An Individual And Collective Responsibility Of Infection Control In Dentistry During COVID-19

 An Individual And Collective Responsibility Of Infection Control In Dentistry During COVID-19

“Knowing is not enough; we must apply. Willing is not enough; we must do”    -Bruce Lee

INTRODUCTION:

The novel coronavirus is now spreading in exponential proportion across the world, crippling even the best health care systems. Times like this call for a collective responsibility, for each of us to do our part. We are all in this together, for the long haul. Infection control is the discipline concerned with preventing healthcare-associated infection. Conventionally hospital acquired infections are associated with the use of artificial devices such as ventilators, central lines, urinary catheters and performance of surgeries, amongst the branch of dentistry. It is the oral and maxillofacial surgeons who may have to manage their patients in ICU settings and consequently have to deal with the infections associated with the use of artificial devices. However, the components of an infection control program comprises protocols dealing with not only patient care but the safety of all health care workers. Including dentists from all branches. Hence it is important to acquire knowledge and inculcate practices of infection control right from the period of undergraduate studies and continue to practice it diligently later in the profession. As dental treatment requires close proximity, face to face practices and can generate droplets or aerosols containing water , saliva , blood , microorganisms and other debris during the procedure dental professionals are at higher risk of SARS-CoV-2 infection.

DISCUSSION: 
POTENTIAL ROUTE OF TRANSMISSION: 

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2), coronavirus can be transmitted directly through cough, sneeze and inhalation of virus-containing droplets and microdroplets from infected individuals. It is also transmittable via contact with oral, nasal and eye mucous membranes. A case report from Germany has provided further evidence regarding possible transmission of COVID-19 through contact with asymptomatic patients. There are also several studies indicating that transmission of COVID-19 may become airborne during aerosol generating procedures .In airborne route, aerosols are smaller particles(<5 microns) during sneezing ,coughing and during use of equipment such as suctioning. These remain suspended in the air and are spread by air currents and can infect others. Incubation period can vary between 7 to 24 days, which in some cases demonstrates no clinical symptoms. Therefore, both patients and dental professionals are at a bilateral risk of being exposed to viral pathogens that can be transmitted through the oral cavity and respiratory tract during dental visits. Dental professionals by their very nature have a high risk of COVID-19 infection due to face-to-face communication with patients and the dental team. In addition, frequent contamination with saliva, blood and other body fluids as well as the use of sharp and high-speed rotary instruments magnifies the risk of infection in dental practices. A published report suggests that transmission of COVID-19 pathogen can also happen via inhalation of airborne viruses suspended in the dental surgeries for long hours. Clinical studies indicate that most of the dental procedures involving use of rotary handpieces generate considerable amount of contaminated and potentially infectious aerosol and droplets .Currently, there is not a practical solution to avoid generation of aerosols mixed with patient’s blood and saliva, and this creates great concerns regarding transmission of COVID-19 pathogenic agents. Moreover, aerosol can stay airborne for an extended length of time entering the patients and dental professionals body through respiratory tract. The aerosol can also settle on the surfaces of the dental instruments making cross-contamination.

IMPACT OF COVID-19 ON DENTAL PRACTICE:

After announcing COVID -19 as a pandemic by the WHO. The American Dental Association announced that all dentists should limit their dental care to only emergency cases. These dental emergency categories include severe and uncontrolled pain; spreading, recurrent or continuing infection; avulsed permanent tooth and severe trauma.

INFECTION CONTROL MANUAL:
STANDARD OPERATING PROCEDURES:
Telephonic prescreening protocol:

• Fix appointment through phone only and discourage walk-in patients.

• Hot spot matching and medical, dental symptom assessments.

• Disclosure /consent form to be sent to patient electronically.

• Ask patient (s) to wear mask and preferably come without any attender.

Reception/waiting area protocol:

• Receptionist/staff should be only in one in number.

• Discourage wearing footwear within clinic interiors/provide foot cover.

• Record patient temperature using digital non-contact infrared thermometer.

• Mandatory use of alcohol-based hand rub and provide mask for everyone.

• Seating arrangement with minimum 3-feet physical distancing.

• Display patient education material on hand and cough hygiene .

Dental operatory protocol:

• Keep the clinical operatory clutter free.

• Improve air circulation and avoid air-conditioners.

• 0.01% NaOCl for disinfection of dental water lines.

• Donning of appropriate PPE (personal protective equipment) for dental surgeon and dental assistant. 

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Patient assessment and treatment protocol:

• Pre-procedural mouth rinse with 1% hydrogen peroxide or 0.2% povidone –iodine for 1 minute.

• Extra oral scrubbing of face with antiseptic wipe.

• Diagnose and treatment plan into aerosol generating procedures (AGP).  It should be done ideally in designated isolation rooms which should be equipped with HEPA filters / augmented ventilation.

• Four-Handed dentistry and rubber dam application for AGP.

• High volume suction and minimize IOPA (Intraoral periapical ) x-ray usage.

Patient discharge: Patient has to be advised to re-mask and proceed to reception area . Again, hand hygiene to be followed and cashless payment should be preferred.

 CONCLUSION:

Thus it is evident that hospital /dental clinic infection control during COVID-19 pandemic is a wide arena which encompasses numerous aspects of health care provision .It is also evident that prevention of health care associated infection is an individual and collective responsibility of all the healthcare workers. Healtcare professionals owe it to the patients and themselves to work towards the end. COVID-19 has had many immediate complications for dentistry, of which some may have;

• Further long-term impacts on clinical practice, dental education and dental research preparedness and contingency planning for modifying clinical practice in dentistry.

• Optimization of cross-infection control protocols.

• Further focus on prevention and oral health promotion for the public.

• Patient empowerment and education. Increased role of e-consultancy and tele-medicine.

REFERENCE:

Guo, Y.R.; Cao, Q.D.; Hong, Z.S.; Tan, Y.Y.; Chen, S.D.; Jin, H.J.; Tan, K.S.; Wang, D.Y.; Yan, Y. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak- A n update on the status. Mil. Med. Res. 2020, 7, 1–10. 

https://www.ida.org.in/pdf/Covid19-IDA-Protocol.pdf

-By

Sarojini 

Student at Clinosol Research