Role of Dentist: COVID19 and Mucormycosis.

Dental practice has evolved over time and has adapted to the challenges that it has faced. The risk of infection spread via droplet and airborne routes poses a significant risk to the dentist who works close to patients. The risk of cross-infection between dental health-care personnel and patients can be very high due to the peculiar arrangements of dental settings. Dental clinics should have air purification systems with high volume excavators and negative pressure rooms for COVID-19 screening. Mucormycosis is a fungal disease that mostly occurs in immunocompromised individuals and those with uncontrolled diabetes. Dental extraction can trigger the occurrence. Increased occurrence of mucormycosis is seen in COVID-affected patients. This article gives a review on the dentistry-related transmission of COVID 19, the relation of COVID and mucormycosis. Copyright:

INTRODUCTION

The identification of the contagious severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) leads the World Health Organization to assert a public health emergency of international concern on January 30, 2020.[1] This open on to a global pandemic by March 11, 2020.COVID 19 had nearly touched every country in the world by mid-March 2021, with 122 and 2.7 million confirmed cases and death respective.[2] The main route of COVID-19 is through saliva droplets with a distance <1 m in between individuals.[3] Certain opportunistic bacterial and fungal infections are seen along with SAR CoV-2. Confirmed cases of mucormycosis are also reported.[4] Due to this pandemic countries have taken some restrictive measures to minimize close contact between individuals to prevent the spread of disease. Thus it became a challenge for dental health-care personnel (DHCP) and dental education institutes.[5]

TRANSMISSION

The transmission of COVID 19 is human to human via droplets while coughing, talking, or sneezing which is later inhaled by healthy individuals.[6] Direct contact with blood, saliva, splatter, droplets, or aerosols, as well as indirect contact with contaminated surfaces,[7] can cause it. Bioaerosols are airborne particles of liquid or volatile compounds that contain or are produced by living organisms. Some studies investigated the level of bacterial aerosol contamination produced during dental treatment procedures such as cavity preparation with an air rotor, history and oral examination, ultrasonic scaling, and tooth extraction under local anesthesia.[8] COVID-19 can be detected on materials commonly used in dental procedures, such as plastic and stainless steel, up to 72 h after surface contamination.[9] These findings call for a rethinking of our current infection control protocols in dental settings to limit the spread of aerosols. This is considered as indirect contact.[10] Another type of transmission is the stool-based transmission, here diarrhea is confirmed in the case of some COVID-19 patients thus the chance of becoming this as the major route of transmission is high if sanitization and personal hygiene is not properly maintained.[11] Weather conditions also have a role on the transmission which is sensitive to some possible confounding factors, where social and economic conditions including government intervention are the leading ones among them.[12] Industrial areas with the highest levels of pollutants are facing mainly high mortality rates from SARS-CoV-2 transmission.[13] In COVID-19 patients the oxygen will be low, increased glucose and iron levels are seen. This is the main cause of facilitating Mucorales spores to develop in such patients leading to mucormycosis.[14]

DENTISTRY AND SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS-2

DHCP needs to add their skill, knowledge, and technology with respect to control infection and follow the protocols recommended by the newer authorities to protect the patients and themselves against infection. Telephone triage is an attempt to make all patients in need of dental care, in this current pandemic condition teledentistry can be a great advance. Teledentistry is defined as a process of networking, sharing digital information, distant consultation, workup and analysis is felt by a segment of the science of telemedicine concerned with dentistry. To determine COVID-19 infection the dentist should evaluate the signs and symptoms of the patients. Administer eligible dentists to test oropharyngeal and nasopharyngeal swabs, dentist are placed because of the detailed understanding of the head and neck anatomy. Globally, the COVID-19 outbreak created a stressful environment. Such a situation will lead to poor oral health, to overcome these situations developing online platforms to provide information on oral hygiene and oral maintenance. To promote good oral health the dentist can also engage in voluntary service for the resident community.[15] Dentist can also adopt both pharmacological and nonpharmacological interventions to deal with the new interventions with the new pandemic. Dentists can detect the first line of diagnosis of the disease because they work in close contact with patients. Dental association and regulatory board have published several guidelines for dental practices, they have recommended suspension of nonemergency dental treatment and providing only emergency dental services.[16] Medical counterparts like patient triage, monitoring vital signs, administering oxygen and writing prescriptions, this can be assisted by a dentist. The Indian Dental Association recommends posting visual alerts like providing instructions about hand hygiene, respiratory hygiene keep tissue or handkerchief while sneezing.[17]

MUCORMYCOSIS-ORAL MANIFESTATIONS

Mucormycosis is an opportunistic fungal infection that is usually suspected in immunocompromised patients with unusual symptoms such as facial pain, sinus pain, or odontalgia. Patients may seek dental treatment first. Dental treatment may also precede such an infection by means of postcurettage wound or postextraction.[18] Intraoral in Patients' necrosis of the palate with black eschar can be seen.[19] Mucormycosis is classified into five according to the anatomic site of occurrence that is (1) rhino cerebral, (2) pulmonary, (3) coetaneous, (4) gastrointestinal, and (5) disseminated.[20] Dentists should be aware of rhino cerebral mucormycosis, especially in patients with diabetes and other immunocompromised conditions. Atypical symptoms such as facial pain, sinus pain or unexpected odontalgia, or otherwise healthy teeth should alert clinicians. If symptoms are considered a rare condition, mucormycosis is promptly urged to seek medical advice. The intraoral examination should be performed to all patients as a typical lesion thus be revealed and estimated, as slight change of the mucosal colors of dehiscence of the palate might be noticed.[21] Similarly, all dental practitioners note the medical history of the patients and modify their therapeutic and diagnostic actions accordingly. In diabetic patients, a raised glycatedhemoglobin level is indicative of poor blood glucose control. If the dentist requests a serum glucose or glycated haemoglobin test, he or she may have underestimated the poorly controlled diabetic condition and should avoid extraction of the maxillary third molar. A more thorough dental examination may have revealed the need for further investigation of the patients' facial pain.[22] Peculiar erythematous hyperplasia seen on the gingiva and it is termed strawberry gingivitis. Oral antral fistula is caused due to the destruction of underlying palatal and alveolar bone. Due to the extension of infection bone necrosis can also occur.[23]

COVID-19 AND MUCORMYCOSIS

Mucormycosis is a rare and severe fungal infection that is caused by a group of mold known asmucormycetes that mostly affect the sinus and brain.[24] The study of the epidemiology of mucormycosis is difficult to determine due to its rarity.[25] The pathway of transmission of infection is through the inhalation of the spore. In some cases, these spores can get inoculated in the skin through injured areas, insect bite etc. The most commonly occurring variant is rhino cerebral type. Dental extraction areas also serve as intra oral portal of entry of fungus.[26] COVID-19 infected people have an increased chance of being infected by opportunistic bacteria and fungus. The reduced partial pressure of oxygen in COVID-19 affected patients is what promotes the growth of Mucorales. Immunocompromised states in COVID-19 also increase the risk of being infected by the fungus.[27] Through various studies, it was stated that COVID-infected patients have secondary bacterial and fungal infections during hospital admission.[28] Special pathophysiological characteristics of COVID-19 that increase the chance of being secondarily infected by fungal infection include extensive pulmonary diseases and alveolar intestinal pathology that enhance the rate of invasive fungal infections.[29] Ulceration that occurs in the palate is a common clinical sign that helps in the diagnosis of mucormycosis.[30] Dentist and maxillofacial surgeons must be increasingly made aware of the early diagnosis of mucormycosis where the patient complains of dental pain and palatal ulceration.[31] Mucormycosis mainly affect the intracranial system thus increasing the fatality rate.[32] Some of the triggering factors of black fungus in COVID 19 patients are (a) these patients often exhibit endothelial damage, thrombosis, leukopenia, and reduction in CD4+ and CD8+ level and this predisposes to opportunistic fungal infection.(b) Decreased pH in patients with diabetic ketoacidosis also provides an acidic medium which is a fertile medium for spores to germinate. (c) Free availability of iron resources.[33] Postmortem studies on COVID 19 affected individuals conducted by Hanley et al. found a case of disseminated mucormycosis affecting lymph node, brain, and kidney.[34] Some authors suggested that the increase permeability of cell walls to pathogens and to the viral replication in the oral mucosa lining provoked by the infection of oral tissues is the cause of the high prevalence of oral necrotic lesions in COVID-19 individuals.[35]

PREVENTION AND INFECTION CONTROL

The success of an effective control program depends upon proper dental office design. Dental offices should have air purification systems with high-volume excavators and negative pressure rooms for COVID-19 screening.[36] Digitized healthcare maintenance can be conducted by a qualified team of dentist and mass COVID-19 testing can be done in patient contact areas to prevent further spread.[37] Teledentistry has altered the face of dentistry and it has gained a stronger foothold in these COVID-19 times[38]. It has the ability to improve, access, deliver and lower the cost of oral health care in rural and urban communities.[39] Dentist work in close proximity with patients and guidelines have been given by several programmers which include American Diabetes Association guidelines[6]: Avoid aerosol-generating procedures, Separate donning and doffing area for personal protective equipment (PPE), and COVID-19 patients should be given emergency care for dental procedures with detailed history taken[40] Several preventive measures are initiated by the United States Department of labor to reduce the possibility of spread in dental health-care facilities which include Staff reduction Protocol, proper training of staff and good hand hygiene practices, infrared thermal screening of patients and isolated consultation rooms if necessary.[40] Preprocedural mouth rinses with 0.5%–1% hydrogen peroxide is used which has nonspecific virucidal activity. Disinfection of workplaces with sodium hypochlorite solution and use of sterilized surgical instruments avoid the risk of cross-infection. Dental chairs and others should be covered with plastic and it should be disinfected with 70% alcohol before and after treatment.[41] Extraoral dental radiographs are preferred which does not stimulate saliva secretion and coughing. Dental schools should improve their education on infection control measures and volunteering acts should be initiated which support medical health care.[42] Disinfection of workplaces with sodium hypochlorite and the use of sterile surgical instruments are necessary. COVID-19 situation has created stress in many people so they have poor oral hygiene as a result dentists can conduct online platforms to provide information on oral health maintenance.[43] Administrative controls are recommended for early diagnosis and isolation of COVID 19 patients, which mainly highlight visitor controls. Fluid repellent surgical masks and physical separation is efficient in reducing transmission of the respiratory virus in hospital settings.[44] All healthcare workers, patients, and their attendants are instructed and encouraged to practice standard precautions. Respiratory hygiene and cough etiquette are necessary to reduce the chance of cross-infection of respiratory disease mainly COVID-19.[45] Specific measures are undertaken for COVID-19 patients and suspected cases which include information about infective risks, patient protection, visitor screening and restricting the number of visitors. Large number of waste are generated from utilization of PPE and other hospital products which should be disposed as per accordance for infectious clinical waste.[46] Mobile equipment and devices should be encouraged like portable electrocardiogram, X-ray machines, etc., which should be cleaned and decontaminated before leaving the lobby as per policies.[47]

CONCLUSION

After assessing the current scenario of the pandemic we can understand that dentists play a major role in preventing COVID-19. Preventive protocols and disinfection procedures should be properly carried out. It is critical to prevent the spread of COVID-19, which has no approved treatment. Teleconsultation and online consultation have to be encouraged. Dentists should balance the act of prescribed guidelines and the provision of emergency services to the patient. Dental professionals are at high risk of contracting COVID-19 and hence protective measures should be properly taken care of to overcome this great pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.