Management of Periodontal Emergency during COVID-19 Pandemic

Abstract

The novel coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus presents with nonspecific symptoms such as fever, dry cough, shortness of breath, weakness, headache, and diarrhea. The primary mode of transmission of SARS-CoV-2 is through direct or indirect inoculation of the mucous membranes (eyes, nose, or mouth) with infectious respiratory droplets or fomites. Periodontal tissue can serve as a barrier to the SARS-CoV-2 virus in infected individuals. There are similarities between COVID-19 and periodontal disease, based on pro-inflammatory cytokines released by the body. A periodontal emergency arises when an acute condition involving the periodontium causes pain, forcing the patient to seek urgent care; therefore, most periodontal treatment can be considered as dangerous work compared to other dental procedures regarding the aspect of bioaerosol generation procedure. Transmission can occur through direct doctor-patient contact, as well as contamination from instruments or surfaces in the dentist’s practice room, and it is recommended to use PPE, to avoid aerosol splashes that occur during the work procedure, where aerosol granules and droplets can last 30 minutes after the treatment procedure is performed. The use of teledentistry is very important in periodontal care, in communication with patients regarding chief compliant, risk factor control, and oral hygiene instruction.

1. Introduction

Coronavirus disease 2019 (COVID-19) was first reported in Hubei Province of China at the end of December 2019. Later, in March 2020, after observing the nature of the virus and its course, the World Health Organization (WHO) announced it as a pandemic [1]. SARS-CoV-2 is mainly transmitted via direct contact with respiratory droplets, through cough, sneeze, and droplet inhalation, or via indirect contact of oral, nasal, and mucous membranes with contaminated fomites or saliva, which may be of particular interest for dental settings, that invariably carries the risk of SARS-CoV-2 transmission, especially considering the interpersonal proximity, the exposure to blood and saliva, the handling of sharp instruments, and the variety of aerosol-generating dental procedures [2, 3]. Therefore, dental patients are very vulnerable and at risk of transmission of the SARS-CoV-2 virus infection, where this virus can be transmitted through direct contact through the mouth and nose in the form of droplets and aerosols containing the virus, originating from infected individuals or through indirect contact with contaminated dental instruments or contaminated teeth [4]. Not only patients but also clinicians who treat patients are also at risk of transmission caused by direct contact with patients who are not wearing masks, as well as aerosols and droplets produced from the mouth of the patient [5]. So, caution is needed for clinicians and patients in carrying out dental actions and treatments.

2. COVID-19 and periodontal disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new type of novel coronavirus that causes COVID-19 [6]. The target of SARS-CoV-2 infection is cells in the respiratory tract, where Protein S in SARS-CoV-2 will bind to (angiotensin-converting enzyme 2 (ACE2) as the receptor [7]. ACE2 is found in pulmonary epithelial cells, myocardial cells, gastrointestinal system, proximal cells of renal tubules, arterial smooth muscle cells, and oral epithelial cells, where the expression of ACE2 will increase in patients with certain conditions, such as, in elderly individuals, obesity, kidney disease, and lung disease that results in individuals with the condition being more susceptible to the transmission of COVID-19 [8, 9, 10]. The SARS-CoV-2 virus will replicate, and the virus that has entered the body will be presented by antigens-presenting cells (APCs) and will induce T cells and B cells as humoral and cellular immune responses [11].

Periodontal disease is an inflammatory disease of dental support tissue that is commonly found in individuals over the age of 30 years and is often found in the elderly population. Severe periodontitis, now known as stage III and IV periodontitis, is the 6th rank disease commonly suffered by adults, affecting 11% of the adult population globally Several studies have shown a link between COVID-19 and periodontal disease, and this is due to the similarity of pro-inflammatory cytokines released by the body. Periodontal disease is a multifactorial disease caused by the involvement of microorganisms and a host response characterized by the production of pro-inflammatory cytokines [12, 13]. Pathogenesis of periodontal begins from the expansion of the subgingival plaque into the gingival sulcus, where microorganisms residing in the subgingival plaque can cause changes in the coronal attachment of the epithelium on the surface of the tooth, and this is due to the presence of an immune response to pathogenic bacteria and endotoxins through the activity of neutrophils, macrophages, and lymphocytes. Host factors also influence the development of periodontal disease, where an inadequate host response in destroying bacteria can damage periodontal tissue [14]. Pathophysiology periodontitis stimulates the occurrence of cytokine responses. Research conducted by Wu et al. (2020) on COVID-19 shows that there is an unfavorable relationship that can cause cytokine storms, where certain elements have similarities with cytokine profiles commonly encountered in periodontitis. Individuals infected with the COVID-19 virus that was accompanied by aggravation so that they had to be treated in the ICU showed an increase in IL-2, IL-7, IL-10, macrophage, monocytes, and TNF alpha. Th17 cells were also found in individuals suffering from SARS-Co V and MERS-CoV [15]. Th17 cells are found in cytokine storms, {Formatting Citation} pulmonary edema, and damaging tissues that may result in lung infections caused by the SARS-CoV-2 virus [16]. An increase in IL-17 was also found in individuals experiencing inflammatory gingivitis and periodontitis [17]. Gupta et al. (2021) found the accumulation of the corona virus in gingival crevicular fluid (GCF) in asymptomatic or mildly symptomatic COVID-19 patients, where the condition is in line with the hypothesis in a study conducted by Badran et al. (2020) where periodontal can serve as a reservoir for the SAR-CoV-2 virus in infected individuals [18, 19].

3. Dental management during COVID-19

Dental care during the pandemic should not be delayed, especially in emergency cases, dental care during the pandemic should be linked to patient risk assessment, patient triage, and infection prevention measures for clinicians or health professionals and nosocomial transmission in dental clinics (Figure 1) [20].

Figure 1.

Illustration of COVID-19 transmission in dental clinic.

Treatment in the field of dentistry can generally be categorized as an emergency, urgent, nonurgent, and advise/self-care (Figure 2). In principle, emergency care in the field of dentistry is associated with acute pain that is urgent for treatment, as well as life-threatening possibilities, including uncontrolled bleeding, significant infections, bending, and orofacial trauma that has the potential to block the airway. Meanwhile, urgent (essential) treatment is the treatment of severe or uncontrolled symptoms that require patients to see a dentist. Nonurgent care or categorized as daily care is a routine treatment carried out by individuals, while advise/self-care treatment is dental care that can be done through telemedicine, related to it the instruction and prescribing of either analgesic or antimicrobial (Figure 3) [21].

Figure 2.

Dental care management that occurs during COVID-19.

Figure 3.

Medical dosage recommendations.

Note: Patients with substantial swellings can progress to life-threatening emergencies, which can increase risks in the setting of reduced health care availability. For that patient, extraction of the causative pathogenic teeth should be prioritized over the restorative rescue. Close follow-up by telephone is recommended [21].

3.1 Recommendations for clinicians to reduce airborne viral contamination

Dental care is usually done in an enclosed space, so the dentist needs to equip himself with some protection, such as masks, gloves, goggles, head coverings, and gowns that reduce saliva splashes that may occur during dental procedures. Aerosol granules or droplets can stay in the air for 30 minutes after the dental treatment procedure is carried out [22]. In addition, the regulation of air circulation in the clinic room is also must be noted, and the common thing to do is to eliminate airborne transmission in the clinic room is to equip the room with the use of a good quality air filter and the presence of an ultraviolet room as part of the air ventilation system [23]. Another tool that should be present to reduce contamination through the air is extraoral suction or known as a high-volume evacuator (HVE), in dental treatment procedures, and a good extra oral suction has a wide opening or mouth and is connected to a drain that reduces the volume of air to 100 cubics of per minute. Several previous studies have suggested that the use of HVE can reduce airborne virus contamination by up to 90%, if the clinic room is not equipped with HVE, and it is recommended to use air vents to facilitate air exchange [24, 25].

3.2 Dental treatment procedures that must be carried out to eliminate viral contamination through the air

To reduce the risk of transmission, it is necessary to have a good strategy in terms of carrying out dental procedures, including [26].

1. The use of rubber dam

The use of a rubber dam is needed for dental treatment procedures that require isolation of the work area, and if it is not possible to isolate the work area such as curettage or other periodontal measures, it is recommended to use hand instruments instead of ultrasonic tools, to reduce the chances of aerosols being generated.

1. Four-handed dentistry is accompanied by the use of suction with high-pressure sucking ability.

2. Avoid drying with a three-way syringe

3. The advice for the patient is to rinse their mouth with an antiseptic before the dental treatment procedure is performed. The use of mouthwashes containing antiseptics has proven effective in reducing the number of microbes in the oral cavity, and it can also reduce the number of microorganisms in aerosols produced by dental treatment procedures [27, 28, 29]. Although the use of chlorhexidine as a mouthwash is not effective in killing SAR-CoV-2, a study conducted by Yoon et al. (2020) has succeeded in proving that there was a temporary reduction in the amount of virus in saliva for 2 hours after rinsing the mouth with chlorhexidine [30, 31, 32]. According to Mady et al. (2020), the use of povidone iodine as a mouthwash before dental treatment can reduce the SARS-CoV-2 virus and also MERS-CoV in 15 seconds with a dilution ratio of 1:30 [33]. While, the use of hydrogen peroxide as a mouthwash is recommended for reducing the SARS-CoV-2 virus still needs further study [34].

3.3 PPE (personal protective equipment)

For professional dentists, the risk of transmission can be prevented by the use of PPE. The recommended use of PPE (Figure 4) includes head coverings, gowns, gloves, face shields, masks, footwear covers, or other equipment that aims to protect against injury or contamination bacteria derived from aerosols or droplets produced during dental treatment procedures [26]. The recommended use of masks is N95/PFF2 because it provides good protection and is recommended internationally; in addition, if needed due to inadequate amount of availability, N95/PFF2 masks can be disinfected first before reuse [26, 35, 36].

Figure 4.

Recommended PPE during COVID-19.

4. Periodontal management during COVID-19

4.1 Prevention of droplet transmission before treatment measures

Dentists who perform periodontal treatment are at risk of being contaminated with the COVID-19 virus through droplets or aerosols generated during the periodontal treatment procedure, through the use of ultrasonic scalers, rotary instruments, and water syringes and air polishers that potentially increase the risk of transmission through cross-transmission between dentists and patients [37, 38, 39]. All dental health care facilities are required to implement triage protocols including detailed medical record data, which contains specific questions that can identify individuals suspected of COVID-19. All patients seeking treatment should be considered potentially infectious. All patient screening actions must be carried out in strict health protocols, and operators should be equipped with PPE during the patient screening process [37, 40]. When the screening process is carried out, the dental professional should ask questions related to patient complaints that lead to emergency care and conduct an assessment to determine whether or not emergency care is necessary [39, 41, 42]. To reduce the occurrence of transmission through direct contact, screening can be done via telemedicine or tele-triage, which can be done via the internet or telephone, and if the patient states to have had contact with an infected individual with COVID-19 recently or is known to have the symptoms of COVID-19, the patient can be prescribed if needed [39, 43].

4.2 Prevention of droplet transmission during treatment measures

Some preventive measures that can be carried out before periodontal treatment include cleaning the surface of the dental unit with material containing 0.5% sodium hypochlorite for 1 minute and sterilizing non-disposable tools [44]. Using an extraoral suction, air purifier and exhaust fan are still being evaluated for effectiveness for dental clinics, if there are patients who are suspected of having COVID-19, and it is recommended that their dental treatment should be carried out in a negative pressure room to reduce the spread of the virus through droplets and aerosols [45]. However, the use of negative pressure rooms has issues because it requires quite expensive costs [38, 45]. After the initial examination, the periodontist is advised to take periodontal treatment measures that are not emergency in nature unless there is pain that is a complaint. The effectiveness of the use of ultrasonic scalers is basically the same as that of manual scalers except that on ultrasonic scalers, and it is more risky in aerosol dispersing, which allows to stick to the corners of the eyes and nose operator [46]. However, if the patient complains of pain leading to emergency measures, it is advisable to perform a scaling procedure manual rather than scaling by using an ultrasonic scaler. The use of mouthwashes containing povidoneiodine 0.2% or 0.5–1% of hydrogen peroxide is recommended before the periodontal treatment procedure to reduce the accumulation of virus in the saliva and also as an infection control for operators [37]. Patients should not do self-medication independently, and if necessary, it is recommended to consult through telemedicine in advance for planning pain-related treatments complained by patients [40]. Dental care and periodontal is a treatment that requires close physical contact, so it would be better if the treatment was made as short as possible, or the treatment procedure was carried out in the area that became complaints only, and the patient’s recall time for maintenance is made a bit long, at least 2 weeks to see the possibility of COVID-19 symptoms in patients [5, 47]. Periodontal disease is a disease with biofilm plaque as the primary etiology, so plaque control is very important, and the use of mouthwashes as an ingredient in dentrifices gives good results especially when combined with scaling treatment. The administration of antibiotics in the treatment of periodontitis is not recommended, since it allows the occurrence of resistance, except in certain cases such as aggressive periodontitis and recurrent periodontitis, which requires evaluation of certain specific bacteria [48]. For periodontal surgical therapy, in the current pandemic situation, it is rather difficult to do, given the necessity of a strict control schedule, so for cases of intra bony defects that require regenerative therapy, and it is advisable to do conservative therapy, such as the use of enamel matrix derivative, for control that can be done via telemedicine/teledentistry as already described above to get good results after regenerative or conservative therapy. It is necessary to motivate the maintenance of good oral hygiene so that good results are obtained well. On the contrary, mucogingival surgery is advised not to be performed or done limitedly during the COVID-19 pandemic [5, 48]. Complex periodontal cases that require cooperation between disciplines as one of the ways to control the inflammation of periodontitis and also rehabilitate the mastication function [49] must be carefully analyzed to obtain the right diagnosis and treatment plan which is accurate, avoid excessive maintenance, and minimize surgical procedures [50]. Teledentistry plays a very important role in periodontal care (Figure 5) among others to regulate patient schedule based on complaint priority, pre-check triage monitoring, diagnosis determination based on staging, grading, and also communication with patients regarding risk factor control and oral hygiene instruction [5].

Figure 5.

Periodontal care flowchart during COVID-19 pandemic.

5. Periodontal emergency management during COVID-19

Cases of periodontal emergence arise when an acute condition that causes pain in the periodontal tissue forces the patient to seek treatment on the spot. Time management is key to avoiding more severe periodontal tissue damage as well as its effect psychically and functionally on patients [51]. Cases related to periodontal emergencies are basically limited, including acute abscesses involving periodontal tissue or endo-perio lesions, necrotizing ulcerative gingivitis and periodontitis caused by stress during the pandemic, dentin hypersensitivity, and lesions oral effects on the quality of life such as ulcers, viral and fungal infections, and cases requiring biopsy [52]. During the pandemic, pharmacological treatment is the best and safest option [37]. According to group disease conditions through the periodontal disease classification approach and the latest conditions 2017, it is actually very unfortunate that there is no grouping of cases periodontal as an emergency, urgent, or elective (Table 1) because the disease can initially be recognized as urgent which can then become an emergence if ignored, which then can trigger irreversible damage, and it should all be done in parallel with the periodontal treatment procedure, minimizing the production of aerosols produced during the treatment periodontal [47, 49].

Emergency	Urgent	Elective
Gingivitis with conditions of stage III gingival index according to Loe and Sillness (1963)	Gingivitis with conditions of stage III gingival index according to Loe and Sillness (1963)	Gingivitis with conditions of stage III gingival index according to Loe and Sillness (1963)
Periodontitis—All stages according to Tonetti’s classification	Mucogingival tissues-related complaints other than esthetic issues	Routine follow-up visits
Replacement of missing teeth (immediate implant)	Peri-implant mucositis	Depigmentation
Peri-implantitis and related mucogingival conditions	Trauma caused due to occlusal discrepancies	Frenectomy
Necrotizing periodontitis and stomatitis	Necrotizing gingivitis	Vestibular deepening
Abscesses	Prosthesis-related issues	Hopeless teeth extraction
Endo-perio lesions	Replacement of missing teeth (delayed implant)	Esthetic-related issues
Pericoronitis

Table 1.

Periodontal condition based on treatment needs.

5.1 Necrotizing periodontitis

Clinical and etiology: Necrotizing periodontitis is also known as an inflammatory disease of severe dental support tissue (Figure 6), associated with the presence of biofilm plaques, which are grouped into acute necrotizing ulcerative gingivitis (ANUG) and necrotizing ulcerative periodontitis (NUP) [51]. ANUG, the necrotic state of tissue, only involves the gingival with a clinical picture of the presence of ulcers and necrotic tissue in the attached gingival, while in NUP there has been damage to periodontal tissue and alveolar bone which results in loss of attachment. Periodontal necrotizing is characterized by the presence of pseudo-membranes. The pain felt by the patient is generally based on the expansion and severity of the lesion area, sometimes accompanied by halitosis. In NUP, there is an interdental crater. This inflammation generally hits the anterior region of the lower jaw. ANUG or NUP is often associated with HIV/AIDS disease or immunosuppressant disease. The etiology of the disease is associated with infection of organisms and is often associated with Spirochaeta and fusiform bacteria, with compromised immunology predisposing factors [53].

Figure 6.

(left) NUG and (right) NUP.

Emergency treatment: For the elimination of plaque deposits and calculus through superficial debridement, it is recommended to use an ultrasonic scaler instead of a hand instrument to minimize pressure on the ulcerated soft rareness, during the pandemic currently, and the use of ultrasonic scalers should be done briefly and quickly, combined with hand instruments. Debridements should be performed daily in the acute phase for 2–4 days. Patients are advised to brush their teeth on a limited basis to avoid pain and disruption of the healing process. Patients are also recommended to rinse their mouth with chlorhexidine 0.2% as much as 2x a day or with 3% hydrogen peroxide diluted with warm water 1: 1 and also with other mouthwashes that function as oxygen-releasing agents, which have an antibacterial effect through the release of oxygen [54]. If it does not also improve, then the patient can be given a systemic antibiotic with metronidazole content (400 mg 3x1 a day) as a drug of choice for cases of periodontitis necrotizing [55].

5.2 Abscesses

5.2.1 Gingival abscesses

Clinically and etiology: Gingival abscesses are generally purulent and localized on the marginal or interdental gingival. A common cause of a gingival abscess is the “trapping” of a foreign body inside a healthy gingival in the sub-gingival region. Foreign objects include fish bones or nail pieces from individuals with a bad habit of biting nails (Figure 7) [51, 56].

Figure 7.

Periodontal abscess features.

Emergency treatment: Preparation of incision and irrigation with saline solution to reduce symptoms. Short-term treatment is recommended through the use of chlorhexidine mouthwash (0.2%) or warm saline solution, especially for areas where brushing is not possible [51].

5.2.2 Periodontal abscess

Clinically and etiology: Periodontal abscesses are defined as the accumulation in the periodontal pocket produced by the destruction of collagen fibers accompanied by bone damage [51, 57]. The most prominent clinical sign is the presence of enlargement in the gingival along the length of the lateral root of the tooth, which is characterized by redness, diffuse, and soft consistency. There is a deep periodontal pocket accompanied by bleeding during probing (Figure 7) [51]. The presence of suppurations that come out through fistulas or walls of periodontal pockets spontaneously or through suppression is also accompanied by the presence of tooth shakes and pain during percussion. Generally, patients complain that their teeth feel rather high. Periodontal abscesses generally come from further periodontitis, derived from pockets, bifurcation abnormalities, or vertical defects [58].

Emergency treatment: Treatment in the case of periodontal abscess is found in the pre-elimination phase, including the management of acute conditions, and drainage, either through a pocket or an external incision. Sometimes, an occlusal adjustment is needed to eliminate the symptom. The administration of antibiotics is necessary if there are indications of infection (fever or lymphadenopathy). If the tooth is no longer maintainable, then the most likely treatment is the removal [51].

5.2.3 Pericoronitis or pericoronal abscess

Clinically and etiology: Pericoronitis is an inflammation of the soft tissue surrounding the crown of a partially erupted tooth. Pericoronal abscesses are generally localized accumulations on the gingival flaps that envelop the crown of a tooth that has not been perfectly erupted [57]. The clinical picture of a periodontal abscess lesion is the gingival redness, softness, suppurative, and pain when touched aching. There is a bending at the angle of the mandible, trismus pain that radiates to the ear area, accompanied by fever and bending lymphadenopathy. The etiology of pericoronitis is the accumulation of plaque on the operculum that covers part of the molar 3 mandibles that are partial eruption and can also be caused by trauma from the opponent’s teeth (Figure 7) [51].

Emergency treatment: The operculum area should be cleaned with an irrigation solution slowly, to remove debris, if needed, that can be done under anesthesia. The operculum removal and occlusal adjustment should be performed to eliminate trauma to the 3-mandibular molar tooth. Antibiotic administration is carried out if there is an indication of infection [51].

5.2.4 Peri-endo abscess

Clinically and etiology: It is a combination of periodontal/endodontic lesions, localized, covering areas that have infection originating from periodontal/pulp tissue. It is the result of “communication” between the periodontal tissue and the pulp. The clinical picture is characterized by the presence of periodontal pockets surrounding non-vital teeth, and soft lesions of the gingival, accompanied by the formation of exudate and fistulas. Teeth that have a peri-endo abscess will hurt when there is percussion and shake, and sometimes there is a vertical fracture of the root (crack). The etiology of this lesion is the presence of an infection that begins with inflammation of the pulp which then extends to the periodontal ligament, or it can also be preceded by inflammation of the periodontal tissue through the formation of a pocket that extends to the musty from the tooth and then radiates to the pulp through the accessory canal (Figure 7) [51, 55].

Emergency treatment: For the drainage through periodontal canal debridement or root canal treatment, incision can be done if the abscess appears to be fluctuating. If necessary, occlusal adjustments should be done. The administration of antibiotics is recommended for the comfort of the patient and if there is an indication of the expansion of infection [51].

6. Discussion

Several studies have shown a link between COVID-19 and periodontal disease, and this is due to the similarity of pro-inflammatory cytokines released by the body [13]. The pathogenesis of periodontal disease begins with the expansion of the subgingival plaque into the gingival sulcus, where microorganisms in the subgingival plaque can cause changes in the coronal attachment of the epithelium on the tooth surface, and this is due to the immune response to pathogenic bacteria and endotoxins through the activity of neutrophils, macrophages, and lymphocytes [14]. Research conducted by Wu et al. (2020) on COVID-19 shows that there is an unfavorable relationship that can lead to cytokine storms, where certain elements have similarities with cytokine profiles commonly encountered in periodontitis [15]. Treatment in dentistry can generally be categorized as an emergency, urgent, nonurgent, and advise/self-care [21]. Dental and periodontal care are treatments that require close physical contact, so it would be better if the treatment was made as short as possible or done as a complaint only, and the patient’s recall time for maintenance was made rather long, at least 2 weeks to see the possible symptoms of COVID-19 in the patient [5, 47]. Cases of periodontal emergence arise when an acute condition that causes pain in the periodontal tissue forces the patient to seek treatment on the spot. Time management is the key to avoiding more severe periodontal tissue damage and its effect psychically and functionally on patients [51]. Cases related to periodontal emergencies are essentially limited, including acute abscesses involving periodontal tissue or endo-perio lesions, necrotizing ulcerative gingivitis and periodontitis resulting from stress during the pandemic, hypersensitivity to dentin, and oral lesions that affect the quality of life such as ulcers, viral and fungal infections, and also cases requiring biopsy. During the pandemic, pharmacological treatment is the best and safest option [37, 52]. During the treatment, if direct contact is required, dentists recommended to use PPE to avoid aerosol splashes that occur during the work procedure, where aerosol granules and droplets can last 30 minutes after the treatment procedure is performed [21, 26]. The use of teledentistry is very important in periodontal care, including organizing patient schedules based on complaint priority, pre-checking triage monitoring, diagnosing determination based on staging, grading, and also communicating with patients regarding risk factor control and oral hygiene instruction [5].

7. Conclusion

Periodontitis is an inflammatory disease of periodontal tissue that is multifactorial; in some cases, it can be aggravated by the presence of systemic abnormalities so that individuals with certain systemic disorders become more at risk, which allows the use of telehealth to be one of the ways of communicating between patients and professionals of various disciplines. Control of routine maintenance of periodontal tissue, monitoring of periodontal tissue health, and control of risk factors aim to reduce the progression of periodontal disease and reduce the risk of tooth loss, which during this pandemic is difficult to do, so far teledentistry is quite reliable for monitoring the health of periodontal tissue, motivating, and provision of periodontal health maintenance instructions. Increased motivation related to the prevention of periodontal tissue abnormalities can be done through teledentistry and other applications by increasing individual motivation and awareness related to periodontal tissue maintenance, especially for individuals with risk factors for systemic disorders who have a more severe risk of transmission of COVID-19.

Acknowledgments

The authors would like to express their gratitude to everyone who facilitated and enabled us to carry out this successfully.

Conflict of interest

There were no conflicts of interest as declared by the authors.