Coronavirus pandemic - time for reflection

Mohammad Zakaria Nassani and Bassel Tarakji

Department of Prosthetic Dental Sciences, AlFarabi College of Dentistry and Nursing, Riyadh, Saudi Arabia; Department of Maxillofacial Surgery and Diagnostic Sciences, Prince Sattam Bin Abdulaziz University, College of Dentistry, Al Kharj, Saudi Arabia.

With the rapid eruption and spread of coronavirus, the face of the world has dramatically and suddenly changed. It is perhaps the first time in the history where people around the globe have shared feelings, shared actions and a shared enemy. Humanity has now realised that despite our diversity it is possible to bring ourselves into one common interest and that health is a great treasure which we must work together to maintain. The maintenance and promotion of the health of humanity is among the most noble of missions.

In the front line in the battle against coronavirus are healthcare providers/workers including medical doctors, nursing staff and members of the medical community. They are the soldiers who defend us, they risk their life to save other lives. But sadly, healthcare professionals, including the dental profession, and healthcare authorities/organisations in most countries have discovered they are ill equipped to deal with a deadly pandemic. This has led to a state of chaos and fear for many.

So, once this tragedy is over, plans must be laid for the times of health crisis. All healthcare professionals must be adequately trained and prepared to be able to work in the midst of a pandemic. Equally, support for the World Health Organisation to remain an international platform that works for the health and well-being of all nations is essential. WHO must be protected from politics and international conflict as its mission is above those and its work has never been so needed or so recognised.

At this difficult moment in human history we need to take some time for reflection to draw lessons and plan for the future. People can now feel and recognise the value and practicality of distance learning, the value of phone applications, the value of working from home, the value of modern tools of communication, and above all the value of health, family and normal life. The coronavirus pandemic will mark a turning point for a radical change and different approach in life and in our relationships, hopefully for the better.

The COVID-19 pandemic and dentistry: is there a bright side?

Reint Meursinge Reynders

Milan, Italy

The scientific literature has been overwhelmed with publications on the COVID-19 pandemic. In a recent study we measured that half of all articles published in the first 3 months of this pandemic consisted of secondary articles, that is, non-original research, such as reviews and editorials.1 In this context it is obvious that another secondary article like this editorial should never be written. However, most of these publications have focused on epidemiological and treatment issues and little has been published on the potentially positive consequences of this pandemic. In this editorial I report on two positive aspects that I observed as a practising orthodontist in Milan, Italy, that is, gathering of knowledge and cooperation. I explain why these items could represent a bright side for dentistry. The consequences reported here are only viewpoints based on my personal experiences and those of my network of Italian dental colleagues and should therefore only be considered as 'hypothetical positive consequences' of the COVID-19 pandemic in dentistry.

Gathering of knowledge

Long lockdowns in Italy have created time for dentists to gather knowledge through individual studying and taking online courses. Many educational paywalls have gone down, for example, an increasing number of free webinars are now given by speakers that in the pre-pandemic era asked fees for their lectures. Competition between speakers and online discussions between lecturers and participants during these webinars are expected to improve both the quality and usefulness of these presentations and will hopefully also give a boost to evidence-based dentistry. Many dental conferences have been cancelled as a result of the pandemic and social distancing will bring down the numbers of doctors attending these meetings. If this trend continues in the post pandemic era then webinars could become the key knowledge translators in Italian dentistry. These developments could imply less time and money wasted on travelling, a reduced carbon footprint,2 and possibly more effective learning. However, as is the case with scientific literature it will be necessary to develop precise guidelines to control the validity of what these webinars report.

Cooperation

Information sharing is crucial for developing strategies for dealing with crises. Since the outbreak of the COVID-19 pandemic cooperation between my Italian colleagues has increased. New networks were formed and existing networks have strengthened, which showed that working together is possibly a defining human trait. The COVID-19 pandemic has drastically changed our lives and I wish all readers of this editorial great strength in adapting to this new reality.

Besides the hardships and dramatic stories experienced by many, I hope that the reported hypothetical positive consequences of this pandemic will provide at least a glimpse of light for both patients and dentists and that their external validity will be extended beyond Italy.

The world post pandemic

Sérgio Araújo Andrade

Professor, Faculty of Dentistry, University of Itaúna (UIT), Itaúna, MG, Brazil

The social isolation promoted by the Brazilian government and the consequent closing of the dental office to elective procedures has led me to reflect. It has also given me time to read the bombardment of information about COVID-19.

My belief is that at the end of the pandemic, which is a global event, COVID-19 will have a lasting effect and be incorporated into global systems. Whilst not being as severe as during the COVID-19 pandemic the influence of the knowledge that such dramatic pandemics are possible will remain. At the end of the social isolation imposed in so many regions due to the pandemic, it seems likely that measures implemented now will become permanently incorporated into our personal and professional daily lives. So, how might dentistry emerge post-pandemic? Will we have rapid tests for COVID-19 to be used before performing dental care? Will we test everyone who attends the dentists even if asymptomatic? Will new routines for clinical apparel, asepsis and antisepsis due to COVID-19, cause longer intervals between consultations? Will it be possible for patients to gather in the dentist's waiting room? Will we be able to attend to the same number of patients per day as now? And, as a consequence of all these possible post COVID measures, will the costs of dental treatment rise dramatically?

The pandemic is sure to have personal, social and economic impacts on individuals and communities across the globe, and amid many uncertainties, we will need to consider how we will act both as individuals and as a profession. Dentistry will need to unite, and act together, and become a more global community. Together we will have to develop global policies regarding personal biosafety, and we will need to work together in both research and practice, worldwide, to develop and implement new guidelines for the profession. So, it is my hope that the glimpse of the future legacy of this pandemic and its effect on us personally and professionally, will help us to be better prepared to deal with this and with other threats that may eventually arise.

Covid and the importance of evidence

Neeraj Gugani

Haryana, India

Indeed the world has witnessed an unprecedented health emergency. A global pandemic of this magnitude, with no known treatments, pressurised governments and policy makers to take multiple draconian measures. For taking these decisions, the authorities had to count on the wisdom of researchers and clinicians from all over the world. Ironically these researchers who have always supported and strengthened the principles of 'evidence-based practice' are now relying on the inverted pyramid of healthcare and are impelled to take decisions on the basis of expert opinions and case reports alone. But do they have a choice? The famous Darwin's theory that stated 'survival of the fittest' is now being looked at through another prism: 'survival of the fastest'. This has prompted multiple fast-track trials on therapeutic drugs and vaccines worldwide and there is a palpable race against time and a strong grit to win over the SARS-CoV-2 virus.

India, a multilinguistic, multi-religious country with a population of over 1.3 billion was also under a national lockdown, in an attempt to flatten the curve. This tough period witnessed a rising numbers of COVID-19 patients, helplessness, hunger, fear of economic crisis but also many courageous stories from the frontline health workers. Though the numbers are still rising, the lockdown is being relaxed zone-wise depending on the positive number of cases. But the virus does not seem to respect these arbitrary boundaries and may spread faster than expected. This will surely impact our life-styles and influence dentistry at large.

The dental fraternity including the clinicians, academics, and other para-dental staff have been eyeing the research community for guidance and help to resume their practices with confidence. As of now, different national dental societies, dental schools, and other local associations have formulated their indigenous SOPs and guidelines, most of which are convoluted and seem to be originating from common resources with anecdotal 'evidence' only.

Dental practitioners seem to have no choice than to rely on these safety protocols, even when the evidence for their efficacy is still questionable. These measures which have revamped the dental practices altogether include social distancing, use of personal protective equipment, enhanced sterilisation protocols, extra-oral suctions, etc. These might act as our saviours but the unseen enemy might break the barriers and also the confidence on 'so called evidence'. We are confident that the ongoing research on safety protocols and data accumulating from different clinical trials will surely help us to optimise these recommendations. And there is no doubt that the science of evidence will ultimately triumph, but till then we have no choice but to patiently wait and keenly watch out as the recommendations and guidelines have a face-lift.

Resilience in the face of Covid

Parthasarathy Madurantakam

Virginia, USA

While I sit down and reflect on the developments of the past month, I cannot but help feel that humans, as a species, have no option but to learn and adapt in the aftermath of the brutal pandemic - COVID-19. In a matter of few weeks, the virus had exploited our cavalier attitude, exposed the fragility of our healthcare systems and has taken the lives and livelihood of thousands of people across the globe. While dentistry will emerge out of this crisis, we should be ready to embrace a new 'normal' in the post-COVID era. Protection in our workplace will probably include enhanced PPE, widespread adoption of rubber dam, face shields, and better engineering controls. All of this will be especially challenging for small practices.

However, what COVID might also have done is given dentists a greater role in the management of this disease. Recent findings, that infected individuals have saliva containing SARS-CoV-2 have opened up the possibility for dentists to be offering routine in-office testing. Such point-of-care tests will allow dental offices to identify asymptomatic carriers (and defer elective procedures) and would allow accurate mapping of the disease spread and contact tracing, whilst enabling us to safely treat disease-negative patients.

As the saying goes, 'the show must go on', and it will. The backdrop and the costumes will change but dentists will persevere to improve the oral health of millions across the globe.

Covid and rethinking priorities

Mona Nasser

Plymouth, UK

Systematic reviews have increasingly played a key role in informing policy and practice in healthcare. Despite their importance, reviews can be disappointing as they can take a long time to conduct and do not reach a clear conclusion on what works or does not work, and ask for more research. The current COVID-19 pandemic has put pressure on the community to develop rapid reviews in response to the most urgent needs and questions and try to formulate pragmatic recommendations despite limited evidence. The dental community was even more under pressure due to the challenges and uncertainties around the risk of infection in dental practices, the limited available evidence and the closure of lots of practices.

I hope that during and after this pandemic, the community will rise to the challenge on building an infrastructure and expertise to conduct evidence synthesis and reflect whether we need to reconsider our approach to research prioritisation in dentistry to be more responsive to changing situations like the current pandemic.