2. Contents:
About the corona virus, prevalence, risk factors
Introduction
01
General transmission, transmission by dental procedures.
Mode of transmission
02
Diagnostic tests, Other measures
Diagnosis
03
Treatment protocols
04
05 Guidelines of prevention, prevention during dental
treatment
Preventive measures
Drug used or treatment
6. • coronavirus to cross species to infect human populations in the past two decades.
1. Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) outbreak in 2002
2. Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in 2012.
Group of viruses : cause a significant percentage of all common colds in human adults and
children.
• Four human coronavirus including- 229E, OC43, NL63, and HKU1 are prevalent and typically
cause common cold symptoms in immunocompetent individuals.
7. • SARS-CoV which causes SARS, has a unique pathogenesis because it causes both upper and
lower respiratory tract infections.
• The genome sequence of 2019-nCoV is about 89% identical to bat SARS-like-CoV and 82%
identical to human SARS-CoV.
• It has been reported that 2019-nCoV uses the same cell entry receptor, ACE2, to infect humans,
as SARS-CoV, so clinical similarity between the two viruses could be expected, particularly in
severe cases.
• The first death: January 9, 2020, in Wuhan and since then more than 370,000 cases and
16,000 deaths occurred worldwide.
16. Dental procedures create particles ofdroplets and aerosol
withCOVID-19
•Firstly, many dental procedures, such as those including the use of high-speed
turbines and running water, release a large number of particles of droplets and
aerosols mixed with the patient’s saliva to the air. These particles are so small that
they could stay airborne for a considerable period of time.
•These particles could also settle on environmental surfaces and other dental
equipment. Researches suggest that the virus could live up to 72 hours on hard
surfaces. Moreover, the dental office usually includes surfaces of metal, glass, or
plastic. Thus, dentists and other patients could easily get infected without proper
control procedures. Because it is tough to avoid the generation of particles of droplets
and aerosol, this is probably the most important concern for dental professionals.
17. -The INCUBATION PERIOD of COVID-19 has
been estimated at 5 to 6 d on average.
-The ASSYMPTOMATIC INCUBATION
PERIOD for individuals infected with
2019-n Cov has been reported to be 1-14
days, and after 24 days individuals were
reported confirmed that those without
symptoms can spared the virus.
- According to kai-wang et al, live virus
present in the saliva also that can spread
easily.
INCUBATION PERIOD
21. • In general, older age and the existence of underlying co-
morbidities (e.g., diabetes, hypertension, and cardiovascular
disease) were associated with poorer prognosis (Kui et al. 2020;
Wang et al. 2020; Yang et al. 2020).
- Serious complications: Acute respiratory distress
syndrome, arrhythmia, and shock (Chen, Zhou, et al.
2020; Huang et al. 2020; Wang et al. 2020).
22. Twenty-five studies reported 180
cases which underwent chest CT,
One hundred thirteen (62.7%) CT
scans presented abnormalities.
The most prevalent abnormalities
reported were ground glass
opacities, patchy shadows and
consolidations.
Radiologicalfeatures
24. All symptomatic contacts of laboratory confirmed cases
All symptomatic health care workers
All patients with Severe Acute Respiratory Illness
Asymptomatic direct and high-risk contacts of a confirmed case should be tested once
between day 5 and day 14 of coming in his/her contact.
Strategyfor COVID19
testinginIndia
INDIAN COUNCIL OF MEDICAL RESEARCH DEPARTMENT OF HEALTH RESEARCH , version 4 , Dated 9/4/2020
27. Generalguidelines
Trained health care professionals to wear appropriate PPE with latex free purple
nitrile gloves while collecting the sample from the patient.
Maintain proper infection control when collecting specimens
Restricted entry to visitors or attendants during sample
collection
Complete the requisition form for each specimen submitted
Proper disposal of all waste generated (yellow)
28. Tilt patient’s head back 70 degrees.
Rub swab over both tonsillar pillars and
posterior oropharynx
Avoid touching the tongue, teeth, and
gums.
Use only synthetic fiber swabs with
plastic shafts.
Do not use calcium alginate swabs or
swabs with wooden shafts.
Place swabs immediately into sterile
tubes containing 2-3 ml of viral transport
media.
Oropharyngeal swab/
throat swab
29. Tilt patient’s head back 70 degrees.
Insert flexible swab through the nares
parallel to the palate until resistance is
encountered or the distance is equivalent to
that from the ear to the nostril of the
patient.
Gently, rub and roll the swab.
Leave the swab in place for several
seconds to absorb secretions before
removing.
Nasopharyngealswab
30. investigations
RT - PCR
Rapid Diagnostic Tests (RDTs)
Rapid diagnostic tests based on
Antigen Detection
Rapid diagnostic tests based on host
Antibody Detection
31. Reverse transcriptase polymerase chain
reaction (RT-PCR)
An ideal diagnostic is both specific and
sensitive, which means that people who
Test positive truly have the disease and
none of the people carrying the virus slip
through the test as a false negative.
Throat or Nasal swab
RT-PCR
32. Once at the lab, the RNA must first be converted to DNA using an enzyme called reverse
transcriptase.
Then, specific sequences of DNA (primers) designed to recognize complementary virus
sequences are added, so that another enzyme—usually a modified form of Taq
polymerase—can make a copy of a short length of viral DNA.
This process is repeated for 20-30 cycles, exponentially amplifying the amount of viral DNA
so that it can be detected.
Having the entire virus genome was crucial for designing primers that would detect only
SARS-CoV-2 and not SARS-CoV or any other closely related coronaviruses.
33. For people anxiously waiting for their test
results
In contrast, rapid test kits can give results
in under an hour, making point of care
diagnostics possible.
Tested at their local general practitioner
and receive their results at the same visit.
RapidDiagnostictestskits(RDTs)
34. Viral proteins (antigens) expressed by the COVID-19 virus in a sample from the respiratory tract
of a person.
If the target antigen is present in sufficient concentrations in the sample, it will bind to specific
antibodies fixed to a paper strip enclosed in a plastic casing and generate a visually detectable
signal, typically within 30 minutes.
The antigen(s) detected are expressed only when the virus is actively replicating; therefore, such
tests are best used to identify acute or early infection.
Rapid diagnostic tests based onAntigen Detection
35. The tests work depends on several factors, including
1) The time from onset of illness
2) The concentration of virus in the specimen
3) The quality of the specimen collected from a person and how it is processed
4) The precise formulation of the reagents in the test kits.
WHO does not currently recommend the use of antigen-detecting rapid diagnostic
tests for patient care, although research into their performance and potential
diagnostic utility is highly encouraged.
36. Presence of antibodies in the blood of people
believed to have been infected with COVID-19
Antibodies are produced over days to weeks after
infection with the virus.
In some people with COVID-19, disease confirmed
by molecular testing (RT-PCR), weak, late or absent
antibody responses have been reported.
Rapid diagnostic tests based onhostAntibody Detection
39. • Chloroquine, a widely-used anti-malarial and autoimmune disease drug.
• Block virus infection by increasing endosomal pH required for virus/ cell fusion, as well as interfering
with the glycosylation of cellular receptors of SARS-CoV.
• An immune-modulating activity, which may synergistically enhance its antiviral effect in vivo.
• Cheap and a safe drug
• It is believed to interfere with coronavirus replication through reduction is cellular Mitogen- Activated
Protein Kinase (MAPK) activation, through post transitional modification of viral proteins in host Golgi
such as altering the maturation of the coronavirus envelope “M” protein which is critical for viral
assembly, and through other mechanisms of immune system modulation.
42. bcg
• BCG is known to have in reducing the incidence of respiratory viral infections, its
use during the COVID-19 pandemic may prove beneficial.
• Results of upcoming clinical trials are eagerly anticipated and encouraging.
• Studies conclude: received BCG as a mass vaccination will have less frequency of
COVID-19.
• Using oral zinc sulfate combined with BCG immunotherapy to have more effective
protection against infection including COVID-19 than BCG immunotherapy alone.
• BCG vaccine has much more rapid action in people who have already been BCG
vaccinated.
43. Melatonin
• Melatonin, a well-known anti-inflammatory and anti-oxidative molecule, is
protective against ARDS caused by viral and other pathogens.
• Effective in critical care patients by reducing vessel permeability, anxiety,
sedation use, and improving sleeping quality, which might also be beneficial
• for better clinical outcomes for COVID-19 patients.
• Notably, melatonin has a high safety profile.
• There is significant data showing that melatonin limits virus-related diseases
and would also likely be beneficial in COVID-19 patients.
• Additional experiments and clinical studies are required to confirm this
speculation.
Zhang R, Wang X, Ni L, Di X, Ma B, Niu S, Liu C, Reiter RJ. COVID-19: Melatonin as a potential adjuvant treatment. Life Sciences. 2020 Mar 23:117583.
48. Table2:Recommended medications for Emergency CarePatients reporting
withsevere dentalpainduringCovid-19Pandemic
• The most recommended drugs of choice for treating severe pain are:
✓ Acetaminophen 1000 mg (every 6 – 8 hours) OR
✓ Ketorolac Tromethamine 10mg (every 6 hours) OR
✓ Piroxicam 20 mg (every 12 hours) OR
✓ Ibuprofen 600 mg (every 6 hours) [Use with caution]*
*Current WHO guideline has contraindicated the usage of Ibuprofen during COVID -19
Pandemic. However with conflicting research in this issue this position statement
would recommend the usage of alternative medications to ibuprofen given in this
above.
49. “Emergency Severity Assessment of the associated
dental condition. Only patients which fall under
Emergency/Urgent Care should be attended to or
scheduled immediately for management. While others
may be tele-counselled, put under pharmacological
management if needed and kept on a telephonic follow
up for any exacerbation of symptoms.”
—DR.JARBAS BARBOSA,PAHO’sASSISTANT DIRECTOR
”
51. ONE THING ALWAYS KEEP IN MIND
“ EVERY
PATIENTS IS AN
ASSYMPTOMATIC
CARRIER OF
COVID-19”
52. GENERALRECOMMENDATIONS
As outlined previously droplet and aerosol
transmission are significant risks in the dental
practice setting. Due to the potential risk of
asymptomatic COVID-19 patient presenting in the
dental setting appropriate measures to limit risk
should be taken.
If aerosol generating procedures are
undertaken, operators should wear
appropriate personal protective equipment
ideally comprised of a fluid-resistant mask,
visor and apron. It is important to remember
to put on and remove PPE in an order that
minimizes the risk of contamination.
Even when not using aerosol generating
procedures, it is important that robust infection
control measures are employed. In non-clinical
areas such as reception and waiting areas
thorough cleaning should take place.
54. Step 1: TELEPHONIC PRESCREENING PROTOCOL
• Fix appointments through phone only & Discourage Walk-in Patients
• Hot Spot Matching & Medical Symptoms Assessment
• Dental needs assessment
• Disclosure/ Consent Form to be sent to patient - electronically (If possible)
• Ask patient to wear mask and preferably come alone without any attender
Step 2: RECEPTION/ WAITING AREA PROTOCOL
• Receptionist / Staff : One Person
• Discourage footwear within clinic interiors/ provide foot cover
• Record patient temperature using Digital Non-contact Infrared Thermometer
• Mandatory use of Alcohol Based Hand Rub (ABHR) & provide Mask for everyone
• Seating arrangement with minimum 3 feet Physical Distancing
• Display Patient Education Material on Hand & Cough Hygiene
• Patient to submit signed Disclosure/ Consent Form ( Table 1)
Step 3: DENTAL OPERATORY PROTOCOL
• Keep the clinical operatory clutter-free
• Improve air circulation and avoid air-conditioners
• 0.01% NaOCl for disinfection of dental water lines
• Donning of appropriate PPE for Dental Surgeon and one dental assistant
Patient Scheduled For Physical Visit
Patient Guided Inside Dental Operatory
55. Step 4: PATIENT ASSESMENT AND TREATMENT PROTOCOL
• Pre-Procedural Mouth rinse: 1% Hydrogen peroxide or 0.2% Povidone-iodine : 1 min
• Extra oral scrubbing of face with Antiseptic wipe
• Diagnose & Treatment Plan Into Aerosol Generating Procedures (AGP) and Non Aerosol Generating
Procedures (Non-AGP)
• Four-Handed Dentistry and Rubber Dam Application for AGP
• High Volume Suction & Minimize IOPA usage
AEROSOL GENERATING PROCEDURES (AGP)
Should be ideally done in designated Isolation Rooms for AGP which
should be equipped with HEPA Filters / Augmented Ventilation
NON - AEROSOL
GENERATING
PROCEDURES (AGP)
Step 5: PATIENT DISCHARGE
• Patient advised to re-mask and proceed to reception area
• Hand Hygiene
• Electronic Treatment records only
• Cashless payment preferred
Patient seated on Dental Chair
56. Step 6A: POST - TREATMENT AIRBORNE CONTAMINANT REMOVAL PROTOCOL
Room should be well ventilated with a minimum 6 ACH (Air Changes per Hour) : Table 3
AEROSOL GENERATING PROCEDURES (AGP)
One or more of the following four contaminant removal techniques
should be followed
• Vacate the operatory during disinfection procedure
NON - AEROSOL
GENERATING
PROCEDURES (AGP)
HEPA AIR
FILTERS (min 12
ACH)
20 minutes Air
filtration with
HEPA 13 / HEPA
14 Filters
UVGI (Ultraviolet
Germicidal
Irradiation) +
Ventilation (min 6
ACH)
5 minutes UV-C
Irradiation of 245
nm, 40 W per 100
sq.ft
ONLY NATURAL
VENTILATION
(min 6 ACH)
60 Minutes Cross
ventilation and
additional
ventilators (pedestal
fans, exhaust fans)
DISINFECTANT
DEFOGGING
30 - 45 minutes
Hydrogen Peroxide
Vapor (HPV) or
Chlorine Dioxide
Step 6B: POST –TREATMENT CHAIRSIDE DISINFECTION PROTOCOL
57. Step 6B: POST –TREATMENT CHAIRSIDE DISINFECTION PROTOCOL (Minimum 20
mins):
• Instrument change • Flushing of suction and spittoon drainage with 1% NaOCl
• Disinfect 3 feet area around Chair & Mop the clinical area
Step 7: PROTOCOL AT THE END OF CLINICAL DAY
• REPEAT STEP 6B and 6A in this order
• DOFFING OF PPE IN SEPARATE AREA
• BIO-MEDICAL WASTE IN DOUBLE LINED YELLOW BAGS ONLY
Step 8: WHEN GOING HOME AFTER A WORKDAY
• we should change from scrubs to personal clothing before returning home
•Upon arriving home, we should take off shoes, remove and wash clothing [separately from other
household residents], and immediately shower.
62. hand Hygiene
• According to the CDC hand hygiene guidelines, dentists should perform
hand hygiene before and after all patient contact, contact with potentially
infectious material, and before putting on and after removing PPE,
including gloves.
• It should be performed by using alcohol-based hand rub (ABHR) with 60-
95% alcohol or washing hands with soap and water for at least 20
seconds. 62
64. A study published in 2017 in the Journal of Infectious Diseases evaluated the
virucidal activity of ABHS against re-emerging viral pathogens, such as Ebola virus,
Zika virus (ZIKV), SARS-CoV, and MERS-CoV and concluded that the enveloped
viruses could be effectively inactivated by both WHO formulations I and II (ethanol-
based and isopropanol-based respectively).
Siddharta A et al. Virucidal Activity of World Health Organization–Recommended Formulations Against Enveloped Viruses,
Including Zika, Ebola, and Emerging Coronaviruses. The Journal of infectious diseases. 2017 Mar 15;215(6):902-6.
64
65. Use of ABHS by dentists in viral outbreak situations.
Another advantage: less irritating to the hands.
Excessive hand washing with soap and water can cause skin damage and increase
the risk for infections.
Drying hands with a towel remove pathogens first by friction during rubbing with the
drying material and then by wicking away the moisture into that material.
The CDC recommends the use of alcohol-based hand rubs containing various
emollients and other skin conditioners as a strategy to reduce skin damage, dryness,
and irritation.
Cure L et al. A systematic approach for the location of hand sanitizer dispensers in hospitals. Health care management science. 2014 Sep 1;17(3):245-58. Vermeil Tet al. Hand hygiene in hospitals: anatomy of a
revolution. Journal of Hospital Infection. 2019 Apr 1;101(4):383-92.
65
66. NOTE:
• After using an alcohol-based hand rub, the dentist must dry his or her
hands thoroughly before putting on gloves, because any residual alcohol
may increase the risk of glove perforation.
Vermeil Tet al. Hand hygiene in hospitals: anatomy of a revolution. Journal of Hospital Infection. 2019 Apr 1;101(4):383-92.
Gold NA, Avva U. Alcohol Sanitizer. InStatPearls [Internet] 2018 Nov 11. StatPearls Publishing.
66
67. PERSONAL PROTECTIVE EQUIPMENT (PPE)
01 03
02 04
Lab coat or apron
(wear it correctly)
Surgical masks and
respirators
Safety gloves (must
be worn to the wrist)
Eye or face protection
(such as glasses)
68. a. A triple-layered surgical mask can be worn by all health care providers
when within 1–2 meters of patient.
b. Particulate respirators (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 routine dental practice.
c. If available an FFP3-standard mask should be used and in COVID-19
positive patients this would be considered essential.
Masks
71. Re-useofN-95
•Use the respirator without
changing it between
patients for a 6 hour
session
•Wear a surgical mask over
the respirator and change
that after every patient
•Store in a clean, dry
container like brown paper
bag for 4 days
•Recommended 5 masks
reuse protocol for 20 days
72. 72
Eye & face protection
• Upon entry to the patient room -
Goggles or a disposable face
shield
• Reusable –clean and disinfect
• Disposable –discard
73. 73
Gowns
• Isolation gown upon entry into the patient room
• Mandatory for aerosol-producing procedures,
where splashes and sprays are anticipated
• Attention should be paid to training and proper
donning (putting on), doffing (taking off), and
disposalof any PPE.
82. Table 6: RECOMMENDED DISINFECTION AND STERILIZATION PROTOCOLS FOR DENTAL CLINICS
TREATING PATIENTS DURING COVID-19 PANDEMIC
83. disinfectionofaerosol
1ml of 5% NAOCL mixed in 5 liter of dental
waterline
1ml of 3% NAOCL mixed in 3 liter of dental
waterline
92. 01
02
03
04
•Screening of patient
•Visual alerts in reception areas
•Seating arrangement with social
distancing of 1-2 m
•1% Hydrogen peroxide or 0.2%
Povidone-iodine mouth rinse
•Proper DPE
•Avoid AC and use of natural &
mechanical ventilators
•0.01% NAOCL in Dental
water line
•Surface disinfection with
1% NAOCL
•Insist in ABHR & face mask
for ALL
•HEPA filters & UV-C lights
•Extra oral suction &
disinfection device 05
06
Coronavirus disease 2019, also called COVID-19, is the latest infectious disease to rapidly develop worldwide.
In late December 2019, Chinese authorities informed the WHO that, due to unknown cause, an outbreak of pneumonia emerged in Wuhan, Hubei province.
On January 7, 2020, a new type of coronavirus was isolated and few days after the disease has been named “coronavirus disease 2019”.
Many of the reported cases mostly had links to the Huanan Seafood Wholesale Market, which also sold live animals; therefore, the virus is believed to have a zoonotic origin. (Chinese Journal of Epidemiology, 2020)
Coronaviruses belong to the family of Coronaviridae, of the order Nidovirales, comprising large, single, plus-stranded RNA as their genome. Currently, there are four genera of coronaviruses: αCoV, β-CoV, γ-CoV, and δ-CoV15,16. Most of the coronavirus can cause the infectious diseases in human and vertebrates. The α-CoV and β-CoV mainly infect the respiratory, gastrointestinal, and central nervous system of humans and mammals, while γ-CoV and δ-CoV mainly infect the birds.
They come in contact with another person infected with the virus
Someone infected coughs or sneezes directly to them
They touch any surface with little droplets from infected people’s cough or sneezes and then touch their eyes, nose or mouth
Droplet containig virus in the air- airborne- orpet and in nose, mouth, possibly lungs
Droplet fall on surface/ objects – other peron touch that surface or obect and get infected by indirect transmission- and that ropllet eventually get into nose and mouth.
By the direct or indirect transmission virus enter into the body. So now how the virus attach to the human cells? So for that we have to understand the structure.2019-nCoV is nothing but it is single strain RNA virus. it possessed the typical coronavirus structure with the “spike protein” in the membrane envelope, and also expressed other polyproteins, nucleoproteins, and membrane proteins, such as RNA polymerase, 3-chymotrypsin-like protease, papain-like protease, helicase, glycoprotein, and accessory proteins. The S protein from coronavirus can bind to the receptors of the host to facilitate viral entry into target cells.
viruses bind to the human cell via the spike (S) protein to angiotensin-converting enzyme 2 receptor (ACE2) to gain entry.
A dentists are one of the occupations with the highest risk of contracting COVID-19. Dentists can easily be exposed to the virus since the dental care setting frequently includes face-to-face communication and exposure to body fluids, such as saliva.
dentists are at high risk because the work requires working in close proximity to other people. It is impossible to implement social distancing in the dental setting. And most of the time, dentists come in direct contact with the patients’ saliva, which could include coronavirus.
THE RED CIRCLE SHOWING THE HIGH RISK ZONE, WHERE WE ARE WORKING WITH THE PATIENT. So dental profession having the higher risk.
atypical symptoms, such as muscle pain, confusion, headache
Fatigue
diarrhea, and vomiting
In late march ICMR recommended HCQ prophylaxis.
Now a day’s HCQ prophylaxis is goes out of window. ICMR recommended that there is no use of HCQ prophylaxis or treatment. There is no evidence for HCQ prophylaxis or treatment
NO SPECIFIC ANTIVIRALS have been proven to be effective as per currently available data. However, based on the available information (uncontrolled clinical trials), the following drugs may be considered as an off – label indication in patients with severe disease and requiring ICU management:
Recently reported study on the use of Remdesivir for COVID-19 treatment is not a clinical trial, but an observational study which found that 68% or two out of three patients after treatment with the drug did not require ventilator support or their need for oxygen support reduced.
Novel coronavirus are spread by people who have the virus coming in to contact with people who are not infected. The more you come in to contact with infected people, the more likely you are to catch the infection. Social distancing is infection control action that can be taken by public health officials to stop or slow down the spread of a highly contagious disease.
Medical mask, good breathability, internal and external faces should be clearly identified
The Renin-Angiotensin (Ang) System (RAS) regulates blood pressure through conversion of angiotensinogen to angiotensin I and ultimately angiotensing II, catalyzed by ACE2. Moreover, fluid and electrolyte balance, in addition to, systemic vascular resistance are regulated by the RAS.
Ang I and Ang II are cleaved by ACE. Binding of Ang II to the Ang II type 1 receptor results in vasoconstriction, inflammation and apoptosis. Ang-(1-7) acts against the effects of Ang II. Therefore, the endogenous ratio of Ang II: Ang-(1-7) is affected by the balance between ACE and ACE2 levels 8 . Furthermore, vitamin D may suppress RAS activity through inhibition of renin.
Hypovitaminosis D is attributed to the increased risk of lung injury and acute respiratory distress syndrome (ARDS) as well as diabetes, Cardiovascular event and associated comorbidities, which are the main causes of severe clinical problem in COVID-19 patients. Considering the protective role of vitamin D through modulating the innate and adaptive immune system as well as inhibition of Renin Angiotensin System (RAS), vitamin D supplementation might boost the immune system of COVID-19 patients and reduce severity of the disease in vitamin D deficient individuals.