During the ongoing COVID-19 crisis, professionals related to dentistry is one of the most highly susceptible groups to contract the disease. Not only that, but any treatment of patients with COVID-19 also creates a further risk of spreading the infection.
Close contact with patients, exposure to bodily fluids like saliva, close proximity to the face, and the handling of sharp instruments all increase the risk of infection. Either from patient to dentist or vice-versa.
As per reported cases, the symptoms of COVID-19 takes around 10 to 14 days to fully appear. Hence, in that period the individual if not aware, tested, isolated or quarantined, may spread the infection to an even larger number of people.
And in a country like India, with a population of a BILLION+, it demands even a stringent protocol when it comes to dental practice during the times of COVID-19 Pandemic.
So what can a Dentist or You do to keep yourself, your dental practice and your patients safe? We have compiled a list of procedures and protocols collected from reputed dental groups in the World that you can implement to control the spread of COVID-19 in your dental office.
Why a Dental Clinic is HIGHLY Susceptible to COVID-19 Infection?
For the general population hand washing and social distancing may be adequate modes to control the infection. But when it comes to dentists or dental office things are slightly different or more complex. This is because the three most common ways for the spread of the COVID-19 virus are all RELEVANT to a dental practice/set up.
- Spread via Air: The most common mode of spread is Aerosols. Every dental procedure especially where there is the use of burs or ultrasonic scaling leads to the production of Aerosols or droplets that transmits the infection.
- Spread by Contact: In a dental office, chances are high to come in contact with bodily fluids, patient materials, contaminated dental instruments, and environmental surfaces spreading the infection.
- Surface spread: COVID-19 Virus has been reported to stay active on a surface for more than 4 hours. Hence there is always a chance of infection spread as people come in contact with surfaces in a clinic. (which already many carry infection due to exposure to Aerosols & Patient body fluids.
In the peak of COVID-19 infection, elective dental treatments are not advised. However, a dental surgeon might need to carry out emergency dental treatments. In such a case it is important that the dentist follows the protocols to avoid any chances of infection by COVID-19.
A recent study published in the International Journal of Oral Science has investigated the ways in which you can contribute to preventing infection in your dental practice and protect yourself, your staff and your patients from unnecessary viral contamination. These are the most important tips:
1. Evaluate and take proper travel/case history of your patients
Ask the correct set of screening questions:
- Are there episodes of a fever within the past 14 days?
- Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing, within the past 14 days?
- Within the past 14 days, have you traveled to areas with documented 2019-nCoV transmission? Have you made an International journey?
- Have you come into contact with a patient with confirmed 2019-nCoV infection within the past 14 days?
- Have you come into contact with people who come from areas with recently documented fever or respiratory problems within the past 14 days?
- Have you come in contact with at least 2 people with documented experience of fever or respiratory problems within the last 14 days?
- Have you recently participated in any gathering, meetings with an unverified status of COVID-19?
After the screening questions, it is advisable to record the temperature of the patient & follow the instructions below
- If the patient replies yes to any of the screening questions, and his or her body temperature is below 37.3°C, you can postpone the treatment until 14 days after the exposure event. Note: The patient should be instructed to self-quarantine at home and report any fever experience or flu-like syndrome to the local health department.
- If a patient replies “yes” to any of the screening questions, and his/her body temperature is no less than 37.3 °C, the patient might need immediate quarantine. Note: The dental professionals should report to the infection control department of the hospital or the local health department.
- If the patient replies no to all the screening questions, and his or her body temperature is below 37.3°C, you can treat the patient with extra protection measures and do your best to avoid spatter or aerosol-generating procedures. Note: Its advisable only emergency treatments are carried out. Elective procedures can be postponed for later.
- Finally, if the patient replies no to all the screening questions, but his or her body temperature is 37.3°C or higher, the patient should be directed to the fever clinic or special COVID-19 clinic for further medical care.
Point of confusion: All the above questions can be answered wrong or false (intentional or unintentional). In that case, the risk factor increases. Hence, irrespective of the history or findings if your friend even minute of symptoms like respiratory distress, it is advisable to inform the patient and get tested by authorized govt. facilities.
2. Mind your Hand Hygiene
- before the patient examination;
- before dental procedures;
- after touching the patient;
- after touching the surroundings and equipment that have not been disinfected; and
- after touching the oral mucosa, damaged skin or a wound, blood, bodily fluid, secretion or excreta.
Moreover, all staff should take extra care to avoid touching their own eyes, mouths, and noses after or during a treatment.
3. Always use PPE (Personal Protective Equipments)
Even during routine dental treatment Airborne infections via aerosols are an area of concern. During the pandemic of COVID-19, it’s even more important to carefully use personal protective equipment to prevent exposure to droplets or body fluids that may carry the infection.
Based on the possibility of the spread of 2019-nCoV infection, three-level protective measures of the dental professionals are recommended for specific situations.
- Standard protection for staff in clinical settings: Disposable working caps, surgical masks and working clothes (white coat), protective goggles or face shields, and disposable latex or nitrile gloves.
- Advanced protection for dental professionals: Additional disposable isolation clothing or surgical clothes overworking clothes in addition to standard protection.
- Strengthened protection for being in contact with patients with suspected or confirmed COVID-19: If this does occur, and you cannot avoid close contact, special protective outerwear is needed. If not available, working clothes with extra disposable protective clothing over them and impermeable shoe coverings should be added to what has already been listed.
4. Using Mouth Rinses before dental procedures
Guideline for the Diagnosis and Treatment of Novel Coronavirus Pneumonia (the 5th edition) released by the National Health Commission of the People’s Republic of China state, chlorhexidine, which is commonly used as a mouth rinse in dental practice, may not be effective to kill 2019-nCoV.
Since 2019-nCoV is vulnerable to oxidation, a preprocedural mouth rinse containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone is recommended, for the purpose of reducing the salivary load of oral microbes.
5. Use of Rubber Dams
The use of rubber dams can significantly minimize the production of saliva- and blood-contaminated aerosol or spatter, particularly in cases when high-speed handpieces and dental ultrasonic devices are used. It has been reported that the use of rubber dam could significantly reduce airborne particles in ~3-foot diameter of the operational field by 70% (Ref)
6. Use the Correct HandPiece
Study has shown that the anti-retraction high-speed dental handpiece can significantly reduce the backflow of oral bacteria and HBV into the tubes of the handpiece and dental unit as compared with the handpiece without anti-retraction function. (Ref)
7. Management of Medical Waste
It’s needless to say that the proper management of Medical Waste is a routine to prevent infections. Its more so now in the scenario of Pandemic COVID-19. Mark the surface of the bags and handle them according to the requirements for the management of medical waste. Also, keep in mind that the waste generated by the treatment of patients with suspected or confirmed COVID-19 is regarded as infectious medical waste.
If at all you are treating a COVID-19 confirmed patient, please update the concerned govt. authorities in your region. In the case of a worldwide pandemic, it is important that all such patients are accounted for so that proper quarantine and control can be done.
8. Disinfecting the Dental Office & Clinical Environment
In all the points covered above, it’s clear that the dental office environment can be highly infectious. So, regular and thorough disinfection is mandatory to limit the spread of COVID-19.
All the methods from 1 to 8 if followed properly help in maintaining the disinfection. The clinical area should be cleaned and disinfected regularly in accordance with available safety protocols, as should the public areas and appliances, including door handles, chairs, desks, and lifts.
Since December 2019, the newly discovered coronavirus (2019-nCov) has caused the outbreak of pneumonia in Wuhan and throughout China. Since then the virus has spread multiple countries and has been declared by WHO as a Global Pandemic.
— World Health Organization (WHO) (@WHO) March 30, 2020
The spread has been rapid and there is no clear cut vaccine against COVID-19. With no definite treatment at present, the only logical way of controlling the spread is social distancing, avoiding large groups with many people with unverified travel or health status and maintaining proper disinfection in-home and a dental office.
A dental office in this scenario can be highly infective if proper protocols are not maintained. As of now, all elective or cosmetic procedures are to be postponed. Only emergency dental treatments are to be carried out after proper approval and screening of the COVID-19 status.
Check the webinar video by ADA on the protocols to be followed by the Dentists and Dental Professionals
On 17 March, the Dental Council of India advised dental colleges to halt all college activities, including classes, seminars, workshops, and camps, until 31 March. The council also issued clinical practice guidelines for dental teams on 17 March, and these included the following recommendations:
1. Every patient should be scrubbed with isopropyl alcohol extra-orally.
2. A preprocedural rinse with povidone-iodine should be used by every patient.
3. N95 masks or at least three-ply masks should be worn, as well as protective eyewear, a head cap, and a face shield.
4. Dental clinics should be fumigated periodically.
The IDA also has preventive guidelines for dental teams, and these can be accessed here.