CORONAVIRUS, COVID 19 PANDEMIC AND DENTAL CARE- 6

Coronaviruses are a large family, named due to the presence of crown-like spikes over its surface, identified first in chicks in the 1930s and the human coronaviruses in the 1960s. Human coronaviruses cause upper and lower respiratory tract infections. Until the outbreak of SARS, the coronaviruses were considered as minor pathogens and caused only upper respiratory infections. The Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and
the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infect the lower respiratory tract. A new coronavirus was identified in December 2019 as the cause of a disease outbreak called Novel Corona Virus Disease known to be originated in Huanan Seafood Wholesale Market, Wuhan, China. Many people with pneumonia of unknown etiology were admitted to Wuhan hospital and on 29 th December 2019, the cases were reported to the Center for
Disease Control (CDC). Researchers found that patients had worked in the Huanan Wholesale Market, a selling hub of animals. By laboratory analysis etiology was confirmed and the causative organism, a novel β genus Coronavirus, responsible for the ongoing pandemic, and the disease was named Novel Coronavirus- infected Pneumonia (NCIP).

Post-COVID syndrome, Importance of Dental Care and COVID Vaccine

1. Introduction
2. Post- COVID syndrome
3. COVID 19 and Dental Care
4. Top Tips for Good Oral Health at this COVID- 19 Pandemic
5. COVID Vaccine
6. Summary
7. Conclusion

1.Introduction
On January 30, 2020, the World Health Organization (WHO) announced the COVID-19 outbreak a Public Health Emergency of International Concern and on March 11 th declared it as a pandemic. The Common symptoms of COVID 19 are cough, fever, loss of taste, loss of smell and, shortness of breath, and few patients report post-COVID syndrome after recovery. The virus spreads from person to person via small droplets produced by coughing, sneezing, and
talking. As Dentists work very close to the mouth and throat of patients and some dental procedures generate small droplets called micro aerosols from patient’s mouth, it is very difficult to minimize the chance of getting infected by the novel coronavirus, despite using best practices and protective clothing to minimize cross-contamination. Therefore, Dentists should take proper infection control measures and should follow the guidelines for the reduction of aerosols during procedures and carry out only emergency treatments.

2. Post-COVID 19 syndrome

Post-COVID syndrome develops after the recovery of COVID 19 and is a rare, unique phenomenon, particularly the extreme fatigue, difficulty breathing, brain fog, joint pain, chest pain, inability to concentrate and impaired memory, loss of taste and/or smell and sleep issues.
This phenomenon is mainly because the virus not only affects the lungs but also has an impact on the heart, brain, kidneys, and digestive system.
The post-Covid-19 Syndrome can be tackled through clinical assessment, psychological intervention, and comprehensive rehabilitative care. Physical rehabilitation will play a crucial role in assessing and addressing its impact on decreased exercise tolerance, and muscle weakness.
Psychological evaluation plays a big role in assessing Post Traumatic Stress Disorder (PTSD) amongst those who have battled severe COVID19 and had a prolonged stay in the hospital. So these areas of focus will help diagnose and treat the long and short-term complications amongst Covid-19 survivors.

3. COVID 19 and Dental Care
Common oral and dental diseases and conditions in which patients seek dental treatment are,dental caries and its sequelae, gum diseases like gingivitis and periodontitis, bad breath, tooth sensitivity on the consumption of sweet, sour, hot or cold foods and drinks, mal-aligned teeth, the oral manifestation of systemic and immunological disorders, habit associated disorders, temporomandibular joint disorders, drug-induced oral conditions and so on. Also, studies
showed that poor oral health predisposes to some systemic conditions or aggravates existing disorders. Some such conditions are heart disease, endocarditis, diabetes mellitus, premature birth, and low birth weight. Bacteria from the oral cavity may spread through the bloodstream  and sometimes cause infective endocarditis. So a healthy mouth helps to maintain a healthy body.
Loss of taste(ageusia) and appearance of rashes in the mouth are oral manifestations ofCOVID- 19. The common enanthems in the oral cavity associated with COVID- 19 are in erythematous-vesicular, macule, papule, and petechial patterns. Petechia is pinpoint bleeding spots, macules are colored flat lesions less than one centimeter, vesicles are small fluid-filled sacs, and papules are raised lesions less than one centimeter. Oral ulceration, gingival inflammation, and periodontitis also have been reported.
As Dentists are medical professionals who are working extremely close to the mouth and throat, it is very difficult to minimize the risk of contamination by the novel coronavirus, even though with the best protective measures. Dental associations around the world advise dental practitioners to decrease contact with patients and to perform only emergency dental care.
Dentists must take standard precautions (hand hygiene, personal protective equipment, disinfection of environment, and so on); airborne precautions, contact precautions, and eye protection (e.g., goggles or face shields) while performing procedures.
General Public should seek dental consultation only for urgent situations like severe persistent pain not responding to analgesics, uncontrolled bleeding from gums, swelling over the facial area, and traumatic injury to the maxillofacial region. Get an appointment over the phone, do a phone consultation, or do online registration before visiting a Dental clinic. Do not visit a Dental clinic if the person is above 65 years, on immune suppressive treatments, and medically compromised conditions like diabetes, cardiac diseases, asthma, immunocompromised, liver disease, and kidney disease. Read the instructions displayed, do hand rub for a minimum of 20 seconds, fill the questionnaire, cooperate with the preprocedural checking, and sit in the waiting area by keeping a safe distance. Do not touch unwanted objects or surfaces. After dental procedure do payment through card or google pay like apps. Proper hand rub and body wash immediately after reaching home.

4.Top Tips for Good Oral Health at this COVID- 19 Pandemic
A link between good oral care and a reduced risk of acute viral respiratory infection has been proved. The presence of periodontal disease in COVID- 19 patients increases the chance of severity due to the hyperinflammatory state. Through proper oral hygiene practices, avoidance of smoking, and control of stress, can maintain periodontal and oral health effectively. The basic oral hygiene tips to prevent dental problems during COVID- 19 pandemic are 1.
Brush the teeth at least for three minutes, twice daily with fluoride toothpaste. 2. The best time to brush the teeth is just before going to bed at night. 3. Reduce the sugar intake or restrict it at mealtimes. 4. Use interdental brushes or floss to clean the interdental spaces. 5. Use of mouthwash once daily helps to keep the mouth fresh, reduce tooth decay and gum diseases. 6. Sugar-free chewing gums help to stimulate saliva production which neutralizes the plaque acids, in turn, reduces tooth decay. The toothbrush should not be stored in a common toothbrush holder in a humid atmosphere and
change brush at least once in three months. Toothbrush disinfection can be achieved by overnight immersion into 0.12 to 0.2 % chlorhexidine or by UV light.

5. COVID Vaccine

I) Vaccine in General
A vaccine is a biological preparation that provides active acquired immunity to a particular infectious disease.  A vaccine typically contains an agent that resembles a disease-causing microorganism and is often made from weakened or killed forms of the microbe, its toxins, or one of its surface proteins. It works by stimulates, prepare and train the body";s immune system to recognize the agent as a threat, destroy it, and to further recognize and destroy any
of the microorganisms such as bacteria or viruses associated with that agent that it may encounter in the future. The administration of vaccines is called vaccination. Vaccination is the most effective method to prevent contagious diseases.

II) Ingredients in a Vaccine

Vaccines contain tiny fragments of the disease-causing microorganism or the blueprints for making the tiny fragments. Also, contain other ingredients to keep the vaccine safe and effective. Each component of the vaccine serves a specific purpose, and are safe for biological use. The main ingredients are, 1.Antigen: It is the active component of a vaccine that helps to generate an immune response. They may be a small part of the disease-causing organism, like a protein or sugar, or maybe the whole organism in a weakened or inactive form. 2.
Preservatives: Preservatives prevent the vaccine from being contaminated once opened the vial and used for vaccinating more than one person. Some vaccines do not contain preservatives because they are stored in one-dose vials. The most commonly used preservative is 2-phenoxyethanol. 3.Stabilizers: It prevents chemical reactions within the vaccine and keeps the vaccine components from sticking to the vaccine vial.  Stabilizers may be sugars, amino
acids, gelatin, and proteins like albumin. 4.Surfactants: Surfactants keep all the ingredients i the vaccine blended. They prevent settling and clumping of elements that are in the liquid form of the vaccine. 5. Diluent: A diluent is a liquid used to dilute a vaccine to the correct concentration before use. The most commonly used diluent is sterile water. 6.Adjuvant: Some vaccines contain adjuvants that improve the immune response to a vaccine, mainly by keeping
the vaccine at the injection site for a little longer or by stimulating local immune cells. The adjuvant may be a small amount of aluminium salts.

III) Important Steps to develop Vaccine
Like all medicines, a vaccine must go through extensive and rigorous testing to ensure its safety and efficiency for public use. It first undergoes screenings and evaluations to determine which antigen should be used to invoke an immune response. This preclinical phase is done without testing on humans. An experimental vaccine is first tested in animals to evaluate its safety and potential to prevent disease. If the vaccine triggers an immune response, it is then tested in human clinical trials in three phases. Phase 1: The vaccine is given to a small number of volunteers to assess its safety, to confirm its immune response, and determine the right dosage. Generally in this phase vaccines will be tested in young, healthy adult volunteers. Phase 2: Then it's given to several hundred volunteers to further assess its safety and ability to generate an immune response. There are multiple trials in this phase to evaluate various age groups and different formulations of the vaccine. Phase 3: The vaccine is next given to thousands of volunteers to determine if the vaccine is effective against the disease it is designed to protect against and to study its safety in a much larger group of people. Most of the time phase three trials are conducted across multiple countries and multiple sites within a country to confirm its clinical efficiency.

IV) About COVID Vaccine
Researchers all over the world are developing vaccines to fight COVID 19 Pandemic using various technologies like viral vectors, protein subunits, nucleic acid, live attenuated, and inactivated viruses. There are more than 50 COVID 19 Vaccines in the trial all over the world.
Vaccination has started in few countries. All the vaccines are trying to achieve immunity to the virus, and some might also be able to stop transmission. They do so by stimulating an immune response to an antigen, a molecule found on the virus. In the case of COVID-19, the antigen is typically the characteristic spike protein found on the surface of the virus, which it normally uses to help it invade human cells.

V) Different COVID Vaccines developed so far
i) Oxford University-AstraZeneca vaccine
This Vaccine is produced by Oxford University and AstraZeneca got approval for clinical use on 30 December 2020 following trials and is effective in 70% of people. Perfecting the dose could increase protection by up to 90%. This is one of the easiest vaccines to distribute because it doesn’t need to be stored at very cold temperatures. It is prepared from a weakened version of a common cold virus from chimpanzees, that has been modified to not grow in humans. It is given in two doses 4-12 weeks apart. In this vaccine, 1. Scientists take genes for the spike protein on the surface of Coronavirus and insert it into a harmless virus to make a vaccine. This vaccine will be injected into the patient. 2. The vaccine enters the cell and starts producing the spike protein. The body’s immune system will be activated to produce antibodies to destroy spike proteins. 3. If exposed to Coronavirus the antibodies and T cells will be triggered to fight the Virus.

ii) Pfizer-BioNtech vaccine
Pfizer/BioNTech coronavirus vaccine was approved by Russia for widespread use on 02 December 2020 and 90-year-old Margaret Keenan was the first patient to receive the vaccine at University Hospital in Coventry. This vaccine is up to 95% effective and it is given in two doses, three weeks apart. Full immunity starts seven days after the second dose. The vaccine must be stored at a temperature of around -70 degrees Celcius and it should be transported in a special box packed in dry ice and installed with GPS trackers. It's an RNA Vaccine and uses the tiny fragments of the Virus’s genetic code. This starts making part of the virus inside the body, which the immune system recognizes as foreign and starts to attack. It’s the first time got approval for
an RNA Vaccine to use in humans.

iii) Moderna vaccine
It offers 94.5% protection and is given in two doses, four weeks apart. It is easier to store than
Pfizer's because it stays stable at -20C for up to six months.
Other vaccines under trial are,
A) Sputnik V Vaccine, which works like the Oxford Vaccine and is 92% efficient. Its production
by Dr. Reddy’s Laboratories Limited and Sputnik LLC and it’s a combined vector vaccine.
B) Janssen’s offers stronger and long-lasting immunity.
COVID Vaccines approved in India
i) Oxford University-AstraZeneca vaccine is the first COVID 19 vaccine approved in India.
ii) Covaxin is India’s indigenous COVID 19 Vaccine by Bharath Biotech in collaboration with the
Indian Council of Medical Research and National Institute of Virology.
iii) Covishield vaccine is developed by Oxford University in collaboration with pharma major
AstraZeneca and manufacturing by Serum Institute of India.
Covaxin and Covishield vaccines are approved for clinical use in India by DCGI on January 3,
2021.
VI) Vaccine protect everyone?
People respond differently to immunization. The vaccine could be less successful in old people
whose immune system does not respond as well. Multiple doses can overcome this problem,
and alongside a chemical (called an adjuvant) that boosts the immune system also be given.
VII) Who gets the vaccine first?

Prioritize people based on risk and the order of priority as follows,
1. Healthcare workers in the public and private sector.
2. Frontline and municipal workers
3. Age above 50 years
4. Areas with high COVID 19 infection
5. Remaining population
VIII) Side effects/ Adverse Reactions of COVID 19 Vaccines
The most common side effects of the COVID Vaccine are pain at the injection site, fatigue,
headache, muscle pain, chills, joint pain, and fever. Severe allergic reactions and life-
threatening anaphylactic reactions with any of the ingredient of the vaccine is the very rare
adverse reaction with the vaccine.
An immediate allergic reaction to any component or a previous dose of a vaccine is the definite
contraindication to vaccination. Those who are immunocompromised or receiving
immunosuppressant therapy, with severe febrile illness, those with current or previous COVID
19 infection and have bleeding disorders or on anticoagulant therapy requires caution in the
use. Individuals who are unwell and experiencing COVID 19 symptoms should not receive the
vaccine until recovery. Ideally, vaccination should be deferred until recovered from COVID 19
and at least four weeks after onset of symptoms or from the first positive PCR. In pregnancy
where the risk of exposure to the virus is high can not skip the vaccine.
IX) COVID Vaccine Dry Run
Dry run is a dummy process that will help the Government to assess how ready they are ready
for the COVID 19 immunization program at the national level.
6. Summary
i) Post-COVID syndrome develops after the recovery of COVID 19 and is a rare, unique
phenomenon, particularly the extreme fatigue, difficulty breathing, brain fog, joint pain,
chest pain, inability to concentrate and impaired memory, loss of taste and/or smell and
sleep issues.
ii) A link between good oral care and a reduced risk of acute viral respiratory infection
has been proved. The presence of periodontal disease in COVID- 19 patients increases
the chance of severity due to the hyperinflammatory state. Through proper oral hygiene
practices, avoidance of smoking, and control of stress, can maintain periodontal and
oral health effectively.
iii) Even though various preventive measures are there to control COVID 19, the only
method to eradicate the COVID 19 Pandemic is an effective vaccination.

7. Conclusion
At this time of COVID- 19 pandemic, the Dental sector must have specific features that give  importance to infection control and provide protocol-oriented quality service that intern helps to prevent cross-infection. Prioritize the dental services and provide care that helps to reduce harm to both the dental professionals and patients from exposure to COVID-19. Thus, as a reputed Dentist our first concern in this current scenario should keep the patient safe, ourselves safe, staff safe, and the community safe. And, hope through effective vaccination program can be able to eradicate the COVID 19 like other pandemics in human history. Having a vaccine alongside better treatment and preventive measures is the current strategy.