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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 429-433

Dental measures during the COVID-19 pandemic in cancer patients


1 Department of Dental and Prosthetic Surgery, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Dental and Prosthetic Surgery, Tata Memorial Centre-Advanced Centre for Treatment, Research and Education in Cancer; Department of Dental and Prosthetic surgery, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission11-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance29-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Madhura R Sharma
Department of Dental and Prosthetic Surgery, HBB.217, Tata Memorial Hospital, Parel, Mumbai - 400 012.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_217_20

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How to cite this article:
Dholam KP, Sharma MR, Gurav SV, Singh GP, Manjrekar N. Dental measures during the COVID-19 pandemic in cancer patients. Cancer Res Stat Treat 2020;3:429-33

How to cite this URL:
Dholam KP, Sharma MR, Gurav SV, Singh GP, Manjrekar N. Dental measures during the COVID-19 pandemic in cancer patients. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 29];3:429-33. Available from: https://www.crstonline.com/text.asp?2020/3/3/429/295548



The first case of coronavirus disease 2019 (COVID-19) was reported toward the end of December 2019. Thereafter, it was declared a pandemic by the World Health Organization. The dental health-care personnel's (DHCP) work involves close contact with the oral cavity, fluids, and blood, thus classifying them under the very high-risk category. According to the European Society of Medical Oncology guidelines, the treatment of patients with cancer during this pandemic depends on the order of priority: high, medium, or low, which in turn depends on the overall survival benefit and the level of improvement in the patients' quality of life. However, considering the emergency of the oncology patients requiring treatment, it becomes essential to provide optimum oral and dental care at the earliest to facilitate the indicated oncology treatment. Therefore, the dental professionals should take adequate measures to prevent cross infection when providing primary oral health care to the patients with cancer in these unprecedented times.

There has been an upsurge in the number of individuals affected by COVID-19 during the past few months globally. The pandemic poses a great challenge, especially for patients diagnosed with cancer and undergoing treatment.[1],[2] There are limited data on the pattern of care for patients with head-and-neck cancer during the COVID-19 pandemic.[3],[4] The spread of infection among these patients is a major challenge, which may be either due to the immunosuppression related to oncology treatment, hospital visits, or contact with a COVID-positive person during treatment.[5] Amidst this present calamity, the Tata Memorial Hospital, a tertiary health cancer care institute, has laid down guidelines to mitigate the risks associated with COVID-19 to continue providing the best oncological care and treatment to the patients with cancers.[6]

The severe acute respiratory syndrome coronavirus-2 mainly spreads through contact with an infected individual or through droplets.[7],[8] Under these circumstances, close contact of a DHCP with the oral cavity and fluids of patients makes them highly susceptible to infection. There are detailed guidelines provided by the Dental Council of India and the Indian Dental Association to prevent infection and minimize the risk of its spread. The primary recommendations of these guidelines are to discontinue all aerosol-generating procedures and carry out only emergency or urgent dental procedures with due precautions during the pandemic.[9] Considering the general emergency of all oncology treatment, it becomes essential for the DHCP to provide optimum care and form a seamless link to facilitate the indicated treatment for oncology such as surgery, radiation, and chemotherapy.

This article aims to illustrate the role and duties of a DHCP in providing dental care that is deemed urgent/emergent in patients undergoing treatment for cancer during the pandemic.


  Spectrum of Patients Reporting to the Dental Department at a Cancer Institute Top


The majority of the patients reporting to a dental setting in a cancer center are those with head-and-neck cancer (HNC). According to the study by Patil et al., the number of patients has decreased due to the pandemic, and the treatment pattern for patients with HNC has to be planned taking into consideration the prevailing situation.[3]

The majority of the referred patients are those who have undergone surgery and require fabrication of obturators or guide bite prosthesis (GBP) [Figure 1] and [Figure 2]. The patients are also referred for dental care before the initiation of radiotherapy and antiresorptive/antiangiogenic medication. These prophylactic measures are considered essential to prevent radiation- or medicine-induced osteoradionecrosis of the jaws.[10]
Figure 1: Patient feeding with Ryle's tube due to large maxillary defect

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Figure 2: Mandibular molar traumatizing the operated site

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  Being a Frontline Dentist in Coronavirus Disease 2019 Pandemic Top


The possibility of transmission of disease from asymptomatic carriers has been reported.[11] Thermal screening at the entrance of the institute is the preliminary method to screen asymptomatic carriers. DHCP working in the front line during the COVID-19 pandemic must be alert to identify patients with respiratory illnesses and provide them with a disposable 3-ply surgical face mask. Such patients are then referred to the fever clinic in the institute. A COVID-19-specialized medical team does further evaluation as per the institutional protocol.[12]

The use of personal protective equipment (PPE) [Figure 3] is emphasized for dental personnel who treat patients. The use of PPE, which consists of a head cap, protective goggles/loupes, face shield/visor, mouth mask (double = N-95 respirator + outer disposable mask to cover the nose and mouth), coveralls with a hood, footwear, and double gloves.[13]
Figure 3: Dental procedures carried out by operators using personal protective equipment

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Due to the rapidly mutating nature of the novel coronavirus, recommendations may change rapidly with increasing information becoming available about the disease. DHCP must check for updates on the Centers for Disease Control and Prevention's coronavirus infection control web page for health-care professionals.

In the current situation, essential dental screening and dental procedures are carried out. Before entering the operatory, patients are asked to answer a simple questionnaire about their recent social activities. Their responses are reviewed by the DHCP of the operatory, and subsequently, the patient may be deemed appropriate/safe for dental assessment and treatment. This reduces the “chair-side time” or “patient-to-doctor contact time” and is beneficial in situ ations where the patient is asymptomatic or has not mentioned any recent contact history. If suspected of being infected, the patients are advised a radiological examination by orthopantomography. Intraoral and periapical X-rays are contraindicated. In case of extremely infected or symptomatic teeth, extraction under antibiotic prophylaxis is advised before the initiation of radiotherapy or antiresorptive/antiangiogenic medication. Prior consultation with the concerned radiation/medical oncologist to weigh the risk of infection and the benefit of dental treatment may also be done on a case-to-case basis.


  Preparing the Operatory Area Top


The operatory is cleaned and sanitized with a detergent followed by 0.5% sodium hypochlorite. Other disinfectants such as 7.35% hydrogen peroxide with 0.23% peracetic acid or 1% hydrogen peroxide with 0.08% peracetic acid could be used, but precautions must be taken as it can corrode metal instruments. The iodophor germicidal detergent solution, following the product label for dilution, could also be used. Barrier tapes are attached on all surfaces where susceptible contact is expected such as the dental chair armrest and console, controls, computer keyboard, and mouse. When the patients enter the dental operatory, they must keep all their belongings in their bags, which should be kept out of the operatory or handed over to an attendant waiting outside the operatory. The clinic staff should not touch any patients' belongings inside the operatory. The patient is then given a preprocedural mouthwash (preferably 1.5% hydrogen peroxide or 0.2% povidone) and asked to rinse with it for about 30 seconds. This may significantly reduce the microbial load in the oral cavity fluids.[14]


  Nonaerosol Generating Procedures Top


  1. Examination and consultation for oral hygiene maintenance during radiotherapy and chemotherapy
  2. Nonsurgical extraction of grossly carious teeth with periapical infections, which may hamper the oncology treatment. Emergency extraction can be done after reviewing the blood profile (complete blood count, coagulation profile, and blood sugar levels)
  3. Removable prosthodontics


Elective definitive dental procedures are deferred. Essential interim provisional prosthesis for patients who have undergone ablative cancer surgeries is indicated. This assumes significance, especially in patients undergoing maxillectomy and who are dependent on Ryle's tube for feeding. This creates significant discomfort and negatively affects the postoperative functional recovery. Fabrication of the interim obturator helps in restoring the essential oral functions; therefore, a delay in such treatments is unwarranted. Further, the patient may require adjuvant radiotherapy. This can lead to restriction of mouth opening, which could complicate the impression-making procedures.

Similarly, for cases of postsegmental mandibulectomy, GBP is essential. GBP guides the remnant mandible in a proper occlusal position before the onset of fibrosis, which prevents the ideal occlusal position. At our center, we attempt to fabricate and deliver these prostheses on the same day. This reduces the number of visits of the patients to the hospital and thus the risk of exposure. This is achieved with the help of efficient and well-trained maxillofacial technicians. Care is taken to carry out proper disinfection of impression/models to ensure the safety of the working team.

Impressions made in alginate for a maxillary obturator or a GBP are immersed in a disinfectant such as 0.1%–1% sodium hypochlorite solution for a period of 30–60 min [Figure 4] and [Figure 5]. The laboratory technicians are equipped with N-95 respirators, head caps, goggles, face shields, and latex gloves. Pouring of impression, retrieval of the casts, and fabrication of prosthesis are carried out with the utmost care to minimize the risk of cross infection to the laboratory personnel.
Figure 4: Intraoral impression of maxillary defect

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Figure 5: Complete disinfection protocol followed for transfer of intraoral impression to the dental laboratory

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At the time of prosthesis insertion [Figure 6], the prosthesis is immersed in a solution of 0.5% povidone-iodine and saline for 20 seconds before insertion. This decontaminates the surfaces of the prosthesis and reduces the chances of cross infection, if any, in the clinical environment. Patients are asked to wash their hands thoroughly followed by the use of hand sanitizer before practicing the insertion and removal of the prosthesis under the supervision of the operating DHCP.
Figure 6: Final intraoral maxillary prosthesis fabricated and disinfected before insertion

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  Disinfection of the Operatory Postprocedure Top


It is important to note that the virus can survive on plastic and stainless steel surfaces for almost 3 days.[15] Therefore, all dental instruments must be sterilized with the utmost care as per the protocol at the end of the treatment and after the patient leaves the operatory. The parts of the chair that are covered with the barrier tape must be wiped with 70% ethanol or 1% sodium hypochlorite while being cautious about not damaging the upholstery. These disinfectants effectively reduce the infectivity of the coronavirus within a span of 1 min.[16]


  General Safety Measures for the Dental Clinic Area Top


  1. The doorknobs, light switches, cabinet handles, and front desk area are frequently cleaned and disinfected with 70% ethanol or 0.5% sodium hypochlorite
  2. All hard surfaces in the waiting area are regularly wiped with 0.5% sodium hypochlorite
  3. Thermal screening is carried out for all DHCPs at the entrance every day
  4. There is a minimum 15 min time gap between appointments to allow for the operatory to be disinfected for the next appointment
  5. The disinfection of the operatory at the institute is controlled by the centralized ventilation system, which is operated according to the standard health-care licensing requirements. Natural ventilation at our institute operates at a minimum of 6–8 air changes per hour (ACH). The exhaust also consists of high-efficiency particulate air (HEPA) filters for up to 10 mm so that the air released is virus free.


In case an emergency aerosol-producing procedure is carried out, the following disinfection protocol becomes essential:

  1. HEPA filters with H13 with more than 99.95% or H14 with more than 99.995% particulate retention must be used. The filters require a minimum of 12 ACH and/or disinfectant fogging of 30–45 min
  2. Disinfectant fogging with hydrogen peroxide vapor or chlorine dioxide for 30–45 min
  3. Ultraviolet germicidal irradiation (UVGI) plus ventilation for 2 min to 6 hours depending on the wattage of the light source, room size, and ultraviolet light position in the room.


The availability of HEPA and UVGI filters has been limited, but we will procure and install these at the earliest, following the institute protocols.


  Management of Medical Waste Top


Dental operatory medical waste is disposed of daily, strictly in accordance with the instructions of the Biomedical Waste Management Policy of the hospital infection control committee. Reusable equipment, such as extraction forceps, diagnostics, and impression trays, must be properly pretreated, cleaned, sterilized, and stored for the next procedure.

The COVID-19 outbreak has posed numerous unique challenges to the various health-care providers. In view of the uncertainty about the period of the pandemic, as dental professionals, we cannot deprive the patients of the basic treatment, especially those suffering from cancer. Therefore, the dental professionals should take adequate measures to prevent cross infection while providing primary oral health care to patients with cancer in these unprecedented times.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank all the members of the Dental and Prosthetic Surgery Department, Tata Memorial Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yeoh CB, Lee KJ, Rieth EF, Mapes R, Tchoudovskaia AV, Fischer GW, et al. COVID-19 in the cancer patient. Anesth Analg 2020;131:16-23.  Back to cited text no. 1
    
2.
Bansal N, Ghafur A. COVID-19 in oncology settings. Cancer Res Stat Treat 2020;3 Suppl S1:13-4.  Back to cited text no. 2
    
3.
Patil V, Noronha V, Chaturvedi P, Talapatra K, Joshi A, Menon N, et al. COVID-19 and head and neck cancer treatment. Cancer Res Stat Treat 2020;3, Suppl S1:15-28.  Back to cited text no. 3
    
4.
Yuen E, Fote G, Horwich P, Nguyen SA, Patel R, Davies J, et al. Head and neck cancer care in the COVID-19 pandemic: A brief update. Oral Oncol 2020;105:104738.  Back to cited text no. 4
    
5.
Brunetti O, Derakhshani A, Baradaran B, Galvano A, Russo A, Silvestris N. COVID-19 infection in cancer patients: How can oncologists deal with these patients? Front Oncol 2020;10:734.  Back to cited text no. 5
    
6.
The Tata Memorial Centre COVID19 working group. The COVID19 pandemic and the Tata Memorial Centre response. Indian J Cancer 2020;57:123-8.  Back to cited text no. 6
    
7.
Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents 2020;55:105924.  Back to cited text no. 7
    
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Pande P, Sharma P, Goyal D, Kulkarni T, Rane S, Mahajan A. COVID-19: A review of the ongoing pandemic. Cancer Res Stat Treat 2020;3:221-32.  Back to cited text no. 8
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Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for Clinical Dental Care. J Endod 2020;46:584-95.  Back to cited text no. 9
    
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Waghmare M, Ahuja A, Pande P, Mahajan A. The mystery of the jaw pain. Cancer Res Stat Treat 2020;3:93-6.  Back to cited text no. 10
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11.
Ye F, Xu S, Rong Z, Xu R, Liu X, Deng P, et al. Delivery of infection from asymptomatic carriers of COVID-19 in a familial cluster. Int J Infect Dis 2020;94:133-8.  Back to cited text no. 11
    
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Pramesh CS, Badwe R. Cancer management in India during Covid-19.N Engl J Med 2020;382:e61.  Back to cited text no. 12
    
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Kulkarni T, Sharma P, Pande P, Agrawal R, Rane S, Mahajan A. COVID-19: A review of protective measures. Cancer Res Stat Treat 2020;3:244-53.  Back to cited text no. 13
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14.
Ramesh A, Thomas JT, Muralidharan NP, Varghese SS. Efficacy of adjunctive usage of hydrogen peroxide with chlorhexidine as preprocedural mouthrinse on dental aerosol. Natl J Physiol Pharm Pharmacol 2015;5:431-5.  Back to cited text no. 14
    
15.
Van Doremalen N, Bushmaker T, Dylan H, Myndi G, Amandine G, Brandi W, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 15
    
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Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J 2020;32:181-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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