Post COVID Dentistry: Dental Office Preparation

COVID-19, a virus belonging to a family of Coronavirus has brought the entire world to face a period of global recession. First time in the global history as per reports on crude oil dated 21st April 2020, 0% of oil production was noted. These kinds of incidents confirm the severity of COVID-19 outbreak which has massively affected the routine human activities. The only sign of relief from this virus as of now is that people are following social distancing and hygiene measures. The medical fraternity and their associated health professionals are the only source of service available in this emergency to treat the human race. They have even lost their lives and the worst part is that in some cases, their family and loved ones were not allowed or missed the final rituals at their funerals. Even now there is no clarity about the general situation attaining a normal state and start dental practice or any consensus about when people should resume their routine work & start dental practice. Dentists, dental chair side assistant and dental receptionist are the people generally occupied in a dental office. They are at high risk of direct transmission of COVID-19 via cough, sneezing, droplet infection, contact transmission (oral, nasal and eye mucosa) and aerosol production while working on a COVID-19 positive patient. According to few authors, presence of COVID-19 in the saliva gives a diagnostic clue for asymptomatic COVID positive and carrier patients .

General Symptoms of COVID-19 Patients Includes

Fever ≥100.00 F, sore throat, shortness of breath, cough, flu like symptoms, loss of smell and taste sensations, history of international travel in past 2-3weeks, social gatherings and regular hospital visits. Occupational risk is highly associated with patients who are healthcare professionals themselves. One more symptom of dental interest is bluish lips which generally indicates severe COVID 19 infection.

Protocol For Post Lockdown Dental Clinical Practice

Considering the present scenario, dental surgeon should consider each and every patient as a COVID-19 positive case and deal with it with utmost precautions, thereby following strict norms of infection control procedures. Following are the guidelines for emergency dental procedures

1. Initial screening of the patient should be obtained by non contact infrared digitial thermometer gun to check the temperature

• If positive temperature: Advise patient immediately to mask themselves and move them to an isolated place. Invite an oral medicine specialist to perform additional screening, delay the dental treatment and do the necessary medical management. If case is more suspicious, refer to him the nearest COVID hospital
• If normal temperature: Advise the patient to sit on a dental chair and perform routine dental procedure wearing a standard Personal Protective Equipment (PPE)

2. Performing dental procedures with airotor handpiece, ultrasonic scaler, air/water syringe (Aerosols)

• In COVID-19 positive patients: Medical management for at least 14 days should be carried out and preferably no dental procedure should be initiated. If the dentist has accidently contacted the patient and comes to know about the patient’s COVID-19 positive illness, then the dentist should immediately undergo self-quarantine for two weeks
• In COVID negative patients: Do case selection and diagnose if Atraumatic Restorative Treatment (ART) can be performed, that involves zero aerosol production. Incase of contraindication for ART, then perform the routine procedure with standard PPE using micro-motor if possible

Operator Concern for Performing Dental Treatment Post-Lockdown

Dental operator needs to follow recommended guidelines in order to treat any patient during post-lockdown period. Dentist must use PPE which contains

• A gown extending from neck to knees, arms to end of wrist with a wrap around at the back
• Facial mask or a respirator (N95) should be used
• Face shield or wide goggles to cover the eyes
• Extended cover wrist gloves need to be used with PPE
• Care must be taken to keep hands away from the face with limited touching round the dental chair
• After completion of the dental procedure proper disposal of the PPE should be initiated by removal of the gloves at first, facial shield/goggles secondly, third removal of the gown and finally removal of the mask or respirator followed by hand washing with 60-70% alcohol based sanitizer for 20-30 seconds or soap and water for 40-60 seconds

Preparation of operating room along with dental chair

1. Flush all water lines connected with operating dental chair with attached airotor hand pieces. This can be done by using 0.01% of sodium hypochloride/chlorhexidine solutions daily before the start of dental procedures
2. Ultrasonic scaler tip should be flushed with 0.01% of sodium hypochlorite/chlorhexidine solutions for 30 seconds
3. Covering the dental chair operating handles by separating mediums using vinyl plastic sheet
4. Light handles/switch, arms of the dental chair, high volume suction attachment and curing light tip must be covered by disposable plastic sheet
5. Non dental attachments like x-ray viewer box, computer keyboard with mouse, adjustment handle under operator and assistant chair must be covered with necessary aseptic vinyl sheet
6. Proper waste disposal should be followed
7. Entire clinic floor must be disinfected by 1% sodium hypochlorite solution and metal surfaces like door handles, sanitary attachments must be cleaned with 70% of alcohol every 2 hours
8. Heat sensitive equipment must be dealt with 2% Glutaraldehyde. eg Pre-sterilisation of rubber dam sheets
9. Preparation of waiting and reception area – Besides sterilisation, this includes prevention of crowding and maintaining social distancing in the waiting area. Some suggested measures are

• Maintain 1 metre distance between patients in waiting area between chairs
• Spread out your OPD/work timings
• Work on strict appointments taken on telephone which are amply spaced out by you with a 30 minute gap between each patient

This will avoid patients collecting in the waiting area. 10. It is advised to alter the clinic design and way of working slightly as it will take time for us to assume our normal working pattern. Some suggested measures are

• Dividing the clinic into areas, allowing a single path of entry and exit to certain areas of clinic only
• Isolating negative but suspicious cases into another area or another dental chair if possible
• Timing suspicious patients or any aerosol procedures as the last patient of the day

Fumigation Procedure in Dental Office

1. High level disinfection for dental operatory must be delivered once in a week using formaldehyde gas with addition of potassium permanganate and 40% of formalin
2. For an effective fumigation quantity of formaldehyde is mandatory. For every thousand cubic feet of air volume, 280 ml of formalin and 150 mg of potassium permanganate is necessary
3. Fumigation is done by placing the mixture of formalin and potassium permanganate solution at 4 corners of the operating room in enamel bowls and formaldehyde gas is allowed to react with them
4. Operatory temperature during fumigation must be maintained at 25-300 C with 55-60% of relative humidity
5. Water must be sprinkled over the floor of operating room before the start of the fumigation procedure in order to maintain humidity
6. The entire fumigation must be carried for routine cases (overnight) and 24 hours in cases of gross contamination eg COVID-19

Recommended Prophylactic Drugs for the Present Scenario in Treating COVID-19 Asymptomatic Patients

1. Conditions like pulpal and periapical pathologies are best treated with NSAID’s in combination with Acetaminophen eg 400-600 mg of Ibuprofen with 1000 mg of Acetaminophen.
2. Before starting any dental procedure, use of stabilised chlorine dioxide as an oral rinse is an effective way to oxidise Coronavirus in the oral cavity
3. Use of resorbable medicated sutures should be initiated
4. A prophylactic dose of chloroquine/hydroxychloroquine 400 mg twice a day for 1st week and weekly once for 7 weeks is recommended for dental professionals and dental staff. Still, it is a debatable topic

Summary

Treating COVID-19 positive patients whether symptomatic or asymptomatic is a new challenge for the dentists during revival of their dental practice. It is very important for the dentist to screen the patients before start of dental procedures. For non-tested self-quarantined COVID-19 positive patients the dentists must be aware that at least 3 days (72hours) have passed after quarantined periods with no COVID-19 related symptoms and medications. For test based COVID-19 positive patients, same proctocols as mentioned for non tested patients should be kept in mind along with further double screening with nasopharyngeal swab specimens should be done for two consecutive days with should provide negative results. Social distancing must be encouraged in the dental clinic and the dental personnel must be 6-feet or 2-meters apart.