DT India & South Asia No. 7, 2020

Oral health matters! The Lancet first ever commission on Oral Health / For the young dentist: 5 steps to stand out in the post-Covid world through strong online branding / Clinical use of Chlorine dioxide in the prevention of coronavirus spread through dental aerosols. / Dr Hirji Adenwalla – a pioneer in cleft surgeries in India, a great humanitarian and visionary / Safer dental clinics are just a swab away: Testing patients for SARSCoV- 2

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Table of contents

DENTALTRIBUNE
The World’s Dental Newspaper · South Asia Edition

Published in India

www.dental-tribune.in

Post-Covid world

Dental aerosols

For the young
dentist: 5 steps
to stand out in
the post-Covid
world through
strong online
branding

Clinical use of
Chlorine dioxide in
the prevention of
coronavirus spread
through dental
aerosols.

” Page 03

07/20

A pioneer

SARS-CoV-2

Safer dental clinics are
just a swab away:
Testing patients for
SARS-CoV-2

Dr Hirji Adenwalla – a
pioneer in cleft
surgeries in India, a
great humanitarian
and visionary
” Page 04

” Page 06

” Page 07

Oral health matters! The Lancet first
ever commission on Oral Health
across the world have been
appointed as Commissioners on
the first-ever LCOH. LCOH will be
co-chaired by Colombian public
health dentist Dr Carol GuarnizoHerreno and UK’s Prof. of public
health dentistry Dr Richard Watt,
who also is the Director of WHO’s
Collaborating Centre on Oral
Health Inequalities.
Key Priorities of Lancet’s
Commission on Oral Health:

and minimising environmental
impact.
4. Commercial Determinants
Highlight and expose the
influence of industry and profit
motives on all aspects of oral health
including education, research,
service delivery and policy and
develop appropriate means of
minimising this influence and
improving the transparency of
industry relationships with oral
health stakeholders.

The Lancet in early 2020 established a Commission on Oral Health.

by Dr Divyesh Mundra
Last year, The Lancet Series
aimed to get global oral health
on global health agendas. On 25
June 2020, The Lancet announced
that 27 experts across research,
policy, advocacy & clinical
dentistry from 16 countries will
continue this work via a Lancet
Commission on Oral Health.
Dr Divyesh Mundra gives more
details on the Lancet Health
Commission and its plans.
In July 2019, The Lancet
published a path-breaking twopart Oral Health Series that
highlighted the global public
health burden of oral diseases
affecting 34% of the population
across the globe and the need
for a radical reform of dental
care systems, whose treat-overprevent model has failed to
combat the global challenge of
combating oral diseases.
In recognition of the global
public health importance, woeful
neglect of oral diseases and
commitment to include global
oral health within medicine
and global health agenda, The
Lancet in early 2020 established a
Commission on Oral Health.
What
is
Commission?

the

Lancet

A Lancet Commission is a
scientific review, inquiry and
response to an urgent and often
neglected or understudied health
predicament.
Importance of the Lancet
Commission
Lancet Commissions are
international, science-led, multidisciplinary collaborations that

aim to achieve transformational
change with a particular focus on
policy or political action.
Composition
of
Lancet
Commission on Oral Health
(LCOH):
27 experts across clinical
dentistry, academic research,
policymaking, health and human
rights advocacy from 16 countries

SN.

Nationality

Name

Education

Current Organisation

1

India

Dr Manu Mathur

PhD (Epidemiology)

Public Health Foundation of India (PHFI)

2

India

Mirai Chatterjee

MPH (John Hopkins)

SEWA RURAL, Gujarat

3

Thailand

Dr Supreda A

DDS

Thai Promotion Health Foundation

4

Thailand

Dr Viroj T

MD, PhD

Ministry of Public Health

5

USA

Dr Habib Benzian

DDS, MScDPH, PhD

New York University

6

USA

Dr Cristin Kearns

DDS, MBA

Univ. of California, San Francisco (UCSF)

7

USA

Dr Robert Weyant

DMD, DrPH

Pittsburgh Univ. School of Dental Med

8

Canada

Dr Paul Allison

OMFS, DrPH, PhD

Canadian Academy of Health Sciences

9

Canada

Dr Mary McCallum

DMD

Private Dental Practice

10

UK

Dr Blanaid Daly

MSc DPH, PhD

Dublin Dental University, Ireland

11

UK

Dr LD Macpherson

Dentist + MPH+ PhD

University of Glasgow, UK

12

UK

Katie Dain

MA (SOAS), London

CEO, NCD Alliance, London

13

Brazil

Dr Roger Celeste

PhD (Epidemiology)

UFRGS

14

Brazil

Dr Marco Peres

PhD (Epidemiology)

Griffith Univ., Queensland, Australia

15

Brazil

Dr Aluisio J Barros

MD, PhD

University Federal de Pelotas (UFPel)

16

South Africa

Dr Lekan Ayo Yusuf

PhD (Health Educn)

Deputy VC, SM Health Science Uni

17

South Africa

Dr Usuf Chikte

Msc DPH + PhD

Stellenbosch University, South Africa

18

France

Dr Benoit Varenne

PhD (Epidemiology)

NCD Department, WHO

19

Netherlands

Dentist Stephan Listl

PhD (Economics)

Radboud University, Netherlands

20

Hong Kong

Dr Judith Mackay

Medical Dr.

Hong Kong University (HKU)

21

Kenya

Dr MW Muriithi

BDS +MPH

Ministry of Health, Kenya

22

Australia

Dr Sharon Friel

MSc, PhD

Australian National University (ANU)

23

Japan

Dr Manabu Sumi

Medical + PhD

Ministry of Foreign Affairs, Japan

24

Fiji

Dr Leenu M

MDS (Orthodontics)

Private Group Dental Practice

25

Colombia

Dr Gina Watson

MBBS + MPH

Country rep of WHO/PAHO in Ecuador

1. Governance and Advocacy
for Global Oral Health
Explore best practices to raise
the political and policy profile
of oral health and integrate
oral health within the wider
health policy and development
frameworks.
2. Equity, Social Justice and
Oral Health
Develop improved evidencebased monitoring systems to
assess oral health equity, review
evidence of the effectiveness
of interventions to reduce oral
health inequalities and inform
policy development to promote
oral health equity.
3. Health System Reform,
Governance and Transformation
Provide evidence to support
policymakers to develop robust
and resilient oral healthcare
systems across the globe including
human
resources,
payment
systems, integrated delivery
models, relevant technology

Background of Lancet Oral
Health Series:
Lancet’s series published
on 18th July 2019 on Oral health
argued that it has been isolated
from traditional healthcare and
health policy for too long. It
called for greater prominence of
oral health on the global health
agenda campaigning for NonCommunicable diseases (NCD’s)
and Universal Health Coverage
(UHC).
Key Messages:
1. Despite being largely
preventable, oral diseases are
a major global public health
problem. Most prevalent oral
diseases globally are untreated
dental caries in deciduous as
well as permanent teeth, severe
periodontal disease, complete
tooth loss and cancers of the lip
and oral cavity.
2. Most prevalent Oral
Diseases worldwide (2010)

[2] =>

2

News

a.
Untreated caries in
permanent teeth: Ranks 1st,
affecting 35% OR 2.4 billion
people
b.
Severe Periodontitis: 6th,
affecting 10.8% OR 743 million
people
c.
Untreated caries in
deciduous teeth: 10th, affecting
9% of the global child population
d.
Complete tooth loss
affects 2.3% OR 158 million people
e.
Lip and oral cavity
cancers: Top 15 most common
cancers in 2018 (IARC)
3. Oral diseases impose a
substantial economic burden
on individuals, families and
societies.
In 2015, oral
diseases
accounted for the US $ 357
billion in direct costs (treatment
expenditures) and the US $
188 billion in indirect costs
(productivity losses due to
absence from work and school)

07/20

4. Personal consequences of
chronic untreated oral diseases are
severe and include unremitting
pain, sepsis, reduced quality of
life, lost school days, disruption
to family life and decreased work
productivity
5.
Oral
diseases
share
common risk factors with other
NCD’s which include tobacco use,
harmful alcohol consumption
and free sugar consumption. Of
particular concern is the effect
of free sugar consumption on the
prevalence of caries, obesity and
diabetes. Integrated public health
policies needed to tackle shared
common risks
6.
21st-century
dentistry
continues to adopt a treatment
dominated,
interventionist,
increasingly
high-tech
and
specialised approach to dental
care. Such an approach has failed
to tackle the global burden of oral
diseases. Radical reform of dental
care systems urgently needed

7. A preventive approach
focusing on population-wide
impact needed as the current
individualistic clinical paradigm
has failed to achieve sustained
improvements in population oral
healthy.
8. Provider payment systems
should put more emphasis on
incentivising prevention instead
of rewarding restorative and
interventionist dental care
9. A range of highly developed
corporate marketing strategies is
used by the global sugar industry
to increase their sales and profits.
For e.g. By 2020,
Coca- Cola set aside the US
$ 12 billion on marketing across
Africa
PepsiCo set aside the US $ 12
billion for marketing its products
in India
WHO’s total budget of 2017
was the US $ 4.4 billion

Tighter
regulation
and
legislation
by
governments
required
10. Pressing need to develop a
clear and transparent conflict of
interest policies and procedures
to limit the influence of the sugar
industry on dental research and
oral health policy.

Author:

Dr Divyesh B Mundra
is an analytical healthcare
management professional.
Masters
in
Health
Administration (MHA) from the
most reputed Tata Institute of
Social Sciences (TISS), Mumbai.
Since then, he is working for
one of India‘s most innovative
healthcare organisations (private
hospital chain) based out of
Bangalore, Karnataka. He is an
avid reader and tweets daily on
the Indian healthcare system.

In 2015, oral diseases
accounted for the US $ 357
billion in direct costs (treatment
expenditures) and the US $
188 billion in indirect costs
(productivity losses due to
absence from work and school)

Dr Divyesh B Mundra

Researchers develop saliva-based
SARS-CoV-2 test and examine
COVID-19 prevalence among dentists
by Dental Tribune International
S A S K A T O O N ,
Saskatchewan,
Canada:
Researchers from the University
of
Saskatchewan
(USask)
in Saskatoon are currently
working on two large projects
that have recently received
substantial federal funding.
The first project is aimed at
developing a novel saliva-based
test for SARS-CoV-2 detection,
whereas the second one aims to
examine COVID-19 incidence
rates among Canadian dentists.
The two projects, led by
the University of Regina (U
of R) in Saskatchewan and
McGill University in Montreal,
respectively, have secured $1.2
million (€1.1 million) in funding
from the Canadian Institutes of
Health Research. Approximately
half of the funding, over
$550,000 (€445,000), will go to the
researchers at the USask College
of Dentistry and the USask
Vaccine and Infectious Disease
Orga n i zat ion—Inter nat iona l
Vaccine Centre.
The first part of the project
will be led by Dr. Walter
Siqueira, an associate dean at
the USask College of Dentistry,
in collaboration with Prof. Jun
Yang of Western University in

London, Ontario, and will focus
on developing a new diagnostic
test for the detection of SARSCoV-2 peptides in saliva.
“We expect that the accuracy
of this test will be high because the
peptide/proteins we are using is a
marker for a specific SARS-CoV-2
antibody, whereas other tests
often aren’t that specific”
According to the researchers,
the test has clear advantages over
similar SARS-CoV-2 detection
methods currently being used
in research. For example, it is
less invasive and more sensitive
and yields results in less than 5
minutes. Additionally, the test
will come at an affordable price
and can conveniently be taken
at home or in places that do not
have health care facilities.
The
prototype
testing
device will be similar in size
to a cellphone and will include
features similar to those of
pregnancy tests. Once the virus
biomarkers combine with SARSCoV-2 antibodies, an indicator
will turn a certain color, thus
indicating the presence of the
virus in the saliva.
“We expect that the accuracy
of this test will be high because
the peptide/proteins we are

using is a marker for a specific
SARS-CoV-2 antibody, whereas
other tests often aren’t that
specific,” Siqueira noted in a
press release. “As well, other
saliva-based tests are based on
ribonucleic acid (RNA) which
synthesizes proteins, but this test
is based on proteins themselves,
and since proteins last longer in
the saliva than RNA, the virus is
more detectable,” he added.
Siqueira hopes that the test
will also prove useful in detecting
mild or asymptomatic COVID19 cases, since most of the tests
currently in use are not able to
do so. The saliva samples will be
acquired from the Saskatchewan
Health Authority and the Royal
University Hospital, and the test
should become available to the
public by March 2021.
A different part of the study
is being led by a researcher from
U of R, Dr. Mohan Babu, who
is responsible for developing
antiviral peptides that will block
SARS-CoV-2 from entering or
replicating human cells.
Examining
COVID-19
incidence rates among Canadian
dentists
In the second project, the
researchers will collect saliva
samples from dentists in Canada
to determine the incidence rate of

Dr. Walter Siqueira from the University of Saskatchewan College of Dentistry
is the lead researcher in a study aimed at developing a test that identifies
SARS-CoV-2 peptides in saliva. (Image: University of Saskatchewan)

COVID-19 among dentists upon
their return to the workplace.
“The close contact between
dentists and patients, along with
the use of aerosol-generating
procedures,
makes
dental
offices a potentially high-risk
environment for the COVID19 transmission,” said Siqueira.
“Now that dental offices are
beginning to reopen, they
are implementing infection
control, treatment protocols
and other procedures, but there
is minimal scientific evidence
to support these measures.
More information is needed to
ensure we have evidence-based
infection control guidelines that

protect both the patients and the
dentists.”
The researchers will collect
saliva samples from 220 dentists
every four weeks for one
year. They will also distribute
questionnaires that contain
COVID-19-related
questions.
The data will enable the team to
accurately assess the potential
risk of infection in dental offices,
to determine the correct personal
protective equipment that should
be used in dental settings, and to
identify appropriate infection
control measures in order to
ensure the safety of patients and
staff.

[3] =>

News

07/20

For the young dentist: 5 steps to
stand out in the post-Covid world
through strong online branding
by Rajeev Chitguppi, Dental
Tribune South Asia

thought leader in Dentistry, you
need to create a dedicated group
of friends (i.e. fellow Dentists) and
followers (i.e. prospective patients)
over a period of time, who will
vouch for your opinion and will
spread the word about you.
Thought leadership takes time
(sometimes years); knowledge and
expertise in the stream; a high level
of punctuality & commitment (in
creating & disseminating content).
All your efforts in personal online
branding should aim at making
you emerge as a Thought Leader
in Dentistry.

Dr Kumar Anshul (BDS,
MBA), who has leveraged social
media & personal branding to
his advantage at multiple times
during his professional journey,
gives tips for the young dentists
on how they should establish
their brand using some of the
best tools available online.
“The world accommodates
you for fitting in, but only
rewards you for standing out.”―
Matshona Dhliwayo
As we slowly come out of
lockdown, we can’t help but
wonder how exactly a postcoronavirus world will look like
and how will it impact the day-today clinical practice of a Dentist.
Though not all dental procedures
are ‘elective’ over an extended
period of time (which means,
sooner or later, an ailing patient
has to knock the doors of a dental
practice), an average middleclass tax-paying citizen will
think twice before shelling out
cash for treatment, thanks to the
knee-deep recession perpetuated
by mass-layoffs, job losses and
reduced levels of production- all
brought up by the pandemic.
This article discusses a few
steps you should take, a few
changes you should make in your
lifestyle and a few skills that you
should master to continuously
pursue differentiation, make your
online branding game strong,
thereby standing out amongst the
crowd.
Improving
your
online
presence is not limited to joining
multiple dental groups on
Facebook and discussing your
cases there. Having a strong
digital identity should be aimed
at improving your brand equity
and let the people in your vicinity
know that you exist (and exist for
good). Here are some handy tips.
1. Start collecting & documenting
reviews/testimonials from patients
You should ensure that
every patient who is happy
with the treatment leaves with a
documented review/testimonial.
These testimonials can be a gold
mine later for your blog, website,
promotional material & social
media handles. There are multiple
ways to record/document a
testimonial depending upon the

For the Young Dentist: 5 steps to stand out in the post-Covid world through strong online branding: Dr Kumar Anshul

feasibility & willingness of the
patient concerned: a.
Video: A clear 30-60
seconds video shot on your
smartphone will do the needful.
You might want to do a few trialruns before shooting the final
version.
b.
Google Reviews: If
your clinic is listed o Google,
you should request the patient to
write an online review on Google
as well (in addition to the video
testimonial)
c.
Facebook
Reviews:
If your Facebook page is up &
running (explained later), you can
give the link of the review section
(every Facebook page has a review
section, the link of which can be
shared to the patient) to the patient
and request him/her to write a
review
d.
Post-It: In case of
geriatric or paediatric patients,
where it is difficult to get an
online review, you can request
them to write it on a simple Post-it.
You can use the images of these
Post-it reviews later in your online
promotional material. Avoid using
Visitor’s Book to get the review
written as they can’t be used later
for promotion on digital platforms.
2. Start building a mailing list
Even before you start content
creation and dissemination, you
must start building a mailing list.
As a rule, you should include the
e-mail ids of your patients. Next
would be to collect business cards
from people around your vicinity
(who can be your prospective
patients) and get someone to
manually add all the emails
in your mailing list. Email Ids
collected from these two sources
can be used to build your initial
mailing list which you can keep

building in the future with the
help of your website/blog & social
media campaigns. You can use
Mailchimp (Free for 500 emails)
or Mailerlite to drive your Email
Marketing.
3. Personal Blog
Regardless of the fact that you
have your own dental practice
or you work with an institution/
organization, a personal blog
will not only help you to put your
thoughts in words, but will also
put you ‘out there’. You can write
about your experiences in Dental
School, oral hygiene awareness,
new advancements in Dentistry
etc. Try to write on topics which
targets the two most important
segment- Prospective patients &
fellow dentists.
You can easily start a blog
on Wordpress. For a more
sophisticated design (without the
knowledge of any programming
language), you can use Wix or
Weebly. Once your blog is up &
running, you should move to
the next step- registering your
presence on major social media
platforms.

own practice yet, you can use a
Generic name such as “Dentistry
by Dr XYZ”. What is important is
to include your own name & profile
picture to push your own brand
identity.
b.
Instagram
is
more
visual-based and hence the
best platform to share your
clinical cases and pictures of
your community participation,
workshops, courses etc. Ensure
you link your Instagram page
to the Facebook Page so that you
don’t need to post twice. Also,
use proper hashtags to attract the
audience towards your page.
c.
LinkedIn, by far, is the
most professional social media
platform. The best advantage of
LinkedIn is that you can maintain
your full professional identity &
achievements at one place in your
Linkedin Profile, which you can
share it among your target segment.
You can mention your education,
description of your professional
experience, certifications, patents,
media releases etc. The new feature
on LinkedIn also allows you content
creation in the form of blog posts &
videos.

4. Learn the basics of Social
Media:- The three most viable social
media channel on which a Dentist
should be present are Facebook,
Instagram and Linkedin
a.
Apart from your personal
profile on Facebook, it is advisable
to have a Facebook Page. The page
should be named on your own
name (for ex. Dr XYZ) if you want
to share non-dental content on the
page or your dental clinic’s name
attached to your own name (for ex
Smile Dental Clinic by Dr XYZ) in
case you want to keep it exclusively
for dental content. In case you are
a consultant and don’t have your

5. Be a thought leader through
strategic & continuous content
creation
Regardless of the platform, you
use to create content, the trick is to
have a well thought of strategy and
timeline for creating content (blog
posts, videos, social media posts
etc) and following it rigorously.
Hubspot has a free online course
on Inbound Marketing which is
strongly recommended to help
you devise your content strategy.
A thought leader is someone
who is well-informed, opinionated
and a trusted resource for his/her
area of expertise. To become a

Author:

Dr Kumar Anshul

Dr Kumar Anshul has
worn ‘The Marketing Guy’
hat in different capabilitiesas a freelancer during his
undergraduate days in the dental
school, as an entrepreneur,
as a Marketing Manager for
a bootstrapped startup, as a
Marketing & Communication
Manager for a leading Dental
Equipment firm and finally
as a Marketing Strategy &
Communication Manager for
one of the world’s largest Medical
Device firms.
He has leveraged social
media & personal branding to
his advantage at multiple times
during his professional journey
and lately has started one-toone coaching to young Dentists
on career development, personal
branding & digital marketing
through his Instagram channel:https://www.instagram.com/
ansh_isb/
Dr Anshul is BDS from
Manipal University and an
MBA from Indian School Of
Business, Hyderabad. In his free
time, he likes to blog on www.
kumaranshul.com and dabble in
foreign language learning.

[4] =>

4 News

07/20

Clinical use of Chlorine dioxide
in the prevention of coronavirus
spread through dental aerosols.

Use of Chlorine dioxide in the prevention of coronavirus spread through dental aerosols.

by Rajeev Chitguppi, Dental
Tribune South Asia
This article by Dr Anuj
Gandhi and Malvika Gandhi
reviews the literature available
on the use of Chlorine Dioxide
in dental clinics and makes a
hypothesis as to why ClO2 is safe
even in higher concentrations
when added to the dental unit
waterlines in order to minimize
the virus transmission through
dental aerosols.
What is the current pandemic
all about?
Coronavirus disease/ COVID19/ SARS-COV2 is an infectious
disease caused by a coronavirus.
Infected patients show symptoms
like temperature, cough, loss of
smell, respiratory illness. They may
do away mild symptoms without
any special treatment. Patients of
low immunity, aged or having a
history of COPD, cardiovascular
disease, diabetes cancer, are very
susceptible and need immediate
attention. Coronavirus spreads
through infected patient’s saliva
droplets and nose discharges. [1].
What is chlorine dioxide
(ClO2)?
Chlorine dioxide is a yellow
to
reddish-yellow
artificially
manufactured
gas.
Chlorine
dioxide is added to water for
surface treatment and to make
water fit for human consumption.
When chlorine dioxide is added to
water it forms chlorite ion which is
also used to decontaminate water.

[2] Chlorine dioxide is used in the
pre-oxidation stage, wherein the
ClO2 oxidizes the floating matter,
bringing
about
coagulation,
prevents the growth of algae
and bacteria (biofilm). Chlorine
dioxide is active as a biocide for 48
hours in the water.
Coronavirus
and
dental
practice threat Coronaviruses
is present in saliva in par with
levels found in nasopharyngeal
samples. One patient’s saliva also
showed virus till 11th day after
being hospitalized. Thus, salivary
gland cells are being studied in the
role of virus entry, and progress
of infection. ACE2 is highly
available in the epithelial lining
of oral mucosa making COVID
19 infections highest in the oral
mucosa.
Covid-19 spreads from one
person to another. When an
infected person sneezes, coughs or
speaks the saliva droplets or nasal
discharges get released in the air.
These discharges are heavy and
thus don’t travel far and settle
down quickly on the ground or
tables doorknobs clothes etc. [3] If
a healthy individual comes across
these droplets or breathe the air
where the infected has sneezed
or spoken, there are chances of
COVID-19 to be passed on to the
other. In a patient setting if a
dental practitioner comes across a
Covid-19 infected patient there are
100% chances of the dentist getting
infected. In such a situation Dental
practitioners are at great risk.

How deadly is SARS COV2
Virus?
The COVID-19 virus enters
the human cells by binding to the
host cell via their spike protein to
angiotensin-converting enzyme 2
receptor (ACE2). Infected patients
with SARS COV2 spread more
viruses in their asymptomatic
stage, and those in the later stages
of disease shed it at a faster rate. The
virus is studied to be more efficient
in travelling more distance and
becoming aerosolized [4]. Higher
viral loads have been detected
in nasal passages and the upper
respiratory tract of infected people,
thus when such patients talk,
open their mouth, sneeze or they
emit out loads of virus. Similarly,
regular dental procedures like
ultrasonic scaling, airotor based
procedures
produce
various
infected aerosols. This increases
the chance of infecting the doctor
and their fellow practitioners.
Also since the virus may settle
on the chair the instruments the
dental tray etc. the chances of
disease transmission increase to
other patients as well.
A respiratory infection can be
transmitted via various particles/
molecules:
1. Droplet nuclei: less than 5
mm(diameter) [11]
2. Droplet: more than 5-10mm
(diameter)[11]
3.
Aerosols:
less
than
50mm(diameter)[10]
4. Splatter: more than 50 mm
[10]
Nose filters out particles above
10 microns, particles below 10

microns enter the respiratory tract
and particle below 0.1 microns
like the coronavirus enter the
bloodstream and start targeting
organs of the body. When a virus
gets into the air as aerosols during
sneeze cough or dental treatments
they can travel a long-distance and
propagate secondary infection in
the environment. These aerosols
remain in the air and pose a
threat to healthcare workers and
contaminate surfaces.
Viruses are contained in the
following places for the specified
duration.
• Up to 72 hours on plastic and
stainless steel surfaces.
• Up to 24 hours on cardboard
surfaces.
• Up to nine hours on copper
surfaces.
• Up to three hours in
suspended aerosols.
One study showed that
ultrasonic sterilization transmits
100,000 microbes per cubic foot
with 6 feet of aerosolization and
that microbes can last between
35 minutes-17 hours. [5] Covering
these dangers to dentists/
healthcare professionals /patients;
OSHA
(OCCUPATIONAL
SAFETY
AND HEALTH ACT) released
“Guidance
on
Preparing
Workplaces for COVID-19.
This document categorizes
occupations
with
aerosol
production as very high risk,
occupation. [6]
So how can dentists minimise
the virus load in their set up for

the prevention of transmission of
disease?
Coronavirus is known to be
mostly present in the mouth and
respiratory tract. Dentists can
minimise the risk of viral load
considerably by rinsing every
patient’s mouth before they walk
into the clinic and during their
procedure. Chlorine dioxide can
be used for the same. The EPA has
set maximum concentration as
0.8mg/l for chlorine dioxide and
1.0 mg/l for chlorite ion. [7]
Japanese researches have
demonstrated that gargling with
drinking water reduced the
incidence of upper respiratory
tract infection. This very much
coincided with the presence of 0.5
mg /l of chlorine which had been
used to disinfect water.
The following study shows the
use of chlorine dioxide in reducing
virus load in aerosols.[8] A cohort
of 120 patients with chronic
periodontitis was pooled in for a
single centre; double-blind; three
group parallel designed the study.
The study aimed at studying the
efficacy of commercially available
pre-procedural
mouthwash;
chlorine dioxide mouthwash,
water and 0.2% CHX Gluconate.
The aerosol produced by the
ultrasonic unit was collected from
5 locations in the mouth. The same
was then smeared on blood agar
plates and incubated at 37°C for48
hours to study the growth of CFUs.
The result showed the number
of CFUS to be drastically lower in
patients that underwent mouth
rinse with chlorine dioxide & 0.2%
CHX Gluconate as compared to
the water mouth rinse candidates.
Also, CFUs drastically reduced in
the plates with samples from the
chlorine dioxide. However, their
mean post-procedural CFUs were
not very different.
Conclusion: Chlorine dioxide
mouth rinse is found to reduce
virus load significantly.
Please
note
in
certain
places chlorine dioxide is used
for disinfection. Ogata found
that the antimicrobial nature
of chlorine dioxide is derived
from its property of denaturing
proteins present on virus cells.
This
denaturation
involves
the oxidation of certain amino
residues majorly tryptophan and
tyrosine present in the proteins. [9]
In
2012,
Ogata
further
confirmed this theory by studying
chlorine dioxide’s antimicrobial

[5] =>

News

activity with respect to Influenza.
The inactivation of influenza virus
was brought about by denaturing
of the tryptophan residues in its
spike proteins. This denaturation
led to the destruction of the
virus’s host cell receptor binding
capability. Interestingly spike
protein of Covid-19 contains 54
tyrosine, 12 tryptophan and 40
cysteine residues. It’s an extremely
important understanding that if
these viruses come across aqueous
phase of chlorine dioxide, the
antimicrobial denaturing activity
of the COVID 19 virus will begin,
causing rapid inactivation of the
virus. [9]
How does chlorine dioxide
inactivate covid19 virus?
Coronaviruses have spike
proteins on their surface. These
spikes have host binding sites
on them. When chlorine dioxide
comes in contact with the virus it
denatures the tyrosine tryptophan
residues on the spike protein,
deactivating the receptor binding
and oxidises the viral genetic
material.
The genetic material is made of
purines and pyrimidine (guanine,
cytosine adenine thymine) and the
unique sequence of these make
the difference. The guanine base
undergoes oxidation when ClO2
comes in contact with the virus.
This oxidation of guanine results
in the formation of 8 oxyguanine
which stops the replication of the
viral nucleic acid production and
thus stops the virus multiplication.
So if chlorine dioxide has a
denaturing effect, how are the
tissues of the human body not at
risk?
Human cells have glutathione
in mM concentration, in addition,
they also have vitamin C & E.
Together glutathione and vitamins
reduce chlorine dioxide. Human
cells are much bigger than bacteria
or virus. So their glutathione
reserve is also high. It’s said that
even an isolated human cell can
stay in chlorine dioxide solution
for a much longer time than
bacteria or virus. And as we all
know the human body is made
up of tissues consisting of cells.
Thus we can guess the magnitude
of glutathione and vitamins in the
human tissues.
Also, multicellular organisms
have constant transport of
antioxidant and vitamins to the
tissues helping them to sustain
chlorine dioxide attack and
recovery. Comparing the size of
a bacterium/virus to a human
tissue we can very well decipher
that bacteria/virus needs a small
amount of chlorine dioxide to
be inactivated, and this small
amount will be safe for human
consumption. [9]

07/20

How much time does chlorine
dioxide (CIO2) take to inactivate
the virus?
Viruses are smaller than
bacteria. Inactivation time of virus
is shorter than inactivation time of
bacteria under the same conditions
of CIO2 strength, temperature etc.
The following arguments support
this assumption:
The diameter of COVID 19
virus is 120nm
1. Viruses are smaller than
bacteria,
so
the
diffusioncontrolled reaction with CIO2
would be faster in the virus.
2. CIO2 need not penetrate
the virus to inactivate it; it can
merely react with a few tyrosine
tryptophan bases in the protein to
denature the host binding sites.
3.
Viruses
don’t
have
glutathione or similar protective
metabolic molecules to protect
themselves from CIO2 attack.
(Viruses have no metabolic
activity)
These points lead to the fact
that after contact is made between
virus and chlorine dioxide
inactivation is quick. However,
for a virus in aqueous phases like
nasal discharge or fluid droplet
or epithelial lining of mucous
membranes, the diffusion of
chlorine dioxide in the water is
a rate-limiting step. The time
required to inactivate the virus
is shorter as compared to the
time required for the CIO2 to be
transported to the virus.[9]
An on-going study (expected to
be completed in June) is reviewing
the efficacy of oral chlorine dioxide
in the treatment of COVID 19
patients. https://clinicaltrials.gov/
ct2/show/study/NCT04343742
What makes us hypothesize
that Chlorine dioxide will be
useful in reducing transmissions
in clinical settings?
Dilution: EPA has approved
a concentration of 0.8 mg/l of
chlorine dioxide in drinking water
[7]. However this water isn‘t going
to be ingested, so we can safely
hypothesize the use of a higher
concentration for reducing viral
load spread through aerosols.
Chlorine dioxide’s long history
in the use as a disinfectant. Its use
in drinking water treatment gives
confidence that it can be edible
at specified concentrations. It
would also be safe to increase the
concentration of ClO2 in water,
this will significantly
reduce the viral load while
working with dental handpieces
as the patient is not going to ingest
it. Using a rubber dam along with
chlorine dioxide will reduce the
chances of transmission to the
dental operator and also reduce
the virus in aerosols. Proved
efficacy against SARS coronavirus
family of virus. It’s easy to use, so
we can consider its use in high-

speed handpieces as an irrigant,
this
will inactivate the virus in
saliva and in aerosols. This will
not affect the dental instruments
like other irrigants.
Chlorine dioxide is not
pungent at a very small quantity
that may be used for irrigation in
dental setups. It is economical to
use.
PLEASE TAKE NOTE THAT
THIS
CHLORINE
DIOXIDE
WATER IN ADDITION TO
OTHER SAFETY PROCEDURES
WILL SIGNIFICANTLY REDUCE
VIRAL LOAD.
References:
1. WHO. 2020. CORONAVIRUS.
[ONLINE] Available at: https://
w w w.who.i nt/h e a lt h - topic s/
coronavirus#tab=tab_1. [Accessed
18 May 2020].
2.
National
Center
for
Biotechnology
Information.
PubChem Database. Chlorine
dioxide,
CID=24870,
https://
p u b c h e m . n c b i . n l m . n i h .g o v/
comp ou nd/C h lor i n e - d iox ide
[accessed on May 18, 2020]
3. WHO. 2020. Q&A on
coronaviruses (COVID-19). [ONLINE]
[Accessed 18 May 2020].
4. Perio implant advisory.
2020. COVID-19 and the problem
with dental aerosols. [ONLINE]
Available
at:
https://www.
p e r i o i m p l a n t a d v i s o r y. c o m /
p e r io do n t i c s/o r a l-m e d i c i n e anesthetics-and-oral-systemiccon ne ct ion/a r t icle/14173521/
covid19-and-the-problem-withdental-aerosols. Accessed 19 May
2020.
5. Miller RL. Characteristics
of
blood-containing
aerosols
generated by common powered
dental instruments. Am Ind
Hyg Assoc J. 1995;56(7):670-676.
doi:10.1080/15428119591016683
6 Guidance on preparing
workplaces
for
COVID-19.
US
Department
of
Labor.
Occupational Safety and Health
Administration. 2020. https://
w w w.osh a.gov/Publ icat ion s/
OSHA3990.pdf
7 AGENCY FOR TOXIC
SUBSTANCES AND DISEASE
REGISTRY. 2020. Public Health
Statement for Chlorine Dioxide
and Chlorite. [ONLINE] Available
at:https://www.atsdr.cdc.gov/
ph s/ph s.a sp?id=580&t id=108.
[Accessed 19 May 2020].
8 Saini R. Efficacy of a
preprocedural
mouth
rinse
containing chlorine dioxide in
the reduction of viable bacterial
count in dental aerosols during
ultrasonic scaling: A double-blind,
placebo-controlled clinical trial.
Dent Hypotheses 2015;6:65-71
9. Kály-Kullai, K & Wittmann,
Maria & Noszticzius, Z & Rosivall,
Laszlo. (2020). Can chlorine
dioxide prevent the spreading
of coronavirus or other viral
infections? Medical hypotheses.

Physiology international. 1-11.
10.1556/2060.2020.00015.
10. Harrel SK, Molinari
J. Aerosols and splatter in
dentistry: a brief review of the
literature and infection control
implications. J Am Dent Assoc.
2004;135(4):429‐437.doi:10.14219/
jada.archive.2004.0207
11 WHO. 2020. Modes of
transmission of the virus causing
COVID-19: implications for IPC
precaution
recommendations.
[ONLINE] Available at https://
w w w.w h o . i n t /n e w s - r o o m /
commentaries/detail/modes-oftransmission-of-virus-causingcov id-19 -i mpl ic at ion sfor-ip cprecaut ion-recom mendat ion s.
[Accessed 22 May 2020].

Authors:

IMPRINT
PUBLISHER & CHIEF EXECUTIVE
OFFICER
Torsten R. OEMUS
CHIEF CONTENT OFFICER
Claudia DUSCHEK
DENTAL TRIBUNE SOUTH ASIA
EDITION
PUBLISHER
Ruumi J. DARUWALLA
CHIEF EDITOR
Dr. Meera VERMA
CLINICAL EDITOR
Dr. Dilip DESHPANDE
RESEARCH EDITOR
Dr. Shobha DESHPANDE
ASSOCIATE EDITOR
Dr. GN ANANDAKRISHNA
EXECUTIVE EDITOR
Dr. Rajeev CHITGUPPI
DESGINER
Anil LAHANE
PRINTER
Mehernosh & Burzin MISTRY
Ampersand, Mumbai, India
Material from Dental Tribune
International GmbH that has been
reprinted or translated and reprinted
in this issue is copyrighted by Dental
Tribune International GmbH. Such
material must be published with
the permission of Dental Tribune
International GmbH. Dental Tribune
is a trademark of Dental Tribune
International GmbH.

Dr Anuj H. Gandhi

Dr Anuj H. Gandhi
BDS. (M.G.V. Dental College,
Nashik)
Basic Implantology (Bapuji
Dental College, Davangere.)
F.I.C.O.I, U.S.A.
Clinical Mastership in Oral
Implantology from StonyBrook
University.
One Year Online Externship
Program, Dental XP, Atlanta,
USA
KOL - BioHorizons
KOL - Dentium

Malvika A. Gandhi

Malvika A. Gandhi
Btech in Biotechnology (DY
Patil University)
MBA Marketing (Cardiff
University, UK)
3 years of work experience
with Lupin pharmaceutical
company
(management
licensing) for the India market
and CIS Market

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[6] =>

News

07/20

Dr Hirji Adenwalla – a pioneer in cleft
surgeries in India, a great humanitarian and
visionary

Dr Adenwalla, the Smile Maker, put smiles on the face of more than 15,000 children by doing cleft surgeries, a
lot of them free of cost. (Photo: smiletrain.org)

by Rajeev Chitguppi, Dental
Tribune South Asia
Dental
Tribune
South
Asia pays tribute to Dr Hirji
Adenwalla - an eminent cleft
lip and palate surgeon who
passed away on 27th May 2020.
The man, who was fondly
called as the Smile Maker, put
smiles on the face of more than
15,000 children by doing cleft

surgeries, a lot of them free of
cost.
A highly inspiring story
in times ofDr Hirji Adenwalla
completed his medical education
and specialization in surgery at
Jerbai Wadia Hospital in Bombay
and moved to Kerala, where
he founded the Charles Pinto
Centre for Cleft Lip and Palate
at the Jubilee Mission Hospital,

Thrissur in 1959. The centre was
named in honour of his former
boss. Although he excelled as
a surgeon and gained massive
respect from all around, he kept
on thinking about serving the
poor people in the area.
In the late nineties, he shifted
his focus exclusively into cleft lip
and palate, in which he gained
immense experience and started

treating a huge number of poor
patients from all over India and
surrounding countries. He went
on to operate around 500 to 600c
left cases per year for nearly 2
to 3 decades up to the age of
around 90 yrs. He cared for the
poor to an extent that he had a
charitable account of his own.
If ever he came across any poor
patient he would give them the
money to pay the hospital bills
and operated on the patients free
of cost.
He was the one who got the
Smile Train project to India and
helped thousands of poor people
benefit from cleft surgeries free
of cost. After working for over
40 years and treating children
with cleft problems, a new
partnership was formed in 2001,
when Jubilee Mission Hospital
and Dr Adenwalla became Smile
Train’s first Indian partners. Over
the next 19 years, Smile Train
helped the Charles Pinto Centre
transform into a modern, multidisciplinary hub of cleft care and
training with Dr Adenwalla at
its core. Under Dr Adenwalla’s
guidance, the centre went on to

become one of India’s leading
comprehensive cleft training
centres, which has been guiding
young medical students coming
there from all over India.
An excellent teacher, highly
principled professional, who
never compromised on ethics at
any point in time. Dr Adenwalla
fought cancer in his seventies
bravely and overcame it. Dr
Adenwalla continued to perform
at least four cleft surgeries per
week till the day he passed away
in that same small house on the
Jubilee hospital grounds, which
he and his wife had first moved
into more than 60 years ago.
Credits:
1. Dr Sachin Majati - Oral
Maxillofacial
Surgeon
who
worked under Dr Adenwalla‘s
mentorship.
Dr Adenwalla was the one
who got the Smile Train project
to India and helped thousands
of poor people benefit from cleft
surgeries free of cost.

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5/7/19 11:42 AM

[7] =>

News

07/20

Safer dental clinics are just a swab
away: Testing patients for SARSCoV-2
typically the spikes on the surface—
from samples that are collected in
the nasal cavity. The scalability
of antigen testing, relative to RTPCR or isothermal amplification
methods, has resulted in this
method being touted as a solution
for the mass testing that countries
may require before they can reopen
their economies and education
systems completely. These tests
may however be less effective in
testing asymptomatic individuals.

by Jeremy Booth, Dental Tribune
International
LANSING,
Mich.,
U.S.:
Allowing dental professionals
to test their patients for SARSCoV-2 would decrease the high
risk of transmission of the virus
in dental clinics. Furthermore,
dentists in some jurisdictions
are now being prevented from
performing elective treatment
if their patients have not tested
negative for the virus. Dental
Tribune International (DTI)
spoke with a Michigan State
University (MSU) researcher
who has developed a point-ofcare testing kit that would be
suited to dental settings.
Dentists in Japan now have
authorization to take nose and
throat swabs so that patients can
be tested for SARS-CoV-2, and
U.S. dental organizations have
issued an urgent call to get testing
kits into clinics throughout the
country.
As this story went to press, a
mandate to restart elective medical
care in Alaska effectively ruled out
the broad recommencing of elective
dental care because it stated that
patients must return a negative
test result for SARS-CoV-2 within
48 hours prior to a procedure that
generates aerosols. The Alaska
Board of Dental Examiners asked
state regulators for dentists to rely
instead on strict patient screening
protocols, but this was rebuffed
by the state’s chief medical officer,
Dr. Anne Zink. “It’s increasingly
challenging to identify COVID
patients,” she told local radio
broadcaster KTOO. “This is an
incredibly sneaky disease that
appears to be most contagious
in the pre-symptomatic or
early symptomatic people with
symptoms that can look almost
like anything else.”
Alaska is one of the first U.S.
states to reopen nonemergency
health services, but may not be the
last jurisdiction to place its dentists
in a paradoxical situation where
they are unable to treat patients
without proof of a negative test
result, yet are not in a position to
administer the tests themselves.
SARS-CoV-2 testing kits for
the dental team
The urgent need for such
testing kits has led to a flurry of
activity by test developers, such

American Dental Association Executive Director Kathy O’Loughlin has said that “all dentists need a fast point-of-care test
that accurately predicts the presence or absence of COVID-19 virus in real time.” (Image: Photoroyalty/Shutterstock)

as Dr. Brett Etchebarne, who runs
the Etchebarne laboratory at MSU
College of Osteopathic Medicine,
where he is also assistant
professor of emergency medicine.
Etchebarne has developed an in
vitro diagnostic test, one variation
of which has been developed to
suit smaller health practices such
as dental clinics and could easily
be administered by dental teams.
“I do believe that the
possibility exists for the dental
practitioner and his or her staff
to take a sample from a patient
while in the waiting area getting
ready for treatment” – Dr. Brett
Etchebarne, assistant professor
of emergency medicine, MSU
“Dentists have the necessary
protective equipment to begin
with, and they are working in
the oral care area already, and
so everything fits together quite
easily,” Etchebarne explained.
“Dentists already have autoclaves
and already do limited kinds of
analytics. I do believe that the
rapid process in which my test is
able to be completed allows for a
solo practitioner, or a technician,
to easily take the swab and easily
lyse the sample so that it is no
longer an infectious, dangerous
pathogen. That sample can then
be analyzed using a molecular
technique that can be run on a
digital drive app or hot plate,
which you could easily work into
a dental clinic or office. So, I do
believe that the possibility exists
for the dental practitioner and his
or her staff to take a sample from
a patient while in the waiting area
getting ready for treatment.”

The reverse transcription
polymerase chain reaction test is
administered using a swab, and
the results can be ready within 15
to 20 minutes, allowing patients to
proceed with their appointment,
Etchebarne said.
With masks and other items
in short supply, the ability
to administer tests in dental
clinics ideally would require
minimal additional personal
protective equipment. Etchebarne
commented that samples are
deactivated in the medium that
is used for analysis, meaning that
samples could be safely handled
using
standard
protective
equipment. “Dentists are already
covered pretty well here, so we are
not looking to add too much to the
equation. All of the equipment used
for the tests would be consumable
and disposable, so that the risk of
further transmission of infection
is really obviated.”
Etchebarne and his team
have developed variations of the
test that use nasopharyngeal or
oropharyngeal swabs, and they
are working on a saliva sampling
method that would remove the
need for a swab altogether. When
DTI spoke to Etchebarne on April
28, he said that he was currently
awaiting emergency authorization
from the U.S. Food and Drug
Administration (FDA) for the test.
“I am hoping that we will
have all loose ends tied up in the
next few weeks, and that a whole
new platform will be available to
people, which I think is going to
be quite exciting, based on our
analysis and all that we are hearing
from the various collaborators and

helpers that we have had in order
to make this product available,” he
said.
What testing methods are
available?

The U.S. Centres for Disease
Control’s SARS-CoV-2 RT-PCR
diagnostic panel. (Image: U.S.
Centres for Disease Control)

Currently, there are four main
approaches for testing for SARSCoV-2. Reverse transcription
polymerase chain reaction (RTPCR) tests rely on respiratory
samples that are obtained through
methods such as nasopharyngeal
swab taking. If the virus has
progressed from the throat to
the lungs, sputum samples are
recommended. This method is
being widely used in affected
countries, and the time required
for laboratories to return results
from RT-PCR varies from a few
hours to two days.
At least one isothermal
amplification test has been
approved by the FDA, and
researchers in South Korea
have found that isothermal
amplification may deliver faster
results owing to the ability to run
the tests in decentralized facilities.
Antigen tests detect proteins
from the surface of the virus—

A SARS-CoV-2 point-of-care
serological test being
administered in Peru. (Image:
Luis Enrique Saldana/CC BY 2.0
creativecommons.org)

Serological
tests
detect
antibodies in a blood sample that
the body produces in order to fight
the virus. This testing method
could be useful in measuring the
percentage of a population that
has contracted and may therefore
be immune to the virus.
Demand
for
SARS-CoV-2
testing kits has led to the sudden
emergence of a commercial market
for testing kits that American
Dental Association Executive
Director Dr. Kathy O’Loughlin
dubbed the Wild West. In midApril, O’Loughlin commented
that “all dentists need a fast
point-of-care test that accurately
predicts the presence or absence
of COVID-19 virus in real time.
Unfortunately, very few tests have
met a high standard for specificity
and sensitivity, which means a
potential for high rates of false
negatives and false positives,” she
warned.

All dentists need a fast
point-of-care test that accurately
predicts the presence or absence
of COVID-19 virus in real time.
The scalability of antigen
testing, relative to RTPCR
or isothermal amplification
methods, has resulted in this
method being touted as a
solution for the mass testing
that countries may require
before they can reopen their
economies
and
education
systems completely.

[8] =>

7 News

7/19

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) [page_count] => 8 [pdf_ping_data] => Array ( [page_count] => 8 [format] => PDF [width] => 794 [height] => 1134 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => DT India & South Asia No. 7, 2020

[toc] => Array ( [0] => Array ( [title] => Oral health matters! The Lancet first ever commission on Oral Health [page] => 01 ) [1] => Array ( [title] => For the young dentist: 5 steps to stand out in the post-Covid world through strong online branding [page] => 03 ) [2] => Array ( [title] => Clinical use of Chlorine dioxide in the prevention of coronavirus spread through dental aerosols. [page] => 04 ) [3] => Array ( [title] => Dr Hirji Adenwalla – a pioneer in cleft surgeries in India, a great humanitarian and visionary [page] => 06 ) [4] => Array ( [title] => Safer dental clinics are just a swab away: Testing patients for SARSCoV- 2 [page] => 07 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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