Dr. Hana Bougatef – Post graduate student, conservative odontology & endodontics, Dpt. of dental medicine, EPS Sahloul, Sousse, Tunisia
Dr. Mahmoud Smaoui – Post graduate student, conservative odontology & endodontics, Dpt. of dental medicine, EPS Sahloul, Sousse, Tunisia
Dr. Faten Khanfir – University Hospital Assistant at the Dental University of Monastir, Tunisia
Pr. Nabiha Douki – Professor at the Dental University of Monastir, Tunisia
Pr. Sonia Zouiten – Professor at the Dental University of Monastir, Tunisia
Pr. Faten Ben Amor – Professor at the Dental University of Monastir, Tunisia
Dental University of Monastir, Research laboratory of oral health and rehabilitation, LR12ES11, 5000, Monastir, Tunisia
Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is the etiological agent of the severe acute respiratory syndrome corona virus disease 2019 (COVID-19).
The coronavirus disease started firstly in Wuhan, China last December and have become a public health problem for not only China but also countries all over the world. Tunisia, for example, was for a time at stage 3 of the coronavirus epidemic. After applying vigorous and strict recommendations by the government, epidemiological monitoring parameters confirmed control of this epidemic.
Therefore, with no vaccine until now, we should learn how to live with it and more attention should be kept to avoid a second epidemic wave.
Particularly, in dental settings, the risk of cross infection may be higher between dental practitioners and patients due to bio-aerosol generation in the majority of dental procedures.
Our aim in this paper is to sensitize clinicians about infectious risks in dental settings and provide recommended protocols for dental practitioners to avoid cross infection with corona virus 2 (SARS-CoV-2).
Keywords: Coronavirus disease, dental setting, transmission, aerosol, contamination, prevention.
Cornavirus disease, also called COVID-19, is the latest infectious disease started in the area of Wuhan, China, and has rapidly spread across the world. The etiologic agent is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 33
On January 30, 2020, the World Health Organization (WHO) declared the rampant spread of SARS-CoV-2 and its associated disease (COVID-19) a public health emergency. 32 Like most of the countries all over the world, Tunisia has not been spared from the coronavirus. Since March 22, 2020, Tunisia has passed to stage 3 of the coronavirus epidemics. Thus, the Tunisian government has declared total containment from April 19, 2020 until May 4, 2020.
After a gradual and favourable reduction of general containment, now, epidemiological monitoring parameters confirm control of the risk of indigenous transmission and the persistence of an exclusive risk related to imported cases.
These decisions to reduce restrictions on containment and resuming economic activities with the borders opening confront the question of how to avoid a new spread of the SARS-Cov-2 virus that could be generated by the entry of virus carriers.
Therefore, vigorous measures for prevention and appropriate recommendations for dental practice are suggested for patient screening, infection control strategies, and patient management protocol. Based on our experience, guidelines and research, this article aims to sensitize clinicians about infectious risk in dental settings and provides recommended protocols for dental practitioners to avoid another epidemic wave.
Routes of Transmission
The routes of transmission are direct contact, and droplet and possible aerosol transmissions. 9 Consequently, coughing or sneezing by an infected person can cause virus spread for individuals in close contact (within a radius of approximately 6 feet).
This led to the recommendation of social distancing to minimize community spread of the disease. The second route of transmission is if droplets of SARS-CoV-2 land on inanimate objects located nearby an infected individual and are subsequently touched by other individuals.
In fact, SARS CoV-2 can remain viable in aerosol and survive up to 3 days on inanimate surfaces at room temperature, with preference in humid conditions. 35
Thus, hand contact with contaminated surfaces may lead to virus transfer to the eyes, nose, or mouth, resulting in a new case of infection. 9 That’s why, disinfection of objects and hand washing are essential for halting the spread of this disease. 2
Infectious risk in dental settings
In affected patients, it has been proved that this coronavirus is abundantly present in nasopharyngeal and salivary secretions. So, it spreads easily through respiratory droplet/contact with nature. 2
Due to their proximity to the oral cavity, dentists and dental assistants are therefore highly exposed to the virus, in particular during procedures that generate airborne contamination. This involves the suspension of potentially contaminated saliva in an aerosol. These aerosols are mainly generated by the use of rotary or ultrasonic instruments, but also when using air/water syringes. 12, 28
Unfortunately, due to the characteristics of dental setting, patient management generate significant amounts of droplets and aerosols, posing high risks of nosocomial infection. The standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19. 26
When a person coughs, sneezes, laughs, or talks, big and small droplets are generated. Due to gravity, big droplets fall to the ground. Therefore, droplet transmission requires close physical proximity with an infected individual. On the other hand, small droplets may remain in the air for a longer time and travel further before they can enter the respiratory tract or contaminate surfaces. 9 In addition to coughing and sneezing, dental treatments including the use of a high-speed handpiece or ultrasonic instruments with water coolant could make secretions, saliva or blood aerosolize to the surrounding area. 26, 9
Often these bioaerosols are contaminated with bacteria and viruses, and can float in the air for a time and be inhaled by another person. 9 Moreover, infections can occur through the puncture of sharp instruments or direct contact between mucous membranes and contaminated hands. 21 The virus has been shown to be present in human saliva. 8 Moreover, oral mucosal cells have been shown to strongly express the ACE2 (angiotensin converting enzyme 2) receptor on their surface, which is conducive to the adhesion of CoV-2-SARS. 36
Additionally, salivary glands also appear to be a potential reservoir for CoV-2-SARS, especially in asymptomatic patients, which may explain a resurgence of the virus in the oral cavity during salivation. 37 These observations thus place the oral cavity as an important risk area for transmission of this pathogen.
General symptoms such as cough, weakness, myalgia were the most common symptoms. Some clinical case reports have suggested that SARS-CoV-2 may have many oral manifestations. 3 There have been some COVID-19 cases reporting oral manifestations. 25, 31, 22, 5
Some studies proved that the damage of respiratory tract and other organs showed with coronavirus infection can be attributed to the distribution of angiotensin-converting enzyme 2 (ACE2) receptors in the human system. 38
Therefore, cells with ACE2 receptor distribution may become host cells for the virus and further cause inflammatory reactions in related organs and tissues, such as the tongue mucosa and salivary glands. 36
In addition, COVID-19 acute infection treatment and repercussion on the deterioration of systemic health could potentially contribute to negative outcomes concerning oral health. It can lead to various opportunistic fungal infections, recurrent oral herpes simplex virus (HSV-1) infection, oral unspecific ulcerations, fixed drug eruptions, dysgeusia, xerostomia linked to decreased salivary flow, ulcerations and gingivitis. 6, 1, 24 Further studies are needed to investigate the oral manifestations of COVID-19.
Patient management in daily practice
During the covid-19 outbreak, pulpal or periapical lesions, cellulitis and abscess were the most common reason for patient visits to the emergency room. Non-emergency dental procedures were postponed with medical prescription if needed. Now, after the favourable transition of the coronavirus epidemic in many countries, patient management in dental sector is starting to get back to normal daily practice.
However, if adequate precautions are not taken, the dental office can potentially expose patients to cross contamination and can become potential carriers of the disease. 2 Thus, special precautions in a dental setting should carefully be taken. Based on our experience, relevant guidelines and research, we can enumerate some:
1- Back to the activity
As after each prolonged closure, before the firm reopens, it is necessary to carry out the following operations:
• Cold water: purge the entire water circuit for 5 minutes. Do the same with the equipment of the chair (micro-motor cords, multifunction syringe…)
• Hot water: completely drain the water storage equipment by opening all hot water points. If possible, ventilate the room to evacuate the aerosols as quickly as possible.
• Vacuuming: clean filters, test vacuuming and carry out disinfection with the usual product.
• Floors and surfaces: carry out a cleaning of the floors and a treatment of the surfaces with virucidal disinfectant detergent products (standard NF EN 14476).
2- Waiting area
All patients should cover their nose and mouth with a mask. Post a cough etiquette instruction at the entrance of the waiting room. When coughing or sneezing, patients should cover their nose with their elbow, instruct them to dispose used tissues into a waste bin immediately after use and ensure hand hygiene.
Waiting area should be well ventilated without draught generation. For rooms with natural ventilation, 60 L/s per patient is considered adequate ventilation. Spatial separation of at least 1 m should be maintained between patients. 9
3- Ventilation and air conditioning of premises
– Like any workplace, a treatment room must have a supply of fresh air, either through natural ventilation (window or other opening) or through mechanical ventilation. The minimum fresh air flow rate is 45 m3 per hour per occupant.
– It is recommended to identify the type of existing ventilation. The devices allow the supply of fresh air and the extraction of stale air and to check their correct operation, contacting the installer if necessary.
– With regard to SARS-CoV-2, there is a need for additional air renewal, due to the potential contaminated aerosols remaining in suspension in the treatment room, even if the first objective for the practitioner is to reduce the quantity emitted.
– After each aerosol-generating procedure, it is therefore necessary to ensure maximum renewal of the air in the treatment room before admitting a new patient.
– When an aerosol-generating treatment is performed and during the ventilation phase, the door of the treatment room must be closed. In addition, the nursing staff present must be equipped with suitable protection. 23, 29, 16
* Air conditioning:
– Room air conditioners generally do not ventilate the room. The indoor unit takes the air from the room and returns it to the desired temperature. 15, 27
– Recirculating air systems such as air conditioners, whether or not they are equipped with filters, should be shut down as much as possible to avoid dispersion of the generated aerosol and contamination of all surfaces in the room.
– The use of air conditioning in the treatment room remains possible outside the periods when aerosols are produced or still in suspension (i.e. after the end of the ventilation following the aerosolizing procedure).
– If air conditioning is used, it is recommended:
• To use the most efficient filters possible from a health point of view, in relation to the technical compatibility of the installation.
• To change the filters regularly (if possible every week) following the recommendation guides (Ministry, UNICLIMA)
– When using an all-new air handling unit to condition the air, the usual temperature and humidity settings must be maintained. 15, 27
4- Surfaces disinfection
Clinic staff should make sure to disinfect inanimate surfaces in both waiting and operating areas using chemicals recently approved for COVID-19 and maintain a dry environment to curb the spread of SARS-CoV-2.17 They should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient.
In fact, routine cleaning and disinfection are appropriate for SARS-CoV-2 in healthcare settings, including those patients-care areas in which aerosol-generating procedures are performed. Surfaces are disinfected after each patient visit, especially surfaces in close proximity to the operating areas. Surface disinfectants contain 0.5% hydrogen peroxide or 62%–71% ethanol for small surfaces. 18
The WHO recommends the use of sodium hypochlorite for environmental cleaning with concentration of 0.1%, which is effective against coronaviruses in 1 min. 18
5- Patient screening
Dentists should take a thorough medical history from each patient and confirm the health status at each recall visit. This should include personal, travel, and epidemiological history. Temperature and lower respiratory tract symptoms should be closely monitored. Do not forget that symptoms of fever and fatigue could be caused by acute dental infection. 9
6- Patient placement
*Ideally, dental treatment should be provided in individual patient rooms whenever possible.
*For dental facilities with open floor plans, to prevent the spread of pathogens there should be:
-At least 6 feet of space between patient chairs.
-Physical barriers between patient chairs. Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure that extending barriers to the ceiling will not interfere with fire sprinkler systems).
Dental chair should be oriented parallel to the direction of airflow if possible.
*Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and toward the rear wall when using vestibule-type office layouts. 4
7- Patient volume
Ensure to account for the time required to clean and disinfect dental chair between patients when calculating your daily patient volume.
Appointment scheduling: Upon resumption of activity, each practitioner must give preference to patients who have received urgent care during the containment period and patients whose care had been on hold when the containment was put in place.
The organization of appointments must:
– Allow Essential measures and precautions during oral care after deconfinement
– Allow Carrying out disinfection and ventilation procedures between each patient
– Prevent people from staying in the waiting room. In case of group practices, it may be appropriate to provide staggered schedules.
– Encourage the grouping of procedures over a long session. 4
8- Personal Protective Equipment (PPE)
Personal protective equipment (PPE) can form an effective barrier against aerosols generated from the operative site. Dentists should respect the use of PPE and select the appropriate equipment to provide it to medical staff.
They must receive training on and demonstrate an understanding of:
*when to use PPE
*what PPE is necessary
*how to properly don, use, and doff PPE in a manner to prevent self-contamination
*how to properly dispose of or disinfect and maintain PPE
*the limitations of PPE
– Protective eyewear and face shields: infectious droplets could easily contaminate the dentist through contact with the mucous membranes in the eyes. Protective eyewear, or face shield should be worn to protect the eyes from bio-aerosols and droplets created during dental procedure, then they should be disinfected between patients.
– Face masks: at minimum, a surgical mask should be used. It offers both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.
When performing aerosol generating procedures, a particulate respirator that is at least as protective as a National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Standard Filtering Face Piece 2 (EU FFP2), or equivalent, were used. It is advisable to use them judiciously and follow the Centers for Disease Control and Prevention guidelines for N95 respirator use and reuse. 30
There are multiple sequences recommended for donning and doffing PPE. One suggested sequence includes:
*Before entering a patient room or care area:
1. Perform hand hygiene.
2. Put on a clean gown or protective clothing that covers personal clothing and skin likely to be soiled with blood, saliva, or other potentially infectious materials.
3. Put on a surgical mask or respirator.
4. Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If the mask has loops, hook them appropriately around your ears.
5. Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator.
6. Put on eye protection: Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
7. Perform hand hygiene.
8. Put on clean non-sterile gloves: Gloves should be changed if they become torn or heavily contaminated.
9. Enter the patient room.
*After dental care:
1. Remove gloves.
2. Remove gown or protective clothing and discard the gown in a dedicated container for waste or linen.
o Discard disposable gowns after each use.
o Launder cloth gowns or protective clothing after each use.
3. Exit the patient room or care area.
4. Perform hand hygiene.
5. Remove eye protection.
• Remove it carefully. Do not touch the front of the eye protection.
• Clean and disinfect reusable eye protection, according to manufacturer’s reprocessing instructions prior to reuse.
• Discard disposable eye protection after use.
6. Remove and discard surgical mask or respirator.
• Do not touch the front of the respirator or mask.
• Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
• Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
7. Perform hand hygiene. 4, 10
9- Hand hygiene
Use ABHR (Alcohol-based hand rub) with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. The WHO (2020c) stated that hand hygiene includes either cleansing hands with an alcohol based hand rub or with soap and water; both methods are equally effective. ABHRs are preferred if the hands are not visibly soiled; if the hands are visibly soiled, water and soap should be used. The WHO recommended formulations based on 80% ethanol or 75% 2-propanol to be effective against coronavirus. 18
As suggested by WHO (2009), hand hygiene should be performed before touching a patient, before any cleaning or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings. 9
Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Dental healthcare facilities should ensure that hand hygiene supplies are readily available to all medical staff in every care location.
To limit the risk of aerobiocontamination with SARS-CoV-2, the use of preoperative antiseptic mouthwashes has been proposed in several international publications.
Preprocedural mouth rinse is one of the most effective methods of reducing the proportion of microorganisms in oral aerosols. Previous studies have shown that SARS-CoV and MERS-CoV were highly sensitive to povidone mouth rinse. 7
Some recommend the use of chlorhexidine, others, hydrogen peroxide, or povidone-iodine. Therefore, preprocedural mouth rinse with 0.2% povidone-iodine might reduce the load of corona viruses in saliva. 20 Another alternative would be to use 0.5-1% hydrogen peroxide mouth rinse, as it has nonspecific virucidal activity against corona viruses. 18
In addition, it has been proven that CHX is effective against several infectious viruses, including herpes simple virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV). About 0.12% CHX can be used as a preprocedural mouth rinse. 34
11- Rubber dam
Dentists should use a rubber dam in all aerosol-generating procedures. It may be advantageous to place the rubber dam so that it covers the nose. 2
Use of disposable (single-use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross contamination. 9
Extraoral imaging such as panoramic radiography or cone-beam computed tomographic imaging should be used to avoid gagging or cough reflex that may occur with intraoral imaging. When intraoral imaging is mandated, sensors should be well protected to prevent perforation and cross contamination. 34
Dentists should avoid aerosol-generating procedures whenever possible and prefer procedures, reducing the quantity of aerosol produced in the environment.
Minimize the use of ultrasonic instruments, high-speed handpieces, and the air/water syringes to reduce the risk of generating contaminated aerosols. 2
Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only). Reduce the quantity of aerosols created (red ring contra-angle rather than a turbine, minimum water flow required, limit the use of ultrasound, no use of an air-polisher…)
During the operating sessions, the dentist should use handpieces equipped with anti-reflux devices to avoid cross-infections. 33
15- The dental chair
Must be equipped with a disinfection circuit and will be fully disinfected after each patient.
All equipment and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination.
Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.
16- Removal/filter of contaminated air
There are several methods to remove/filter contaminate air in treatment areas; the two most commonly used devices include the inexpensive, high volume evacuator (HVE) and the expensive high efficiency particulate arrestor (HEPA) filters. 9
17- At the end of each half day
– Disinfection of aspirations
– Decontamination of suction filters
– Cleaning of waiting room surfaces if the waiting room has been used
– Seal waste bags with gloves and perform hand hygiene afterwards.
18- At the end of the day
Floor cleaning (HCSP, 10 April 2020) 13
– Wet scrubbing-disinfecting (do not use a vacuum cleaner)
– Use of a product in accordance with standard NF EN 14476 or, failing this, bleach at a concentration of 0.5%
– Respect the contact time necessary for the product to be effective.
– For unsoiled and non-wetted PPE, disposed of in the household waste stream (HCSP, 19 March 2020) 14
– Use a bag dedicated to this waste
– Do not transfer the bag
– Double the bag with a second bag
– Close the bag and store it for 24 hours before putting it away.
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease has gripped the entire world and has caused widespread public health concerns.
Therefore, specific recommendations for dental practice are suggested for patient screening, infection control strategies and patient management protocol in order to prevent cross infection in the dental office.
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