Dental Practice Operations - COVID-19 How to safely provide dental emergency services during the coronavirus Pandemic.

Dentists and dental professionals, who necessarily spend a lot of time in the vicinity of the nasal and oral cavities of patients, are at a greater risk of infection than other medical practitioners.

Dental Practices all over the world have been advised to postpone elective procedures, and if possible, stay open only to take emergency cases. But are all dental practices equipped to provide a safe environment for an emergency dental procedure?

Dentists, dental assistants and dental hygienists are required to wear a new, disposable mask for every patient they deal with, to protect themselves from splashes and sprays from the mouths of their patients.

"But the masks have been in increasingly short supply, due to the current fears over the spread of COVID-19 — and the rush by the general public to buy-up the face masks on the mistaken belief they're needed for protection."

Health officials believe the novel coronavirus is spread by liquid droplets — not in the air. They don't recommend masks for healthy people in the general population, in part because wearing them can backfire, increasing how often someone touches their face to adjust the mask.

But for dental professionals, masks and other EPI are essential!

Coronavirus: safety protocols in the dental practice

The role of dentists and dental operators in preventing the spread of Coronavirus

"The COVID-19 virus first appeared in the Chinese province of Hubei and spread gradually, its impact has now reached global level and has become the number one issue for all media."

During this “Coronavirus emergency”, the question of biosafety has become a priority, so an adequate, careful application of protocols takes on an essential role in the activities carried out in dental practices.

What are the guidelines to be followed?

1. Fairness: treat all patients equally

2. Compliance with basic hygiene rules: wash your hands at the beginning of the day and between each patient. Do not wear nail polish, as it leaves recesses that can harbour micro-organisms. Nails should be well cut. Take off jewellery and watches that you’ll take home later.

3. Use of personal protective equipment:

4. Gown with simple designs, if possible with long sleeves.

• Disposable caps.
• Latex or nitrile gloves, to be changed every 15-30 minutes, since they lose their barrier effect. Obviously, they must be changed after each patient, or if they break.
• Masks of type II or IIR. They must be changed for each patient, and never stored in your pocket or placed near your neck (they will be contaminated with fluids from the patient). If they get wet, they lose their barrier effect, so they must be changed.
• Always wear safety glasses. The eyes are an open wound, so it is mandatory to protect them. Use of visors instead of glasses increases protection and avoids splashing your face mask (even though this must still be changed)."

1. Use a rubber dam to avoid the water nebulised from the turbine mixing with the saliva of the patient.

2. Scrupulously follow the sterilisation process:

• Use appropriate Personal Protective Equipment (clothing, cap, glasses, plastic apron and special thick gloves over latex gloves).
• Immerse instruments in disinfectant immediately after use. Check that the disinfectant product meets all requirements of an effective disinfectant and respect concentrations, time and temperature recommended by the manufacturer.
• Follow good washing practices. Always immerse material to avoid contaminated aerosols. Whenever possible, use a covered ultrasonic tank (avoid handling instruments and aerosols in the atmosphere). A thermodisinfector is the best solution, as the instruments go directly from the mouth of the patient into the machine and come out clean, dry and thermo-disinfected with hardly any handling by staff.
• Make sure instruments are dried thoroughly. Apart from damaging them, leaving moisture on instruments may invalidate the sterilisation process.
• Bag and seal correctly. Fill ? of the bag, leaving 3 cm to the seal edge and cut the bag to 1 cm. Mark the bag with the date it was sealed if the sealer does not have an automatic tracking system.
• Sterilise in a type B autoclave. Do not stack pouches, and do not let them stick to the walls of the autoclave, so that the vapour can circulate.
• Check the chemical indicators on each pouch, perform a Helix test daily and a spore test weekly.

1. Protect surfaces in the practice as much as possible, using disposable material (drapes on counter tops, barrier film over handles, dental chair covers, radiography machine covers, etc.)
2. Thoroughly clean the dental chair with a surface disinfectant after removing the protective films. Always perform these steps in the same order. Bleach is used for counter tops and furniture, as well as for cleaning floors. Always start with the cleanest equipment and progress to the most contaminated.
3. Ventilate the room whenever possible, including the waiting room.

These are fundamental rules, valid not only for the coronavirus, and should accompany medical staff and operators in their daily activities, with or without the Coronavirus emergency.

What the Royal College of Dental Surgeons of Ontario is saying?What extra precautions do we need to take and why? How should emergency cases be managed?

First, emergency cases should be managed via telephone by taking a verbal history of the patient’s condition and providing appropriate pharmacotherapy if indicated.

In those few cases where telephone management is insufficient, clinical assessment may be necessary provided the dental practice has appropriate safety precautions and PPE in place. 

"Scenario 1: Patient presents with an emergency that CAN be managed without generating an aerosol (i.e. high-speed handpiece and air-water syringe will NOT be used)"

• Many dental emergencies can be managed without generating an aerosol.
• Using routine practices and contact/droplet precautions (i.e. procedure/surgical mask, gloves and eye protection), obtain a history of the patient’s condition and conduct an emergency clinical dental examination. Determine the nature of the emergency and provide care.

"Scenario 2: Patient presents with an emergency that CANNOT be managed without generating an aerosol (i.e. high-speed handpiece or air-water syringe MUST be used)"

• The patient must be screened for acute respiratory illness, including COVID-19: Presence of a fever, a cough or difficulty breathing AND any of the following:
• Returned from travel to any country outside of Canada in the last 14 days; OR
• Close contact with a confirmed or probable case of COVID-19; OR
• Close contact with a person with acute respiratory illness who has returned from travel to an impacted area.
• EITHER WAY If the patient screens negative or positive for acute respiratory illness, including COVID-19, care MUST be provided using enhanced precautions (i.e. N95 mask, gloves, eye protection, face shield and protective gown), due to the fact it is proven asymptomatic carriers can transmit the virus.

Take a look at the Practice safe infection control protocols

Practice safe infection control protocols

Use preprocedural rinse of peroxide. The concentration of any rinse used should be at least 0.5%. 

• Use preprocedural rinse of peroxide.  The concentration of any rinse used should be at least 0.5%. Over-the-counter peroxide is typically 2%, so it would need to be diluted. However, in the dental industry, we have two products, Colgate Proxyl and Listerine Whitening Mouthrinse, that are 1.5%. Utilize what you may already have in office or can get through your dental suppliers. Rinse at the beginning of the appointment for 60 seconds and again after the appointment. Over-the-counter peroxide is not currently available in most stores, as the CDC is recommending cleaning surfaces in the home with peroxide.
• At this time, the ADA and CDC are only recommending peroxide to destroy the virus. While chlorine dioxide has been shown to kill some viruses, it is unknown if it is effective against COVID-19. Chlorhexidine is not effective against viruses.
• ALWAYS wear appropriate personal protective equipment (PPE) when working directly with patients.This includes safety glasses, gowns, lab jackets, face shields, gloves, and a mask appropriate for the task.
• Consider alternating levels of mask protection when performing activities to address mask shortage. The layering of lower level mask does not increase your protection.
• Level 1 mask (particulate filtration > 95%): Use when minimal risk of exposure exists. Ideal for procedures where there is a low amount of aerosols (e.g., patient exams, cleaning operatories, taking impressions, trimming/finishing/polishing temporaries, taking radiographs).
• Level 2 mask (particulate filtration 98%): Use when procedures create light to moderate amounts of aerosols. This includes limited oral surgery, endodontics, prophylaxis, restorative/composite, and sealants.
• Level 3 mask (particulate filtration 98%): Use when procedures create moderate to heavy amounts of aerosols. This includes complex oral surgeries, crown preparations, implant placement, periodontal surgery, use of ultrasonic scalers, and laser-based procedures
•  What about N95 masks? N95 mask or respirators can reduce the dental provider's exposure to all airborne particles from large droplets to small aerosols. They must be custom fitted to each wearer and employees must have annual training for the N95. If a dental office elects to use N95 mask, they must have a written OSHA Respiratory Standard. Wearers of an N95 must have medical clearance to evaluate their ability to wear a respirator safely. They are not recommended for persons with facial hair, or some medical conditions. The CDC recommends that in times of shortage, as with the COVID-19 pandemic, only health-care professionals who work in a sterile field or may be exposed to high-velocity splash, spray, or splatter of blood, such as those in an operative or procedural setting, wear N95 respirators.

Patient screening

• Front desk staff should call and screen patients prior to their scheduled appointments. Additionally, staff should screen patients when arriving for their appointments.
• Reschedule any patient who discloses they have had flu-like symptoms that include a high fever, dry cough, or difficulty breathing. Or if they have been in contact with anyone who has tested positive for COVID-19 within the last three weeks or 21 days.

General behaviours

• Avoid direct handshaking, hugging, or greetings that require direct contact.
• Provide hand-sanitizer in all operatories, at the front desk, and in all bathrooms.
• Disinfect common areas including entry doors, reception chairs, and front desk counters throughout the day. Diluted household bleach will kill the virus.
• Wash hands often and refrain from touching your face—eyes, nose, and mouth.

To protect dentists, dental staff and conserve PPE supplies, aerosol-generating procedures should be avoided, if possible. Consider using pharmacotherapy instead.

If your dental practice does NOT have safety precautions in place to manage COVID-19, you are still responsible to triage emergency care via telephone first and then by referral to a nearby dental or specialty practice that can meet COVID-19 safety standards. 

• Contact emergency patients 7 to 10 days after providing clinical care.
• Confirm that the emergency has resolved AND patients are not showing any signs of COVID-19 infection.
• Emergency patients may test positive for the virus some days after their dental visit.

Avoid referring to a hospital dental department at this time!

IMPORTANT:

If your dental practice meets COVID -19 safety standard, including access to and ability to safely use N95 masks, gloves, eye protection, face shield and protective gown, please immediately notify the College at [email protected] The College is collecting this information to help improve patient access to emergency dental care."

This information is a summary from the references cited below with the unique purpose of helping Dentists, Dental Professionals and practices provide a safe and responsible emergency care during these difficult times. There is no original information here, everything has been compiled from the following publications, all rights reserved to the authors. I sincerely hope this helps Dental Industry professionals be ready for our present reality.

Stay safe and be responsible!

Rodrigo Haddad -

Brazilian Dentist and Periodontist living in Toronto / Dental Practice Management, Marketing and Consulting. / Creative Content Development /

STUDIO HADDAD MARKETING - Toronto, ON

[email protected]

Whatsapp/SMS +1(416) 985-8680

REFERENCES:

1. Coronavirus and Infection Control Considerations for Your Dental Practice - https://blog.goetzedental.com/coronavirus
2. Should dental professionals be worried about the coronavirus? - https://blog.clouddentistry.com/dental-professionals-coronavirus
3. Coronavirus and “emergencies” - https://www.reddit.com/r/Dentistry/comments/fj3ph6/coronavirus_and_emergencie
4. Royal College of Dental Surgeons of Ontario - Dental practices offering emergency services - COVID-19 pandemic - https://www.rcdso.org/en-ca/rcdso-members/dispatch-magazine/articles/5296
5. Royal College of Dental Surgeons of Ontario -Guidance on true emergency situations during COVID-19 pandemic - https://www.rcdso.org/en-ca/rcdso-members/dispatch-magazine/articles/5288
6. Centers for Disease Control and Prevention - CDC Developing Guidance Regarding Responding to COVID-19 in Dental Settings -https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html