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Preventive Ways Taken by Dental Workers through COVID-19 Pandemic (A Review Article)

Noor A. Sulaiman*, Huda A. Salim, Saif Saad Ali Al-Jewari

Department of Oral and Maxillofacial Surgery, College of Dentistry, Mosul University, Iraq

Abstract: Covid-19 transmitted by saliva droplets, is considered A serious problem that leads to fatal outcomes including death. Dentistry plays a crucial role in transmission of this infection as it is related to saliva and it's droplets. There are several preventive measures adopted by dental professionals over this pandemic to combat the spread of deadly infection. This review article focused on and illustrated all these measures depending on information gathered from various published articles.

Keywords: COVID-19, dental field and COVID-19, preventive ways to COVID-19

Received August 28, 2021; Revised October 02, 2021; Accepted October 09, 2021

Citation: Noor A. Sulaiman, Huda A. Salim, Saif Saad Ali Al-Jewari, Preventive Ways Taken by Dental Workers through COVID-19 Pandemic (A Review Article). International Journal of Dental Sciences and Research, 9 (2). 27-33. January 2021. doi:10.12691/ijdsr-9-2-2

1. Introduction

COVID-19 is the newest respiratory transmittable infection that has spread quickly across the world [1]. It is an extraordinary condition that has affected the inhabitants generally and produced a contingency situation in health systems globally considering the dental health service system [2].

It was secluded for the first time in Wuhan city, China from patient with pneumonia [3]. A screening way was followed to detect the health of patients, and swabs samples were sent to laboratories for recognizing the cause [4]. “Chinese Center for Disease Control (China CDC) notified about the responsible pathogen and the affected marketplace of seafood was directly locked [5]. The World Health Organization(WHO) pronounced the fast distribution of “Coronavirus Disease 2019 (COVID-19)” as a global communal health contingency of significance with an average mortality rate of 3.4% [6,7]. Till October 3, 2020 “35.7 million” confirmed COVID-19 cases and 1.35 million deaths have been reported around the world [8].

Whereas COVID-19 is considered fatal for overall populations, healthcare workers and hospitalized patients are at a higher risk because they are handling persons symptomatically and/or asymptomatically infected with COVID-19 [9]. The dental profession is going through a histrionic alteration by the outburst of (SARS-CoV-2) and will remain the same in near future [10]. In dentistry, COVID-19 is basically transmitted by air, droplets, and touch [11,12]. Because of the closeness between patients and dental workers during the treatment sequence so they are not only infected but also act as spreaders during person to person transmission either by non-invasive oral cavity fluid as a patient's cough or sneeze, or using a high-speed handpiece or ultrasonic devices, which liberate aerosols (maybe with saliva, blood, bacteria, and viruses) to the air. So, using appropriate protective measures is crucial [13,14]. Dental instruments pose a high risk of virus spread if they are not cleaned and sterilized appropriately, as most of them are manufactured from polymeric materials and metal, and the virus could stick to and stay on these materials for numerous days [15,16]. As a result, any instrument or materials used in a patients mouth must be considered highly critical [17,18,19].

Many literature have been performed to detect aerosols and droplets and distinguish them depending on their ability to transfer the COVID-19 virus. Identifying the dental activities that produce aerosols may include the virus is fundamental for specifying the risk grade of these procedures, this aids in determining which Personal Protective Equipment (PPE) is necessary [17,18,19]. In this review we summarized the preventive measures needed to be followed by dental workers during work to decreased infection and/ or transmission of this infection.

2. Material and Method

The words “COVID-19”, “COVID-19 and dental field”, “preventive methods of dental workers in COVID-19”, were used to find articles about Preventive ways taken by dental workers through COVID-19 pandemic, using PubMed, PubMed Central, Cochrane Review, Embase and Google scholar. The articles with English language that related to COVID-19 and dental workers with preventive ways against it were incorporated in this review, articles other than that were excluded. Initially, the title of the article was read, if it fits with the general idea of the review, the abstract was read, if required information was found then the whole article was read then either included in or excluded from the review according to the inclusion and exclusion criteria mentioned previously. Also, particular bibliographies of specifically selected articles were searched on goggle.

3. Virus Morphology, Entry and Replication in Host Cells

Depending on genomic sorting and phylogenetic relationship, coronaviruses have been categorized into the subfamily Coronavirinae that involves four genera Alphacoronavirus (αCoV), Betacoronavirus (βCoV) derived from bats and rodents, Gammacoronavirus (γCoV), and Deltacoronavirus (δCoV) originated from avian class [20].

SARS-CoV-2 was insulated from nasopharyngeal and oropharyngeal swabs 3 days after infection, were injected in the Vero cells, prefixed with 2% paraformaldehyde, and 2.5 percent glutaraldehyde, and then inspected by transmission electron microscopy. SARS-CoV-2 showed a unique shape, which spherical to pleomorphic enveloped particles, about70 to 90 nm in size present in a series of intracellular organelles, most remarkably vesicles [21]. The envelope is embossed with prominence glycoproteins and frames a core involving matrix protein that contains a single strand of positive-sense RNA (Mr 6 × 106) associated with nucleoprotein [22]. The virus has important proteins are nucleocapsid protein (N), membrane (M), spike glycoprotein (S), and envelope small membrane protein (E) and supplementary glycoprotein that has acetyl esterase and hemagglutination (HE) properties [23]. The envelope glycoproteins allow attachment of the virus to the host cell and hold the fundamental antigenic epitopes, specifically the epitopes predicted by neutralizing antibodies [22].

Virus spike glycoprotein tie to both priming of the S protein and cellular receptor through host cell proteases then adopts by the ACE2 receptor and primes S proteins via the TMPRSS2 serine proteases [24]. Then it undergoes structural modifications, leading to the connection of the viral envelope protein and host cell membrane after endosomal entry [25,26]. This is associated with the release of viral RNA into the host cytoplasm, where it is interpreted and produced the replicase polyproteins pp1a and pp1b, which are further divided into small proteins by virus-encoded proteinases. Coronavirus duplication needs ribosomal frame shifting during the translation process and produces both genomic and multiple copies of sub genomic RNA species through intermittent transcription of viral proteins. The binding of viral RNA and protein in the endoplasmic reticulum (ER) and Golgi complex produce Virions that are released from the cells by vesicles [24]. SARS-CoV-2 like SARS-CoV can be spread extra pulmonary because of extensive ACE2 receptor expression in tissues, but experiments have exposed that the spikes protein of SARS-CoV-2 has a 10-20-fold higher attraction than the spikes protein of SARS-CoV. [27].

4. Transmission, Clinical Features and General Precautions

It is still unclear which animal play a role in development of SARS-CoV2 virus and transport it to human although bats considered as the source of it [28]. Infection occur either directly by contacting with infected person, breathing of short-range respiratory droplets of these patients or even asymptomatically infected persons while coughing and sneezing [29,30,31,32], or indirectly by touching polluted surfaces with airborne and fomite, then touch their mouth, nose, or eyes [29,30,33,34,35]. After that, Virus transferred to the upper respiratory tract parts, mainly oral, nasal, or ocular mucosal surfaces [36]. The virus can stay alive on inorganic surfaces that are touched frequently daily for long period of time reaches nine days if not disinfected [37,38].

COVID-19 virus needs two to fourteen days to progress [39]. Clinical features extending from symptomless; acute respiratory distress syndrome to septic shock and multi-organ failure so is categorized depending on its severity to mild, moderate, severe and critical [40]. Most common symptoms in order of incidence seen to be fever, cough, fatigue, excretion from the throat or lungs, dyspnea, and dizziness, headache, diarrhea, nausea and vomiting were less common [41].

To prevent the transmission of infection, People should be guided to use towels to suck respiratory fluids and get rid of them in the next disposal bin. They must also be learned about the importance of hand hygiene after touching respiratory fluids or infected products and substances, persons suffering from signs and/or symptoms of a respiratory disease irrespective of the cause, must be advised to cover their nose and mouth during sneezing or coughing [42]. Constructions and places that have been contaminated with SARS-CoV-2 should be carefully cleaned before re-use, by disinfectant materials recognized as useful against CoVs. General preemptive cleaning with water and home cleansing agent, and traditional antiseptic items, in spite of the deficiency of evidence for their efficiency toward SARS-CoV-2 should be used. There are various active elements available in non-healthcare and non-laboratory areas, such as sodium hypochlorite (family home bleach) and ethanol [43].

5. Preventive Ways of Dental Workers

Preventive measures that should be employed in the dental field at the COVID-19 pandemic can be separated into four steps: (a) patient triage pre-admission, (b) patient evaluation post admission, (c) throughout dental care, and (d) Post-treatment disinfection.

(a) Patient Triage pre-admission

Patient triage is one of the strategies and rules that may be followed previous to the patient's admission at the dental clinic, in order to detect the possibly infected persons of COVID-19 and evaluating the necessity of fast and emergency dental treatment. Different geographical areas (like China, Italy, and the United States) with clinical services employed phone triage with a screening questionnaire to judge the potential threat of COVID-19 spread and the kind of dental management needed [44,45,46]. Patients with COVID-19 symptoms, or contacting with infected people, or been to areas with a high cluster of COVID-19 cases in the last 14 days, and require critical dental treatment should be deferred for a few weeks, and given pain or infection control medications until successive negative swab tests 24 hours apart are gained [47,48,49]. Few reports recommended using a similar questionnaire again, and measuring the patient's temperature with a non-contact temperature sensor when the patient is in the dental clinic [45,46,47,48,50].

(b) patient evaluation post admittance

After admission to the dental office, protective procedures comprise screening of patients, wearing protective masks of all entering persons. Most recent advice from health - care officials insist on the importance of wearing a mask, gloves, and protective goggles for patients in the waiting room, keeping a 1 m personal space, washing their hands with an alcohol-based sanitizer and the use of personal protective equipment (PPE) by dental workers [47,48,49,51,52,53]. All hygienic equipment should be available which includes (towels and no-contact bins for discarding the used towel, adequately presented alcohol-based hand disinfectant and cleansing products containers, and sterile towels for washing hands) for patient respiratory hygiene-cough etiquette [42]. Dental practitioners must take into account reducing the number of patients in a waiting room with rising the period of visit for every patient to accomplish as much as can of treatment in a single visit in order to decrease the recurrent exposure to the virus [47,54,55]. Only the patient should enter the operating theatre without any companion [49,51]. Posting awareness posters at the door and strategic sites (waiting rooms, cafeterias, and elevators), on the way of COVID-19 transmission, with hand hygiene, cough etiquette, and respiratory hygiene. These comprise the way of covering the nose and mouth during coughing or sneezing, how to get rid of tissues and infected materials in discarded containers, and when and how to implement hand hygiene [56]. patient with a temperature of more than 100.4 F or 38 C and require extremely urgent treatment should be done in an airborne infection isolated room (AIIR) or negative-pressure room [44,45,46,48]. These are single-patient separation rooms that change air six times per hour [46,57]. The air from these areas is expelled outsides, away from locations of crowds or human traffics. It is circulated via a high-efficiency particulate air (HEPA) filter, which is kept in place by a negative-pressure control system [46,57,58].

(c) Controlling Infections Throughout Dental Treatment

Before entering the operating room , patient´s medical history should be taken, if he had any signs or symptoms of flu-like disease, had contact with any COVID-19 patient or travel to areas with high incidence of COVID-19 in last 14 days ago, body temperature of both patient and medical staff must be detected (56). Staffs with respiratory infections should keep their distance and remain at home [71]. Soap or alcohol (70-90%) should be used by dental workers for hand cleaning before the examination of the patient, preceding to oral operations, when the gloves are torn during the operation, after taking off the gloves and when contact with the patient or with non-disinfected surroundings or tools [30,59].

During dental management the following procedures help to increase protection against the infection which includes:

1. Pre-operative antimicrobial mouthwash: before beginning the dental operation, the patient is advised to rinse with mouth wash formed from an oxidizing agent including 1% hydrogen peroxide or 0.2 percent povidone–iodine for 60 seconds which suggested to reduce the infection rate in aerosol particles [30,59]. Several researches have showed that chlorhexidine may not be effectual against SARS-Cov-2 due to virus susceptibility to oxidation and a lack of information and clinical records about this subject [45,49].

2. Using Rubber Dam And High-Volume Saliva Ejectors: Rubber dam prevents all sources of aerosol pollution from blood or saliva by covering the throat and tissue region, and keeping only the tooth/teeth receiving management, also, may offer a 70% reduction in aerosol particles [60,61]. A high-volume evacuator (HVE) or high-efficiency particulate arrestor (HEPA) filter when placed within 6-15 mm of the aerosol-producing tip, can clean about 90 percent and 99.99 percent of polluted air [46].

3. Eliminating Aerosol-Generating Operations: dental caries can be treated by a little invasive chemomechanical intelligence agent called CariSolv, in order to decrease the transmission rate of infection, and scaler can be used for periodontal treatments in which a rubber dam cannot be performed [45,54]. An anti-retraction valve is used as an external defensive way to reduce the distribution of tiny droplets or aerosol spray despite there is few clues on its efficiency in minimizing transmission danger [62].

4. Extra-Oral X-ray: Alharbi et al. proposed extraoral x-rays such as orthopantomograms and cone-beam computer tomography(CBCT) rather than intraoral X-Ray to prevent gag reflex and hypersalivation [44].

5. Personal protective equipment (PPE): are intended to insulate health-care staffs from transmittable microorganisms or agents. Face shields, face masks, gloves, protective eyewear, reusable or disposable gown, head coverings and protective footwear are examples of personal protective equipment (PPE) [63]. In dental operations, disposable surgical gowns or autoclavable full-sleeve surgical gowns are favored, and should be changed if they have been used between patients, pierced or highly contaminated with body fluid. The following sequence should be used before wearing PPE: gown-mask-respirator-face shields - goggles-gloves. While taking off PPE should be done in the following steps: gloves, goggles/face protector, gown, and mask/respirator [48]. Various opinion presented about which filtered face-piece (FFP) used for aerosol particles - and non-aerosol-producing dental operations. Some studies found FFP1/standard surgical mask used for non-aerosol-producing operations and an FFP2/N95 or greater for aerosol-producing operations [45,46]. Others anticipated FFP2/N95 for any and all operations for physicians, dental surgery dental assistants, and the front counter personnel [48,64]. A systematic analysis of clinical studies equating the effectiveness of N95 respiratory protection to a regular surgical mask presented no superior defense against influenza [61]. Several studies shows that little infectious molecules of equal to 3 μm in diameter will stay airborne in an isolated chamber permanently [65]. Patients and dentists may be exposed to collected little airborne infectious particles by respiratory tract while walking into a room where aerosol-producing operations were done when using limited airborne safety and using a regular surgical mask [45,64,65,66]. So, as SARS-Cov-2 is highly infectious relative to influenza, it recommended the wearing of FFP2/N95, for all dental operations with both medical and non - medical operations [32,66]. Dentists must remember not touching their lips, eyes, or nose during work [45,67], and wash hands with soap and water for at least 20 seconds. When hands are not clearly dirty (by saliva or blood) or do not have access to running water, use ABHRs [68,69]. Following a two-before-and-three-after procedure was advocated by the CDC and WHO, considered as a major role in preventing transmission of infection [50,70].

(d) Post-treatment disinfection

1. Disinfection of operating rooms and waiting room, involving the doorhandles, seats, grounds, tables, toilets, and stairwells between patients, with an Environmental Protection Agency (EPA)-registered hospital disinfectant (Isopropyl alcohol, 0.5 percent –1 percent sodium hypochlorite). Reusable dental instruments or devices must be meticulously washed, disinfected, or sterilized with an oxidizing antiseptic and preserved according to the rules established by the local health specialist before being used on any patient [30,48,71]. Surface protections must be employed to protect difficult-to-clean areas (e.g., switches of dental chairs) and must be changed between patients [71].

2. Post dental treatment: using water, soap, and mechanical motion (brushing or scrubbing) remove dirt, debris, and organic material such as blood or body fluids, even though it does not kill microorganisms [72,73]. Starting with the least soiled surfaces and provoke to the most soiled, so that debris/dirt falls to the floor and is cleaned last. After each usage, cloths must be discarded, and regular cleaning should be initiated with new cloths [72]. After washing, disinfection with chemical agents must be used to remove any remaining microbes and could minimize SARS COV 2 virus contamination on surfaces which include: ethanol 70%-90%; Products containing chlorine (e.g., hypochlorite): at a concentration of 0.1 percent (1000 parts per million) for general environmental disinfection or 0.5 percent (5000 parts per million) for major spills of blood and bodily fluids; Hydrogen peroxide concentration greater than 0.5 percent [12].

After a patient without COVID-19, wait 15 minutes after the treatment is completed to permit droplets to fall from the air sufficiently then clean and disinfect the dental operatory [68,74]. Cleaning must be in unidirectional mopping technique by different mops from internal to external sites using moist mop of fresh prepared 1 percent sodium hypochlorite with just a touching duration of 10 minutes [69,75]. After scrubbing, wash the mop by clean water, disinfect with 1 percent sodium hypochlorite, and let dry in the heat [75]. The dental seat and any associated pieces around 3 feet cleaned and disinfect in same way then dried [75]. Using ultra - sonic cleaners and autoclaves of the type B (vacuum type; wrapped/unwrapped, solid/hollow items) or N (nonvacuum; unwrapped solid items) are recommended for dental instruments and equipment sterilization [71]. Equipment used for suspected/positive COVID-19 patients should be color-coded and preserved away from other equipment. Cleaning and decontaminating of switchable face protective equipment must be done [72]. Fumigation is done either each and every day in hospital or heavy contact locations or biweekly in nonclinical or restricted areas of contact [69]. It is not advised to use spray disinfectants or fumigating on a regular basis for COVID-19, as this may have side effects on dental workers' health [76,77]. Also, spraying of disinfectants in these places can miss covered or multifaceted configurations surfaces so disinfectants must be used with a disinfectant-soaked towel or wipe. Chemical, electronic, and biological detecters should be used to evaluate the effectiveness of sterilization procedures [68].

3. Using UV light radiation: UV light poses antimicrobial properties and can efficiently constrain different kinds of types viruses [78]. UV light at 254 nm has been documented to deter the SARS virus, although it might be harmful to the eyes and skin [79,80]. Microbes, whether bacteria or viruses sized a micrometer or less. So, UVC may occupy and destroy them [81]. As corona viruses have matching genomic sizes, far-UVC light is likely to have same suppression activity to other human corona viruses [80,82].

4. Ventilation: Directed air flow must be operated to get rid of contaminated aerosols, splattering, or fog from the dental environment [69]. Chamber ventilation or filter air cleaner for 30 minutes preceding disinfection process after treatments can help reducing the threat of getting infected [83,84]. Outside air must be pulled into the building, pass from a less contaminated areas (staff work location) towards high polluted site (therapeutic location), and then return outside through fans/exhaust or HEPA filters [69]. HEPA filters and UVC are used to decontaminate the air [60,85]. HEPA filters decrease virus concentricity and confines the spreading out of contagious airborne viruses [85]. Natural ventilation or mechanical ventilation by fans or exhaust can be used, if HEPA filters are not available, to eradicate fog or aerosols formed throughout therapy procedures [85]. Few reports from Italy and China showed the use of ventilation among patients in treatment/waiting areas [50,55].

5. Medical Wastes Handling: Dealing with medical waste and disposal represent indirect health risks associated to environmental pollution, so biomedical wastes must be ravage according to regional health authority strategies. Peng et al. [45] suggested allotting a temporary storage container in the center for medical waste. Medical wastes of suspected-confirmed COVID-19 cases should be disposed in multi-layered packaging with appropriate tagging, and gooseneck band [30,45]. Contaminated disposable PPE, like gloves, gowns, and head covering, should be securely get rid in a sack in the clinical site [45].

6. Conclusion

COVID-19 is a highly contagious disease that has spread rapidly around the world and has caused catastrophic consequences for many countries. Health workers including dentists and auxiliary personnel are the most vulnerable people to this infection due to direct contact with the patients infected or non-infected with it. There are many rules and guidelines that help avoid or reduce the risk of infection among this group.

Acknowledgements

The Authors thank all staff of the Oral and Maxillofacial Surgery Department in Dentistry College/Mosul University.

Conflict of Interest

All Authors declare no conflict of interest.

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