Clinical Dental Care Epidemiology, Prevalence, Symptoms and Routes of Transmission of Coronavirus Disease 19: A Systematic Review of Literature and Meta-Analysis

Objective: To evaluate the epidemiological evidence, symptoms, and transmission routes of Coronavirus Disease 19 for clinical dental care. Material and Methods: PubMed, Embase, ISI, Scopus, Medicine have been used to search for articles until October 2020. Therefore, EndNote X9 was used to manage electronic resources. A 95% confidence interval (CI) effect size, random effect model, and the REML method were evaluated. Forty-one articles were found. In the first step of selecting studies, 40 studies were selected to review the abstracts. Finally, six studies were selected. Results: The effect size of symptoms of COVID-19 was fever: 92% (ES = 0.92, 95% CI 0.79-1.06), cough: 73% (ES = 0.73, 95% CI 0.59-0.88), headache: 8% (ES = 0.8, 95% CI 0.06-0.22), myalgia 13% (ES = 0.13, 95% CI 0.01-0.27) and nasal congestion 22% (ES = 0.22, 95% CI 0.06-0.39). The following recommendations are appropriate during COVID-19 for dental emergency management: personal protective equipment and hand cleanliness practices, personal protective equipment (PPE), preprocedural mouth rinse, single-use (disposable), cone-beam computed tomography (CBCT) and periapical (PA) radiography, Rubber dam, sodium hypochlorite for root canal irrigation, disinfect inanimate surfaces, ultrasonic scaling instruments and airborne infection isolation. Conclusion: Fever should be used as the first sign in the diagnosis; dentists should measure the fever of all patients at the time of arrival and before any procedure and then ask about other symptoms.


Introduction
Since the development of the novel 2019 coronavirus infection (2019-nCoV) in Wuhan, China, in December 2019, it has rapidly advanced into a public health crisis and spread to several other countries [1].
Corona Virus Disease (COVID-19) [2] was declared by the World Health Organization (WHO) on February 11, 2020. The previously temporarily named 2019-nCoV has now been renamed severe acute respiratory syndrome coronavirus-2, SARS-CoV-2 [3] by the international committee on virus taxonomy. Reported early studies transmitted from animals to humans, but studies have illustrated through droplets or direct contact, human-to-human transmission of the covid-19 [4,5]. So far, the 2019-nCoV has affected more than 43,150,456 reported cases, according to a new report from the University of Johns Hopkins (JHU) center for science and engineering in systems (CSSE) (October 26, 2020) (Figure1).
Dentists are at high risk and may be carriers of the disease, according to several published reports on the health care provided by SARS-CoV-2 [5,6]. Therefore, appropriate measures should be taken to identify, prevent, and manage this crisis [7]. It can attribute these risks to the type of dental intervention. In addition, if not cautious enough, patients will be exposed to contaminants at the dental clinic [8]. Given the global statistics and the fact that this disease is evolving day by day, dental procedures should be aimed at recognizing the symptoms, identifying suspected patients, infected patients, as well as knowledge of epidemiology and how to perform dental procedures to be done. So far, studies have not been conducted to examine the symptoms, how dentists are involved, epidemiology in dental offices, so other studies were used to present the study to evaluate the symptoms and epidemiology in the meta-analysis, so that at least useful solutions for dentists can be provided with better understanding.
The present systematic literature review and meta-analysis aim were to evaluate the epidemiological evidence, symptoms, and transmission routes of Coronavirus Disease 19 for clinical dental care.

Search Method
The PubMed, Embase, ISI, Scopus, Medicine have been used to search for articles until October 2020.
EndNote X9 software used to manage electronic resources. PubMed Searching was performed using mesh The inclusion criteria were randomized controlled trials, controlled clinical trials, prospective and retrospective cohort studies, and cross-sectional studies. In vitro studies, case reports, case studies, and reviews were excluded from the present article.

Quality, Data Extraction and Statistical Analyses Methods
The Newcastle-Ottawa score was used to assess the non-RCT studies included in the present systematic review and meta-analysis [9]. The scale scores for low risk was 1 and for high and unclear risk was 0, scale scores range from 0 to 8, and a higher score means higher quality for data extraction, two reviewers blind and independently extracted data of studies that included. The effect size of symptoms with a confidence interval (CI) of 95%, the random effect model, the REML method were calculated. In order to deal with potential heterogeneity, random effects were used, and I2 showed heterogeneity. I2 values above 50% signified moderate-to-high heterogeneity. The Meta-analysis was evaluated using the statistical software Stata/MP v.16 (The fastest version of Stata).

Results
In the initial search with keywords, 41 articles were found. In the first step of selecting studies, 40 studies were selected to review the abstracts. Then, studies that did not meet the inclusion criteria were excluded from the study. In the second step, the full text of 25 studies was reviewed. Finally, six studies were selected ( Figure 2).

Figure 2. Flow chart.
In various ways, COVID-19 affects various people. Most people are infected with mild to moderate disease and recover without hospitalization. Fever, cough, tiredness, and less common symptoms are the most      A funnel plot showed a publication bias (Figure 8). About 92% of patients have a fever. As a result, patients' fever should be checked in dental care before any procedure, then ask patients for other symptoms. It should be noted that some patients are carriers and have only mild symptoms (carriers). It takes an average of 5-6 days for a person to get the virus to show symptoms, but it can take up to 14 days.

Bias Assessment
According to NOS tools, three studies had a total score of 5/8, two studies had a total score of 4/8, and one study had a total score of 6/8. This outcome showed scores ranged from 6 to 8 were low risk of bias or high quality, and 3 to 5 were moderate risk of bias (Table 2).  [16]. 5) Salivary particles, aerosol, and fomites [17][18][19].

4) Contact with an infected person
According to the mentioned transmission routes, COVID-19 can spread to dental offices. As a result, hands should be washed regularly, all equipment and surfaces should be disinfected regularly, and personal protective equipment and preferably disposable items should be used.

Patient Screening
Identification of suspected patients or carriers of Covid-19: 1) Emergency dental care: using negative pressure rooms or rooms for isolation of airborne infection (AII).
2) Urgent dental care: pharmacological and phone tracking with video treatment.
3) Elective dental care: postpone of treatment for 14 days or/and initial screening via telephone.

Patient Assessment
As soon as the patient is scheduled for dental treatment, a comprehensive medical history, screening questionnaire for COVID-19, and true emergency questionnaire should be completed.

Discussion
The present review showed that dentists or dental assistants should examine the patient's condition and fever upon arrival. According to the American Dental Association's recommendations, dentists can decide to provide or delay dental care after seeing the condition of the teeth. In case of an outbreak, dental priority is with emergency treatments [20].
The following recommendations are appropriate during COVID-19 for dental emergency management: personal protective equipment and hand cleanliness practices, personal protective equipment (PPE), preprocedural mouth rinse, single-use (disposable), cone-beam computed tomography (CBCT) and periapical (PA) radiography, rubber dam, sodium hypochlorite for root canal irrigation, disinfect inanimate surfaces, ultrasonic scaling instruments, and airborne infection isolation. Global precautions should be taken to minimize the prevalence of COVID-19.
Also, the precautionary measures examined in this study should be taken by dentists to prevent infection. Endodontists are in a special position as they can be called for in suspected or known patients with COVID-19 to treat and manage severe odontogenic pain, swelling, and dental alveolar trauma [21,22].
Dentists need to consider each patient as a carrier and take all patient precautions. Adequate training should be given to dentists and all persons involved in dental care. Also, by educating people in the community and avoiding unnecessary visits to dental offices, preventing further transmission of this virus and its spread is possible. Lack of studies in dentistry, asymptomatic people, small sample size, and the absence of a control group in some studies can be considered the limitations of the present study. The strengths of the present study are that the cohort studies have been selected for medium to high quality.

Conclusion
Pesqui. Bras. Odontopediatria Clín. Integr. 2021; 21:e0229 Fever should be used as the first sign in the diagnosis; dentists should measure all patients' fever at the time of arrival and before any procedure and then ask about other symptoms. The use of prevention and treatment protocols can be considered important for dentists and dental patients. Recommended, retrospective and prospective research is recommended in dental care associated with COVID-19, and more studies are requested in the future.