This presentation showing the information about pandemic covid-19 situation. It is also including covid-19 in dental practice.

1. consideration
indental
practice
Prepared By: Dr. Riya Shah
(2nd Year PG in Periodontics)

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

3. About COVID- 19
Introduction

5. CHARACTERISTICSOF2019NOVEL CORONAVIRUS

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.

8. Prevalence
• Confirmed- 46,64,486
• Recovered- 17,08,969
• Deaths- 300,254
Worldwide:
• Confirmed- 90,927
• Recovered- 34,109
• Deaths-2872
In India:
• Confirmed- 11,380
• Recovered- 4499
• Deaths- 659
In Gujarat:

9. transmissibility

10. HOW doYOUget COVID-19?
Cough,sneeze,and
droplet inhalation
transmission
DIRECT
TRANSMISSION
Contact with oral,
nasal, eye and
mucous
membrane
INDIRECT
TRANSMISSION

12. STRUCTUREOFVIRUS

13. How
SARS-COV-2
BINDSTOTHE
HUMAN
CELL?

14. DENTAL
AEROSOLIZATION

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

19. WorkerExposure(OSHA2020)
Very
high
High
Medium
Low risk
Healthcare workers, laboratory personnel,
morgue workers performing autopsies
Medical transport workers, workers preparing
for cremation of suspected patients
Frequent exposure to people who may be
affected
Minimal occupational contact

20. Clinicalmanifestations
PANDEMIC (COVID-19)
Cough Fever Shortness
Of Breath
Sore Throat
● Atypical symptoms, such as muscle pain, confusion, headache
● Fatigue
● Diarrhoea and vomiting

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

23. LaboratoryDiagnosis

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

25. • Throat and nasal swabPreferred
sample
• Nasopharyngeal swab,
• Endotracheal aspirateAlternate:
Samplecollection

26. Respiratoryspecimencollectionmethods
Lower respiratory tract
Bronchoalveolar
lavage, tracheal
aspirate, sputum
Collect 2-3 mL into
a sterile, leak-proof,
screw-cap sputum
collection cup or
sterile dry container.
Upper
respiratory
tract
Nasopharyngeal
swab /
oropharyngeal swab

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

38. treatment

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.

44. “Dentistry”
During &
After
COVID-19
lockdown??
How to
REBOOTING
The Dental
Practice
After
lockdown??

46. Duringlockdown

47. EmergencySeverityAssessment

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
”

50. HowToPrevent AnOutbreak?
RECOMMENDATIONSFORINFECTION
PREVENTIONANDCONTROL

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.

59. WHOrecommendations

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

63. 63

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

69. 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

84. DEFOGGING:
•Hydrogen Peroxide Vapour ( HPV)
•Chlorine dioxide
Fumigation with aldehyde based
disinfectant is not recommended

86. BOOST
YOUR
IMMUNITY

87. COVID-19
IMMUNE
SYSTEM
BOOSTERS

88. AYURVEDIC
IMMUNE
SYSTEM
BOOSTERS

90. Ghavideldarestani M, Honardoost M, Khamseh ME. Role of Vitamin D in Pathogenesis and Severity of COVID-19 Infection.

91. Takehomemessage
/Mustdochecklist

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

93. CONCLUSION

94. Dentistryfortomorrow

95. THANKYOU..!!
For More Query:
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