Need to see a dentist during the pandemic?

Health care facilities are in much demand during the Covid-19 pandemic, but one branch of medicine that is not seeing any patients is dentistry. 

The patient cannot wear a mask, it is impossible for the dental surgeon to maintain physical distance during treatment, and patients, dentists and their nurses all face extended exposure to virus-carrying aerosols.

The World Health Organization (WHO) has advised patients to delay visiting their dentists during the pandemic, and the Nepal Ministry of Health has told dental surgeries to close during the lockdown period.

However, dentists interviewed for this overview told Nepali Times if there is one field of medicine that is most prepared to stop the spread of infections, and who were already following strict protocols, it is oral care.

“Long before Covid-19 dental clinics already had strict protocols to prevent the spread of airborne infections, so if any doctors already had  preventive measures in place it would be dentists,” says dental surgeon Sushil Koirala of the Punyaarjan Foundation.

Koirala says most dentists in the region were already following the WHO protocol from the SARS epidemic in 2003, and even before that dental clinic staff in Nepal have been taking precautions against tuberculosis, seasonal influenza, and other airborne pathogens.

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For the first four months of lockdown after March, the government ordered all dental clinics closed, and had allowed oral care departments in two hospitals to remain open for dental emergencies. However, they soon closed after staff tested positive for the novel coronavirus. 

From March to mid-July most dentists spoke to their patients on the phone about symptoms, and depending on the case, the patients were given advice, prescribed painkillers or antibiotics.

Over 90% of the cases were gum infections or tooth decay due to excessive snacking during the lockdown. Most could be treated with analgesics and mouthwash. 

“With the more serious cases, we practiced a crude form of telemedicine where we asked the patient to take a live video of their oral cavities so we could advise on a course of action,” Koirala says. “Some of my patients learnt to take really good selfies.”

Even when the restrictions were partially lifted on 21 July, clinics were still largely empty because the patients were too scared to visit, and the staff stayed away. Dental clinics then followed their standard protocols, adding new guidelines on pre-appointment interviews, disinfection of surgery after every patient, personal protective equipment, and procedures like limiting the number of patients and minimising contact.

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Some innovative clinics like Healthy Smiles in Kathmandu developed their own protocols a based on guidelines issued by the US Centre for Disease Control (CDC) and have made videos to illustrate the process to patients.

“As this is a droplet infection with aerosol transmission, our attempt is to minimise it with online screening of limited patients, social distance and masks, well ventilated rooms with negative pressure along with high vacuum dental suctions and a floor level exhaust at floor level,” explains dental surgeon Neil Pande of Healthy Smiles.

After every patient, the entire outer wear is changed by all to ensure no cross contamination between patients. The donning and doffing of PPE is carried out in a strict sequence and disinfected before cleaning. 

All the surfaces are decontaminated with 70% alcohol three times, once immediately after and other twice after, with an interval of one hour. Healthy Smiles actually got Nepali engineers to design and build its new ventilation system that sucks air out of the surgery and passes it through HEPA filters to decontaminate it.

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“We believe infection control to be one of the main pillars of the healthcare system, and it is even more important during this pandemic,” Pande says. “It has completely changed the face of dentistry.”

Elsewhere in developed countries, many dentists have defied the WHO’s recommendations saying they are already used to taking necessary precautions to prevent infections. 

In fact, they argue that patients may suffer other health complications if they cannot see their doctors in time, and that oral infections can worsen the outcome of patients with Covid-19.  

In Singapore, where a very strict testing and tracing regimen is in place, dental clinics have remained open and the flow of patients is at 80% of pre-pandemic level. In Australia, except in the state of Victoria, most dentists are seeing patients.

In Nepal, Punyaarjan Foundation has published a booklet and posters in Nepali that allow individuals and families to self-evaluate their own risk levels with various activities. 

Says Sushil Koirala: “Dentists are taught to be extra-cautious about infections, and with this publicity material we want to share that knowledge with the Nepali public -- that the only way to fight infectious disease transmission is through individual responsibility and discipline.

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