1Department of Orthodontics, Jaipur Dental College, Jaipur, Rajasthan, India, 2Department of Orthodontics, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India, 3Department of Periodontics, Jaipur Dental College, Jaipur, Rajasthan, India, 4Grover Dental Clinic, Jaipur, Rajasthan, India
Address for correspondence: Dr. Ishan Grover, 633, Acharaya Kriplani Marg, Adarsh Nagar, Jaipur, Rajasthan, India. E-mail: ishan297@gmail.com
Submitted: 05-Jun-2020
Revised: 21-Jun-2020
Accepted: 24-Jun-2020
Published: 28-Jul-2020
DOI: 10.4103/sidj.sidj_22_20
Saint Int Dent J 2020;4:11-16.
Copyright: © 2020 The Saint's International Dental Journal
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This article was originally published by Wolters Kluwer Medknow Publications & Media Pvt Ltd and has now been officially transferred to Society of Dental Research & Education due to a change in publishing entity.
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease (COVID-19) has spread to almost every country of the world with the number of cases increasing exponentially almost everywhere. Recently, the number of cases in India are also on a rise, expecting to reach its peak very soon. The deadly virus has its impact on almost every sector and it has serious implications on dentistry. Dentists and particularly orthodontists treat a number of cases in a day without being able to maintain the appropriate distance between the individuals as advised by the WHO, which brings them to the top of high-risk group. This review is an attempt to compile material from the available literature to help reduce the risks involved the performing orthodontic procedures, prevent the transmit of this contagious disease at the orthodontic office and also suggests certain home remedies which the patient can use to tackle short-term orthodontic emergencies.
Keywords: Coronavirus, coronavirus disease 2019, orthodontics
The novel coronavirus disease (COVID-19) is an infectious disease caused by a member of the coronavirus viridae family of Nidovirales order (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]), perhaps originated in Wuhan, Hubei, China, in December 2019. The disease has spread to each nation within the world, with a sharp increase in the number of cases ever since its origin.[1] The epicenter of the outbreak has been persistently changing, and currently, the number of cases is showing exponential growth in India, with nearly every segment extremely influenced by the pandemic COVID-19.[2]
Individuals confirmed with COVID-19 develop SARS-like symptoms of respiratory tract infection, including fever, sneezing, coughing, vomiting, fatigue, loss of taste, and smell sensation, and severe pneumonia.[3,4] The disease onset could be mild, moderate, severe, or critical. Symptoms among infected individuals may vary from being asymptomatic to acute respiratory distress syndrome, septic shock, multiple organ failures, and even death in critical cases.[5]
Oral health-care providers and patients can be exposed to this pathogenic microorganism, and dental care setups invariably carry the risk of the 2019 nCoV infection due to the specificity of its procedures. The procedures include face-to-face communication with patients, frequent exposure to saliva, frequent spitting by the patients’ pre- and posttreatment, and the handling of sharp instruments.[6] Several studies have reported cross-transmission of COVID-19 among one health-care worker to another,[7] from health-care worker to patient and vice versa, or from patient to patient within the same facility.[8]
An orthodontist conventionally treats several patients in a day who belong to a variable age group. Adults, however, children have also been reported to be an asymptomatic carrier of the disease.[9,10] The incubation period of this disease is up to 24 days, and it is highly contagious during this latency period. It creates the possibility of disease spreading within the orthodontic center. Furthermore, aerosol generation procedures, which are a routine occurrence in the orthodontic clinic, are a corroborated route of infection transmission.[11-13]
The objective of this audit is to give bits of knowledge on risks involved in orthodontic clinics and about safety measures that must be followed in orthodontic offices. It additionally incorporates the management of orthodontic emergencies that the patients can endeavor at home. Both the orthodontist and the patient must corroborate to avoid the cross-contamination of this dangerous pandemic.
This review includes publications in English and non-English languages that matched the search terms up to May 30, 2020. Studies were retrieved from the following electronic databases: PubMed, MEDLINE, Scopus, CINAHL, and Google Scholar.
The main author, with the help of the research assistant, conducted the search using the following terms: COVID, COVID-19, 2019-nCoV, SARS-CoV-2, Corona, COVID, dental, dentist, dentistry, oral, orthodontic, Orthodontist, management, infection control, contamination, risks, and Transmission.
Works of literature that drop inside the scope of this survey were included and retrieved in full content. References of those articles were screened and utilized using the snowballing approach to discover additional pieces of evidence if left in general search.
The findings of these kinds of literature, including studies, are reviewed and discussed below. Due to the quickly advancing nature of COVID-19 and restrictions in quality of proving full accessible, peer-reviewed and more latest publications were given priority for this commentary.
Hand sanitizing of the patient before entering the clinic
We should provide a new mask and gloves before proceeding to the outpatient department
Past medical history of high fever, flu-like symptoms, cough, and travel history.
Orthodontists, or oral health-care providers in general, work in very close proximity with the patient, which keeps orthodontics at the highest point of acquiring an infection while performing the treatment procedures.[14] The current recommendation by the World Health Organization (WHO) of maintaining a distance of at least three-six feet[15] between individuals is practically not possible in a dental operatory owing to the nature of the treatment, which makes the orthodontist and the oral health-care providers’ assistant highly prone to infection.
Factors which increase the risk of COVID-19 transmission are as follows:
Use of hand drills in orthodontic practice
Cleaning residual adhesives
Insertion or removal of clear aligner attachment
Adjusting or making alterations in fixed orthodontic appliances.
Asstated in literature published, COVID-19 with long latency is a warning to orthodontist and the working team, since the infection transmission can lead to asymptomatic carriers and can spread infections to others.[16]
Saliva: Saliva is a promising noninvasive specimen for diagnosis by reverse transcription-polymerase chain reaction, monitoring, and infection control in patients with 2019-nCoV infection with detection of the virusin as much as 91.7% of the COVID positive specimenstaken.[17] Since the orthodontist works in close contact with the patient’s saliva, it is the foremost common source of contamination
Aerosol: Using a highspeed airotor handpiece during debonding or using an ultrasonic scaler during a dental cleaning or bracket bonding, produces aerosols a combination of materials originating from the treatment site and from dental unit waterlines, which can splatter in the operator’s room further and transmit infection.[18]
This aerosol is very likely to be contaminated with the patient’s blood, saliva, or high concentrations of infectious microbes like those produced by coughing or sneezing.[18,19] Moreover, aerosols containing microbes are found to reach as far as 2 m from the patient’s mouth.[20] This means that microbes could contaminate surfaces in the entire operatory. The aerosol could contaminate the dental unit waterline, resulting in the spread of infection.[21] Aerosols containing germs of 0.5–10 microns can remain airborne for as long as 20 min, increasing the risk of being inhaled and posing a potential infectious hazard.[22] This collectively presents a perilous risk with the highly contagious nCOVID-19.
Orthodontic instruments: While most of the archwires are individually packed, there is a significant risk of cross-contamination if an orthodontist reuses or recycles an improperly sterilized archwire.[23,24] In addition, orthodontic brackets, elastomeric chains, photographic retractors, debonding burs, mini-screws, and orthodontic markers, without sufficient sterilization and disinfection, are a potential hazard.[25] Orthodontic instruments including band seaters, band removers, pin and ligature cutters, and distal end cutters that come in direct contact with patients’ saliva and blood are considered dangerous as well.[26]
Strict adherence to the foremost up-to-date guidelines from central, state, and local public health authorities or dental regulatory bodies is essential for all orthodontists. In the current phase of the COVID-19 pandemic, most authorities have suggested that all elective and routine dental treatments ought to be suspended and that only emergency dental treatment can be provided. A real dental emergency is the one that deals with uncontrollable pain, swelling, bleeding, infection, and trauma to teeth or other soft and hard tissues of the head and neck. From an orthodontic perspective, orthodontic emergencies may include the impingement of a fixed orthodontic appliance into the gingiva or palate, periodontal abscess around the molar band, missing or broken bracket, pocky wire, broken or loose-ended fixed retainer, loose intraoral fixed appliances, or oral mucosa leading to severe pain and/or infection or other conditions where a lack of management could be harmful to the patient.[27]
The orthodontist must adhere to the following precautions in order to minimize the risk of transmission of infection at the orthodontic office:
To reduce the risk of infection transmission at the orthodontic clinic, the orthodontist must adhere to the following precautions:
Wherever possible, the orthodontist must first try to deal with an orthodontic emergency through the wireless communication mode
Patients should only be given an appointment after they confirm that they do not show any obvious signs and symptoms of the infection
Upon arriving at the dental clinic, the patient should be screened for any symptom of COVID infection, and its body temperature should be enlisted with contact-free forehead infrared thermometer or digital cameras with infrared temperature senses
Taking the medical history of the patient on preformed pro forma with specific COVID-19 relevant questions which should be filled by the patient before initiating any dental work should be made mandatory.[6]
This includes (travel history, clinical characteristics, and laboratory tests) with the following points:
History of high fever (37.3°C or higher) or use of antipyretic medication in the past 14 days
Complaint of lower respiratory tract infection, including dyspnea in the last 14 days
History of travel to a COVID-19 epidemic area or social contact with confirmed COVID-19 patient in the past 14 days.
If the patient is a suspected asymptomatic carrier, then the appointment should be rescheduled, the information should be conveyed to designated COVID-19 centers, and 14-day self-quarantine should be advised at home. A reported COVID-19 Patient with acute symptoms is unlikely to visit the orthodontic clinic, but if the patient has demonstrated any symptoms, recording, and referral to the COVID19 assigned hospital is mandatory.
Before emergency treatment, adequate sanitization with alcoholic hand hygiene solution and safety measures for a patient and specialized professional should provide personal protective equipment (PPE) such as disposable sleeve waterproof coats or Tyvek suits, disposable head cap, protective goggles or visor, disposable long shoe cover, and disposable double pair nitrile gloves.[28] Patients should be told to wear a mask (FFP2 or FFP3 facial mask) while they wait for their turn in the waiting area. COVID-19 is reported to transmit through contact of the virus with ocular mucosa; thus, any contact with mucosal tissue of the eyes, nose, or mouth should be avoided.[29]
5. A daily assessment should be done for the entire clinic staff, including the orthodontist, dental assistant, and janitor. Anyone displaying signs related to COVID-19 should be informed to COVID-19-assigned hospitals including prohibited to work with immediate effects
6. A mouth rinse using 0.12%–0.2% chlorhexidine gluconate before any procedure could help minimize the number of microbes within the oral cavity[30]
7. Aerosol-producing procedures should be strictly restricted[30]
8. As recommended by the WHO, both the office staff and the patient should follow manual hygiene measure to wash and adequately rub the hand with soap or 70% ethyl alcoholic-based solution for at least 20 s[6]
9. A strict surface disinfection protocol should be applied after every patient. A recentstudy reported SARS-CoV-2 viability up to 3 h in aerosol, with a half-life of 5.6 h on stainless steel and 6.8 h on plastic surfaces
10. Cutting efficiency of instruments with cutting tips such as pin and ligature cutters and distal end cutters is reduced upon autoclaving. Therefore, these instruments must be adequately disinfected with 2% glutaraldehyde or 0.25% PAA. Intraoral photography mirrors and cheek retractors also must be disinfected after every use. All the instruments upon autoclaving in sealed pouches or disinfection must be kept in UV chambers for storage until used for the next patient
11. Or thodon tic instruments can be a source of cross-contamination if they are not adequately sterilized or disinfected appropriately. According to the guidelines of disinfection and sterilization procedures, reusable instruments such as orthodontic pliers should be cleaned, sterilized, and disinfected after each treatment. Disposable waste should be disposed of and discharged in a double-layer yellow clinical waste bag with a special tag and should be tied with gooseneck knot
12. All working staff in dental setup must be specifically trained for don, doff, and dispose of COVID-19- or non COVID-19-related medical wastes. flushing dental unit water lines for at least 2 min or using disinfectants to improve the quality of water within the dental unit and minimize the risk of infection..
It is interesting to note that, despite having a high level of knowledge and taking all the necessary precautions, dentists all over the globe are living in a state of constant fear of acquiring the disease while performing routine dental treatments. This anxiety has led to the modification of their practices or duty hours, and most of the dentists are rendering emergency dental care only. Some of the dentists, mainly the elderly, have even shut down their practices.[30]
Here are some measures that can be taken to reduce the stress levels:
Attending continuing dental education sessions online cannot only enhance the knowledge of the orthodontist, but it can also create a positive change by reducing the anxiety levels
The role of local or central government and other dental decision-making authorities is very important in regulating the extra financial burden of the PPE kits or sanitization devices which the dentist has to bear. They must provide these at an affordable price to the dentist
Indulging in relaxation activities such as yoga or meditation during the free time can help reduce the stress. Sessions by trained psychologists and counselors must be provided to all dental health-care professionals
Finally, sound knowledge of the virus and its mode of transmission would also help alleviate anxiety among dental professionals.
The disease outbreak has not just created stress and anxiety among the orthodontists, but it has impacted the patient’s mental health as well. The orthodontic patients are expected to visit the orthodontist every 30–40 days, and failing to do so can adversely affect the treatment. The major stress that the patient encounters is regarding the delay in treatment time which unfortunately is inevitable, however, stress related to problems caused by broken orthodontic appliance or an impinging wire can be taken care of at home after a proper consultation with the orthodontist, and several measures suggested in Table 1 can be efficiently used to manage short-term orthodontic emergencies.
Table 1: Advice that can be provided to the patient for short-term management of orthodontic emergencies at homea
| Orthodontic complications | Management |
|---|---|
| Irritation caused by orthodontic bracket/band or archwire on lips/cheek due to friction between | Application of small piece of orthodontic relief wax over irritating bracket or wire mucosal tissue and brackets |
| Topical anesthetic gels such as Orabase (Colgate-Palmolive) or Dologel (Dr. Reddy’s Laboratories Ltd.) can provide relief from mouth sores | |
| Metal ligature which has become loose or is irritating | Use of sterile tweezer to remove the loose ligature |
| the mucosa | If a pigtail of the ligature is irritating the mucosa, it can be bent or bowed with a cotton bud or a pencil eraser |
| A loose orthodontic bracket or band or molar tube | If the bracket has become loose and the patient is cannot visit the orthodontist, the bracket can be removed with the help of a sterile tweezer If a bracket or tube which is used to anchor the elastics is broken, the use of elastics should be stopped immediately If the last bracket or tube of the arch is loose, the bracket or tube can be removed, and the extra wire cut with the help of a nail clipper. The nail cutter should be disinfected before and after use |
| Protruding wire at the end of braces | A protruding wire is sometimes a result of slipping away of the wire from one side to the other. In such a condition, a sterile tweezer can be used to pull back the wire Orthodontic relief wax may be used until an appointment with the orthodontist has been fixed A sterile nail cutter can be used to remove the extra wire |
| Any orthodontic bracket swallowed accidentally | Orthodontic bracket, if swallowed accidentally, is usually passed through the digestive tract uneventfully Only in cases where after swallowing, the patient feels difficulty in breathing or has sudden coughing, they are referred to a hospital emergency department |
| Broken bonded retainer | If the retainer is completely broken, the patient should remove the entire retainer and start wearing a removal retainer if provided by an orthodontist If the retainer is removed from one or two teeth only, the patient should try to bend the retainer so that it does not hurt, or they can attempt to cut the retainer from only these teeth with a cutter |
| Severe pain or infection in the gingiva caused by embedding of part of an orthodontic appliance in the gingiva | An attempt to remove such an appliance, especially a piece of wire, can be made by using a sterile clipper to cut it or a sterile tweezer to pull it out |
a Significance – Patient can manage orthodontic related problems at home without visiting clinics during COVID-19 Outbreak
Attention should be given to the following points while asking patients to handle an orthodontic emergency at home:
Patients should be informed about changes in the orthodontic clinic/office working as recommended by the local public health or dental regulatory authority
A wireless means of communication (mobile, telephone, video calling, and E-mail) should be provided to patients to enable them to contact the orthodontist and even send clicked images to their mobiles or E-mail. Remote communication facilities will help the patient solve and manage any orthodontic emergency problems that are easily manageable at home
Patients should also be reminded always to wash their hands before and after placing and removing appliances or elastics.
Table 1 is adapted from online resources posted on the website of the American Association of Orthodontists, British Orthodontic Society, and circulations of the Indian Orthodontic Society.
These home remedies can be attempted for short-term management only. However, not all the problems can be solved at home and the patient only in case of serious emergencies should plan an appointment with the orthodontist.
In this challenging time of COVID 19, the orthodontist, dental office staff, and the patient should work in synchrony to minimize the risk of transmission of the deadly infection being transmitted among themselves. The orthodontist needs to stick exclusively to the guidelines issued by the concerned authorities and adopt all the fundamental preventive measures in the dental office. The patient should also attempt to tackle the emergencies at home after consultation with the orthodontist before planning a visit to the orthodontic office. The orthodontist should also be accessible via E-mail or by phone/video call and guide the patient in every possible way. We can conquer this highly contagious virus only by working together in emergencies and helping each other out.
The current therapeutic strategies and our best weapon for dealing with these novel respiratory tract viruses (CoVs-19) are only supportive and preventive measures that will help to reduce CoVs-19 in community transmission. In Italy, in northern regional areas, including all countries initially, and then eventually around the peninsula, political and health authorities are making extraordinary attempts to control a pandemic wave that is seriously threatening the global health system. The authors have used a tool known as the “StatPearls,” a platform within the PubMed scenario to collect information and scientific evidence and to provide an overview of the topic that can continuously be updated.
Nil.
There are no conflicts of interest.
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