Introduction

On 8 January 2020, a novel coronavirus (SARS-CoV-2) was officially announced as the pathogen causing COVID-19 by the Chinese Center for Disease Control and Prevention¹. The COVID-19 epidemic started in Wuhan, China, in December 2019 and quickly became a challenging public health issue in China and worldwide. On 30 January, the World Health Organization (WHO) announced it as an international public health emergency and, in March, as a pandemic. It was clearly determined that the virus had high and sustained human-to-human transmissibility⁽².

Thus, it became a challenge for health professionals in general and dental surgeons in particular due to the high risk of cross-infection in dental environments. This made it necessary and urgent to implement rigorous and effective infection control protocols in all the countries and regions affected by COVID-19 ³.

The COVID-19 incubation period-the time between exposure to the virus and onset of symptoms-is 5 to 6 days on average, but it can be between 0 and 14 days. Many studies are underway worldwide to better understand the virus transmissibility, severity, and other related resources. The available information shows that the virus spreads through respiratory droplets (expelled when talking, coughing, or sneezing) and by direct contact with infected persons or indirectly through contaminated hands, objects, or surfaces, in the same way as other respiratory pathogens spread. Transmission may also occur through aerosols (smaller and lighter than droplets) generated during specific procedures⁽⁴. The absence of a vaccine with proven effectiveness invites us to reflect on the need for protection barriers to prevent the disease and its spread.

All care is insufficient because many people infected with the virus may not take the necessary precautions and spread it unknowingly because they are asymptomatic. Moreover, some people have mild symptoms, and others have severe symptoms, which can lead to death. Currently, the most common signs and symptoms of COVID-19 are fever, cough, and shortness of breath. There are other non-specific or atypical symptoms such as sore throat, diarrhea, anosmia (inability to smell) or hyposmia (decreased smell), myalgia (muscle pain), and tiredness or fatigue⁽⁵.

Given the above, it is essential to implement biosafety protocols for dental practitioners at all stages of patient care. So far, there are no conclusive documents or resolutions on how dental care should be implemented in the world. The general recommendation so far in different Latin American countries is for dental surgeons to postpone routine procedures unless they are clinically urgent or an emergency. Professionals must take strict personal protective measures for such procedures and avoid or minimize interventions that may produce droplets or aerosols^(3,6.

Caring for patients with special needs

Patients with special needs (PSN) have disabilities (physical, mental, sensory, developmental, behavioral, emotional, cognitive) and limited conditions that require medical care (systemic health problems that require specialized treatment programs or services). The pathological condition may be congenital or acquired and cause limitations or incapacity in day-to-day activities ⁷.

The current COVID-19 pandemic increases the existing inequalities sustained by this population: they are vulnerable to developing severe health conditions, poverty, neglect, violence, and abuse. Besides, they also have less access to education, employment, health care, and society participation⁽⁸.

This situation is worrying throughout Latin America. According to the Economic Commission for Latin America and the Caribbean (ECLAC), there are over 70 million people with disabilities, amounting to 12.6% of the population⁽⁹. This figure is close to the 15% reported in the latest WHO’s World Report on Disability¹⁰.

Prevalence rates are not constantly updated and there are variations among countries: Brazil (23.9%)⁽¹¹, Chile (16.7%)⁽¹², Uruguay (15.9%)⁽¹³⁾ , Paraguay (11.6%)⁽¹⁴, Argentina (10.2%)⁽¹⁵, Perú (5.2%)¹⁶, Colombia (4.1%)¹⁷, Ecuador (2.43%)⁽¹⁸.

These data reflect the urgent need to act and ensure that these people are protected and cared for during the pandemic, taking into account their social and economic conditions. Many of them require additional support for basic hygiene procedures, live in crowded residential institutions with limited social distancing options, and have a fragile connection with the labor market. Additionally, lockdowns and travel restrictions have disrupted access to goods and services that are essential to their well-being. This can cause considerable stress and anxiety to them and their families ¹⁹.

Latin America has significant regulations and publications that aim to ensure the rights of this population. There follow some examples: Brazil’s informative material People with disabilities, rare diseases and COVID-19, which helps disseminate the necessary care they require⁽²⁰; Uruguay’s COVID-19 and caring for persons with disabilities of Uruguay, which provides guidance for their care during emergencies⁽²¹; Colombia’s report Persons with disabilities, differential challenges in the framework of COVID-19, which focuses on this issue¹⁷; the Guide to prevention against coronavirus prepared by the National Committee of Persons with Disabilities in Bolivia, which provides recommendations by type of disability²²; Argentina’s Recommendations for the care of persons with disabilities and persons with mental health problems who are undergoing referral and/or hospitalization in a second-level hospital, which ensure continuity of care, support and treatment⁽²³; Peru’s Legislative Decree No. 1468, which establishes prevention and protection regulations for persons with disabilities during the state of emergency²⁴ and Chile’s Special considerations for the management and treatment of persons with disabilities during the SARS-CoV-2 Pandemic to improve health-care response during the health emergency ²⁵.

Regarding oral health, Governments must ensure that persons with disabilities have access to dental care because they are at high risk for oral diseases. This may be exacerbated by the impact on people’s general health and by the emotional and psychological implications the current situation has for them and their families and/or caregivers⁸.

Remote dental care-teledentistry-should be the first line of care during the public health crisis and when face-to-face contact between patient and specialist is impossible due to geographical distance or other impediments. It should be considered a fundamental tool at this time since it enables professionals to assess the degree of urgency or emergency for dental care, stressing the importance of solving the problem and following up on the case. Each country has a teledentistry council that guides its practice. Chile pioneered in Latin America by establishing Telehealth in 2007. It also has a Guide to good practices and telemedicine recommendations in times of COVID-19, which includes the entire health team. Colombia and Peru have implemented guidelines for teledentistry practice during the COVID-19 pandemic. Argentina, Bolivia, Ecuador, Paraguay, and Uruguay have telehealth legislation that includes dentistry and other health specialties ^26-27.

The Latin American Association of Pediatric Dentistry has launched a series of documents and directives to support professionals and families on how to approach the dental care of children during this health crisis. They are fully applicable to patients with special needs and are based on the best scientific evidence available⁽²⁸. These measures are difficult to implement if the practitioner does not have the necessary knowledge, empathy, and ability to deal with this type of patient and their environment and help them understand changes and process their feelings.

As health professionals, we are responsible for transmitting healthy habits and prioritizing prevention, always attempting to be conservative and as minimally invasive as possible. Patients with special needs cannot sustain further harm during and after the pandemic. Their care and attention must be essentially transdisciplinary, considering the different types of disabilities and respecting the beliefs, feelings, and complaints of the patient and their relatives and/or caregivers to establish effective health communication.

It is still challenging to establish when and what new measures will be taken for the dental care of patients with special needs. There is still a lot to learn about COVID-19. Therefore, professionals must remain rational when considering dental care in these moments of considerable uncertainty. Risks and benefits should be weighed, and care should be simplified or postponed when possible. Additionally, we should establish alternatives and means to provide support, information, and security⁽²⁹. The pandemic shows us that advancing health promotion is the way forward, without waiting until emergency situations decrease people’s quality of life.