The present data of subjects for the comparative study were obtained from the daily dental OPD attendance register of our hospital; Department of Dentistry, NEIGRIHMS (Meghalaya) which was recorded on daily basis during normal working days from the month of March 2020-May 2020. There is no criteria for inclusion or exclusion of the subject, unlike interventional study. The present study also excluded patient consent form since the study does not involve any form of intervention to the subjects. All the subjects who had attended to dental OPD during the pandemic and phase-I lockdown were included, to seek a relief from any dental related pain of three months i.e., from (March 2020-May 2020). The current data of the subject’s attendance was compared with the previous year of 2019 and 2018 of the same months from March to May which is considered to be a normal flow of patients in daily dental OPD services in normal days. The data does not include the management part of the previous year 2019 and 2018 since the present study was to know how the COVID-19 pandemic and phase-I lockdown impacted non-COVID-19 dental patients and their emergency care during this pandemic.

Management Strategies of a Patient during Pandemic at Dental OPD

Since this district had already detected a few positive cases so each and every patient coming to the hospital was mandatory to screen for COVID-19 for the safety of entire staff working in the hospital. There is a system of initial screening facilities at the hospital which comprises of TEAM where an initial screening is done with the help of thermal scanner followed by proper history taken by COVID-19 management team outside the main OPD entrance before entering to the main OPD building or MRD section of the hospital. History includes cough, cold, fever or any travel history in past 14 days as shown in [Table/Fig-1]. During this pandemic the dental OPD patient hall was arranged in such a way that at least six feet distance was maintained from unaffected patients [7]. Since infection can occur as a result of close direct interpersonal proximity (distance less than 2 m and duration greater than 15 minutes or following contact with hands which have come into contact with contaminated surfaces or airborne particles [8]. The patient was not examined in the dental OPD room or in dental chair just to contain the spread of this contagious virus during this phase unless we were in need of air rotor for emergency cases of a patient. While examining, a distance was maintained between examiners and the patient as much as possible, but dental profession is such that it has to be examined from a close distance to get a clear view of the problem inside the oral cavity. But if the patient is having partial or complete trismus it becomes more difficult for the dentist to examine the patient properly. If patient does not need an immediate requirement as per his/her complaints, just do consultation and defer till things get normalised. If a patient had an acute case of pain with swelling which needs to be examined in the procedure room individual patient are allowed to enter the procedure room (in the case of minor patient) single companion for minor (especially mother) had to attend along with a patient in the procedure room [4]. Most importantly we never use dental chair in this time of crisis to avoid and prevent the contamination of the procedure room as well as dental chair. We had used the patient waiting area for consultation with the help of torch light as shown in the [Table/Fig-2a,b,c]. Once the examination or consultation was done for each patient, the examination gloves were discarded and the hands were washed properly with soap. The torch light and face shield were scrubbed after every patient with alcohol-based hand sanitiser.

[Table/Fig-1]:

Proforma to be filled by the patient.

[Table/Fig-2]:

Examination done in the patient waiting area.

The present study aims at scrutinising the changes that COVID-19 pandemic has made in the patient flow in the hospital. The study argues that COVID-19 pandemic has substantial potential to reduce flow of various patients despite prolonged morbidity and will continue to do so. In order to do that, the study looked into the patient flow per week during three consecutive years which are recent past in the year 2018, immediate pre-COVID situation in 2019 and during the present COVID-19 pandemic. To analyse the data of the present study SPSS version 26.0 with Windows 10 was used.

The statistical value of the patient flow which represented with X1 for new patient/week, X2 for old patient/week and X3 for total no. patient/week with t-stat value of 8.25***, 4.58*** and 6.56*** for new patient/week, old patient/week and total no. of patient/week, respectively. For F-stat (ANOVA) with a value of 39.35***, 33.52*** and 39.07*** for new patient/week, old patient/week and total no. of patient/week respectively. Where ‘p’ is significant at <0.01 and <0.001.

Number of patient attendance at daily OPD services during phase-1 lockdown (March 2020-May 2020) are presented in [Table/Fig-3]. Number of patient attendance at the daily OPD services during March to May 2019 are presented in [Table/Fig-4]. Number of patient attendance at our daily OPD services during March to May 2018 are presented in [Table/Fig-5]. Data showing total numbers of patients attending dental OPD services during different years (2019 and 2018) from March to May including year 2020 is shown in [Table/Fig-6].

The data from [Table/Fig-3,4 and 5] represents three consecutive years from (2020 to 2018) of three months (March to May) of patient flow in dental OPD at the hospital NEIGRIHMS (Meghalaya). The [Table/Fig-6] shows a consistency in total number of patient flow/month during two consecutive year of 2019 and 2018 at the OPD which are represented with figure of 3383 and 3111 respectively during immediate pre-COVID-19 and recent past COVID-19 year of three months from March to May. But when the data was observed during COVID-19 situation of three months from (March 2020-May 2020), the total number of patient flow/month significantly decreased to 847, as compared to the year of immediate pre-COVID-19 (2019) and recent past COVID-19 (2018) of three months. So from the above data, we can also interpret that there is a profound impact of COVID-19 pandemic on the dental OPD patient flow at the hospital during the COVID-19 pandemic.

Changes in OPD patient flow: COVID-19 pandemic has revealed a sharp contrast in OPD patient flow during pre-COVID-19 and COVID-19 situation. During the two periods (recent past in 2018 and pre-COVID-19 in 2019) preceding onset of the COVID-19 pandemic, flow of total OPD patients continued to rise. However, there was an anomaly in the increase. Though follow-up OPD patient per week continued to rise during recent past and pre-COVID-19 period yet a significant fall in the number of new OPD patients was seen. Follow-up patient as well as total number of OPD patient/week showed an increase in 46% and 14% during recent past (2018) and pre-COVID-19 (2019) period. However, there was a significant fall in new OPD patient/week (about 34%) during same year. Nevertheless, onset of COVID-19 pandemic led to significant decrease in both the follow-up OPD patient/week and new OPD patient/week affecting overall number of patient flow/week during the COVID-19 situation as shown in [Table/Fig-7,8]. The table shows the trend in patient flow over the periods of recent past in 2018, pre-COVID-19 in 2019 and COVID-19 in 2020.

[Table/Fig-8]:

Trend in patient flow over the periods of recent past in 2018, pre-COVID is 2019 and COVID in 2020.

The [Table/Fig-9] shows that, there is statistically significant difference in the amount of patient flow among different group of patients with ANOVA (F-stat) and t-stat among different group of patients during the period of recent past and COVID-19 situation as shown in [Table/Fig-10], where N is the number of observations and p is significant at **<0.05, ***<0.01.

[Table/Fig-11] shows that, even knowing the fact about COVID-19 is contagious still 847 patients [Table/Fig-3] had attended the dental OPD at the hospital during pandemic because of an inevitable circumstance for a patient to relieve a pain and swelling as much as possible. Out of 847 patients, 305 patients had come with a complaint of toothache due to dental caries or caries exposure of tooth. Extraction of one lower left deciduous central incisor tooth was done at dental OPD with proper precautionary measures. Grinding of one tooth was done tooth No.46 (Lower right first molar) at OPD as shown in [Table/Fig-6]. The patient had history of maxillofacial trauma along with fracture of tooth due to road traffic accident a week back and he was complaining of severe pain in tongue and not able to eat for almost a week. On oral examination, it was found that the tooth was severely fractured; only a portion of tooth was left with sharp edges in oral cavity. It was also found that there was ulcerated area in tongue on both side of lateral and dorsal surface too.

Immediately, grinding was done so as to relieve the patient from the sharp edges of that particular tooth, besides that antibiotics and analgesic was also prescribed. And the rest of the patient’s complaints are as shown in the [Table/Fig-12]. From this data, it can be concluded that due to the COVID-19 pandemic it had affected the normal routine dental services to a non-COVID-19 dental patient at the dental OPD as compared to the previous year (2019 and 2018) of three months. The data also suggests that there might be a lot of dental patients who want to visit dental OPD for their emergency care but were unable to access the dental OPD due to COVID-19 pandemic as well as phase-I lockdown.

[Table/Fig-12]:

Shows different type of patient complaints during COVID-19 pandemic and phase-I lockdown from (March 2020-May 2020).

As per the above data it also suggests that no matter what might be the situation, the DHCP are always at risk since even during the peak time of pandemic DHCP had to work in oral cavity while it remains open, where oral cavity is supposed to be one of the transmission route for acquisition of the COVID-19 virus [4]. So by the virtue of DHCP profession itself they have to work in close contact with patients as much as possible which increases the risk to them. Working in close interpersonal contact with the patient while doing the dental procedure increases the risk for disease acquisition [8]. Besides that DHCP have to work with aerosol generating dental equipments [1].

The rampant spread of SARS-CoV-2 across the globe within different individuals will definitely unfurl this infectious disease at any point of time to DHCP through the COVID-19 infected individual by the virtue of their unique way in dealing with the patients as compared to other professions. Even in the phase of COVID-19 pandemic and phase-I lockdown, patients will keep on visiting the dental OPD which remain functional to get relief from the pain and other dental emergency issues. Even though it was pandemic, still 847 patients had attended Dental OPD during this pandemic and phase-I lockdown from March 2020-May 2020, which comprised of new cases, follow-up cases and in-patient cases. But when the data was compared of the total number of patients from each year of three months (March to May) of year 2019 and 2018, the overall total number of patients during pandemic year 2020 (March to May) had profoundly decreased in the total number of patients inflow in our OPD during pandemic shown in [Table/Fig-6]. And when it comes to dental examination, intraoral examination is the only option with close contact with the patient as much as possible for proper view, unless patient developed a complete trismus of oral cavity.

Dental chair and the surrounding area of dental clinic must be taken into account as it acts as source of infection after aerosol instruments are used. Since some studies indicate that hand contact with contaminated surfaces may lead to pathogen acquisition and transfer to eyes, nose, or mouth and this could lead to SARS-CoV-2 infections, like several nosocomial pathogens [9]. There is report from the other study also [3] that the diseases can transmit during incubation periods while an infected patient remains asymptomatic. As per some studies the incubation period of this virus last up to 14 days [10]. But other studies say that the incubation period for SARS-CoV-2 range from 0-24 days [7]. This variation in an incubation period of the virus might insidiously infect susceptible individuals during an asymptomatic stage to DHCP, even to the patient and vice-versa while doing dental procedure. Other conditions like oral examination and closed contact between the patient and the dentist during procedures also poses maximum risk between the dental surgeon and a patient during asymptomatic/ incubation periods. But from the OPD data it has been found that, daily routine OPD dental patient and routine follow-up case had dropped tremendously but still even a single patient can act as a risk for a source of potential infection to other.

No one can predict when the crises of this pandemic will end; even there is no surety about the infectious nature and the future status of this present COVID-19. Keeping in mind the infectivity of SARS-CoV-2 and its contagious nature to health providers, strict protocol has to be maintained to contain the virus as much as possible even during any normal dental procedure.

It is known that, unless our body develops natural herd immunity or vaccination occurs it’s always a risk to any form of profession where human contact is concerned especially healthcare workers. The only way we can keep the profession going is by taking special precautions and proctecting ourselves by maintaining strict protocols during any dental procedure.

The actual fact about the significant decrease in the overall numbers of patient flow at the OPD during this pandemic is not known but it might be the patient’s mental perception that they will acquire SARS-CoV-2 infection just by attending the dental OPD during the pandemic. So just to avoid acquisition of COVID-19 infection during the pandemic they have to go through such a tremendous burden of toothache and their dental emergencies related pain without attending any dental OPD during this period. This study was only a part of one district of North-East India at the dental OPD, Department of Dentistry, NEIGRIHMS hospital (Meghalaya) but when the entire nation or whole world is taken into consideration, an enormous number of patients in urgent need of dental treatment would be impacted by the COVID-19 pandemic.