Endodontic implications and innovative preventive strategies during novel COVID-19 pandemic requiring emergency endodontic treatment

Endodontics a specialty branch in dentistry frequently deals with endodontic emergencies and during this COVID-19 pandemic Emergency Root Canal Treatement (ERCT) is often required to manage acute pulpitis with or without space infections. There are various routes of disease transmission in endodontics. When treating patients requiring emergency access opening the treating doctor should be extremely vigilant and cautious regarding its spread and containment of COVID-19 virus by utilizing certain innovative strategies such as HEPA fi lters, High volume extraoral suction, and other devices manufactured from Polyethlene to safeguard from aerosols generated during emergency endodontic therapy. Review Article Endodontic implications and innovative preventive strategies during novel COVID-19 pandemic requiring emergency endodontic treatment Navin Mishra1*, Isha Narang2, Ragini Mishra3, Krishna Biswas4, Dristi Kaushal5, Priyankar Singh6 and AK Sharma7 1Assistant Professor, Conservative Dentistry & Endodontics, IGIMS, Patna, India 2Consultant Endodontist, HCMS, Govt of Haryana, India 3State survelliance offi cer cum State Nodal Offi cer COVID-19, Bihar, India 4Senior Resident, Lady Harding Medical College, New Delhi, India 5Senior Resident, AIIMS, Rishikesh, India 6Assistant Professor, Maxillofacial Surgery, IGIMS, Patna, India 7HOD, Dentistry, Haryana, India Received: 06 June, 2020 Accepted: 30 June, 2020 Published: 01 July, 2020 *Corresponding author: Dr. Navin Mishra, Assistant Professor, Conservative Dentistry & Endodontics, IGIMS, Patna, India, E-mail:

Chinese government on 7 January [1], declared to be a Public Health Emergency of International Concern on 30 January 2020, and recognized as a pandemic on 11 March 2020 [2].
It is an ongoing pandemic of coronavirus disease 2019 (COVID-19), also called as SARS COVID-2 [3]. As of 16 April 2020, more than 2060927cases of COVID-19 have been reported in 210 countries and territories, resulting in over 134354 deaths. More than 511356 people have recovered. The case fatality rate was estimated to be 4 percent in China [4], but varies signifi cantly between countries and in India it is reported to be around 3.4%.
In India the total number of confi rmed cases with recovery is 10477 and 1488 respectively. Mortality rate in India has slightly increased from 3.4 to 3.95 in few days i.e from 11 th April 2020 to 16 th April 2020 ( Figure 1).
The mortality rate in our state is around 1.42% which is Citation: Mishra agencies has advocated general preventive measures which   include hand washing for 20 to 30 seconds with soap and water, covering one's mouth when coughing, maintaining distance of 6 feet from other people and self-isolation for people who are suspected. Person having an infection should be isolated and monitored [13]. India and our state of Bihar has actively implemented lockdown with total travel restrictions, quarantined those who are suspected and effectively managing those infected patients in dedicated covid 19 hospitals. Bihar has a dedicated COVID-19 hospital (NMCH, Patna) which is managing and treating such cases.
Endodontics which is speciality branch in dentistry deals with endodontic emergencies and during this covid 19 pandemic emergency root canal treatement (ERCT) is often required to manage acute pulpitis with or without space infections.
There are various routes of disease transmission in endodontics. When treating patients requiring emergency endodontic treatment the doctor should be extremely vigilant and cautious regarding its spread and containment of this virus:

Airborne route (Dental Aerosol And Splatter)
The terms "aerosol" and "splatter" were fi rst coined by Micik and colleagues [14]. Aerosols are particles less than 50 micrometers in diameter and because of their meagre size they can stay airborne for certain period of time before settling on environmental surfaces or enter the tracheobronchial trees by coughing or sneezing or by certain dental procedures like ultrasonics or airotor handpiece used for cleaning and access cavity preparation for endodontics respectively through mouth, nose or eyes. The smaller particles of an aerosol (0.5 to 10 μm in diameter) have the potential to penetrate and lodge in the smaller passages of the lungs and are thought to carry the greatest potential for transmitting covid -19 infections. Splatter is defi ned as airborne particles larger than 50 μm in diameter. These droplets are ejected balistically/forcibily from the dental operating site and follow an arc of a trajectory. They then fall onto the surface or any orther fomites. These particles are too large to become suspended in the air and are airborne only briefl y. With time the droplet containing virus/microrganisms begins to evaporate, and its size becomes smaller, and has the potential to stay airborne as a dust particle. In todays scenario splatter droplets also may be a potential source of infection in an endodontic treatment setting. Splatter and droplet nuclei also have been implicated in the transmission of diseases such as TB, SARS, measles, herpetic viruses and even COVID-19 virus.
The potential routes for the spread of infection in endodontics are direct contact with body fl uids of a suspected or infected patient, contact with environmental surfaces and instruments containing the virus 1.
The smaller particles of an aerosol have the potential to penetrate and lodge in the smaller passages of the lungs and are thought to carry the greatest potential for transmitting infections.  The virus mainly spread between people during close contact, often via Aerosols (miniature droplets) produced during coughing, or sneezing [5]. This virus spreads at a faster rate when people don't follow social distancing and without knowledge of respiratory hygiene remain in close contact with each other within 1 to 2 metres (3 to 6 feet) [6,7]. Aerosols containing millions of virus usually fall to the ground or surfaces like stainless steel, cardboard, metals, monitors or any other fomites and after the droplets gets dried the virus can remain active for hours to few days and can infect anyone who touches the infected surfaces or fomites and touch their face [8]. Coronavirus major symptoms include dry cough, high fever and diffi culty in breathing in later stages [9]. It is most contagious during the fi rst three days after onset of symptoms. Various studies have reported that its spread may be possible before appearance of any symptoms and also in the later stages of the disease so it becomes extremely diffi cult to contain this virus worldwide [10].
Major complications include pneumonia involving different lobes of both the lungs simultaneously, myocarditis and acute respiratory distress syndrome which requires ventilator support and is life threatning [11,12]. The incubation period range from two to fourteen days but typically symptoms of dry cough and fever appears on average on 5 th day after exposure to the virus [12]. the mutagenic potential of the virus and its novelity it is prudent to state that till date there is no known vaccine or specifi c antiviral treatment and primary treatment is predominantly symptomatic and supportive.

Innovative preventive measures to tackle COVID 19 infection in endodontic speciality
Endodontist or other dental professionals will encounter patients with suspected/infected COVID-19 patients and will have to act diligently to provide care and also to stop the spread of this deadly nosocomial infection in dental operatory.
Endodontic procedures will invariably use airotors and thus will produce airborne particles from the oral cavity. Airotors Covid 19 virus that is present in aerosol form has the potential to enter the respiratory tract through leaks in masks so mask should be changed after 8 hours. These particles can remain in the air of the operatory for up to 30 minutes after a procedure [6]. hence, after a endodontic/dental procedure, the operator after donning of PPE the potential for contact with this airborne virus still remain for limited period of time. It is a matter of great concern that in centralized AC units of a hospital or endodontic clinic this airborne contaminant can enter the ventilation system and spread to other areas of the hospital or clinic.
Method of reducing viral load produced during endodontic procedures is the use of a preprocedural rinse with povidone iodine 0.2-7.5% for one minute before initiating endodontic procedure as it effective against the virus because chlorhexidine is inaffectiver preprocedural rinse against this virus.
The use of a rubberdam will reduce all contamination arising from saliva or blood from oral cavity to a greater extent. In acces opening during emergency endodontic treatment with rubber dam the only remaining source for airborne contamination is from the tooth that is undergoing treatment. This will be limited to airborne tooth material and any organisms contained period. An evacuator that pulls a high vacuum but does not remove a large volume of air, such as is used routinely for hospital suction, is not considered an HVE.
The usual HVE used in dentistry has a large opening (usually 8 millimeters or greater) and is attached to an evacuation system that will remove a large volume of air (up to 100 cubic feet of air per minute). The small opening of a saliva ejector does not remove a large enough volume of air to be classifi ed as an HVE [7]. 4. Use of micromotors for emergency root canal opening 5. Using chemical like carisolv to soften dentin.