BAt the end of December 2019 at Wuhan Central Hospital, Hubei Province, China, the death of many people in a local hospital with an unknown disease was reported by Dr Li Wenliang [1]. Rapidly spreading diseases involved many of the people of Wuhan suffering severe pneumonia of unknown cause [2]. The emergence of the unknown disease was caused by the novel coronavirus (2019 n CoV), which is called Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) [2,3]. Later on, the disease was named COVID-19 (COrona VIrus Disease-19), has resulted in an unprecedented global public health crisis [4], prompting the world health organization (WHO) to declare it a public health emergency of international concern (PHEIC) [5]. It gives threat and danger to people because of clinical features of COVID-19 range from an asymptomatic state to severe acute respiratory distress syndrome and multi-organ dysfunction. The symptomatic COVID-19 may present with a dry cough, fever and dyspnea [6], but also anosmia, ageusia and, in few cases, diarrhoea [7]. Oral and cutaneous manifestations have been reported [8]. SARS-CoV-2 is considered a threat and danger in human than previous epidemics because of its mode of transmission-it has a high spreading potential via all possible mode of transmission [9-12].
The COVID-19 outbreak has spread exponentially and unpredictably across the world causing, along with the so mentioned health burden, devastating global, personal, social, economic impacts. All health professionals have been overwhelmed by the effect of COVID-19 on healthcare resources. Dental and oral health care workers (DOHCWs) activities were limited exclusively to emergency treatments with proper personal protective equipments (PPEs) by the Centers for Disease Control and Prevention (CDC) [13]. The simple logic was put forward behind this strict guideline that DOHCWs were placed on the backseat to reserve the manpower if medical health professionals infected or scarcity occurred, preserve scarce personal protective equipment (PPE), observe social distancing, and protect the employees and patients from risks of potential exposure and illness. However, this strict guideline gives extensive work to DOCHWs working in the oral and maxillofacial surgery field who are working in an emergency department, encounter a high number of patients. Even, simple oral and dental problems are presenting in an emergency as a result of the closure of the oral health care centre, and patients have only insight way to get treatment. Additionally, they are receiving only conservative treatment (mainly antibiotic and analgesic) in an emergency, the simple diseases have progressed to severe disease with extensive extra-oral swelling, trismus and airways obstruction which have needed urgent intervention to save life patient. This is incense the burden on hospitals emergency departments already struggle with the pandemic; affect management urgent conditions such as oral and facial injuries, facial bone fracture, acute bleeding, incision and drainage. Looking at this devastating impact on oral health care services and patients, oral health experts’ response is much visible [1,14-16]. However, impacts on DOHCWs have been described in literatures in multidimensional aspect [17-22]. COVID-19 affect the DOHCWs personal and psychological wellbeing; social life with family, friends and community; monthly income. DOHCWs are invariably at a higher risk of contracting SARS CoV-2 due to their direct exposure to saliva and blood, longer duration of work and work close physical contact with the patients [23-25]. They possess a threat to transmit SARS-CoV-2 among patients, family members, and the community from the workplace [26]. This pandemic has created hostile environments for DOHCWs due to violence, discrimination and harassment [27]. Moreover, they are more concern about physical isolation, social distancing and quarantine; are only insight management modalities for COVID-19, separate them from loved ones and peers when they are the desire to be present with their families. All of those factors develop psychological issues and scare, hesitative to continue their service. Additionally, majorities of oral health services of Nepal have been provided by private sectors or owned dental clinic [28]; closer of service centre lead to no patient care, even in emergency or urgent cases. Patients receive dental treatments only from 10% of the dentist [29]. Consequently, two-third DOHCWs are severely affected by the financial burden as most dentists (over >90%) work in the private sector [30]. They are not receiving a salary during or partial monthly salary this lockdown even from university private institutions or hospital and clinics. Most of them are on forced leave.
This is the state of the oral health crisis, unable to access oral health services in public may precipitate anger and aggression against DOHCWs. Therefore, this pandemic bought new challenges to the dental professionals include: protecting the health of the family, students, faculty, staff and public; ensuring the continuity and quality of oral health services and dental education; keeping up with guidance [31-33]. Many decision and practice modification should need managing, support from all sectors of the community is need to establish oral health service in full strength.
Learnings from a past similar type of pandemic (SARS CoV-1) evidence, professional priority shifted to contagion limitation in the oral health service centre. They are keeping themselves updated with developments in practice protocols for the present situation and future practices. Creative interventions ‘Eagle- Eye Observers’ have been suggested to reduce risks of infection in a clinical setting [34]. Standard infection control precautions are mandatory; it is a set of practices that are applied to the care of patients, regardless of the state of infection (suspicion or confirmation), in any place where health services are provided. Considering every individual patient as a potential candidate for COVID‑19 infection, protocols have developed as patient triage, mouth rinses prior to the procedure, hand hygiene, personal protective equipment for DOHCWs, the limit of APG, cleaning of potentially contaminated surfaces. The patients’ triage is strongly recommended when patients entered dental clinics [16,25]. The purpose of triage is to identify possible critical cases, reduction of the number of patients in the waiting room, exclude patients with COVID-19 related symptoms (coughing, sneezing, respiratory difficulty). Body temperature should be registered, possibly with a contact-free forehead thermometer [16]. Further, hygiene could be maintained by providing disinfectant and surgical mask supply to all patients while waiting in the waiting room. Mouth rinses containing 1% hydrogen peroxide or 0.2% povidone can be used to reduce the microbial load in saliva, with a potential effect on SARS-CoV-2. In particular, mouth rinses are strongly recommended in cases where the rubber dam is not used for the dental procedure.
Dental armamentariums, work surfaces and personal items such as pens, stethoscopes and mobile phone may get contaminated with aerosol or droplet containing SARS-CoV-2. Cleaning of potentially contaminated surfaces is much needed for the clinic environment. Metal, glass, and plastic surfaces are the fomites of virus live for several days [35,36] and its virulence at room temperature remains from 2 hours up to 9 days. Their activity is a decrease in decreasing the humidity from 50% to 30%.
A dry, well-lit airy clinical environment is recommended. The predictable shortages of supplies are associated with a high infection rate in HCWs i.e. availability of personal protective equipment and sanitisers [37]. To limit the aerosol transmission of SARS COV-2, the use of protective equipment, including gloves, masks, protective outerwear, protective surgical glasses, and shields, is strongly recommended to protect the eye, oral, and nasal mucosa [16]. Each dental procedure will result in direct contact with body fluids and aerosol production [38]. Therefore, such as infrastructure modification, duration of the working hour (full time), environmental hygiene and hand hygiene [39]. Nosocomial transmission of SARS CoV-2 is associated with overcrowding, absence of isolation room facilities and environmental contamination in dental practices.
Procedure prioritization has shifted to limit the aerosol-producing procedure. It is advisable to minimize the operations involving the generation of aerosol and droplets while employing the use of personal protective equipment. Oral health education and academic activities are rapidly being moved to online platforms in dental school. Traditional, clinical practice is moved to teledentistry, teleconsultation and telediagnosis [40]. Similarly, oral health educators grasp the opportunity of free time from clinical work to research in the field of oral and dental health during this COVID-19 outbreak. They are focusing innovation for safe practice to develop evidence and impact of COVID-19 on DOCHCWs and dental practice.
The primary objective of this study is to determine the effect of the COVID-19 pandemic on Nepalese dental and oral health care workers and their practices. A secondary objective is to identify factors that may limit access to adapt to new normal COVID-19 and to estimate the adequacy of access to PPEs. By identifying those factors, we may address those factors in future management in dental practices. However, to the best of our knowledge, this is the first study conducted in Nepal to find the impact of the COVID-19 pandemic on DOCHWs.