Dental Practice In Covid-19 Times
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– Dr Priti Jaiswal

Abstract

The epidemic of corona virus has become a great challenge not only in India but all over the world. The World Health Organization has declared the outbreak of the novel corona virus pandemic, a public health emergency of international concern. Infection control measures are mandatory everywhere to control the further spread of the deadly virus and thus control the epidemic situation. Due to the characteristics of dental settings, the risk of cross infection can be high between patients and dental practitioners. Every dentist who is setting up a new or resuming his old practice, must know that strict and effective infection control protocols are urgently needed in the field of dentistry in this pandemic era. This article, based on our experience and relevant guidelines and research, introduces essential knowledge about COVID-19 and nosocomial infection in dental settings, and provides recommended management protocols for dental practitioners and dental students in affected areas.

Introduction

Coronavirus disease 2019, also known as COVID-19, has rapidly become a worldwide emergency. The World Health Organization (WHO) has recently declared the global pandemic. The COVID-19 pandemic represents an unprecendented global public health crises.[1] The epidemics of coronavirus disease 2019 started from Wuhan, China, in December 2019 and have become a major challenging health problem not only for China but for other countries also around the world. COVID-19 not only affected the health sector, but the entire economy has crashed. Its an alarming situation for the entire world.

The novel coronavirus belongs to the family of single stranded RNA known as ‘coronaviridae’. [2] This family of viruses are known to be zoonotic and are transferred from animals to humans. There is a strong evidence that this novel corona virus has a similarity with coronavirus species found in bats and potentially pangolins, confirming the zoonotic nature of this new cross species viral mediated diseases. [3,4]

This includes severe acute respiratory syndrome coronavirus SARS-Cov, first identified in 2002 and the middle east respiratory syndrome corona virus MERS Co-V first identified in 2012. [5] As the published genome sequence for this novel coronavirus has a close resemblance with other beta coronaviruses SARS-Cov and MERS Co-V, the Coronavirus Study Group of the International Committee on Taxonomy of Viruses has given it specific name SARS-Cov-2, even though it is popularly called as COVID-19 virus.[6,7

Due to the characteristics of dental settings, the risk of cross infection may be high among dental practitioners, patients and laboratory personnel. For dental practices and hospitals in countries/regions that are (potentially) affected with COVID-19, strict and effective infection control protocols are urgently needed. This article, based on our experience and relevant guidelines and research, introduces the essential knowledge about COVID-19 and nosocomial infection in dental settings, and provides recommended management protocols for dental practitioners and students in (potentially) affected areas.

Routes of Transmission

Direct contact (person-to-person) and indirect contact (close contact less than 6 feet, inhaled droplets, aerosols, fecal-oral routes) are the major routes of transmission for COVID-19.[8-10] The incubation period of COVID-19 disease is usually long (varied from 3 – 14 days); however, it differs from one person to another. [11] Asymptomatic patients and stealth carriers can transmit and infect other individuals.[12]

Clinical Manifestations

The most commonly reported signs and symptoms are fever (98%), cough (76%), dyspnea (55%) and myalgia or fatigue (44%). Unlike patients with other human corona virus infection upper respiratory tract and intestinal manifestations such as sore throat, rhinorrhea and diarrhea are infrequent. [13,15]

Diagnosis

Following the outbreak, the full COVID 19 genomic sequence was released in public databases. [16] This facilitates the way for further PCR assays for virus detection. The WHO recommendations for outpatient cases and patients with more critical conditions include rapid collection and nucleic acid amplification testing (NAAT) of nasopharyngeal and oropharyngeal swabs as well as sputums and/or endotracheal aspirate or bronchoalveolar lavage. [17]

Management Protocols For Dentist At the Reception

Following the announcement of disease outbreak by international or local authorities, dentists can play a significant role in disrupting the transmission chain, thereby reducing the incidence of the disease by simply postponing all non-emergency dental care for all patients. The dentist and entire staff must be vaccinated for COVID-19 (both doses).

If in case dentist has to look patients, then the receptionist on the desk should first ask the patient to disinfect their hand by sanitizers which is generally kept at the entry and ask the patient about their general health, symptoms of cough, cold, throat pain , fever, B.P , diabetes or any other immuno-compromised disease, travel history, meeting with someone who has travelled . All these questions can be asked on telephone before scheduling the appointments.

If the patient is not having any of the above symptoms but is immunocompromised, postpone their appointments and asked them to bring consent of their physician before starting treatment. Patients should be asked to sign the consent form related to COVID at the dental office at the reception only. Patients are advised to come all alone, if not possible then the accompanying person should wait outside the clinic.

Receptionist should check the temperature with infra red thermometers and pulse by pulse oxymeters. These are just to check asymptomatic carriers. If the temperature and pulse rate are varying from normal range we can suspect and can avoid such patients, like high temperature more than 100° F and low pulse approx. less than 90%. A normal pulse oximeter oxygen level reading is between 95% and 100%, and anything less than 90% is considered dangerously low, or hypoxic.

Receptionist should also ask the patients to maintain distance at the waiting room. Isolate suspected patients before and during care to minimize their direct contact with other patients and staff and immediately report any cases to local and state public health authorities.

Air conditioners should not be used and if using temperature should be between 24°-27°. The CDC strongly recommends that all health care staff, including dentists and personnel, should receive the flu vaccine and that staff with influenza must not report to work. [18,19]

After the thorough history patient with disposable shoe covers, gloves, head caps should enter the doctor’s chamber.

Seven Golden Steps to be followed in the dentist’s chamber

The dentist follow meticulously these Seven Golden Steps in their practice:

STEP 1: Help Patient with disposable drape.

STEP 2: Preprocedural mouth rinse with 0.2% Povidine iodine solution or 1.5% hydrogen peroxide.

STEP 3: For diagnosis, prefer using extraoral radiographs and CBCT.

STEP 4: Avoid performing aerosol producing procedures.

STEP 5: Use of Rubber Dam with high volume evacuators while performing aerosol producing procedures.

STEP 6: Six handed dentistry is advisable to reduce surface contamination.

STEP 7: Surface disinfection after completing procedure.

Segmenting work into aerosol and non aerosol procedures

Dentists work can be divided in two segments:

  1. 1st Operatory: non aerosol procedures includes routine check up, diagnosis and treatment planning, extractions, CD, RPDs, digital photographs.
  2. 2nd Operatory: aerosol procedures includes emergency access opening, tooth preparations, surgical extractions, dental implants, scaling etc.

For the operatory of non aerosol procedures we are ready to take the new patient within 15-20 minutes as we need to do-

  • Change of instruments
  • Flushing of suction and spittoon drainage with 1% NaOCl
  • Disinfect 3 feet area around chair.

For the operatory of aerosol procedues along with the above procedures, we have to do some add on procedures like given below and one should vacate the operatory during disinfection procedures which will require 1 to 2 hours to disinfect. For aerosol procedures dentist should use electric dental handpiece motor which are an alternative to air turbine powered handpiece motors and high vac suction to reduce aerosol.

Add-on procedures to be done in operators of aerosol procedures:

  • HEPA Filters: HEPA stands for ‘high-efficiency particulate air’. Minimum (12 ACH). 20 minutes is required for air filtration with HEPA 13/ HEPA 14 filters.
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HEPA filters
  • UV Germicidal Irradiation: 15 minutes of UV-C Irradiation of 245 nm, 40W per 100 sq.ft is required. Remember to avoid direct exposure to UVC, especially skin and eyes.
  • Good Natural Ventilation (min 6 ACH): 60 minutes cross ventilation and additional ventilators (pedestal fans, exhaust fans) There should be minimum six air changes per hour and then only the next patient is allowed to enter.
  • Extra-oral Suction: Extra-oral suction devices can be used which removes the aerosols which are produced by hand-pieces and ultrasonic scalers to prevent cross-contamination. Studies have shown that a combined use of intra and extra-oral suction devices resulted in lower level of aerosol and bacteria colony, suggesting the benefit of installing an extra-oral suction device for aerosol reduction during dental treatment. [20,21]
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Extra-oral suction device
  • Aerosol Protection Dome : is a four legged acrylic device which is placed above the patients head. It is covered fully with disposable cellophane sheets. Slits are made by scissors on sides for dentist and assistants to operate. It helps in blocking the aerosol droplets, hence allowing the dentist to safely accessing the patient.
img 20200422 wa0016
Aerosol Protection Dome
  • Fumigators: uses Formalin and Formaldehyde vapours. These vapours rupture cell wall and typically kill/inactive bacteria and viruses.
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Fumigators
  • Foggers: 30-45 minutes, Hydrogen Peroxide Vapour (HPV) or Chlorine Dioxide is generally used.
  • Sub-Micron Dry Fogging Machine: Instead of heat, it uses sound energy to break particles into sub-micron size and dissipates it into the clinic atmosphere using small but powerful, low energy fans. Dry fog does not need electronics to be covered. It needs no mopping as it is completely dry.
Screenshot2021 09 02at6 22 05PM 5e9dfa15c6c1025058ce31aecb2ff0e5 800
Sub-Micron Dry Fogging Machine
  • Dehumidifiers: Should also check the humidity of the working office. It should always be 50-55% RH.
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Dehumidifiers

Sterilisation & Disinefection Protocol

Dentist should use class B autoclave and ultrasonic cleaners for sterilizing dental instruments. Dental personnel should use N95 respirators or respirators that offer a higher level of protection instead of a facemask when performing or present for an aerosol-generating procedure. Make sure the personal protective equipment being used is appropriate for the procedures being performed. Basically there are three types of Personal Protection Equipment (PPE).

  • Basic kit 45 GSM used for all housekeeping staff , administrative staff, pharmacy staff and all visitors
  • Medium Kit 70GSM used for all OPD staff, radiology staff , patients attendants
  • Advanced Kit 180GSM Doctors in ICU with positive cases.

Use a rubber dam when appropriate to decrease possible exposure to infectious agents.

Impression (alginate/ Elastomeric) – Wash Dental impression in running water with brush ensuring making it free from any saliva. Disinfect with 1:10 sodium hypochlorite solution by immersing in it for 10 minutes or with any formaldehyde or glutaraldehyde disinfectant solution following manufactures guidelines. After drying of impression pack it in impervious zip-lock bag to send it to lab.

Wax rims and wax bites: can be disinfected using sodium hypochlorite spray; “spray-wipe-spray” technique.

Acrylic appliance: Povidine Iodine or 1% Sodium hypochlorite.

Fixed prosthesis disinfection: Immersion in Cidex or 1% sodium hypochlorite.

Gypsum casts: Microwave irradiation for 5 min at 99 W. ADA recommends use of chlorine compounds, iodophors, combination of synthetic phenols, glutaraldehyde.

Mode of Payment

Should accept card payments and other modes of E- payment to prevent cross-contamination.

Now is the time for a dentist to switch to digital dentistry, one visit dentistry, completely in house minimum human contact and minimally invasive dentistry!

Hand Hygiene for Dentist

Wash hands with soap and water for at least 20 seconds after contact with patients or use an alcohol-based hand sanitizer with at least 60% alcohol, if soap and water is not available. [20]

Waste Disposal

Ensure safe waste management. Treat waste contaminated with blood, body fluids, secretions and excretions as clinical waste, in accordance with local regulations. Human tissues and laboratory waste that is directly associated with specimen processing should also be treated as clinical waste. Discard single use items properly.[21]

Insurance Policies

As per guidelines issued by the Insurance Regulatory and Development Authority of India, all claims related with the COVID-19 treatment will be liable to get the coverage under a stanard health plan.

Term Insurance Policy: is a type of life insurance policy that provides coverage for a certain period of time or a specified “term” of years. If the insured dies during the time period specified in the policy and the policy is active, or in force, a death benefit will be paid.

Professional Indemnity Insurance: protects professionals against claims of negligence or breach of duty made by a client as a result of receiving professional services.

Conclusions

The significant limitation of clinical and surgical activities in the medical and dental sector has represented a very impactful measure on the economy of the sector. The widespread outbreak of COVID-19 and the pandemic of the novel corona virus has become a global concern and a serious threat to the health, well-being, and survival of humans. The characteristics of dental treatments and the possibility of aerosol production during such ministrations classify dentistry as one of the most high-risk jobs in the world. But if we dentist follow the above mentioned protocols meticulously in our practice, we can overcome this fear of not only COVID-19 but with other bacteria and viruses also to a large extent and resume our practice with gusto!

The existing knowledge on COVID-19 is currently limited, and studies for vaccines, effective medicinal drugs, and possible treatments are imminent. Comprehensive research and investigations are needed.

References

  1. Centers for disease control and prevention. Transmission of coronavirus disease 2019 (COVID-2019). Available at:https://www.cdc.gov/coronavirus/2019 ncov/about/transmission.html. Accessed 18 March ,2020
  2. Gorbalenya AE, Baker SC, Baric RS et al. The species Severe acute respiratory syndrome-related coronavirus: classifying2019-nCoV and naming it SARS-CoV-2 Nat Microbial2020.https://doi.org/10.1038/s41564-020-0695-z
  3. Zhou P, Yang X-L, Yang X-G et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature2020;579:270-3
  4. Wahba L, Jain N, Fire AZ et al. Identification of a pangolin niche for a 2019-n-CoV like coronaviruse through an extensive meta-metagenomic search. bioRxiv 2020 https://doi.org/10.1101/2020.02.08.939660.
  5. Wax RS, Christian MD. Practical recommendations for critical care anesthesiology teams caring for novel coronavirus(2019 –nCoV) patients. Can J Anaesth 2020 https://doi.org/10.1007/s12630-020-01591-x.Accessed 18 March 2020
  6. Zhu N, Zhang D, Whang W, et al. A novel coronavirus from patients with pneumonia in China,2019. N Engl J Med2020;382:727-33.
  7. Gorbalenya AE. Severe acute respiratory- syndrome related coronavirus-the species and its viruses, a statement of the Coronavirus study group.bioRxiv 2020 https://doi.org/10.1101/2020.02.07.937862
  8. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci.2020;12(1):9.doi:10.1038/s 41368-020-0075-9 [Pub Med:32127517].[Pub Med Central:PMC705427]
  9. Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et al. High expressions of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci.2020;12(1):8.doi:10.1038/s41368-020-0074-x[Pub Med:32094336].[Pub Med Central:PMC7039956]
  10. Lu CW, Liu XF, Jia ZF. 2019-nCov transmission through the ocular surface must not be ignored. Lancet.2020;395(10224).e39.doi:10.1016/S0140-6736(20)30313[Pub Med:32035510].[Pub Med Central: PMC7133551]
  11. Backer J A, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus(2019-nCov) infections among travelers from Wuhan, China,20-28 January 2020. EuroSurveill. 2020; 25(5). doi:10.2807/ 15607917. ES.2020.25.5.2000062. [Pub Med:32046819].[Pub Med Central:PMC7014672].
  12. Shi Y, Wang Y, Shao C, Huang J, Gan J, Huang X, et al. COVID-19 infection: The perspectives on immune responses. Cell Death Differ. 2020. doi:10.1038/ s41418-020-0530-3[Pub Med:32205856].
  13. Huang C Wang Y, Li X, Ren L, Zhao J, Hu Y et al (2000). Clinical features of patients infected with 2019 novel coron virus in Wuhan, China. Lancet 395(1022):497-506
  14. Guan W, Ni Z, Hu Y, Liang W, Ou C He J et al. Clinical characteristics of coronavirus disease 2019 in China. N EngL J Med https//doi.org/10.1056/NEJMoa2002032
  15. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y et al(2020). Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia, in Wuhan China: a descriptive study. Lancet395(10223:507-517)
  16. Cohen J(2020) Chinese researchers reveal draft genome of virus implicated in Wuhan China outbreak.
  17. Organization WH. Laboratory testing of 2019 novel coronavirus(2019-nCoV) in suspected human cases, interim guidance , 17 January 2020.2020
  18. ADA releases coronavirus handout for dentists based on CDC guidelines: American Dental Association; Available from:https://www.ada.org/en/publications/ada news/2020 archive/February ada –releases-coronavirus handouts-for-dentist-based-on-cgc-guidelines.
  19. CDC reminds clinicians to use standard precautions, recommends isolating patients with coronavirus symptoms: American Dental Association ;2020. Available from:https://www.ada.org/en/publications/ada news/2020 archive/february /cdc -recommends –isolating- patients -with -coronavirus –symptoms.
  20. Infectious diseases:2019 Novel coronavirus: American Dental Association;2020. Available from:https://success.ada.org/en/practicemanagement/patients/infectious- diseases-2019-novel-coronavirus?ga_2.107628096.39854 0419.1583353764-477095557.1583353762.
  21. Indian Dental Association’s Preventive Guidelines for Dental Professionals on the Coronavirus

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Dr Priti Jaiswal
Dr. Priti Jaiswal is a prosthodontist and a senior lecturer in the Dept. Of Prosthodontics, VSPM DCRC, Nagpur.

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