**3. Measures to protect individuals from the COVID-19 outbreak**

In order to be protected from the COVID-19 pandemic, CDC recommends additional infection prevention and control measures to be applied for all patients in addition to standard routine healthcare practices due to the nature of the pandemic. Some of these guidelines a applicable to all settings where healthcare services are provided, while others are not designed for environments other than healthcare facilities (e.g., restaurants, cafes, shopping malls, entertainment centers). Guidelines generally include information about the ways of transmission of COVID-19, patient care and management, patient triage protocols, complications that may develop due to the disease, telehealth strategies, various transportation vehicles and medical equipment transportation, or laboratory working conditions and raising awareness. For example, while requesting a dental examination for patients with suspected or confirmed SARS-CoV-2 infection, it is recommended to use triage protocols to understand whether this appointment is necessary or whether the patient can be managed from home in quarantine conditions. COVID-19 patients who complete the 14-day isolation period at home can benefit from dental healthcare by following standard precautions. Hand disinfectants containing ≥70% alcohol, antiviral-antibacterial wipes and disposable materials are required to be kept in the entrance areas of healthcare facilities and waiting rooms, and patients are required to be informed with various warning signs. Like all citizens, all healthcare professionals, including dentists, are warned about certain safety rules. From the simplest to the most complex, publications are constantly being updated to protect people against the SARS-CoV-2 virus. Accordingly, your dentist and other healthcare professionals working with them should wash their hands before and after each procedure and sterilize the instruments. It is emphasized that especially some dental tools and needles should never be reused. Most dental procedures in dentistry produce significant amounts of droplets (>5 μm), as well as aerosols (5 μm), although not approved by the World Health Organization (WHO) as a general route of transmission. These droplets and aerosols create a potentially high risk of infection transmission [15–18, 23]. Due to this very close contact, a high viral load may be encountered when transmission through droplets occurs. However, considering that thousands of droplets or aerosols may be spread even while speaking, we need to understand well that we are facing a virus that chose the most difficult form of transmission to be protected from [24]. Transmission may occur by contact other than droplets. Direct contact with urine, tears, respiratory secretions, mouth secretions and blood is considered risky [9, 25–27].

As known, since the morbidity and mortality of COVID-19 is closely related to age, immune system deficiencies, presence of chronic diseases and especially viral load [17, 28], due to the nature of the profession (working in the oral cavity), the field of dentistry is included in the high risk category. For this reason, if procedures that can create aerosol during dental care are applied, four-handed dentistry, high evacuation suction and dental dams should be used to minimize the amounts of aerosols and droplets that are created [15, 16, 18].

In line with IPC recommendations, patients in the 14-day quarantine period based on prolonged close contact with someone with SARS-CoV-2 infection and not yet confirmed to be COVID-19-negative by a polymerase chain reaction (PCR) test should be isolated and not categorized in a cohort with patients with suspected or confirmed SARS-CoV-2 infection. Since dentists generally do not provide inpatient treatment services, while facing such a situation, they should contact their nurses or clinicians for the patient's triage [15].

Among measures to be taken in the dental clinic, the right triage is perhaps the most important. Questions about the health status of the patient calling for an


#### **Table 2.**

*Questions about the health status of the patient who is calling for an appointment.*

appointment should be asked. Dentistry personnel should also call patients and question their current health status before their scheduled appointment (**Table 2**). It is strongly recommended that questions and practices include the following information and rules [7, 11, 12, 15, 16, 25, 29–32].

#### **3.1 Practices and rules for patient appointments**

Instruct the patient to wear a facemask when entering the dental clinic and not to remove it unless the dentist instructs them to do so. Have patients have their temperature measured as a routine procedure in dental clinics during the COVID-19 pandemic. Tell patients that they should make an appointment. Make appointments so that patients do not coincidence with each other. Limit the appointments to a certain number of patients. Tell patients that they should not bring any companions except in special cases. If a patient with COVID-19 symptoms has been taken in at the dentistry clinic, isolate the patient in a pre-created area for the necessary evaluations, routine blood analysis (e.g., hemogram and routine biochemical tests) and PCR test. Postpone dental treatment until the test result comes out. In the case of a positive test result, postpone dental treatment until the incubation period (14 days) is over. Postpone treatment for patients hospitalized with COVID-19 for at least 30 days.

#### **3.2 Recommendations for the dentist and working environment**

Dentists should talk to their patients using a surgical mask. If the dentist has symptoms like those of COVID-19, they should stop performing dental treatment, take a PCR test and isolate themselves for 14 days if the disease is confirmed or suspected. Moreover, a healthy lifestyle should be maintained during isolation. To avoid cross transmission, ensure that a limited number of patients are admitted to waiting rooms and with a distance of 2 m. Remove all reading and other materials from the waiting room. Make sure that disinfection is ensured every evening after the end of working hours and that the rooms are ventilated. Post your instructions on hand hygiene (cleaning with soap and water) and respiratory hygiene (behavior while coughing or sneezing) in the waiting room and entrances with visual

#### *Impact of COVID-19 on Oral and Dental Health Delivery and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.98522*

warnings or signs. Put a hand sanitizer in waiting rooms. Distribute information leaflets to patients. However, remind them that these brochures should not be handed over. Ensure the use of a high-volume exhaust (HVE) filter and a high efficiency particulate air (HEPA) filter to filter contaminated air in dental clinics. Have the filters disinfected every day. Prevent employees from working in the dental care room without adequate protective equipment. It should be mandatory to use protective clothing, caps, respirators, gloves, disposable shoe covers, protective glasses and/or face protective shields to protect the skin and mucous membranes of dentists and other workers from contamination with blood and secretions of patients.

Antimicrobial products are recommended for patients to rinse their mouth before dental operations (gargle with chlorhexidine and similar antiseptic solution), as it will reduce the number of germs in the oral cavity [25, 30].

Dental healthcare personnel (DHCP) should be limited to one patient each time. Contact with more than one patient at the same time will distract the staff and increase the risk of infection. The dental operator should only have clean or sterile supplies required for the dental procedure and should not use auxiliary staff unless necessary. For this reason, the setting should be kept ready so that the required tools are easily accessible. The material remaining after the process should be considered contaminated and subjected to a medical waste management procedure. During the operation, the dentist must be protected by using a shield and an N95 mask. If an aerosol- or droplet-forming procedure will not be applied, shields and surgical masks may be used. Surgical gloves and protective clothing should be changed every time. Therefore, disposable protective clothing should be preferred. Food and drinks should not be consumed during work. The environment should be sterilized with disinfectant spraying devices at the beginning and after the process. All surgical and dental instruments should be sterilized in accordance with the applicable standards, and the necessary number of materials should be available each time, because if a dental tool contaminated with SARS-CoV-2 comes into contact with the oral mucosa, the virus will enter the organism due to the highly expressed ACE-2 receptors, especially in the epithelial cells of the tongue [11, 16, 33]. Therefore, dental procedures to be performed should be designed in such a way that they do not create aerosols, and if possible, only hand tools should be used. This is because dentistry professionals work in the patient's mouth, and this carries a high risk of COVID-19 infection. While working in the mouth, droplets will be scattered with the patient's saliva and inhaled through breathing. Meanwhile, people in the immediate area will be at a high risk of infection. Therefore, all asymptomatic patients should be assumed COVID-19-positive, and action should be taken accordingly. There are recommendations to prevent SARS-Cov-2 virus transmission, such as the use of a suction cannula for rapid spray/saliva aspiration or the use of Tyvek garments and sprays designed for protection of dental care workers [15, 34–37]. Moreover, although there are no data that it reduces SARS-CoV-2 viral load, the mouth should be rinsed with preprocedural mouth rinses (PPMR) containing an antimicrobial product (chlorhexidine gluconate, essential oils, povidone-iodine or cetylpyridinium chloride) before the procedure. Two different studies showed that mouth rinsing before a routine procedure inhibits most bacterial aerosols produced by the usage of an ultrasonic unit, and chlorhexidine is more effective [38, 39]. Furthermore, Kaufman et al. [39] reported that universal barrier measures for protection from infections and effective routine infection control will prevent infections in dentistry. The virus is very sensitive to ultraviolet light and heat, and if it is kept at 56°C for 30 minutes, the virus will be inactive. Lipid solvents such as ether, 75% ethanol, chlorine-containing disinfectants, peracetic acid and chloroform can kill the virus [11, 40]. These lipid solvents are used to disinfect the environment of the dental clinic and the surfaces of objects. As a result, antiviral

mouthwash application of the patient to reduce viral load, use of suction cannula for rapid spraying/saliva aspiration, use of N95 masks as well as dentist's shield, continuous environment disinfection and vaccination are known as the most effective measures. However, since it would be possible to evaluate the effectiveness of the recommendations offered through long term prospective studies, these recommendations should be considered as confidence increasing approaches towards oral and dental health for the time being. In addition, through meta-analysis studies to be conducted by using the data to be obtained from these recommendations that could be applied in different centers, the problems related to the application of these recommendations and the concerns about their effects on the efficiency of oral and dental health can be eliminated. Hence, we believe that these recommendations would be a good topic for research in various areas related to dental health.

In addition to all these precautions above that need to be followed, scientific authorities suggest that vaccination of healthcare personnel working in the frontlines is seen as the most effective method in countering the COVID-19 pandemic [41–43]. According to the results of a study conducted in the UK, vaccination, even if it provides limited protection against infection, can have a significant effect in preventing the spread of COVID-19 and reducing its outbreaks [44].

### **4. The importance of physical distance in the work environment**

It is known that COVID-19, which has caused great concern worldwide, is asymptomatic in many people. Test positivity is quite common before the symptoms of the disease appear. Laboratory findings of these asymptomatic people are also normal. However, since COVID-19 causes hyperinflammation, significant changes such as lymphopenia, high neutrophil to leukocyte ratio, increase in CRP, ferritin, D-dimer and procalcitonin levels are found in the biochemical results of many symptomatic people [45, 46]. People who are asymptomatic are highly effective transmitters in spreading COVID-19. These are called asymptomatic carriers [47, 48]. Moreover, studies have shown that the viral load in the airway samples of asymptomatic patients is similar to that of symptomatic patients [49]. For this reason, dental health and other healthcare professionals should also continue their work in compliance with physical distancing principles (at least one meter) [50, 51] because transmission from healthcare workers to healthcare workers is a danger that should be taken seriously for healthcare institutions [52]. In cases of suspected COVID-19 cases, personnel working together are also recommended to have SARS-CoV-2 PCR tests.

If the patient who is treated in a dentistry clinic shows signs or symptoms immediately (within one to two days) after the treatment, or if they are diagnosed with COVID-19, the situation must be reported to the dental clinic [21]. Procedures for providing this feedback should be established because almost all people are susceptible to COVID-19. The incubation period is usually 3–7 days but may extend up to 14 days. Moreover, many cases showing that it takes up to 24 days have been reported. During this incubation period, patients can transmit the virus to others. It was even found that people may be infected during their recovery period. The symptoms of the disease are usually fever, dry cough and fatigue. These may be accompanied by nasal congestion, runny nose, sore throat, myalgia and diarrhea. In severe cases, acute respiratory distress, septic shocks, metabolic acidosis and multiorgan failure may develop [11, 12, 25, 30, 53, 54].

In a review conducted by Marcelo Coelho Goiato, 47 articles and 9 websites were examined, general information about SARS-CoV-2 was collected, and forms of transmission and measures in dentistry were reviewed. In the review, it was reported that the SARS-CoV-2 virus was transmitted to 213 countries as of May

*Impact of COVID-19 on Oral and Dental Health Delivery and Recommendations… DOI: http://dx.doi.org/10.5772/intechopen.98522*

2020 [8]. With 208 countries registered with the United Nations and an estimated 13 unregistered countries in the world, SARS-CoV-2 has spread almost all over the world, and millions of people have already lost their lives. There are worries that these numbers will increase even more. These figures show that the SARS-CoV-2 virus should be taken seriously. As to be understood from here, it is not possible that oral and dental health services will not be affected by this. The main question is what kind of precautions we can take to maintain these healthcare services. In clinical practice, oral and dental healthcare providers continue their profession with fear, as they come into contact with many patients every day and are exposed to many infection risks, including SARS-CoV-2 [11, 27]. The best way to overcome this fear is to have a broad knowledge of COVID-19 and follow the recommendations of the authorities working on this issue. This way, dentists will protect both their own health and the health of their patients and other people.

Another fear of all healthcare professionals, including dentistry professionals, is the possibility of transmitting this infection to their close relatives, since they work closely with infected patients [11, 16, 54]. In a study by Sabino et al., the finding that 29% of 138 patients who received hospital treatment in the city of Wuhan in the Hubei province of China for COVID-19 were healthcare workers [26] justifies this concern.
