COVID-19: Suggestion of Management Algorithm for Dentistry

Aim: COVID-19 disease, first seen in 2019, has spread to many countries and regions quickly, and the number of confirmed deaths and cases continues to increase. Effective infection control can prevent the spread of the virus which would lead to bringing the pandemic under control. As the SARS-CoV-2 virus is present in salivary secretions, the risk of cross-infection in dental health services is high. In this study, a review of and recommendations for preventive measures and treatment procedures that are needed in dentistry in consideration with published studies and guidelines are provide. Materials and methods: Published studies and guidelines on COVID-19 were evaluated. Results: A review of and recommendations for preventive measures and treatment procedures that are needed in dentistry in consideration with published studies and guidelines are provide. Conclusion: During the pandemic, a simplified patient care flow chart was created in dentistry. The measures to be taken during patient care are summarized.


Introduction
Pandemics or pandemic diseases are epidemics that are widely spread such as a continent or around the world. Several epidemics were seen in the world from past to present such as Antonine Plague [1] (AD 165), Black Death [2] (1346-1353), and Third Cholera Pandemic [3] (1852-1860). COVID-19 disease, named by the World Health Organization (WHO) and first seen in the city of Wuhan in China at the end of December in 2019, is one of these epidemics [4][5][6].
The virus causing the disease was first named as 2019-nCoV [5].
Later, the name was revised as "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)" by the Coronavirus Study Group of the International Virus Taxonomy Committee [7]. The World Health Organization (WHO) declared this global pneumonia epidemic as a public health emergency of international concern. As of June 10, 2020, the number of diagnosed cases is over 7 million, and the number of deaths is over 404.000. In this study, a review of and recommendations are provided for preventive measures and treatment procedures that are needed in dentistry in this pandemic that has a high risk of spread.

General Symptoms and Modes of Transmission of the Disease
In general, fever, coughing, expectorating, sore throat, and headache are the clinical symptoms seen in patients with new coronavirus pneumonia. The disease has the stages of mild disease, pneumonia, severe pneumonia, acute respiratory distress syndrome, sepsis and septic shock, respectively [8,9].
Modes of transmission of the virus include inhalation of droplets formed during coughing or sneezing, and through oral and nasal mucosa. The entrance of the virus to the body is not limited to respiratory mucosa. The virus can enter through the conjunctiva of the eye as well [10,11]. In a study conducted by Sabino-Silva et al., three different paths were proposed for COVID-19 to appear in saliva [12]: First, COVID-19 in upper and lower respiratory tract enter the oral cavity through fluid droplets frequently exchanged by organs [7,13,14]. Second, COVID-19 present in blood can access the mouth through crevicular fluid which is an exudate unique to oral cavity including local proteins derived from proteins which are derivatives of extracellular matrix and serum [15]. Lastly, another way of COVID-19 to be present in the oral cavity is the minor and major salivary gland infection along with the release of particles in saliva through salivary tract. It should be noted that salivary gland epithelium cells can be infected with SARS-CoV-2 shortly after an infection in rhesus macaque which leads to the thought that salivary gland epithelium to be potentially an important source of the virus [16].
Virus can hang in the air for 3 hours through aerosols. It was found that the virus stays for 72 hours on stainless steel and plastic surfaces, for 8-24 hours on carton, and for 4-8 hours on copper surfaces [17]. Chest Computed Tomography and Real-Time Fluorescence polymerase chain reaction (RT-PCR) are used for diagnosis of the disease. Despite the high ratios of accuracy, these tests can't provide a 100% diagnosis of the disease [18,19].

Step 1-First Evaluation Prior To Physical Examination
We recommend an evaluation of the general condition and the need for dental treatment through a form to be filled online prior The last 2 questions are for the evaluation of the need for dental treatment. The X-ray taken in the last 6 months is evaluated to make a guess on the cause of the complaint the person described in the previous question. If one of the procedures requiring an emergency dental treatment described in step 2, the patient should be called in to the clinic for physical examination. The need of an emergency dental treatment of patients who responded "yes" to one of the first 5 questions should be evaluated by the dentist. The examination can be done by taking necessary and additional measures in the clinic, or in the patient's house or the hospital in which the patient is quarantined.

Step 2-Physical Examination
The physical examination of patients should be performed in private rooms. Mobile dental treatment services to be provided in patients' homes can be offered to prevent patients from leaving their homes and being in contact with other people and patients who contacted the dentist. The chair and the surfaces that the patient had touched before and after the examination should be cleaned with 70% ethanol or 0.1% sodium hypochlorite. Studies have shown that SARS, MERS, and SARS-CoV-2 coronaviruses can be disinfected with these solutions [20,21]. The safety measures to be taken by health professionals are published by WHO: [22] 1) Protective particle masks such as N95 masks certified by the USA National Institute for Occupational Safety and Health (NIOSH), European Union (EU) standard FFP2 or an equivalent should be used [23,24]. When disposable particle breathing device is used, a leak tightness control should be performed. It should be noted that beard may prevent the breathing device from fitting tightly [24].
2) Eye protection should be used (googles or face shield).
3) Clean, non-sterile, long-sleeve clothing and gloves should be worn. If the gowns are not water-resistant, then healthcare workers should use water-proof gowns for procedures that are expected to produce high levels of fluids that may penetrate the gown.
4) The number of people in the room should be limited to the absolute minimum required for patient care and support.
After the health professional takes preventive measures and before the patient is examined, 1% hydrogen peroxide or 0.2% povidone iodine gargle should be done [25]. Intraoral X-ray examination is the most common radiographic method for diagnosis in dentistry. However, it can induce saliva secretion and cough [26].
Therefore, extra oral radiography such as panoramic radiography and conical beam computed tomography should be preferred over intraoral radiography such as periapical X-ray.

Conditions Requiring Emergency Dental Treatment According to American Dental Association (ADA) Guidelines [27].
Dental emergencies that potentially threaten life: Other emergency dental care: 1) Extensive dental caries or defective restorations causing pain.
3) Denture adjustment on radiation/ oncology patients. 4) Adjustments or repair of dentures when function is impeded.

5) Changing temporary fillings in endodontic access cavities
in patients experiencing pain.

6) Cut or adjustments of an orthodontic braces or apparatus
that perforate the oral mucosa or causes ulceration In case of need for emergency dental treatments, step 3 should be followed.

Step 3-Dental Treatment Procedures
If conditions requiring dental treatment emerge following the examination, safety measures described in step 2 should be continued. Patient should do a 1% hydrogen peroxide or 0.2% povidone iodine gargle again. Regardless of aerosol formation in the procedure, health professionals must wear goggles [28].
Bacteria spread to several surfaces in a dental clinic was shown as a result of aerosols produced from rotation devices used in dentistry [29][30][31][32]. In a study conducted by Al-Amad et al., it was shown that the use of rubber-dam in dental procedures, despite its clinical benefits, is associated with higher bacterial aerosol levels in the head area [22]. Thus, we do not recommend using rubber-dam in dental procedures during this period.
High speed dental aerators without valves to prevent suction may aspirate and eject fluids and debris accumulated during dental treatment procedures. Microbes including bacteria and viruses can contaminate the air and water tubes in dental units more and potentially cause cross infection [25]. Therefore, aerators with valves for suction prevention should be used. High suction potential drain apparatus and saliva suction devices should be used to reduce aerosol secretion during treatment [33,34]. Portable treatment frames can be used to limit the spread of aerosol. In life threatening conditions of excessive bleeding, abscess blocking the airway and facial trauma, the patient should be redirected to a specialized doctor.  Plan an analgesic treatment Extensive dental caries or defective restorations causing pain 1) "Chemomechanical Caries Removal" methods can be preferred to reduce aerosol formation to minimum 2) Manage the process with temporary restorative methods if possible (silver diamine fluoride, glass ionomers)

Step 4-Medical Waste Management and Disinfection After Treatment
Medical waste should be moved to the temporary storage area of the medical institution. Re-usable dental devices should be sterilized according to the "Infection Control: Device and Equipment Sterilizations Protocols'' issued by the ''Centers for Disease Control (CDC)'' [35,36]. Areas within a diameter of 3 feet of the treatment area should be cleaned with 70% ethanol or 0.1% sodium hypochlorite. The room should be aired with airconditioning systems with filters.