Dental Practice In Covid-19 Times

- 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. 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’. 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.

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. 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. The incubation period of COVID-19 disease is usually long (varied from 3 - 14 days); however, it differs from one person to another. Asymptomatic patients and stealth carriers can transmit and infect other individuals.

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.

Diagnosis

Following the outbreak, the full COVID 19 genomic sequence was released in public databases. 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.

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.

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.