Asepsis of Dental Clinic During Covid-19

Author: Dr. Honey Singhal

While the universe spins around,

You remain there, unwavering,

Shining bright, and giving direction

To always find the way home.

Contribution of doctors and other healthcare providers was highly recognized and appreciated globally as they emerged as real heroes during Covid19 pandemic. The epidemic emergency outbreak started in China and got transmitted all over the world like a fire in the jungle. The pandemic brought the medical profession and doctors specifically in limelight. Homage was paid to doctors in several magnanimous and diverse ways throughout the world for they put their own lives at risk to serve others. Saviours must be themselves safe and healthy to be able to serve others hence it is crucial for them to take all precautions and measures to prevent exposure to the virus. To serve the society it is important to first serve a gift of health to oneself too.

The nature of virus being highly contagion got recognized quickly and the medium of diffusion is majorly accepted to be via inhalation of droplets carrying the virus. Virus uses human body as the carrier to survive and sustain but it is known that virus could also persist outside human body in aerosols or fomites.

Out of various disciplines of medical world, dental society was stated to be at highest risk. Most dental procedures are such that dentists are in close contact to patients’ oral cavity and thus in close proximity to saliva, blood, and other respiratory tract secretions. Covid19 attacks respiratory system via oral cavity, hence viral load is extremely high inside the mouth. General symptoms like coughing or sneezing might become the cause or transmission of the virus as saliva gets expelled out in micro droplets. A patient could be asymptomatic but is a potential carrier of the disease, therefore it is strongly advisable to handle every patient as a probable source and every measure should be taken to ensure non-transmission to people around. Various precautionary measures to be taken like anti-microbial mouthwash and rubber dam to reduce the probable viral load inside the mouth. This article tries to incorporate most of the required modifications to be brought into practice having the invisible enemy around us.

A remarkable fact is that dentistry being considered to be highest at risk for transmission of Covid-19 virus, cases found Covid-19 positive were least prevalent among dentists as compared to other healthcare providers. This indicates how extraordinarily alert dentists have been to save themselves and their patients from transmitting the infection.

As per the study published in JADA (The Journal of the American Dental association) from The American Dental Association Science and Research Institute, fewer than 1 percent of dentists were found covid-19 positive.

Dr. Marcelo Araujo, Ph.D., CEO of the ADASRI, chief science officer of the ADA and senior author of the report asserted that, “This is very good news for dentists and patients…This means that what dentists are doing — heightened infection control and increased attention to patient and dental team safety — is working.”

Tremendous unexpected changes were seen and are still in process ever since covid-19 has hit the world. Interpersonal distance between dentist and patient cannot be maintained most of the times. Most of the procedures lead to aerosol production which elevates the risk of airborne infection hence much higher risk of corona spread as well.

Probability is never zero, unless something is impossible. As it is not possible to achieve an absolutely transmission-free environment inside a dental clinic, any patient who is Covid-19 positive must NOT be treated in an office-based dental clinic.

This article aims to highlight practical measures to be undertaken to minimize the risk factors inside a dental clinic during the Covid-19 pandemic:

• Appointment-based practice – Gap between appointments to ensure optimum disinfection before next case. Attend only pre-appointed patients who have been screened for probable symptoms
• Telephonic Triage & Selection of Case – Initial screening could be done over the phone and check for symptoms like cough, sore throat, running nose, breathlessness, fever etc. when patient is physically present. Cases to be avoided: General examination, teeth whitening, ultrasonic scaling, cosmetic concerns, general follow-ups, etc. Cases selected for treatment could include patients with severe pain, growing pathology, highly infectious stage, cases with bleeding disorders, swelling, accident trauma cases and cases which require immediate extraction.

• Preparation of clinic before starting the day – Disinfection of dental chair and all other equipment must be ensured. Availability of all disposables like mouth masks, gloves, gowns, head caps, show covers etc. must be checked.

• As the Patient walks in – As soon as the patient enters the clinic premises, he/she must be screened for symptoms. It must be ensured that patient enters the clinic wearing a mouth mask. Additional protective wear like single-use shoe covers and head cover should be provided. Enquire about patient’s travel history and social exposure.

• Place Plastic or glass barriers with a small window or two-way speakers at reception area for extra protection.
• Seating Arrangement – Rearrangement of seats in the waiting area to make certain that advisable physical distancing is maintained. Health journals, magazines, books, flyers, toys, TV remote, etc. must not be kept in the waiting area to avoid touching by different people. Adult patients should be advised to come unaccompanied and minors to be accompanied by only one guardian.

• Patient Consent and Declaration Form – It should be mandatory for every patient to sign the consent and declaration form. With latest technology at hand it could be web-based also. Required changes should be made in the forms considering the pandemic situation. Covid19 specific conditions could also be included in the patient consent form to make it legally applicable and it will also provide leverage to the dentist to deny any treatment to the patient if patient disagrees.

• During clinical treatment 
• For the doctor – Personal Protective Equipment (PPE)

• For the assistant – all protective wear and usage of intraoral and extraoral suction throughout the treatment procedure
• For the patient – Patient should be guided to co-operate for 4-handed treatment procedure and be at ease during the treatment.

• After clinical treatment
• Cleaning of all hand instruments, 3way syringes, water outlets, dental chair, overhead light etc.
• Patient should wear a fresh surgical mouth mask again and must be advised to inform if any adverse symptoms appear post treatment. Guide the patient towards advised protocol if any symptoms are experienced.

• Sterilization of Instruments – Autoclave all autoclavable instruments before starting the day. Disinfect all clinical and non-clinical surfaces. Replace single-use products with fresh sterilized ones after every patient. Cover all the tubing with sterilized material before starting any procedure and sterilization of reusable root canal files and burs using a glass bead sterilizer.
• Prophylactic medication for clinician & assistants
• Usage of rubber dam for isolation and use of a high velocity suction. Train the assistant to help reduce aerosol transmission by effective intra-oral n extra-oral suction technique.

• Prefer hand scaling instead of ultrasonic scaling when unavoidable.

• Usage of anti-microbial mouth rinse to reduce probable precautionary viral load.
• If dental operatory is not efficient to handle medical emergencies for patients who are at higher risk then refer them to a better-suited hospital.
• Track the attended patients later for about fourteen days to check if they develop any symptoms of Covid19. Required measures could be taken as patient was probably a carrier of corona virus during the visit to dental clinic.
• Extra-oral suction – Use and extra-oral suction to reduces high volume of aerosols and droplets produced during treatment.

• Double gloves to be worn by the clinician for extra protection.
• Air purification system with HEPA filter and UV light could be used inside the dental clinic.
• Especially designed aerosol mitigation devices to be made a part of dental procedure to further minimize risk of transmission
• Continuous disinfection process for surfaces exposed to maximum touch by people.
• Ventilation and maintenance of natural air circulation inside the dental set-up.
• Frequent servicing of the air conditioning system.
• Availability of surgical 3ply mouth masks, sanitizers and paper napkins within reach for auxiliaries and patients.
• Cashless/contactless/online mode of payment should be encouraged.

• Placement of covered dustbins at appropriate places.
• Dedicated area for changing the protective wear for dentist and attendants.
• Separate area for cleaning and sterilization of used instruments.
• Modifications in the restroom: Disposable paper towels, sensor soap dispenser, sensor taps etc.
• An efficient fumigation system to disinfect the whole work environment inside the clinic.
• Anti-retraction handpieces to be used. Using a disposable handpiece is also a good option.
• Training of attendants and staff – They should be trained for efficient sterilization, disinfection and other basic hygiene chores. Rotational work shifts should be preferred. Screening of the staff at regular intervals to check for any symptoms of the disease. Frequent morale boosting. Should remain in disinfected surgical clothing inside the clinic.
• Disinfection of floor, cabinets and other surfaces by 1% sodium hypochlorite
• Four-handed treatment technique in every case to be operated.
• Impressions to be sent to the laboratory must be thoroughly disinfected.
• Avoidance of procedures which would cause aerosol production, if possible. Devices which lead to aerosol production are high and low speed handpieces, surgical handpieces, hard-tissue lasers, ultrasonic devices and air polishing devices.
• Usage of a particulate filter respirator (N95) instead of a regular surgical mask wherever aerosol generating procedure is unavoidable.
• Patient must always wear a mouth mask unless seated in the dental chair for treatment/examination.
• Educate your patients via display of visual information at the entrance and at reception area about basic etiquettes of how to cough or sneeze in public areas, about social distancing, proper and frequent hand wash, how to dispose of any waste material and importance of wearing a proper mouth mask.
• Disinfect stationary and all other personal belongings like bags, lunch packs, laptops, mobile phones etc. which we carry from home to clinic and from clinic to home. All these belongings should be kept in a different section which is away from the clinical area.
• Conditions to be agreed and followed by patients could be ensured by informing about the same at the time of appointment or via text message or email so that they enter the dental clinic prepared and do not object to the same.

This article intends to dispense a note of awareness to minimize the risk factors, so as to avert this deadly disease in a dutiful and fearless manner. Covid19 might stay for a longer time than expected or might stay forever and we learn to co-exist eventually. So, unless we know the viral enemy well and ways to defeat it, let’s be prepared and educate ourselves and others to deal with it. Since doctors must take the responsibility towards patients, we must not deviate from our job rather than anticipating and being fearful.

To sum-up, as actions speak louder than words, let’s do our best to serve ourselves, our employees and our patients. After all, the brightest stars are those who shine for the benefit of others. Keep shining!

References:

https://www.ada.org/en/publications/ada-news/2020-archive/october/ada-study-finds-covid-19-rate-among-dentists-less-than-1-percent

Author: Dr. Honey Singhal

She is the content expert at Dentalkart.com. A Dental Surgeon by profession, a Researcher by choice and a Writer at heart.  She endeavours to culminate both her skills of dentistry and literature via this platform to enlighten the readers. When not with patients, books and laptop, she is found either chatting with friends in a café or painting a canvas or listening to her favourite music.