyperreactivity or eosinophilic inflammation. However, the nebulization was shown to increase the risk of viral deposition in the lower lung. In the face of uncharted territory and unprecedented times, there is a lot much to be learned about the impact of pediatric asthma in the course of infection with the SARS‐CoV‐2 virus.

Poor access to health care can be detrimental to pediatric health, and children with special needs are potentially at higher risk for severe diseases. Accordingly, developing countries such as Brazil are suffering even more with the SARS‐CoV‐2 outbreak. The epidemy has exponentially advanced overall the country. The official numbers are underestimated, challenging any further politics to prevent virus dissemination, that is, contingency plans and scientific studies. In the dental community, doubts about the outbreak have led to an array of professional concerns in terms of patient care provisions and safety measures. Until June 2020, there is no vaccine available for COVID‐19, although several research groups have formulations in the testing phase. By now, a consensus about the guidelines applicable for special care management in the dental clinical setting remains unclear.

We hypothesize that the prevalence of preexisting breathing problems in the population with developmental disabilities may serve as a predictor of possible complications in cases of infection with the new coronavirus. From our point of view, the implementation of new and stricter biosafety protocols is needed. The dental team, patients, and caregivers need to be constantly aware of the appearance of common COVID‐19 symptoms, begin self‐isolation, and avoid virus dissemination. Moreover, it is also possible to consider implementing preadmission or preprocedure testing for COVID‐19, depending on testing availability and how rapidly the results are delivered. Despite that, there are limitations on this approach, like negative results from patients or professionals during the SARS‐CoV‐2 incubation period, who could become a transmission source later after testing. Moreover, individuals can be exposed or contribute to cross‐contamination even by taking public transportation or while going to the supermarket. Accordingly, the gap between the moment of testing until the results are delivered or the patient is admitted will always be an uncovered risky period.

We believe that minimize elective treatments as far as possible are essential to reduce the exposure risk of special care patients while the pandemic exists. Otherwise, if necessary, elective treatments should be performed preferably in individuals who do not have any preexisting respiratory conditions. A second precaution, when available, would be the IgG and IgM anti‐SARS‐CoV‐2 serology, even though it is still unknown whether these patients are immune and for how long. Finally, the dental team should be prepared for dental emergent/urgent situations, and remote support should always be offered to patients and caregivers whenever requested.