International Journal of Science and Healthcare Research Vol.5; Issue: 3; July-Sept. 2020 Website: ijshr.com Review Article ISSN: 2455-7587

COVID-19 in Children: Its Impact on Oral Health and Paediatric Dentistry

Paloni B. Koticha1, Debapriya Pradhan2, Farhin Katge3, Vamsi Krishna4, Parin Bhanushali1, Devendra Patil1

1Senior Lecturer, 2Professor, 3Professor and Head of Department, 4Reader, Department of Paedodontics and Preventive Dentistry, Terna Dental College, Nerul, Navi Mumbai.

Corresponding Author: Farhin Katge

ABSTRACT syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome SARS-CoV-2 is a novel strain of coronavirus coronavirus (MERS-CoV) are some of the that has not been recognized in humans earlier. lethal varieties which emerged in 2002 and The disease originated in China and has now 2012 respectively.[2]SARS-CoV-2 also become a pandemic affecting countries called as 2019 novel coronavirus has worldwide. The clinical characteristics in children seem to be milder as compared to recently emerged in Wuhan city of China.[3]It belongs to the genus of beta adults, but the exact clinical features related [4] COVID-19 is still unknown and unclear. This is coronavirus that originated in bats. The the reason why a child can be considered as a transmission of this virus occurs through “Silent carrier” for COVID-19. However, the droplets and infected fomites.[3]Currently it importance of children in transmitting the virus is causing a severe outbreak of a disease remains undefined. During this period of termed as COVID-19 in India and other pandemic, management of child's oral health countries, leading to global pandemic. presents specific difficulties related to the Considering the extensive spread of infectious spread of the disease. Dental clinics SARS-CoV-2 and reports of its spread to and Dental hospitals are considered to be health care providers, dentists are hotspot for any type of cross contamination [5] which may eventually result in transmission of considered to be at higher risk. This high disease. Hence, paediatric dentist are in a unique risk can be ascribed to aerosol generation, situation as they are approached for the handling of sharp instruments and vicinity [5] assessment and management of odontogenic of the patient. In the view of current pain, swelling and dental alveolar trauma in COVID-19 crises, management of oral these children. The purpose of this article is to health presents specific challenges related to review the impact of COVID-19 on paediatric infectious spread of the disease. These dentistry and paediatric oral health. concerns can be managed by implementation of oral health prevention Keywords: Coronavirus, pandemic, COVID-19, methods and specific protocols. Taking children, paediatric dentistry children into consideration, paediatric

dentists are carrying out procedures that not INTRODUCTION only limit the spread of the contagion but at Coronaviruses (CoVs) belong to the the same time maintain the integrity of the large family of Coronaviridae. These RNA child`s oral health. These procedures viruses range from 60-140 nanometer with include Alternative Restorative Technique spike like projections on its surface. This (ART), chemomechanical caries removal strain of viruses are considered to have a and Hall technique. On the other hand zoonotic nature and cause respiratory illness preventive strategies include use of sealants, in humans.[1]Severe acute respiratory

International Journal of Science and Healthcare Research (www.ijshr.com) 377 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry remineralising agents and resin infiltration The incubation period of the disease technique. [6]Moreover, home care measures is 7-14 days. Children suffering from this taken up by parents acts as an additional infection may be asymptomatic or have mild advantage. Hence, this review article symptoms. [13]These symptoms may include focuses on COVID-19 in children and its fever, dry cough and fatigue with a few impact on paediatric oral health and upper respiratory symptoms like nasal paediatric dentistry. congestion. It rarely progresses to lower Role of children in transmission of respiratory tract infections. Moreover, COVID-19: obscure symptoms such as nausea, Children are asymptomatic or show diarrhoea, hyposmia and dysguesia have mild symptoms when affected by COVID- also been reported. [14] With emerging cases 19 which has raised concerns for its hidden of COVID-19 in children a recent trend of role in transmission. The role of children in Kawasaki like disease also called as spreading the disease was a major question multisystem inflammatory syndrome (MIS- since the early days of pandemic. The C) has been noted. It usually manifests itself reason can be attributed to their playful and 3 to 4 weeks after the child recovers from talkative nature. Children talk loudly and SARS- CoV-2 infection and develops express themselves without restraints. antibodies against the virus.[15]Overall the Documentation suggests that talking loudly prognosis of COVID-19 is good in children and shouting may cause the spread of the with a fatality rate of 0.01 %.[16] infection through droplets. Similarly, Oral manifestations of COVID-19 in touching the face, nose and mouth is children: common during play among children. The intraoral findings in a child [7]These age specific concerns might suggest affected by the disease are usually non- their role in transmission. However, on the specific which can be attributed to the mild contrary there is light evidence by World form of COVID-19. Martin et al in 2020 Health Organisation (WHO) which presented a case series on oral suggested there is no transmission from manifestations as ulcers and blisters in child to adult. [8-9] patients affected or suspected of the disease. Reasons children spared from COVID- [17]However, the patients were adults with 19: underlying comorbidities. There is no The published data regarding literature yet available that states the COVID-19 globally supports the notion that intraoral findings in a COVID positive most children don`t exhibit severe disease. child. Paediatric dentists should be vigilant It is unknown why the children are less while examining COVID positive children severely affected. However, three theories due to the paucity in information. have been proposed for the same. Firstly, it Laboratory findings: was noticed that tendency toward immune Children affected by COVID-19 dysregulation is less in children. [10] show a reduced amount of white blood cell Secondly, markers of pro-inflammatory count particularly lymphocytes and response like C-reactive protein is neutrophils. Thrombocytopenia may occur. uncommon in children which is suggestive In patients severely affected by COVID-19 of reduce inflammatory response to show elevated liver enzymes, as well as infection.[11]Lastly, reduced expression of abnormal coagulation and elevated D- angiotensin converting enzyme 2 (ACE-2) dimers. [18] receptor which is necessary for binding of Radiological findings: On chest the virus further reduces the incidence of radiography, children mostly show bilateral COVID -19 in children.[12] patchy airspace consolidations often at the General manifestations of COVID-19 in periphery of the lungs, peribronchial children: thickening and ground-glass opacities. [19]

International Journal of Science and Healthcare Research (www.ijshr.com) 378 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry

Prevention of COVID-19 among travel history or those with respiratory children: infections or fever. Moreover, it is Role of the family members: imperative to target various risk factors like As small children may not be able to immune compromised state and comorbid take their own responsibility, parents or conditions to limit the chances of getting guardians are expected to take the charge infected. [22] for the same. Centers of Disease control and Management of COVID-19 in children: Prevention (CDC) has proposed various Treatment of children affected by guidelines in order to create awareness and COVID-19 is mainly symptomatic. [23] prevention among children about COVID- Supportive treatment including sufficient 19. The recommendations for its prevention fluid, calorie intake and additional oxygen among children include: [20] supplementation should be instituted in 1. Monitor the activities of children at these children.[24]The antiviral treatment home, school and outside the home constitutes use of lopinavir, ribavirin and setting.[20] chloroquine diphosphate.[25] 2. Restrict large group activities and keep Measures taken by dentist to limit the distance during play and interaction.[20] spread of contagion: 3. In the home and school setting, there is a Teledentistry: It is defined as the use of need to keep the surfaces and objects telehealth systems and methodologies in sanitized as these remain the medium of dentistry. [21] During this pandemic of transfer of pathogens.[20] COVID-19 it is gaining attention from 4. Group travel, picnics and study tours are various health care providers. Teledentistry to be discouraged.[20] is an effective way to triage patients with 5. Children need to be taught about hand symptomatic or possible COVID-19 hygiene regularly and they need to be disease. Tele triage can be done using the monitored for implementation of the COVID-19 screening questionnaire that same.[20] includes:[26] Role of Health care professionals: 10. Any exposure to a person with known or On the other hand a paediatric suspected COVID-19 infection in last 14 dentist plays a pivotal role in oral health days? [26] education when children are considered and 11. Recent travel history in areas with high thus explaining them its importance. This is number of COVID-19 cases in last 14 days? usually done by conducting dental camps [26] and providing early identification with 12. Presence of any symptoms of respiratory prompt treatment. Considering the COVID - illness such as fever or cough in last 14 19 crises it becomes difficult to conduct days? [26] these camps, in such situations preventive 13. Have you or any household member had strategies play a vital part. Social and digital history of exposure to COVID-19 biological platforms can be used to educate the child material? [26] and parent. Teledentistry is gaining attention If response to any of the above in this pandemic as the patients cannot come question is affirmative then dental treatment up for regular check-ups.[21]The main is not carried out.[27] Use of contact free objective of these guidelines is to avoid any forehead thermometer for every paediatric unfavourable consequences and thus patient and accompanying person is maintain good oral health. mandatory.[28]In situations where patients Apart from the precautions present with fever of dental origin treatment suggested, children should avoid contact can be performed. [27-28] (Fig. 1) with persons or other children with recent

International Journal of Science and Healthcare Research (www.ijshr.com) 379 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry

Child with accompanying parent

Tele-dentistry

COVID-19 screening questionnaire

Symptomatic Asymptomatic

URGENT CARE (Pain/swelling) EMERGENCY CARE ELECTIVE CARE Pharmacological 1. Defer treatment management: 2. Follow up to be  Antibiotics: 1. Preferred treatment maintained in hospital set up. Amoxicillin or its 2. Low aerosol combination. generating  Analgesics: procedures Paracetamol Follow up to be maintained

Figure 1: Algorithm for pediatric patient screening in COVID-19 (Adapted from Ather et al) [28]

In this midst of COVID-19, triage of various guidelines given by American dental treatment modalities for paediatric dental association (ADA) we have deduced patients has become the need of hour. The a table for paediatric population on dental primary dental care relies on provision of procedures. [30-31](Table1). These procedures three A`s that include analgesics, are divided on the basis of pain relief and antimicrobials and advise. [29] Based on the type of dental procedure to be conducted.

[30-31] Table 1: Treatment triage for paediatric patients (Adapted from ADA) EMERGENCY CARE URGENT DENTAL CARE ELECTIVE DENTAL CARE Immediate care to be delivered Medications are given for symptomatic relief along with (deferred dental procedures) dental procedure AEROSOL GENERATION WITHOUT AEROSOL GENERATION Cellutis Irreversible pulpitis Reversible pulpitis Dislodged restoration with no pain (Acute cellulitis of dental origin, Ludwig`s Angina) Trauma to the oral cavity Dento alveolar abscess Unavoidable extraction Fracture involving enamel or dentin Cracked tooth Avulsion Luxation injuries Adjustment of orthodontic appliances (if inhaled piece of tooth) Uncontrolled bleeding Fracture involving enamel, Acute pericoronitis Esthetic procedures dentin and pulp Avulsion Fracture involving enamel Scaling and polishing dentin and pulp Sealant and Varnish application Cavitation that does not cause pain and can be treated with restoration

Waiting Room: 2. When the child washes hands music 1. Animated videos showing the technique should be played for 20 seconds so that of hand hygiene. hands can be washed effectively. 3. Visual alerts at the entrance and in strategic places to provide instructions

International Journal of Science and Healthcare Research (www.ijshr.com) 380 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry

about hand hygiene and respiratory strongly recommended. Taking of hygiene. Instructions should include radiographs should be avoided as it may wearing a facemask for source control. induce gag reflex and thus stimulate saliva [32] secretion. [37] However, other modalities like 4. Provide alcohol-based hand rub with 60- CBCT and OPG can be undertaken. It is 95% alcohol, tissues and no-touch recommended that position of the operator receptacles for disposal. [32] should be at 10 or 11o`clock to avoid 5. Place chairs in the waiting room at least splatter. [36] While the treatment is being six feet apart to maintain social carried out parents are advised to be in the distancing. [32] waiting room unless the child is below 3 6. Remove toys, magazines and other years of age. [38] frequently touched objects that cannot Preprocedural mouth rinses (PPMR): be regularly cleaned or disinfected from Preoperative mouth rinse with waiting areas. oxidative agents has been suggested. [39] 7. Minimize the number of persons in the Chlorhexidine, one of the most commonly waiting room. [32] used mouth wash in dentistry is considered Hand Hygiene: to be ineffective against novel coronavirus. The reinforcement of good hand [40] Alternatively, mouth rinses containing hygiene is essential. WHO recommends the 1% hydrogen peroxide or 0.2% povidone use of the "two before and three after" can be used to reduce microbial load in technique as a regular hand hygiene saliva.[41]It also play a major role in cases procedure. [33] The technique recommended when rubber dam cannot be used. involves washing hands Use of rubber dam:  Before touching a patient, The use of airotor results in  Before clean/aseptic procedures, formation of aerosols and droplets that are  After body fluid exposure/risk, usually contaminated. These aerosols and  After touching a patient and droplets signify a potential route for  After touching patient surroundings. transmission of infectious disease such as Use of Personal protective equipment COVID-19. The use of rubber dam results (PPE): in a significant reduction in the microbial The use of PPE along with content of aerosols produced during operative procedures, thus reducing the risk protective eyewear, masks, gloves, caps and [42] face shield is strongly recommended. [34] of cross-infection in the dental practice. Particulate respirators (N-95 masks Children with special health care needs: authenticated by the National Institute for Dental management always possess Occupational Safety and Health or FFP2- a challenge in these patients due to their standard masks set by the European Union) underlying medical condition. These are suggested for dental practice. [35] A individual are at risk of oral diseases triple-layered surgical mask with a full face throughout their lifetime. When these shield can be worn in cases where patients suffer from pain of dental origin [34] they succumb to self -injurious habits which respirators are not available. The PPE [43] suits and face shields can also be modified further deteriorates their oral health. with various cartoon designs to modify Since the incidence of COVID-19 is more in child`s behaviour. such patients, the treatment for these Dental operatory: patients is usually delayed unless there is an Procedures carried out should be emergency. These patients are always done with minimal or no aerosol generation. treated in a hospital based dental clinics to In cases where it is required the patient prevent cross infection. In addition, should be scheduled at the end of the day. scheduling appointments for these patients [36] Moreover, use of four handed dentistry is also needs special attention as

International Journal of Science and Healthcare Research (www.ijshr.com) 381 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry recommended by (American Academy of 2. Teething problems: Parents are advised Paediatric Dentistry) AAPD. [44] to use clean swabs that help in removal Behaviour management: of food debris between the tooth and In situations where emergency care gingiva. Gel application and chewing on needs to be carried out in patients that are hard foods can be done to reduce the anxious, behaviour management becomes painful symptoms.[49] essential. Children showing extreme 3. Delay in tooth shedding: Children are negative behaviour increase the chances of instructed to bite on foods with hard aerosol spread due to their restless and consistency like bread toast and fruits. crying behaviour pattern. Moreover, the This technique hastens the process of attire of the dentist with PPE further exfoliation by creating pressure on the frightens the child. Use of distraction alveolar bone.[50] techniques like wall mounted television can 4. Tooth ache: The source of tooth ache be used. Apart from this other techniques may be dental caries, a cracked tooth or like tell show do and modelling can make a an infection. For temporary control of significant difference. However, patients symptoms, antibiotic therapy with that require aversive techniques of amoxicillin or its combination and pain behaviour management should be deferred relievers such as paracetamol are as suggested by AAPD. [44] recommended by AAPD. [51]In cases Disinfection: with suspected or confirmed case of Fumigation or fogging with chlorine COVID-19, ibuprofen should be dioxide should be done after every patient. avoided due to its interference with the Contaminated surfaces or those adjacent to immune system.[52] the operating room should be disinfected 5. Pericoronitis: Parents are advised to with 0.1% sodium hypochlorite. Flushing of keep the area clean. As an adjunct suction and disinfection of waterlines with gargles with chlorhexidine mouthwash this agent. Moreover, mopping of the floor can also be done.[53] and cleaning of dental chairs should be done 6. Dislodged restoration: Displaced several times in a day. [45] restoration from a tooth treated Dental management during COVID-19: endodontically or vital pulp therapy In a dental setting SARS-CoV-2 can causes excruciating pain. Parent are be transmitted mainly through aerosol advised to keep the cavity clean to generation. [46]Children can be potential prevent food lodgement along with carriers of this virus along the mild and avoidance of food stuff with extreme asymptomatic course of the disease. temperature.[54] Because of this, children are also called as 7. Patients undergoing orthodontic silent carriers. [9] During this pandemic of therapy: Children who are on a COVID-19 managing dental pathologies in removable appliance therapy their children involves a mixture of preventive parents are strongly advised to follow a and minimally invasive strategies. Due to strict hand hygiene and sanitize the box which not every time a child can visit a in which the appliance is stored at night. paediatric dentist unless it’s an emergency. On other hand for children on fixed In such situation measures taken by the appliance therapy the activation should parents at home. be suspended along with avoidance of Home care measures: sticky foods to avoid undue 1. Oral hygiene: Children must be consequences. [50] instructed to brush twice daily using a Dental emergencies: fluoridated toothpaste. However, in 1. Trauma: infants use of clean cloth or finger is Owing to the playful nature of recommended.[47-48] children, falls account for the major cause of

International Journal of Science and Healthcare Research (www.ijshr.com) 382 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry injuries to the young permanent teeth. Apart enamel and dentin are involved application from these automobile accidents, children of desensitizing paste works.[56]On other with seizure disorders also cause significant hand injuries involving pulp, luxation and dental trauma. When the type of injury is avulsion injuries to the tooth require urgent considered it is seen that permanent teeth dental care. In case of avulsion the parent is are more susceptible to crown fractures in asked to reimplant the tooth. However, if it contrast to crown fractures. This can be is not possible the tooth is kept in transport attributed to low crown root ratio and dense media like milk and taken to the dentist. The alveolar bone.[55] Managing traumatic procedure involves replantation of the tooth injuries at home may be difficult for the followed by application of the splint for 2 parent and child due to the anxiety created weeks. [57] (Figure2) by the fall. However, in cases where only

TRAUMATIC INJURIES TO YOUNG PERMANENT TOOTH

Involving Involving Avulsion Luxation enamel and enamel, injuries injuries dentin dentin and pulp

Application of  Handle the tooth from crown desensitizing portion paste  Clean the tooth if dirty under running tap water for 10 seconds

 Try to reimplant the tooth in the socket and then bite gently on the handkerchief to hold it in position

Not feasible Use of transport Immerse media the toothURGENT in DENTAL CARE transport Figure 2: Treatment of traumatic injuries to youngmedia permanent like teeth. (Adapted from Scottish dental effectiveness programme; 2020)[29] milk Pain and swelling due to dental caries: the indication a single visit or multi visit Caries when involves pulp causes technique is preferred.[61]Single visit agonising pain in deciduous or permanent pulpectomy should be advocated as much as tooth. Initially pharmacological treatment is possible as it not only reduces the symptoms considered as the first line of treatment. In of the child but also reduces the patient cases where there is no relief intervention exposure. However, when the tooth is non along with the medications is considered. restorable or has extensive root resorption it Untreated pulpal exposure are major cause is advisable to extract the tooth followed by of pulpitis or pulpal necrosis.[58]In cases a space maintainer.[61] Considering the where only the coronal pulp is involved various guidelines suggested for emergency agents that induce reparative dentin dental care we have deduced an algorithm formation can be used.[59]On the contrary, for treatment of pain and swelling due to where radicular pulp is affected a caries.[27,60] (Figure 3) pulpectomy is indicated.[60]Depending upon

International Journal of Science and Healthcare Research (www.ijshr.com) 383 Vol.5; Issue: 3; July-September 2020 Paloni B. Koticha et. al. COVID-19 in children: its impact on oral health and paediatric dentistry

Pulpal or periradicular disease

Pharmacological management with analgesics and antibiotics

Symptoms reduced

Yes No

Follow up to be Irreversible pulpitis / phoenix Reversible pulpitis maintained abscess/cellulitis

Administration of local anaesthesia

Rubber dam isolation with high volume suction

Mechanical / chemo mechanical caries removal

Pulpotomy Pulpectomy

 Amputation of coronal pulp.  Access opening and its refinement  Arrest bleeding with 0.3% sodium with micromotor hypochlorite  pulpal extirpation and biomechanical preparation using H files or rotary  Intermittent irrigation with sodium No Yes hypochlorite (0.1%)  Obturation can be done in cases where Place pulp Dry cotton single visit pulpectomy is indicated devitaliser pellet with temporary and temporary seal Dry cotton pellet with seal temporary seal

Figure 3: Algorithm for treatment of pain and swelling with carious pathology

Non-aerosol generating procedures: modification use of silver diamine 1. Alternative restorative technique fluoride (SDF) arrest the dental caries (ART)- It was first developed in and Glass ionomer cement (GIC) seals Tanzania as a treatment approach for the cavity. Moreover, fluoride releasing areas where resources are not available property of GIC gives an additional for a definitive dental treatment.[62]This beneficial effect. [63] procedure is recently gaining more 2. Chemo-mechanical caries removal popularity during this COVID-19 crises technique- It can be defined as a owing to its minimum equipment and no technique of eliminating infected aerosol production. Initially it was used dentine by use of chemical agent.[64]It is only for sealing minimal caries but with not only effective in caries removal but its new modification also called as at the same it is non-invasive. It is (Silver modified atraumatic restorative broadly divided into two types on basis technique) SMART technique it can also of its major content. They can either be be used in teeth with caries sodium hypochlorite based agents or approximating the pulp.[63]In this enzymatic agents. [65] Various studies

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and Cochrane review have claimed its considered its effectiveness ranges from effectiveness. [66-67] Since this procedure 40-60%. [75] It can be considered as a is considered as a biological method of safe and effective way of fluoride treating dental caries, its use can be retention on tooth structure. considered during this pandemic. 2. Pit and Fissure sealants: High 3. Silver Diamine Fluoride (SDF): It is a susceptibility of caries in molars and colourless odourless liquid that not only premolars can be attributed to its arrest caries but also prevents its occlusal surface. Presence of deep progression. [68] It was initially used as a fissures and grooves prevents the preventive agent in Japan. Although it chemical or mechanical cleaning of has several advantages of prevention these areas. Thus application of pit and and arrest of dental caries, it can also be fissure sealants becomes mandatory in used as a desensitizing agent.[69]The children. [77] only disadvantage associated with this 3. Resin infiltration technique: it was liquid is discolouration of teeth first introduced by Munoz et al (2013). overtime.[68] [78] The technique basically involves 4. Hall technique: A non-surgical arresting enamel lesions and also masks technique used to restore asymptomatic the white spot areas. Its mechanism of carious primary molars. [70] It advocates action relies on the penetration of low the use of separators for 3-5 days viscosity resin and thus arrest the caries followed by placement of crown.[70]No progression.[78]A recent meta-analysis local anaesthesia is administered nor is suggested its effectiveness in caries removal of caries attempted. On the reduction.[79]Apart from this various basis of evidence available hall studies are available that show its technique can be effective done on a effectiveness in smooth surface as well child. [71-72] The technique relies on the as proximal lesions.[80] principle of sealing caries from the oral environment and thus stopping its CONCLUSION progression.[70]Apart from its use in COVID-19 seems to affect children primary molars it can also be used in less severely as compared to adults. children have mutilated first permanent However, they remain vulnerable to molars due to hypo-mineralisation. [73] infection and pose a substantial transmission However, literature supporting it is less. risk. Currently there is no active treatment Since this procedure does not involve and diagnosis is still a challenge. These generation of aerosols it can be characteristics put the dental offices at a risk considered as an option during this of cross infection between children and pandemic. dentists. Pediatric dentists during this Preventive strategies: pandemic should enact universal infection With the growing significance of control protocols to the highest standards to preventive dentistry new innovations have limit the spread. Hence, understanding the been developed with the aim of early present situation is helpful in terms of disease prevention: predicting future dental needs. 1. Fluoride varnish: Vast literature is available that supports the effectiveness REFERENCES of topical fluorides on dental caries. [74- 1. Wang L, Wang Y,Ye D, Liu Q. Review of 75] Topical fluorides in the form of the 2019 novel coronavirus (SARS-CoV varnishes can also be used as cavity 2) based on current evidence. Int J liners. [76] AAPD suggests the Antimicrob Agents 2020; 55(6):105948. 2. Petrosillo N, Viceconte G, Ergonul O, application of varnish biannually. When Ippolito G, Petersen E. COVID-19, SARS the caries reduction potential is

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