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      Changes of the patient management in dentistry during the pandemic caused by the SARS-Coronavirus 2—initial perspectives of a clinic of operative dentistry in Europe

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      Clinical Oral Investigations

      Springer Berlin Heidelberg

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          Abstract

          Summary This Letter to the Editor presents a concept for the patient group-related dental treatment during the coronavirus disease 2019 (COVID-19) pandemic. This principle has been developed based on the cooperation of teams of oral health care professionals combined with a rotation system for use of dental units. Background The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in China at the end of 2019 has progressed into a pandemic [1, 2]. While it has successful managed to limit the number of new infections and deaths in China [3], the world is probably still facing the peak of new infections and severe causes of COVID-19 [4]. In Germany, more than 0.15% of the population had been tested positive for SARS-CoV-2 at the middle of April [5]. In Europe, the situation in the health care systems is already extremely challenging in some countries, in particular in Italy [6]. In other countries, such as Austria and Germany, there is currently still sufficient capacity to treat severe cases and the number of deaths caused by SARS-CoV-2 is still low [5, 7]. The pandemic also creates new challenges for dentistry. There are many therapeutic procedures that lead to the release of aerosols [8, 9]. It is currently impossible to assess the risk to dental professionals with any degree of confidence because rapid and reliable tests for the salivary diagnostic for SARS-CoV-2 are not available [8]. In Germany, Institute of German Dentists, in accordance with the Robert Koch Institute, recommends comprehensive measures to protect staff and to limit dental care to emergencies [10]. Moreover, elective treatments should be avoided as far as possible in order to interrupt transmission routes and preserve resources such as protective equipment. Interventions should be postponed to post-pandemic time, and more attention should be paid to the use of electronic patient counselling resources by phone or video [10]. Point of view In this statement, we describe the principles for the patient management of the Clinic of Operative Dentistry, Periodontology and Preventive Dentistry of the Saarland Medical Centre. We considered experiences of Chinese dental clinics [11] and the current German [10] regulations on patient management. This concept might be transferable to other dental clinics as well as in general to other dental offices.Our recommendation is based on: the cooperation of several teams of dental professionals and a rotation system for the treatment rooms resp. dental units. An important premise is that patients have to contact the treatment centre and are already assigned by telephone to patient groups described below (triage). Patients are then called into the clinic on the next possible appointment. Patients who appear on their own initiative are provided with a fixed appointment at the earliest possible time. Only one patient is present in the treatment section at any time. If a separable and safely sanitizable waiting zone is available, the delayed appointment of a second patient can be considered. In the Clinic of Operative Dentistry, six dentists supported by six dental assistants usually treat 35–70 patients daily, in addition to their responsibilities in the undergraduate teaching of dental students. The therapeutic spectrum covers all areas of dentistry with the exception of orthodontics and maxillofacial surgery. There are six dental units available for the treatment of patients in separate rooms. The facilities for the training of undergraduates are currently not used. Currently, only cases of emergency are treated and the number of patients is reduced to less than 10 patients per day. In addition to the above-mentioned general recommendations, two important questions emerge in the current situation: I. How can the management of the different patient groups be organized safely? II. How can staff and treatment rooms resp. dental units be used appropriately? As long as no rapid and reliable test system is available that offers a high probability of excluding an infection, patients are divided into three groups: A. patients who present typical symptoms of colds, flu-like infections or influenza, such as cough, rhinitis or fever, including COVID-19 and SARS-CoV-2 positive; B. patients without respiratory signs whose infection status is unknown [12]; and, C. highly vulnerable corona-negative patients in whom COVID-19 is associated with a high risk of severe course of disease [13]. In the management of patients in groups A and B, the protection of the staff is of primary concern. For patients in group C, the protection of the patient from infection by the staff is crucial as well. Based on our previous experience in the situation of a still continuing spread of SARS-CoV-2, patients in group A are single cases, but the time and material effort for their treatment is very high. Patients in group B appear more often in our clinic, while patients in group C do not need to be treated as often as patients in group B. For group A patients, all dental procedures are postponed as far as possible until after the disease has been passed. If this is not possible, treatment is carried out in the clinic with the best possible protective equipment in a defined, separated section. To avoid contacts of the diseased person to other individuals, treatment in the patient’s quarantine area at home is considered in particular cases (e.g. opening of periodontal abscesses). Here, the dental team is supported by specialists in the treatment of viral diseases. For the treatment of patients in groups B and C, the dental clinic was divided into 2 areas with separate entrances. One section is reserved exclusively for the patients of group C. In this area, a team that does not show any symptoms of disease or, if possible, is tested daily for SARS-CoV-2 before entering into service. The other section is reserved for group B and, if absolutely unavoidable for group A patients. If this division within a dental practice is not possible, practices in the neighbourhood should cooperate exclusively. Our treatment teams of dental health care providers consist of three persons: Experienced dentist in the contaminated area, Experienced assistant in the contaminated area, Second assistant in the non-contaminated area. The second assistant ensures the supply of instruments, materials and equipment specifically required for the patient and assists in fitting and removing the protective clothing. Due to the high physical strain when working under complete protective equipment (disinfectable footwear, coverall/gown, surgeons hood, double gloves, individual magnifying glasses, N95 filtering respirator covered by surgical face mask, face shield covering the front and sides of the face), several teams are available depending on the number of patients. At least two additional personnel are required to guarantee the admittance and phone service as well as the cleaning and disinfection of the used treatment room. The treatment rooms/dental units are operated in a rotation mode. I. dental unit I is used for treatment, II. unit II is cleaned and disinfected, III. unit III is ready to be used for the treatment of the next patient. Based on initial experience, the disinfection of a treatment room and the running of the complete disinfection program of the dental unit requires between 50 min and 1 h. This causes unit II to be blocked parallel to unit I for a certain period of time. A typical operative dental treatment of a patient, e.g. preparation and placement of an extensive filling for a molar, under protective equipment takes more than 60 min. Here, the time for applying and removing the protective equipment is considered. After initial experiences, it has become clear that all preparatory steps and all treatment steps must be carried out calmly and carefully in the current situation. Every existing and new routine must be constantly re-evaluated. The current situation therefore requires a fundamental re-thinking of treatment processes, staff and material resource planning. For each treatment team, three persons are required. Depending on the number of patients and due to the physical and psychological strain and the additional requirements for care, one or two additional teams must be planned. In addition, maximum efforts should be made to reduce the risk of vulnerable patients becoming infected with SARS-CoV-2 by dental professionals. The other decisive limitation is the availability of treatment rooms or dental treatment units. It must be expected that even in larger practices with several treatment units, a much smaller number of patients can be treated daily. It is therefore necessary to cooperate across single dental offices or to concentrate resources in larger practices or clinics. Clinical relevance The approach described could help to ensure the effective use of dental care combined with the best possible protection of patients and staff. This will at least maintain the capacity for emergency dental treatment.

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          Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

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            A novel coronavirus outbreak of global health concern

            In December, 2019, Wuhan, Hubei province, China, became the centre of an outbreak of pneumonia of unknown cause, which raised intense attention not only within China but internationally. Chinese health authorities did an immediate investigation to characterise and control the disease, including isolation of people suspected to have the disease, close monitoring of contacts, epidemiological and clinical data collection from patients, and development of diagnostic and treatment procedures. By Jan 7, 2020, Chinese scientists had isolated a novel coronavirus (CoV) from patients in Wuhan. The genetic sequence of the 2019 novel coronavirus (2019-nCoV) enabled the rapid development of point-of-care real-time RT-PCR diagnostic tests specific for 2019-nCoV (based on full genome sequence data on the Global Initiative on Sharing All Influenza Data [GISAID] platform). Cases of 2019-nCoV are no longer limited to Wuhan. Nine exported cases of 2019-nCoV infection have been reported in Thailand, Japan, Korea, the USA, Vietnam, and Singapore to date, and further dissemination through air travel is likely.1, 2, 3, 4, 5 As of Jan 23, 2020, confirmed cases were consecutively reported in 32 provinces, municipalities, and special administrative regions in China, including Hong Kong, Macau, and Taiwan. 3 These cases detected outside Wuhan, together with the detection of infection in at least one household cluster—reported by Jasper Fuk-Woo Chan and colleagues 6 in The Lancet—and the recently documented infections in health-care workers caring for patients with 2019-nCoV indicate human-to-human transmission and thus the risk of much wider spread of the disease. As of Jan 23, 2020, a total of 835 cases with laboratory-confirmed 2019-nCoV infection have been detected in China, of whom 25 have died and 93% remain in hospital (figure ). 3 Figure Timeline of early stages of 2019-nCoV outbreak 2019-nCoV=2019 novel coronavirus. In The Lancet, Chaolin Huang and colleagues 7 report clinical features of the first 41 patients admitted to the designated hospital in Wuhan who were confirmed to be infected with 2019-nCoV by Jan 2, 2020. The study findings provide first-hand data about severity of the emerging 2019-nCoV infection. Symptoms resulting from 2019-nCoV infection at the prodromal phase, including fever, dry cough, and malaise, are non-specific. Unlike human coronavirus infections, upper respiratory symptoms are notably infrequent. Intestinal presentations observed with SARS also appear to be uncommon, although two of six cases reported by Chan and colleagues had diarrhoea. 6 Common laboratory findings on admission to hospital include lymphopenia and bilateral ground-glass opacity or consolidation in chest CT scans. These clinical presentations confounded early detection of infected cases, especially against a background of ongoing influenza and circulation of other respiratory viruses. Exposure history to the Huanan Seafood Wholesale market served as an important clue at the early stage, yet its value has decreased as more secondary and tertiary cases have appeared. Of the 41 patients in this cohort, 22 (55%) developed severe dyspnoea and 13 (32%) required admission to an intensive care unit, and six died. 7 Hence, the case-fatality proportion in this cohort is approximately 14·6%, and the overall case fatality proportion appears to be closer to 3% (table ). However, both of these estimates should be treated with great caution because not all patients have concluded their illness (ie, recovered or died) and the true number of infections and full disease spectrum are unknown. Importantly, in emerging viral infection outbreaks the case-fatality ratio is often overestimated in the early stages because case detection is highly biased towards the more severe cases. As further data on the spectrum of mild or asymptomatic infection becomes available, one case of which was documented by Chan and colleagues, 6 the case-fatality ratio is likely to decrease. Nevertheless, the 1918 influenza pandemic is estimated to have had a case-fatality ratio of less than 5% 13 but had an enormous impact due to widespread transmission, so there is no room for complacency. Table Characteristics of patients who have been infected with 2019-nCoV, MERS-CoV, and SARS-CoV7, 8, 10, 11, 12 2019-nCoV * MERS-CoV SARS-CoV Demographic Date December, 2019 June, 2012 November, 2002 Location of first detection Wuhan, China Jeddah, Saudi Arabia Guangdong, China Age, years (range) 49 (21–76) 56 (14–94) 39·9 (1–91) Male:female sex ratio 2·7:1 3·3:1 1:1·25 Confirmed cases 835† 2494 8096 Mortality 25† (2·9%) 858 (37%) 744 (10%) Health-care workers 16‡ 9·8% 23·1% Symptoms Fever 40 (98%) 98% 99–100% Dry cough 31 (76%) 47% 29–75% Dyspnoea 22 (55%) 72% 40–42% Diarrhoea 1 (3%) 26% 20–25% Sore throat 0 21% 13–25% Ventilatory support 9·8% 80% 14–20% Data are n, age (range), or n (%) unless otherwise stated. 2019-nCoV=2019 novel coronavirus. MERS-CoV=Middle East respiratory syndrome coronavirus. SARS-CoV=severe acute respiratory syndrome coronavirus. * Demographics and symptoms for 2019-nCoV infection are based on data from the first 41 patients reported by Chaolin Huang and colleagues (admitted before Jan 2, 2020). 8 Case numbers and mortalities are updated up to Jan 21, 2020) as disclosed by the Chinese Health Commission. † Data as of Jan 23, 2020. ‡ Data as of Jan 21, 2020. 9 As an RNA virus, 2019-nCoV still has the inherent feature of a high mutation rate, although like other coronaviruses the mutation rate might be somewhat lower than other RNA viruses because of its genome-encoded exonuclease. This aspect provides the possibility for this newly introduced zoonotic viral pathogen to adapt to become more efficiently transmitted from person to person and possibly become more virulent. Two previous coronavirus outbreaks had been reported in the 21st century. The clinical features of 2019-nCoV, in comparison with SARS-CoV and Middle East respiratory syndrome (MERS)-CoV, are summarised in the table. The ongoing 2019-nCoV outbreak has undoubtedly caused the memories of the SARS-CoV outbreak starting 17 years ago to resurface in many people. In November, 2002, clusters of pneumonia of unknown cause were reported in Guangdong province, China, now known as the SARS-CoV outbreak. The number of cases of SARS increased substantially in the next year in China and later spread globally, 14 infecting at least 8096 people and causing 774 deaths. 12 The international spread of SARS-CoV in 2003 was attributed to its strong transmission ability under specific circumstances and the insufficient preparedness and implementation of infection control practices. Chinese public health and scientific capabilities have been greatly transformed since 2003. An efficient system is ready for monitoring and responding to infectious disease outbreaks and the 2019-nCoV pneumonia has been quickly added to the Notifiable Communicable Disease List and given the highest priority by Chinese health authorities. The increasing number of cases and widening geographical spread of the disease raise grave concerns about the future trajectory of the outbreak, especially with the Chinese Lunar New Year quickly approaching. Under normal circumstances, an estimated 3 billion trips would be made in the Spring Festival travel rush this year, with 15 million trips happening in Wuhan. The virus might further spread to other places during this festival period and cause epidemics, especially if it has acquired the ability to efficiently transmit from person to person. Consequently, the 2019-nCoV outbreak has led to implementation of extraordinary public health measures to reduce further spread of the virus within China and elsewhere. Although WHO has not recommended any international travelling restrictions so far, 15 the local government in Wuhan announced on Jan 23, 2020, the suspension of public transportation, with closure of airports, railway stations, and highways in the city, to prevent further disease transmission. 16 Further efforts in travel restriction might follow. Active surveillance for new cases and close monitoring of their contacts are being implemented. To improve detection efficiency, front-line clinics, apart from local centres for disease control and prevention, should be armed with validated point-of-care diagnostic kits. Rapid information disclosure is a top priority for disease control and prevention. A daily press release system has been established in China to ensure effective and efficient disclosure of epidemic information. Education campaigns should be launched to promote precautions for travellers, including frequent hand-washing, cough etiquette, and use of personal protection equipment (eg, masks) when visiting public places. Also, the general public should be motivated to report fever and other risk factors for coronavirus infection, including travel history to affected area and close contacts with confirmed or suspected cases. Considering that substantial numbers of patients with SARS and MERS were infected in health-care settings, precautions need to be taken to prevent nosocomial spread of the virus. Unfortunately, 16 health-care workers, some of whom were working in the same ward, have been confirmed to be infected with 2019-nCoV to date, although the routes of transmission and the possible role of so-called super-spreaders remain to be clarified. 9 Epidemiological studies need to be done to assess risk factors for infection in health-care personnel and quantify potential subclinical or asymptomatic infections. Notably, the transmission of SARS-CoV was eventually halted by public health measures including elimination of nosocomial infections. We need to be wary of the current outbreak turning into a sustained epidemic or even a pandemic. The availability of the virus' genetic sequence and initial data on the epidemiology and clinical consequences of the 2019-nCoV infections are only the first steps to understanding the threat posed by this pathogen. Many important questions remain unanswered, including its origin, extent, and duration of transmission in humans, ability to infect other animal hosts, and the spectrum and pathogenesis of human infections. Characterising viral isolates from successive generations of human infections will be key to updating diagnostics and assessing viral evolution. Beyond supportive care, 17 no specific coronavirus antivirals or vaccines of proven efficacy in humans exist, although clinical trials of both are ongoing for MERS-CoV and one controlled trial of ritonavir-boosted lopinavir monotherapy has been launched for 2019-nCoV (ChiCTR2000029308). Future animal model and clinical studies should focus on assessing the effectiveness and safety of promising antiviral drugs, monoclonal and polyclonal neutralising antibody products, and therapeutics directed against immunopathologic host responses. We have to be aware of the challenge and concerns brought by 2019-nCoV to our community. Every effort should be given to understand and control the disease, and the time to act is now. This online publication has been corrected. The corrected version first appeared at thelancet.com on January 29, 2020
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              Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany

              To the Editor: The novel coronavirus (2019-nCoV) from Wuhan is currently causing concern in the medical community as the virus is spreading around the world. 1 Since identification of the virus in late December 2019, the number of cases from China that have been imported into other countries is on the rise, and the epidemiologic picture is changing on a daily basis. We are reporting a case of 2019-nCoV infection acquired outside Asia in which transmission appears to have occurred during the incubation period in the index patient. A 33-year-old otherwise healthy German businessman (Patient 1) became ill with a sore throat, chills, and myalgias on January 24, 2020. The following day, a fever of 39.1°C (102.4°F) developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between January 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26 (index patient in Figure 1) (see Supplementary Appendix, available at NEJM.org, for details on the timeline of symptom development leading to hospitalization). On January 27, she informed the company about her illness. Contact tracing was started, and the above-mentioned colleague was sent to the Division of Infectious Diseases and Tropical Medicine in Munich for further assessment. At presentation, he was afebrile and well. He reported no previous or chronic illnesses and had no history of foreign travel within 14 days before the onset of symptoms. Two nasopharyngeal swabs and one sputum sample were obtained and were found to be positive for 2019-nCoV on quantitative reverse-transcriptase–polymerase-chain-reaction (qRT-PCR) assay. 2 Follow-up qRT-PCR assay revealed a high viral load of 108 copies per milliliter in his sputum during the following days, with the last available result on January 29. On January 28, three additional employees at the company tested positive for 2019-nCoV (Patients 2 through 4 in Figure 1). Of these patients, only Patient 2 had contact with the index patient; the other two patients had contact only with Patient 1. In accordance with the health authorities, all the patients with confirmed 2019-nCoV infection were admitted to a Munich infectious diseases unit for clinical monitoring and isolation. So far, none of the four confirmed patients show signs of severe clinical illness. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific. 3 The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak. In this context, the detection of 2019-nCoV and a high sputum viral load in a convalescent patient (Patient 1) arouse concern about prolonged shedding of 2019-nCoV after recovery. Yet, the viability of 2019-nCoV detected on qRT-PCR in this patient remains to be proved by means of viral culture. Despite these concerns, all four patients who were seen in Munich have had mild cases and were hospitalized primarily for public health purposes. Since hospital capacities are limited — in particular, given the concurrent peak of the influenza season in the northern hemisphere — research is needed to determine whether such patients can be treated with appropriate guidance and oversight outside the hospital.
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                Author and article information

                Contributors
                stefan.rupf@uks.eu
                Journal
                Clin Oral Investig
                Clin Oral Investig
                Clinical Oral Investigations
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1432-6981
                1436-3771
                29 May 2020
                29 May 2020
                : 1-3
                Affiliations
                GRID grid.11749.3a, ISNI 0000 0001 2167 7588, Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, , Saarland University, ; Kirrberger Str. 100, Building 73, D-66421 Homburg/Saar, Germany
                Article
                3351
                10.1007/s00784-020-03351-z
                7259739
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                Funding
                Funded by: Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes (8981)
                Categories
                Letter to the Editor

                Dentistry

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