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The culprit, SARS-CoV-2

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What is the direct correlation between dental treatment and the spread of the COVID-19 virus?

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What is the direct correlation between dental treatment and the spread of the COVID-19 virus?

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The World Health Organisation (WHO) has recently declared global pandemic due to the Coronavirus disease 2019, also known as COVID-19. The disease was first identified in 2019 in Wuhan, China and has rapidly spread throughout the world resulting in the pandemic. COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of 25 March 2020, WHO has summarised the COVID-19 outbreak situation as 375,498 confirmed cases, 16,362 confirmed deaths and 196 countries with cases.
People can catch COVID-19 from others who have the virus. The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth. People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets. This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick.The incubation period of this virus is said to be can be up to 14 days, which certain individual can become carriers which do not exhibit any symptoms.

According to the WHO, the most common symptoms of for patients with COVID-19 usually of fever - Fever on presentation 45%. Fever during the period of illness about 85%, cough (65-80%) and myalgia. Some patients may also have a runny nose, sore throat, nasal congestion and aches and pains or diarrhoea. Notably, about 80% of people who get Covid-19 experience a mild case that resemble flu like symptoms and seasonal allergies which is about as serious as a regular cold and recover without needing any special treatment. This might lead to an increased number of undiagnosed cases.

About one in six people, the WHO says, become seriously ill. Severe forms have a predilection for males with a mean age of 56 years. The elderly and people with underlying medical problems like high blood pressure, heart problems or diabetes, or chronic respiratory conditions, are at a greater risk of serious illness from Covid-19.

Some dental procedures are aerosol-based, such as scaling and root planing. Thus, this may lead to airborne droplets of the patient’s saliva, which potentially containing COVID-19 virus to hang in the air. Other dental procedures involve respiratory droplets mixed with saliva and blood that can contain the virus. Although face masks and face shield can protect the dental practitioners from these, but the chances of cross infection still exist as not everyone who walked into the dental clinic wears a face mask and face shield.

Although low scientific evidence proved that COVID-19 virus can be spread through aerosol, but the genetic nature of COVID-19 highly imitates coronavirus, the possibility to spread through aerosol and respiratory drops remains high. The aerosols and respiratory droplets are micro-sized and may remain in the air for a long time, this potentially increase the risk of infection of other exposed individuals.

If a dentist is treating a patient diagnosed with COVID-19 or suspected of having been exposed to the virus, then the treating dentist and any auxiliary staff involved in that treatment should follow the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease (COVID-19) in Healthcare Settings and utilize N95 respirators and surgical face masks/gowns per the recommendations of the U.S. Food and Drug Administration, the CDC, the National Institute for Occupational Safety and Health, and the Occupational Safety and Health Administration.

In a nutshell, dental personnel are extreme at risk of COVID-19 infections. Great care must be taken before, during and after dental treatment. Our close contact with patients and the nature of dentistry which works closely with the oral cavity & all the related aerosols are contributing factors to this. Nevertheless, in our practice, safety comes paramount and we must not be negligent when it comes to infection control

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There are no Drug Administration (FDA)-approved drugs specifically for the treatment of patients with COVID-19.  At present clinical management includes infection prevention and control measures and supportive care, including supplementary oxygen and mechanical ventilator support when indicated.  An array of drugs approved for other indications as well as several investigational drugs are being studied in several hundred clinical trials.

However, US National Institutes of Health (NIH) announced that the drug in question, remdesivir, is being used in the country’s first clinical trial of an experimental treatment for COVID-19, the illness caused by the SARS-CoV-2 virus.

Previous research in cell cultures and animal models has shown that remdesivir can block replication of a variety of coronaviruses, but until now it has not been clear how it does so. The researchers, from the University of Alberta, US, and Gilead, studied the drug’s effects on the coronavirus that causes Middle East Respiratory Syndrome (MERS). They found that remdesivir blocks a particular enzyme that is required for viral replication. Coronaviruses replicate by copying their genetic material using an enzyme known as the RNA-dependent RNA polymerase.

Using polymerase enzymes from the coronavirus that causes MERS, scientists in Götte’s lab found that the enzymes can incorporate remdesivir, which resembles an RNA building block, into new RNA strands. Shortly after adding remdesivir, the enzyme stops being able to add more RNA subunits. This halts genome replication.The scientists hypothesise that this might happen because RNA containing remdesivir takes on a strange shape that does not fit into the enzyme. To find out for certain, they would need to collect structural data on the enzyme and newly synthesised RNA.

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MANAGEMENT OF COVID-19:  NON-PHARMACOLOGICAL COUNTERMEASURES

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MANAGEMENT OF COVID-19:  NON-PHARMACOLOGICAL COUNTERMEASURES

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The implementation of non-pharmacological approaches in minimizing the spread of the 2019 novel coronavirus (2019-nCoV) in the population. The guidance of the application of non-pharmacological approaches towards the 2019-nCoV is based on the current knowledge of the 2019-nCoV and evidence available on other viral respiratory pathogens which are the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV), the Middle East Respiratory Syndrome-related corona virus (MERS-CoV) and seasonal or pandemic influenza viruses.

The main objective of non-pharmaceutical countermeasures is to minimize the impact of an outbreak by minimizing the number of contacts that result in disease transmission via the mode of transmission of corona viruses which are by direct contact through large respiratory droplets. To date, human-to-human transmission through direct contact is the most common transmission mode for 2019-nCoV. A precautionary approach is recommended even though there is no evidence on airborne transmission. This is due to the fact of uncertainties surrounding the potential for aerosol-mediated transmission of the virus.

The non-pharmaceutical countermeasures can range from standard precautions, such as hand, respiratory and environmental hygiene, in the form of personal protective action taken by individuals, to actions requiring the engagement of communities and the involvement of local, regional or national authorities (i.e. social distancing and travel-related measures). One of the non-pharmacological countermeasures is personal protective measures which refer to hand and respiratory hygiene, cough etiquette and use of respirators or facemasks.

Hand hygiene refers to the frequent washing of hands with soap and water or cleaning of hands with alcoholic solutions, gels or tissues. The activity of washing hands should be regularly performed using soap and water for 20 seconds. The risk of transmitting or acquiring 2019-nCoV infection can be decreased by the correct application of hand hygiene. Alcohol-based hand sanitisers give limited added benefit over soap and water in community settings. The alcohol-based hand sanitisers should contain 60−85% alcohol. If hands are soiled, then soap and water should precede the use of alcohol-based hand sanitisers. Proper hand hygiene will need to be performed immediately before and after contact with a patient, before wearing or removing personal protective equipment (PPE) and after contact with potentially infectious material in healthcare settings. The same applies to patients or people caring for patients at home. The effectiveness is likely to increase in combination with other measures such as the usage of facemasks in healthcare settings.

Cough etiquette is defined as an activity of covering the mouth and nose when coughing and sneezing by using a paper tissue or cloth handkerchief with the aim of reducing person-to-person transmission through droplets. Cough etiquette is widely recommended in public health guidelines for all community settings (home, schools, workplaces, healthcare settings, etc.) at all times because droplet is the mode of transmission of corona viruses.

The application of face mask can protect against larger respiratory droplets but are not guaranteed to protect users from airborne infection whereas respirators are specifically designed to protect users from small airborne particles, including aerosols. Surgical masks or respirators should be changed frequently. As a general rule, a mask should be changed as soon as it becomes moist and, in healthcare settings, whenever moving from one patient to another.

The groups who are at risk of high-exposure are care-providers for symptomatic suspected 2019-nCoV cases (before their hospitalisation) and also people in occupations who have extensive face-to-face contact with the public where there is ongoing transmission. These groups should consider the use of surgical masks. Furthermore, consideration in wearing the surgical mask for groups at risk of developing severe complications if infected (e.g. individuals in older age groups or having underlying conditions). In the community setting, even though surgical masks are used as infection control measures when worn by individuals with symptoms, there is no evidence on the usefulness of facemasks worn by persons who are not ill as a community mitigation measure.

One of the measures to reduce the impact of this pandemic is to practice social distancing. In view of this, the Ministry of Health (MOH) has recommended social distancing measures for individuals at workplaces, families at home and also schools and childcare. The MOH encourages employees to stay home and notify workplace administrators when sick. If they develop symptoms at work, they are to avoid contact with fellow employees and inform employers. Furthermore, increasing physical space between workers at the worksite (1 metre apart) and also encourage the no handshake policy.

Self-isolation of individuals with symptoms of a respiratory infection is one of the most important measures for reducing disease transmission and limiting the spread of the virus in the community during an epidemic. During a community mitigation phase, this measure refers to persons presenting with an acute respiratory infection and probable or confirmed 2019-nCoV virus infection, who do not need hospital care. Therefore, individuals at increased risk of severe illness (e.g. those with chronic diseases) should avoid crowded places.

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The most serious complication of a SARS-CoV-2 infection is a type of pneumonia that’s been called 2019 novel coronavirus-infected pneumonia (NCIP). Results from a 2020 study revealed that 138 people admitted into hospitals in Wuhan, China, with NCIP found that 26% of those admitted had severe cases and needed to be treated in the intensive care unit (ICU).

About 4.3% of these people who were admitted to the ICU died from this type of pneumonia. It should be noted that people who were admitted to the ICU were on average older and had more underlying health conditions than people who didn’t go to the ICU.

So far, NCIP is the only complication specifically linked to the 2019 coronavirus. Researchers have seen the following complications in people who have developed COVID-19, such as acute respiratory distress syndrome (ARDS), irregular heart rate (arrhythmia), cardiovascular shock, severe muscle pain (myalgia), fatigue and heart damage or heart attack.

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According to research by Cascella et al, preliminary data suggests the reported death rate ranges from 1% to 2% depending on the study and country. The majority of the fatalities have occurred in patients over 50 years of age. Young children appear to be mildly infected but may serve as a vector for additional transmission.

According to a report by WHO, the severity of COVID-19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks. Children of all ages are susceptible to the disease, but are likely to have milder symptoms and a much lower chance of severe disease than adults; in those younger than 50 years, the risk of death is less than 0.5%, while in those older than 70 it is more than 8% ( Zhang et al, 2020). Pregnant women may be at higher risk for severe infection with COVID-19 based on data from other similar viruses, like SARS and MERS, but data for COVID-19 is lacking (CDC).

Many of those who die of COVID-19 have pre-existing (underlying) conditions, including hypertension, diabetes mellitus, and cardiovascular disease. The Istituto Superiore di Sanità (ISS) reported that 88% of overall deaths in Italy had at least one comorbidity. An additional report by the ISS reported that out of 10.4% of deaths where medical charts were available for review, there were at least one comorbidity in 97.9% of sampled patients with the average patient having 2.7 diseases. According to the same report, the median time between onset of symptoms and death was nine days, with five being spent hospitalized. However, patients transferred to an ICU had a median time of six days between hospitalization and death. In a study of early cases, the median time from exhibiting initial symptoms to death was 14 days, with a full range of six to 41 days. In a study by the National Health Commission (NHC) of China, men had a death rate of 2.8% while women had a death rate of 1.7%. Histopathological examinations of post-mortem lung samples show diffuse alveolar damage with cellular fibromyxoid exudates in both lungs. Viral cytopathic changes were observed in the pneumocytes. The lung picture resembled acute respiratory distress syndrome (ARDS). In 11.8% of the deaths reported by the National Health Commission of China, heart damage was noted by elevated levels of troponin or cardiac arrest (Zheng YY et al, 2020).

Availability of medical resources and the socio-economics of a region may also affect mortality.Estimates of the mortality from the condition vary because of those regional differences, but also because of methodological difficulties. The under-counting of mild cases can cause the mortality rate to be overestimated. However, the fact that deaths are the result of cases contracted in the past can mean the current mortality rate is underestimated.

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From the public health point of view, COVID-19 changes the whole game. Much emphasis is now given on basic hygiene practices and less on treatment. It is truly a “prevention is better than cure” scenario since there is no real cure (yet)!

THE COVID-19 virus has condemned many people in their homes due to their counries own form of containment orders. From the most stringent of lockdown to the harder to enforce, but more liberal social distancing measures. But the objectives are all the same, to prevent the spread of the disease & to reduce the burden of hospitals everywhere.

The utilisation of big data technology and artificial intelligence in analysing the chain of transmission is also leading edge techniques that we should observe and learn from.

Socially, it has changed the landscape of globalisation possibly forever. What was once the proud achievement of mankind to have created an ever-connected world also seems to have been its Achilles heel. International travel ground to a halt and economies faltering are some of the more obvious effects of COVID-19 amongst many, mostly negative consequences.