Department of Periodontology

Faculty of Dental Sciences,

King George’s Medical University
Lucknow
Viral Etiology
COVID-19 virus is similar to severe acute respiratory syndrome coronavirus (SARS-CoV) and
Middle East respiratory syndrome coronavirus (MERS-CoV). The novel coronavirus was
initially named 2019-nCoV and is now officially recognized as SARSCoV-2). It is zoonotic,
with origin from Chinese horseshoe bats (Rhinolophus sinicus) being the most probable cause
(Chan et al. 2020; Lu et al. 2020) and pangolins as the most likely intermediate host (The
Chinese Preventive Medicine Association 2020).

Mode of Transmission.
COVID-19 outbreak started with single animal-to-human transmission, followed by sustained
human-to-human spread (Chan et al. 2020; Del Rio and Malani 2020). Interpersonal
transmission occurs mainly via respiratory droplets and contact transmission (The Chinese
Preventive Medicine Association 2020). In addition, there may be risk of fecal-oral
transmission, as researchers have identified SARS-CoV-2 in the stool of patients from China
and the United States (Holshue et al. 2020). However, whether SARS-CoV-2 can be spread
through aerosols or vertical transmission (from mothers to their newborns) is yet to be
confirmed (Chen, Guo, et al. 2020; WHO 2020c; Zhu et al. 2020).

Dentist at highest Risk:

Figure is taken from the NYT article: The Workers Who Face the Greatest Coronavirus Risk

• Presence of COVID-19 virus in saliva of infected patients. It can have a pivotal role in
the human-to-human transmission.
• Dentists perform aerosol-generating procedures and provide direct care for infected but
not yet diagnosed COVID-19 patients/ suspected cases for surveillance/ patients in
incubation period and unaware that they are infected/ patients concealing history related
to infection; can thus are at higher risk for infection.
• Inhalation of airborne particles and aerosols produced during dental procedures make
it a high-risk procedure.
• Design of dental operatory such that risk of cross infection are more between dental
health care providers and patients.
 Figure taken from “Transmission routes of 2019-nCoV and controls in dental practice” – Peng
et al. 2020

Protocol in Periodontology Department:

Three tier approach:
1. Risk assessment and reduction
2. Prevention
3. Management of the problem.
Figure taken from “Corona Virus Disease 19 (COVID-19: Implication for Clinical Dental care”
– Ather et al. 2020

Risk assessment and Reduction:

• Identify which patients are at higher risk of adverse outcomes from COVID-19.
Higher risk Population:
• > 65 years of age or older
• History of pulmonary disease, chronic kidney disease, liver disease,
cardiovascular disease, HIV, diabetes mellitus
• History of transplants
• Patients on immunosuppressive medications

• Question all patients about symptoms related to COVID-19 (fever, cough, breathing
difficulty).
• Ask about recent travel and community exposure.
• Have staff at entrance screen patients about symptoms: fever, cough, breathing
difficulty.
• Take patients’ temperatures upon arrival.
• Dental clinics are recommended to establish pre-check triages to measure and record
the temperature of every staff and patient as a routine procedure. Pre-check COVID
questionnaire is also recommended.

Prevention:
• Appropriate personal protective equipment (PPE). The use of personal protective
equipment (including masks, gloves, gowns and goggles or face shields) is
recommended to protect skin and mucosa from (potentially) infected blood or
secretions. As respiratory droplets are the main route of SARS-CoV-2 transmission,
particulate respirators (e.g., N-95 masks authenticated by the National Institute for
 Occupational Safety and Health or FFP2-standard masks set by the European Union)
are recommended for the routine dental practice.
•

•
• Hand hygiene is the most critical measure for reducing the risk of transmitting
microorganism to patients (Larson et al. 2000).
• SARS-CoV-2 can persist on surfaces for a few hours or up to several days, depending
on the type of surface, the temperature or the humidity of the environment (WHO
2020). This reinforces the need for the importance of thorough disinfection of all
surfaces within dental clinics.
• Every surface in the waiting room is at risk; therefore, in addition to providing adequate
periodic air exchange, all surfaces, chairs, magazines and doors that come into contact
with healthcare professionals and patients must be considered “potentially infected”.
They should be cleaned with alcoholic disinfectants/ hypochlorite solutions.
• Entire air conditioning system needs to be sanitized very frequently.
• Preoperative antimicrobial mouth rinse could reduce the number of microbes in the
oral cavity.
 • Patients waiting in dental clinic should also be provided with medical masks.
• Ensure patient supplies are readily available: tissues, alcohol-based hand rub,
appropriate facemasks, soap/towels, trash cans.
• Place chairs 6 feet apart in multiple chair setting. If limited space than make only
single chair functional.
• Use barriers if possible.
• Remove toys, reading materials, or other communal objects from waiting room.
• Reschedule non-urgent appointments and postpone elective procedures.
• Stay connected with state health department and Ministry of Health and Family
Welfare (MoHFW) regarding specific guidelines pertaining to the status of COVID-
19 in the area.
• Post signs at entrances and in waiting areas about preventive actions and office safety
protocols.
• Limit non-patient visitors.
• Provide symptomatic patients with facemasks.
• Emphasize proper hand hygiene and cough etiquette for everyone.
• Separate symptomatic patients from healthy.
• After patients leave, clean surfaces with EPA-registered disinfectant.
• Provide at-home care instructions to patients with respiratory symptoms. Follow up
by phone.
• Notify health department of any patients with COVID-19 suspicion.

Management of the problem:

• The management practice of the operating area has to be similar to what happens with
other patients affected by infectious and highly contagious diseases.
• As often as possible, the staff should work at an adequate distance from patients.
• Handpieces must be equipped with anti-reflux devices to avoid contaminations,
improving the risk of cross-infections.
• Periodontal therapy has to shift from ultrasonic towards manual scaling.
• Dentists should take strict personal protection measures and avoid or minimize
operations that can produce droplets or aerosols.
• The 4-handed technique is beneficial for controlling infection.
• The use of saliva ejectors with low or high volume can reduce the production of droplets
and aerosols (Kohn et al. 2003; Li et al. 2004; Samaranayake and Peiris 2004).
• Dental emergencies can occur and exacerbate in a short period of time, and therefore
need immediate treatment. Rubber dams and high-volume saliva ejectors can help
minimize aerosol or spatter in dental procedures.

In order to perform a clinically- and ethically-driven decision-making process, dental

interventions can be divided in the following categories:

▪ Emergency management of life-threatening conditions;

▪ Urgent conditions that can be managed with minimally invasive procedures and without
aerosol generation;
▪ Urgent conditions that need to be managed with invasive and/or aerosol-generating
procedures;
▪ Non-urgent procedures;
▪ Elective procedures.

Furthermore, the following considerations should be assessed before starting any urgent
treatment.
▪ Operative procedures should be as minimally invasive as possible and aerosol-generating
interventions should be avoided whenever possible;
▪ Disposable devices and instrumentation should be used whenever possible to limit cross-
infection risks;
▪ Potential viral load in patients’ saliva could be reduced with 0.23% povidone-iodine
mouthwash for 15 s before intervention (Eggers et al., 2018);
▪ Isolation with rubber dam should be used whenever possible to limit the spread of
microorganisms (Cochran et al., 1989);
▪ Intraoral radiographs should be limited in favor of extraoral imaging, in order to reduce
salivation and gag reflex;
▪ If pharmacologic management of pain is necessary, ibuprofen should be avoided in
suspected and confirmed COVID-19 cases ( Day, 2020). (in Alharbi et al, 2020)
On 1st April the ADA also published an Interim Guidance for Management of Emergency and
Urgent Dental Care:
▪ Uncontrolled bleeding
▪ Cellulitis or a diffuse soft-tissue bacterial infection with
Dental emergencies
intra-oral or extra-oral swelling that potentially
compromises the patient’s airway/ Ludwig’s Angina
▪ Trauma involving facial bones, potentially compromising
the patient’s airway

▪ Severe dental pain from pulpal inflammation

▪ Pericoronitis or third-molar pain
Dental urgencies
▪ Surgical post-operative osteitis, dry socket dressing changes
▪ Abscess, or localized bacterial infection resulting in
localized pain and swelling
▪ Tooth fracture resulting in pain or causing soft tissue trauma
▪ Dental trauma with avulsion/luxation
▪ Dental treatment required prior to critical medical
procedures
▪ Final crown/bridge cementation if the temporary restoration
is lost, broken or causing gingival irritation
▪ Biopsy of abnormal tissue

▪ Initial or periodic oral examinations and recall visits,

including routine radiographs
Non-urgent dental
▪ Routine dental cleaning and preventive therapies
treatments that can be ▪ Orthodontic procedures other than those to address acute
issues (e.g. pain, infection, trauma) or other issues critically
postponed necessary to prevent harm to the patient
▪ Extraction of asymptomatic teeth
▪ Restorative dentistry including treatment of asymptomatic
carious lesions
▪ Aesthetic dental procedure

European Federation of Periodontology Guidelines 2020: