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Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 85-90

COVID 19 pandemic – A need for emerging concern in dental practice

1 Department of Pediatric and Preventive Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Periodontology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India

Date of Submission01-May-2020
Date of Decision02-May-2020
Date of Acceptance13-May-2020
Date of Web Publication04-Jun-2020

Correspondence Address:
Dr. Seema Deshmukh
Department of Pediatric and Preventive Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_73_20

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Outbreak of severe acute respiratory syndrome coronavirus 2 leading to respiratory symptoms associated with fever, cough, and respiratory distress, has been a major global concern leading to the declaration of worldwide lockdown. This rapid spread poses many challenges to the health-care system and, at the same time, provides innumerable threats for the return to the routine services. A part of the health-care system which would require many reformations in dentistry. Saliva being saturated with COVID-19 virus poses a major risk to dental professionals because of the aerosols being produced during the procedures being contaminated with saliva and blood. The disruption of dental services during the period of the pandemic may increase the burden of treatment requirements at a later period. There is also a need to bring about policies and recommendations that focus toward the modifications in treatment protocols. This article analyses the current situation and provides suggestions for modifications that provide effective infection control strategies in the prevention of nosocomial infection in dental settings.

Keywords: COVID-19, emergency dental services, situation analysis, zone of infection

How to cite this article:
Deshmukh S, Murthy PS, Ravindra S. COVID 19 pandemic – A need for emerging concern in dental practice. Int J Health Allied Sci 2020;9, Suppl S1:85-90

How to cite this URL:
Deshmukh S, Murthy PS, Ravindra S. COVID 19 pandemic – A need for emerging concern in dental practice. Int J Health Allied Sci [serial online] 2020 [cited 2023 Dec 10];9, Suppl S1:85-90. Available from: https://www.ijhas.in/text.asp?2020/9/5/85/285969

  Introduction Top

COVID-19, the cause for international public health concerns, has raised various issues regarding the clinical practice among dentists. As this virus is genetically similar to the virus that caused the outbreak of Severe Acute Respiratory Syndrome in 2003, International committee on taxonomy of viruses named it as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is more popularly known as COVID-19.[1]

This large-scale pandemic is believed to have zoonotic origin causing a rapid spread of respiratory distress associated with pneumonia.[2] SARS-CoV-2 is known to be found consistently in the saliva. As a result of which it is being considered as a sample for testing as an alternative to nasopharyngeal swabs.[3],[4],[5] However, the presence of a significant amount of viruses in saliva poses a very high risk to the profession of dentistry.

This puts the dental clinician, the assistant, as well as the patients at a higher risk of contracting and spreading this pandemic. The aerosols generated during the clinical procedures being performed will have larger droplets of saliva, which could have the maximum viral load, thereby spreading the highly infectious condition to anybody in the vicinity. As a result, performing dental treatment has been put to a halt. The pandemic may demand innumerable changes in dental practice in the future.

Effective and efficient dental treatment requires face-to-face communication, providing treatment facilities by being in close proximity of the patients, thereby being exposed to saliva or may even blood, use of instruments for the routine practice, and presence of various surfaces in the dental operatory which can get infected while performing the procedures.[6],[7] All these are considered potential sources of disease transmission. Hence, resuming the dental services may require a certain amount of preparedness from the dentist's point of view. This article provides an overview of the precautionary measures to be taken during dental procedures.

  Understanding the Disease Process Top

Based on the findings of the current research, it has been established that the COVID-19 began with some initial contact with Wuhan seafood market however soon transmission among humans with close approximation was noticed indicating a strong human to human transmission affecting both immune suppressed and normal individuals with equal frequency however occurring less frequently in children.[8],[9]

Based on the various scientific evidence, it was concluded that the major sources of transmission being droplet transmission, contact transmission, and aerosol transmission.[10],[11]

Respiratory droplets (>5–10 μm) laden with the COVID-19 virus load from close approximation with an infected person is considered to be the mode of transmission. There is a high risk of the oral mucosa of the infected person having high counts of the virus. The transmission also occurs through fomites present in the immediate vicinity of the infected person. As a result, the virus may remain alive on the surfaces that have come in contact with the infected individual for a minimum period of 9 days.[12] Certain studies have even postulated the possible fecal – oral transmission to occur.[13],[14] The incubation period of the disease is 2–5 days; however, the exposed person may remain asymptomatic for 14 days.

  General Recommendations for Patient Management Top

There is a need for modifications in the dental hospital/clinic for safe and effective management of the patient during the time of the COVID-19 pandemic. To identify the areas which need these modifications, it initially essential to identify zones of risk in the dental setup. These zones can be divided into red, yellow, and green based on the risk of infectivity with red zone being most infectious to green being least infectious. The risk of infectivity usually depends on the virulence of the organism. With highly virulent organisms like COVID-19, every area in the dental clinical set up could be considered as a potential for cross-transmission.

  • High-risk zones: Patient entry area, reception/waiting area, dental operatory, doffing zone
  • Moderate risk zone: Radiography room, counseling room
  • Low-risk zone: Dental Laboratory, Sterilization area, Donning zone.

High risk zone

It may be extremely important to limit the entry area being populated by the patient entering randomly into the dental hospital set up. The larger the surface area of doors and the knobs that come in contact with the patient entering the clinical setup, the larger remains the risk of cross-transmission. Areas can be designated outside the hospital set up considering a minimum of 2 m distance between the patients. The entry point of the hospital during the COVID pandemic may be modified, as shown in [Figure 1], such that the dental examination can be performed at the entry itself and allowing only those patients requiring emergency dental care to enter the dental operatory. This would reduce the number of patients waiting in the reception/patient waiting area.
Figure 1: Modified entry of the dental hospital

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Patients requiring emergency treatment will now be entering the dental operatory. The dental operatory should be priorly equipped with the instruments, and movement from the green zone to the red zone should be minimized. The materials required for the dental treatment should be dispensed in the green zone itself rather than taking the dental materials to the operatory/working area. The precautions to be taken while performing the procedures are explained further in [Table 1]. The doffing zone should be as close as possible to the dental operatory so as prevent unnecessary movement.[15],[16],[17],[18]
Table 1: Describes procedure wise risk and precautionary measures to be followed

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Moderate risk zone

Most care should be taken in this zone as these areas may have restricted ventilation. Hence preferably, patients' entry into these areas should be avoided. Only essential equipment should be placed in these areas. Keyboards, desktops, and laptops should be covered and should be kept at a sufficient distance from the work area. Sensors used for intraoral radiography should be encased with barriers before use. Whenever required, it would be preferable to take extraoral radiography. Communication time in the counseling room should be as minimal as possible rather, and the instructions may be discussed over telephonic communication.

Low-risk zone

This is zone should be away from the red zone and yellow zone. It is essential to avoid unnecessary movement in this zone to prevent contamination. Impressions being taken to the dental laboratories should be disinfected thoroughly. It is preferable to have a common sterilization area that is sufficiently isolated from the dental operatory, and instruments reaching this area should be priorly disinfected as per the protocol.

Situation analysis

It may be essential at this context to work on the situation analysis by performing the Strength, Weakness, opportunities and threats (SWOT) analysis as this would help us to identify our weaknesses and threats and work on the same. It also does help us maximize our strength, thereby minimizing the risks associated. As a result of this we may be able to come out with strategic plan to handle the current scenario of a pandemic.

Strength in dental clinical set up

  • Postpandemic, there is going to an increased demand for dental services, particularly emergency care. As a result of this, the health services are going to take a center stage in public policies
  • The opportunities may increase further as there will be increased awareness among the general public. Hence, preparedness for providing these services to the patients may be the highest strength of any dental hospital set up.


  • Performing any emergency care would require protective wear like surgical
  • mask, headgear, eye-protective glasses, face shields, personal protective equipment and so on. As there is an increase in demand, the supplies should also increase exponentially. However, this may seem to appear as a difficult task
  • These can also be considered as additional investments by dentists and may work heavily on their finances. This factor becomes two-fold as there is a need for these investments not only for the operator but also for the dental assistant team
  • Even though there might be a sudden increase in need of dental services, the patients may initially focus more on emergency services
  • The repay capacities of the public may also get affected to a certain extent
  • There may also be difficulty in procuring dental supplies resulting in the need for modifications in dental treatment protocols.


  • Maintenance of health focus towards prevention of diseases would become the need of hour leading to the high demand of the health sector
  • Management of the present pandemic also demands innovations in the routine dental practices hence providing opportunities to improvise the same
  • The future may see a new era of research collaborations and promising outcomes. This may broaden the scope of imaginations and incorporation of technological advancements in dental practice.


  • The unseen threat lies in the fact that pauci symptomatic individuals or individuals with no symptoms can also be diagnosed positive of the SARS-CoV 2, thereby demanding unprecedented measures to overcome the condition
  • Lack of scientific evidence regarding the course of the disease is also going to be a major threat
  • Newer regulations may be imposed by the higher statutory bodies and policymakers which may bring in the need for refinement in practice policies
  • The situation may also bring in a decrease in job opportunities for the new graduates or may become difficult for the existing practitioners to cope up with the increasing demands in the additional investments.

  Conclusion Top

Restrictions of dental services in the current epidemiological emergency would have prevented many cross-contamination to occur; however, this puts the need of dental services on high demand. The end of the pandemic has to be marked by the beginning of a new era of dental practices, which demands innovative modifications of the existing systems. There is a constant need for newer models of the treatment protocol and focus now would shift more toward the prevention of invasive dental procedures. This article describes a few such innovative practices that can be employed in the dental practice, thereby preserving the dental health of the patients and the general health of the care providers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gorbalenya AE, Baker SC, Baric RS, de Groot Raoul J, Drosten C, Gulyaeva AA, et al. The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020;5:536-44.  Back to cited text no. 1
Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579:270-3.  Back to cited text no. 2
To KK, Tsang OT, Chik-Yan Yip C, Chan KH, Wu TC, Chan JM, et al. Consistent detection of 2019 novel coronavirus in saliva. Clin Infect Dis 2020. pii: ciaa149.  Back to cited text no. 3
Wyllie AL, Fournier J, Casanovas-Massana A, Campbell M, Tokuyama M, Vijayakumar P, et al. Saliva is More Sensitive for SARS-CoV-2 Detection in COVID-19 Patients than Nasopharyngeal Swabs. medRxiv; 2020.  Back to cited text no. 4
Vinayachandran D, Balasubramanian S, Salivary diagnostics in COVID-19: Future research implications, Journal of Dental Sciences, https://doi.org/10.1016/j.jds.2020.04.006.  Back to cited text no. 5
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.  Back to cited text no. 6
Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): Emerging and future challenges for dental and oral medicine. J Dent Res 2020;99:481-7.  Back to cited text no. 7
Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J,et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.  Back to cited text no. 8
Del Rio C, Malani PN. 2019 Novel coronavirus–important information for clinicians. JAMA 2020;323:1039-40.  Back to cited text no. 9
Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: A scoping review. Infect Dis Poverty 2020;9:29.  Back to cited text no. 10
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 11
Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA 2020;323:1610-2.  Back to cited text no. 12
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.  Back to cited text no. 13
Zhang Y, Chen C, Zhu S, Shu C, Wang D, Song J, et al. Isolation of 2019-nCoV from a Stool Specimen of a Laboratory-Confirmed Case of the Coronavirus Disease 2019 (COVID-19)[J]. CDC Weekly 2020;2:123-4. doi: 10.46234/ccdcw2020.033.  Back to cited text no. 14
Carrouel F, Conte MP, Fisher J, Gonçalves LS, Dussart C, Llodra JC, et al. COVID-19: A recommendation to examine the effect of mouthrinses with β-Cyclodextrin combined with citrox in preventing infection and progression. J Clin Med 2020;9:1126.  Back to cited text no. 15
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.  Back to cited text no. 16
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  [Figure 1]

  [Table 1]


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