key: cord-1030782-7z6nw59t authors: Pruthi, Gunjan; Parkash, Hari; Vijaya Bharathi, P.; Jain, Radhika; Gupta, Arpit; Rai, Sachin title: Comprehensive guidelines to practice prosthodontic procedures and implant treatment during COVID-19 era: A narrative review date: 2020-10-17 journal: J Oral Biol Craniofac Res DOI: 10.1016/j.jobcr.2020.10.010 sha: 6b65826b9ebbfc17b208d2cba346a32a7e9b1b4e doc_id: 1030782 cord_uid: 7z6nw59t OBJECTIVES: To present a comprehensive review of current literature available on Corona virus disease and dentistry, modifications required in dental and laboratory settings; and recommended disinfection protocols in current scenario. Special emphasis has been given to discuss guidelines for handling different prosthodontic procedures and implications of this pandemic on prosthodontic practice, education and research. MATERIALS AND METHODS: Relevant literature pertaining to COVID-19 and dentistry was scrutinized on electronic search engines including PubMed, EMBASE and Cochrane. Guidelines given by various organizations, institutions, national and international regulatory bodies and Indian Prosthodontic Society were also consulted to gather information pertaining to the objectives of our review. RESULTS: and observations: A total of 160 articles including cross-sectional studies, in vitro study, narrative reviews, letters to the editor and opinions were found to be relevant in accordance with our search strategy. Documented literature revealed that Covid-19 pandemic has culminated in serious clinical, financial and psychological implications in the field of dentistry. Certain steps such as adoption of teledentistry, judicious use of protective equipment, use of rubber dams, pre-procedural rinses have been suggested unanimously. However, there is a dearth of evidence-based recommendations in literature. Data regarding consequences of delaying prosthodontic procedures and patients’ perspectives is also sparse. CONCLUSION: The COVID-19 necessitates the need to adopt a balanced approach while treating patients and safeguarding the dental professionals at the same time. Risk-benefit ratio has to be assessed along with stringent following of guidelines and disinfection protocols to combat this unprecedented situation. 2019 when China informed World Health Organization (WHO) of rampant spread of pneumonia-like cases. 1 On March 11, 2020, Covid-19 was declared as a pandemic, a public health crisis that is still having a rippling effect in every sector. 2 Due to its implications, dental healthcare has faced several clinical, psychological and financial repercussions, having unforeseen consequences on dental professionals, patients and lab personnels. 3, 4 Covid-19 virus, having diameter in the range of 100 nm, primarily transmits through person to person contact and direct contact with respiratory droplets. 5 The word 'corona' is derived from its appearance as 'crown-like' while being observed under the electron microscope. 6 It primarily transmits through person to person contact and direct contact with respiratory droplets. Spread through asymptomatic carriers has also been recently documented and is one of the major reasons for creating fear and dilemma in the minds of dental practitioners. 7 The close proximity to oral fluids, aerosols and long incubation period of the virus, place the dental fraternity at a high risk of contracting and transmitting the virus. 8 Ministry of health and family welfare (MOHFW), India has formulated specific guidelines and is playing a pivotal role to constantly update them with changing dynamics of disease. At present, only emergency and urgent procedures have been recommended to be taken up, with extreme focus on personal protective equipment and disinfection protocols. 9 However, the fleeting nature of specialty-wise guidelines and overlap of recommendations given by various organizations; has convoluted its implementation in regular dental setup. 10 The prosthodontic procedures especially need to be modified during the COVID times. The target population, comprising of the geriatric group with or without comorbidities, post-cancer immune compromised patients or patients with extra-oral J o u r n a l P r e -p r o o f maxillofacial defects requiring prosthetic rehabilitation, makes it imperative to lay down guidelines which are versatile and compliant by the patients and doctors as well. 11, 12 The prosthodontist community has to deal with multiple saliva-and blood-contaminating articles which can serve as a potent source of viral transmission. The overwhelming dependence on the aerosol generating instruments during prosthodontic rehabilitation needs urgent and innovative strategies to combat the spread. Sudden lockdown world-wide has left many prosthodontic procedures pending at different steps. The indispensable role played by the laboratory in the prosthodontic reconstruction cannot be undermined and hence extra caution needs to be taken at every checkpoint: collection of the dental impression, pouring of the models, designing and fabrication of prosthesis, finishing and polishing using lathe-driven machines and delivery of the final work at the clinics. Additionally, the consequences can be financially and psychologically devastating for patients, the clinicians and; the lab personnel who have not received their payments owing to incomplete procedures. 13 Thus, with a basic question in mind that how prosthodontics should be practiced during COVID-19 pandemic, an effort has been made to review the existent literature and guidelines from different national and international sources and suggest implementation of a systematic workflow by the dental professionals to ensure a safe practice. Extensive search of literature was performed on electronic database PUBMED, EMBASE and Cochrane by three authors (VB, RJ and GP). Figure 1 depicts the sequential steps involved in procuring the data and analyzing the shortlisted articles. The keywords/medical subject headings (MeSH) terms used for the search strategies were ("Covid-19" OR "coronavirus") AND ("prosthodontics" OR "dentistry") AND ("guidelines" OR "review"). Cross sectional surveys and studies, in vitro studies, retrospective studies, literature reviews and letter to Editor, opinions, editorials published in English language till 30 th June 2020 were included. Duplicate articles and articles in language other than English were excluded. Several guidelines recommended by various international and national organizations such as World Health organization (WHO), Centers for disease control and prevention (CDC), Ministry of health and welfare, India and Indian Prosthodontic society (IPS) were also referred to. Certain opinions expressed in the review are on the basis of clinical and academic experience of the authors. Statistical analysis was not performed because of the heterogeneity of the data and lack of clinical trials published so far. Distribution of types of publications and their country wise representation have been given in Graphs 1 and 2. Various reviews on guidelines and recommendations have been published in literature based on current scenario of pandemic in different countries. It is proposed to follow these guidelines to ensure a safe practice; which are hereby discussed as general (applicable to all dental professionals) and prosthodontic specific considerations. As per the need of the hour, entire clinical setup has been recommended to have separate areas for donning/ doffing, a separate sterilization room along with the segregation of areas into different zones (Fig. 2 ). 14 Its feasibility depends upon basic infrastructure, total area available, number of auxiliary health workers and number of patients reporting per day; all these vary substantially in Government hospitals and private set ups. This area is dedicated to gaining basic information about the patient using individual clinic or institution-based protocol. Non-contact temperature recording, sensor taps, contactless sanitizer dispensers are essential additions in this zone. Here the patient is requested to remove accessories like jewellery, watch etc. and sanitize their hands thoroughly. 15 One attendant per needy patient is preferable owing to the norm of maintaining physical distancing. 16 Patient should be provided with triple layer facemask, disposable shoe-covers, head cap and gloves. A glass barrier can be installed at the reception counter to avoid transmission of droplets between patient and the staff. 17 A screening form (in local and national languages) (Fig. 3 ) and an informed consent should be duly filled by the patient in the language of his or her preference. Online consent before physical attendance of the patient is advisable, keeping the online signature on record. Posters can be designed and displayed to educate patients regarding hand hygiene, respiratory etiquettes etc using one's creativity. A pulse oximeter is a noninvasive, wireless finger tool recommended in screening area for monitoring of significant changes in arterial oxygen saturation in considerably less time, especially in asymptomatic individuals. 18 If the oxygen saturation is less than 93%, referral to a physician for detailed screening is advisable. 19 In India, the use of the indigenous "Aarogya setu application" facilitates COVID-19 contact tracing, and self-assessment. 20, 21 "Namastey campaign" was also started to minimise the transmission of the virus. 22 Non-overlapping appointments with a gap of at least 15 minutes, physical distancing, digital payments are few other recommendations to be followed. 14 J o u r n a l P r e -p r o o f Initial screening and diagnosis, using sterilized instruments is to be done in this zone. Maximum viral load is present at disease onset, mainly in the upper respiratory tract. 23 According to Bidra et al, pre-procedural mouth rinse using oral preparation of Povidone-Iodine (PVP-I) in a concentration as low as 0.5% for at least 15 seconds can completely deactivate the virus. 24 The strong virucidal activity of povidone iodine can be effectively exploited by employing it as mouth gargle against COVID-19. 25 However lack of evidencebased research including randomized controlled trials warrants discretion before any final recommendation. Other chemical based mouth rinses advocated to disrupt the viral lipid membrane include ethanol, chlorhexidine, cetylperidinium chloride and hydrogen peroxide. However, their efficacy specifically against coronaviruses needs to be confirmed. 26 During this phase, an Orthopantomogram (OPG) and cone-beam computed tomography (CBCT) are recommended rather than the intraoral radiographs to prevent salivary contamination. 27, 28 But OPG lacks diagnostic precision and CBCT exposes the patient to a higher radiation dose as compared to an intraoral radiograph. 29 In house facility of taking digital radiographs is preferred rather than sending patients outside for this purpose. ii. This section involves dentist performing those procedures where the use of airotor handpieces and ultrasonic scalers is not incorporated. Hence, priority is given to hand instruments such as spoon excavators and chemical-based caries removal agents. PPE is the sole effective method within the limit of administrative, environmental controls to prevent the spread of infection. 30 The donning and doffing should be done in the specified dedicated areas following sequential steps as lay down by CDC. 31 Four-hand dentistry with involvement of digital workflow is suggested. 32 The use of high-speed hand pieces generates aerosols that are defined as particles which are less than 50 micrometers in diameter. 33 It has been postulated that aerosols have a tendency to remain suspended for at least 30 minutes even after the completion of the procedure and can reach up to 2 feet from the dental chair. 34 As the risk of transmission is high in this area and even the false negative rate of Covid Antigen test is around 30%, it becomes imperative to adopt universal precautions / OSHA guidelines. 35, 36 Only essential items should be kept in open while maximum material and instruments should be kept in closed cabinets. MoHFW has suggested avoiding switching on ceiling fans during such procedures; frequent servicing of air conditioners and; blocking the return air vents in centrally air conditioned operatories. 9 Use of carpets should be discontinued. However, in clinics that are already established and have a limitation due to lack of space and ventilation, it is advisable to filter the contaminated room-air using high volume evacuator and high efficiency particulate arrestor (HEPA) filters. 37 Although expensive option, the HEPA filters have been documented to remove 99 % of particles measuring 0.3 microns in diameter. 8 According to the filtration efficiency, HEPA-13 or H-14 are recommended and the size depends on the total area of the clinic. However, it must be emphasized that these filters are an adjunct to the core strategies needed to combat the transmission. There is paucity in evidence-based research highlighting their role in COVID-19 era. Another recommendation, is the incorporation of the negative pressure rooms to treat the suspected or confirmed cases of COVID-19. 37 Sufficient ventilation, both mechanical and natural with the help of exhaust fans, is suggested to ensure dilution of viral load and expulsion of infected air. 39 In addition to the above precautions, a prior COVID test for patients undergoing aerosol generating procedures is advisable depending upon the feasibility and resources available. 40 It is generally preferred to conduct such procedures during the latter part of the day or keeping a gap of 2 hours before taking up the next patient. Eight o'clock chair position should be J o u r n a l P r e -p r o o f avoided completely to avoid direct contact with the splatter. 6 Rubber dams, low-speed antiretraction hand piece and high-volume suctions rather than chair side suctions are highly recommended. 39 According to Peng et al, rubber dams are capable of reducing airborne particles by 70% within three feet wide operatory. 32 Teledentistry must be encouraged as the first mode of interaction between a dentist and a patient during the COVID era. 41 It serves as an effective means to evaluate the intensity of the patient's complaint, thereby categorizing the procedure into an emergency or urgent one. 42 Lending a patient ear to someone ensures ease in anxiety and fear amongst the distressed population. 43 It helps the practitioner to record a detailed case history without coming in actual contact with the patient. Education posters regarding hygiene or respiratory etiquettes, screenshots of updated Aarogya setu App can be shared between dentist and patient on the phone itself. Video call with the patient can also help to understand the situation better and guide them as required. 44 However, in view of difficult access and understanding in lower socioeconomic groups in India, this facility has limited significance. Other limitations include undue prescription of antibiotics and analgesics instead of treating etiology may sometime worsen the situation and expose the patient to a higher risk and side effects. The selection of right mask in a "proper fit-checked" manner is an absolute necessity measure for the frontline workers while screening and treating the patient. Prevention of cross infection and disinfection of the clinic and laboratory as well are essential steps to maintain a pristine environment by preventing the transmission. Chairside assistants, support staff and laboratory technicians should be trained and recruited on rotational basis with an aim to keep minimum workforce at a particular time. 6 disinfection for dental clinics and laboratories. 53 The advantages of ultraviolent radiation is that it is safe, does not leave any residues, an effective alternative to dangerous carcinogenic chemical disinfectants, has a wide spectrum of germicidal activity and can be used in presence of human beings. 54 , 55 But still it has to be used on individual discretion as it lacks evidence for its specific action against corona virus. Fumigation and fogging are two methods used for disinfection of clinics and laboratory. In fumigation, formaldehyde solution is mixed with potassium permanganate in a fixed proportion. This combination gives rise to fumes, which are very effective in killing bacteria, fungus and their spores but formaldehyde is a known carcinogen, hence fumigation is obsolete now. Fogging can be done with the mixture of hydrogen peroxide and silver ion solution or third generation quaternary ammonium compounds (QACs). 56 It is a rapid, effective and residual-free method making it a more preferred protocol for clinic disinfection. This method of "no-touch surface disinfection" usually takes 45 minutes followed by contact time/dwell time of an hour. It is recommended to carry out these procedures where circulation of clean and natural air is possible post procedure. 9 Dentists (Table 3) . 9 The implications of Covid in different sectors of dentistry have been depicted in table 4. This includes fabrication of complete and partial dentures. Age has been documented as primary risk factor for increasing COVID-19 mortality rate, compounded with the presence of co-morbidities. 57 Hence, a thorough medical case history is a must before starting any geriatric patient to evaluate risk versus need benefit. Completion of pending procedures must be given preference in comparison to starting of new cases to avoid unnecessary implications. Fomites can also lead to the spread of the virus. 60 Hence, impressions, which can act as route of spreading cross contamination between clinic and lab, should be disinfected (sodium hypochlorite 1% for ten minutes) and stored in disposable pouches. 61 If an external laboratory is involved, each work item must be separately stored in a sealed pouch and collected by the delivery boy. The delivery boy should also be provided with basic protective equipment. The prosthesis should be immersed in disinfectant before sending back to the clinic. Dentist can wash and store the prosthesis in a mouthwash before insertion in patient's mouth. Restorations should be fabricated on mounted models on an articulator. This will reduce the probability of repeating the procedure, time required for chairside adjustment, and use of micro motors or airotors. Consent for the final anterior restorations can be taken by sending the pictures to the patient before finalizing them. Lab personnel and technician should practice physical distancing, hand hygiene and optimal disinfection. Computer aided designed and milled restorations should be preferred over conventional casting. Casting metal invariably involves generation of fumes and splatter. Also, digital workflow is proposed to minimize the salivary contact between different materials. 58 Implant dentistry is the most fascinating and earning division for Prosthodontists these days. Deferring patients for placement of implants can lead to big financial and mental trauma to the dental and lab personnel. But implant treatment planning involves multiple dental visits which along with use of surgical aerosol generating hand pieces call for extreme precaution whereas use of osteotomes should be encouraged in order to reduce aerosol formation. 62 Immediate implants with immediate loading should be taken up wherever indicated as they require lesser time number of visits. It is advisable to avoid complex full mouth procedures. Digital impression with scan bodies is suggested as an alternative to conventional impression making. Implant impressions and components need to be carefully disinfected/ autoclaved before reusing them. Careful impression making using resin jig and precise pouring of the impressions are a must in order to prevent repetition of any chair-side step. Fabrication of surgical and interim obturators must be done at this time in order to restore the function of patients with intraoral defects. 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