Recommendations and Management in Dental Practice during Corona Virus COVID-19

The outbreak of novel coronavirus (2019-nCoV) pneumonia initially developed in one of the largest cities, Wuhan, in Hubei province of China last December and have become a major challenging public health problem for not only China but also countries around the world [1]. On January 30, 2020, the World Health Organization (WHO) announced that this outbreak had constituted a public health emergency of international concern [2]. The novel coronavirus was initially named 2019-nCoV and officially as severe acute respiratory syndrome coronavirus (SARSCoV-2). As of February 26, COVID-19 has been recognized in 34 countries, with a total of 80,239 laboratory-confirmed cases and 2,700 deaths [3].


ETIOLOGY
Coronaviruses are enveloped non-segmented positivesense RNA viruses belonging to the family Coronaviridae and the order Nidovirales and broadly distributed in humans and other mammals similar to SARS-CoV and Middle East Respiratory Syndrome coronavirus (MERS-CoV). SARS-CoV-2 is zoonotic, with Chinese horseshoe bats (Rhinolophus sinicus) being the most probable origin [4, 5].

MODE OF TRANSMISSION
Based on genetic and epidemiologic research, it has been found that the COVID-19 outbreak started with a single animal-to-human transmission, which later followed human-tohuman spread [4]. It is now believed that its interpersonal transmission occurs mainly via respiratory droplets and contact transmission [6]. Recent study has found COVID19 in the saliva of infected patients [7]. The COVID-19 outbreak is a reminder that all dental and other health professionals must always be diligent in protecting against the spread of infectious disease. It has been observed in one study that asymptomatic patients and patients in their incubation period are also carriers of SARS-CoV-2 [4].

INCUBATION PERIOD
5 to 6 days is the estimated incubation period of COVID-19, but there is evidence that it could be as long as 14 days, which is now the commonly adopted duration for medical observation and quarantine of (potentially) exposed persons [8].

FATALITY RATE
According to current data, the fatality rate (cumulative deaths divided by cumulative cases) of COVID-19 is 0.39% to 4.05%, which is lower than that of SARS (severe acute respiratory syndrome; ≈10%) and MERS (Middle East respiratory syndrome; ≈34% [9].

HIGH RISK OF INFECTION
People of all ages are generally susceptible to this new infectious disease. But those who are in close contact with patients with symptomatic and asymptomatic COVID-19, including health care workers and other patients in the hospital, are at higher risk of SARS-CoV-2 infection. In an analysis of 138 hospitalized patients with COVID-19 in Wuhan, 57 (41%) were presumed to have been infected in hospital, including 40 (29%) health care workers and 17 (12%) patients hospitalized for other reasons [10].

CLINICAL FEATURES
The coronavirus infection in humans frequently presents with mild severity which includes fever, cough, and acute respiratory disease. Other atypical symptoms include muscle pain, confusion, headache, sore throat, diarrhea, and vomiting [1]. However, severe cases lead to pneumonia, kidney failure or even death [10]. In general, older age and the existence of underlying comorbidities (e.g., diabetes, hypertension, and cardiovascular disease) were associated with poorer prognosis [4, 6].

DIAGNOSIS
The diagnosis of COVID-19 can be based on a combination of epidemiologic information (e.g., a history of travel to or residence in affected region of 14 days prior to symptom onset), clinical symptoms, CT imaging findings, and laboratory tests (e.g., reverse transcriptase polymerase chain reaction [RT-PCR] tests on respiratory tract specimens). It has been observed that a single negative RT-PCR test result from suspected patients does not exclude infection. Clinically, we should be alert of patients with an epidemiologic history, COVID-19-related symptoms, and/or positive CT imaging results [10].

RECOMMENDATIONS AND PRECAUTIONS FOR DENTAL PRACTICE
COVID19 has been put under the category of group B infectious diseases and all health care workers have been advised to use protection measures reserved for extremely infectious pathogens, All routine dental procedures that can produce aerosol [a] or droplet should be suspended till the time respective government has announced lockdown. It is safe to advise prescription to patients on phone or online guiding them. A detailed history of patient who has history of recent [b] travel to any epidemic regions or has been quarantine for 14 days along with fever, cough, sneezing, or COVID-19 related symptoms or contact with a close family member who is confirmed with the infection is advised to undergo a medical examination in a designated hospital.

Patients and their accompanying persons are provided [c]
with medical masks, hand sanitizer and temperature measurement once they enter dental hospital. surfaces up to 9 days at room temperature. Therefore, after every patient treatment, environmental cleaning and disinfection procedures by chemicals approved for COVID-19 is mandatory. Alternatively, patients could be treated in an isolated and well-ventilated room or negatively pressured rooms if available for suspected cases with COVID-19.

CONCLUSION
Currently, the approach to COVID-19 is to control the source of infection. Prevention and control measures like hand hygiene, protective equipment and respiratory hygiene should be updated in all dental clinics. Early diagnosis by quick pathogen tests, isolation, and supportive care for affected patients can lower the risk of transmission.