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Dentistry in Covid-19 Times

Dentistry in Covid-19 Times

What is COVID-19?

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.

Covid-19 decease will transmit person to person primarily by respiratory droplets produced when the infected person coughs or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled. The disease causes respiratory illness (like the flu) with symptoms such as a cough, fever, and in more severe cases, difficulty breathing.

Covid-19 Pandemic is a classic “Black Swan Event”, it’s a single most life changing decease which is totally unexpected and disrupted, many business and economy across the world.

This chart shows the workers Who Face the Highest Risk by Coronavirus.

Why Dentistry is a Risk Branch?

Saliva has a vital role in the human to human transmission. Dentistry can be high risk branch where, dentists performs the aerosol-generating procedures are directly and closely exposed to this virus. Therefore it’s important to dentists adopt preventive strategies to protect themselves and their patients against COVID-19 decease by focusing on patient placement, hand hygiene and all personal protective equipment (PPE).

Transmission of Corona Virus

Practicing Dentistry during Covid-19 Times

Key Recommendations from IDA:

  • Treat emergency patients only
  • Avoid all urgent or elective procedures
  • Avoid all aerosol producing procedures
  • Always use PPE
  • Protect yourselves and your patients

What is a Dental Emergency?

  1. Dental Emergency Care:
  • Uncontrolled bleeding
  • Cellulitis or a diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromises the patient’s airway
  • Trauma involving facial bones, potentially compromising the patient’s airway
  1. Dental Urgency Care:
  • Severe dental pain from pulpal inflammation
  • Pericoronitis or third-molar pain
  • Surgical post-operative osteitis, dry socket dressing changes
  • Abscess, or localized bacterial infection resulting in localized pain and swelling
  • Tooth fracture resulting in pain or causing soft tissue trauma
  • Dental trauma with avulsion/luxation
  • Dental treatment required prior to critical medical procedures
  • Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
  • Biopsy of abnormal tissue

For Above both Follow-up and provide medications to avoid patient contact.

  1. Routine or scheduled procedures:
  • Initial or periodic oral examinations and recall visits, including routine radiographs
  • Routine dental cleaning and preventive therapies
  • Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma) or other issues critically necessary to prevent harm to the patient
  • Extraction of asymptomatic teeth
  • Restorative dentistry including treatment of asymptomatic carious lesions
  • Aesthetic dental procedure

Considerations before Starting Dental Treatment:

  1. Staff Management: How to manage our staff with respect to Covid-19?
  • Actively encourage sick employees to stay at home
  • Give the special importance to respiratory hygiene and hand hygiene by all employees
  • Place hand rubs in multiple locations to encourage hand hygiene
  • Clean all frequently touched surfaces
  • If an employee is confirmed to have COVID-19, inform fellow employees
  1. Personal Protection Equipment (PPE’s)
  • Face Masks
  • Gloves
  • Gown and Head Cap
  • Eyewear Face Shield

 

Face Masks or Respirators:

Procedures Type of Masks
All HCP’s in Clinic Triple layered surgical mask
Entry into the treatment room Respirators (N-95 or FFP-2)
Routine dental procedures Respirators (N-95 or FFP-2)
Aerosol producing procedures FFP-3 standard masks (N-95 respirators or FFP-2, if FFP-3 not available)
Confirmed COVID-19 patients FFP-3 standard masks (N-95 respirators or FFP-2, if FFP-3 not available)

 

Note :
           – Mouth masks are only single use disposable
           – Change the masks after treatment procedure or in between if it is wet or contaminated
           – Remove the masks after exit the room and closing the door.

 

Face Masks – Just putting it on is not enough, Fit it Right!

Strategies for Optimal Use of N95 Masks According to Centres for Disease Control and Prevention (CDC)

  • Extended Use of N95 Masks: Same respirator for 8-12 hours of continuous use, no touching, no removing, change if visiting washroom or taking lunch break.

 

  • Re-use of N95 Masks: Keep aside for minimum 72 hours preferably 1 week, in a brown paper bag, then reuse, wear gloves when re-wearing.

 

Eye wear – sealed eyewear preferable like swimming goggles or similar and face shields compulsory in case of aerosol procedures.

  • Reusable – clean and disinfect
  • Disposable – discard

 

Gloves: Hand gloves are important while entering to patient room, change the gloves if it is torn or contaminated and immediately perform hand hygiene after removing gloves.

Gowns:

  • Isolated gowns while entering into patient room
  • Mandatory for aerosol-producing procedures
  • Attention should be taken while Putting On, Taking OFF and Disposal of any PPE

Patient Arrival: Initially take a temperature when patient arrive and register with the patient address and contact number.

   3. Preparation of Patient Waiting Area:

  • Avoid sweeping with broom
  • Use wet moping with warm water and detergent or hospital disinfectant (eg. Sodium hypochlorite)
  • High Touch surfaces like handles, door knobs etc., must be cleaned more disinfect frequently
  • Eliminate direct contact areas as much as possible and remove all reading material from waiting areas
  • Arrange Hand sanitizer upon entry and exit areas
  • Self-declaration form to be filled by visitors and to be careful of pen used must be sanitised

 

Considerations in the Treatment Area

  1. General precautions: Operatory Room
  • Complete hand hygiene
  • Good ventilation and no AC
  • PPEs for all personnel
  • Handpieces must be equipped with anti-reflux devices
  • High volume saliva ejectors
  • Instruments and handpieces should be cleaned and sterilized after each use or discarded
  • Use 0.2% povidine iodine as preprocedural mouth rinse
  • Clean and disinfect frequently
  • Multi-Chair clinics without cabins should treat single patient at a time in case of aerosol procedure
  • Chair wrapped in barrier film to be changed after every patient
  1. Aerosol Generating Procedures

Aerosols created by Handpieces and air water syringes. It contains large particle droplets of water, saliva, blood and microorganisms. Spatter travels only a short distance and settles out quickly, landing on the floor, nearby operatory surfaces.

Considerations if AGP’s have to be performed

  • Everyone in the treatment room must wear PPE’s
  • No visitors are allowed
  • Only essential HCP,s are allowed, avoid more persons
  • Air purifiers with HEPA filters can used to control aerosol spread, but caution at the time of Filter change
  • Preferably performed in an Airborne Infection Isolation Room
  • Dental handpiece with anti-retractive valves
  • Use of Rubber dam isolation is must

Advisory Note: While performing the Dental Aerosol Generating procedures, it is recommended to use Extra Oral Suction which sucks the aerosols generated.

  1. Cleaning and Disinfection of Treatment Area
  • Post procedural scrub down of operatory, both touch and non-touch surfaces
  • Replace the disposable barriers on touch and non-touch surfaces once completed with the treatment
  • Disinfect the waterline using 0.01% NaOCl in the ratio of 1ml of 5% NaOCl mixed in 5ltrs of suction and three-way water lines
  • Floor – use wet moping – multi Bucket technique;
  • Water Followed by
  • Detergent followed by
  • Low Level Disinfectant like 3% hydrogen peroxide, 1% sodium hypochlorite or 70% alcohol.
  • Fumigation is must while disinfecting the treatment room.

Directives to Patients

  • We should inform our patients that we are back to work and appointments are opened
  • Make sure Elective procedures especially Oral Prophylaxis not recommended till further notice
  • Make preference that appointments are only for practice and don’t allow random walk-in
  • Restrict to additional only one person along with patient
  • We request to go Digital Payments to avoid contaminations
  • Face Masks to be worn by patients as well as attending at all times except when ready for oral exam and make sure to follow strict social distancing.

Take – Home Message

  • Visual Alerts in Reception Area
  • Seating Arrangements with social distancing of 1-2 Meters.
  • Alcohol based hand rub must for patients and HCP’s
  • Face Masks for both Patients & Attenders
  • Provision for Hand wash with Soap & Water
  • Avoid AC and use natural and mechanical ventilators

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