Safe dental practice during COVID-19 - MoHFW guidelines

With the ongoing pandemic, dentists, their patients, and dental auxiliaries are at a high risk of cross-infection. Since the dental treatments require the dentist to be in close proximity with the patient's oral cavity, saliva, blood, and respiratory tract secretions the chances of transmission of the infection are very high. Patients who are asymptomatic could be spreading infection without even knowing. Therefore, all the patients should be considered a potential source of infection.

The Ministry of Health and Family Welfare (MoHFW) has recently issued guidelines for safe dental practice, to be followed in dental clinics located in government and private sector, dental colleges.

"The dental clinics/ hospitals located in the CONTAINMENT ZONE will remain closed; however, they can continue to provide tele triage. Patients in this zone can seek ambulance services to travel to the nearby Dental Facility in non-containment zones, " the guidelines noted

Following are the major recommendations of the guidelines

1. Risk Assessment and management

a. Low-Risk patient:

• Vaccinated patients.

• No active COVID-19 symptoms, RT-PCR negative.

• COVID-19 affected person in whom 14 days have elapsed after resolution of the COVID symptoms and/or RT-PCR negative.

-All dental procedures can be undertaken with appropriate precautions.

b. High-Risk patient

• Patients with COVID-19 symptoms

• Patients with RAT or RT-PCR positive.

- Only emergency procedures should be undertaken with standard COVID protocol.

- If facilities do not exist for COVID appropriate protocol, high-risk patients may be referred to higher centers for management.

2. Protocols for Dental Clinic/ OPD

2.1 Teleconsultation

• Teleconsultation will be preferable

• Prior teleconsultation will also facilitate to identify of patients requiring physical examination in the clinic

2.2 Appointment system (time-based appointment to limited numbers)

• One patient at a time in the examination room, if possible, without an attendant.

• Sufficient time should be given for patient evaluation and for time in-between patients.

• Appoint patients with co-morbidities or other vulnerable groups at a separate time or early morning slot.

• Walk-in patients without appointments should be discouraged.

2.3 Screening of patients at OPD/ Dental Clinic entry:

• All patients entering Dental Clinic/ OPD should be screened for symptoms of COVID to avoid/minimize exposure to staff and to patients.

• Patients having symptoms suggestive of Covid 19 shall be referred to a Covid treatment facility.

• Regulate entry of patients and ensure the use of mask/face cover, hand hygiene, and physical distancing, as per the standard protocols advocated by M/o Health & Family Welfare.

2.4 Waiting area

• Display visual alerts at the entrance of the facility and in strategic areas (e.g., waiting areas or elevators) about respiratory hygiene, cough etiquette, physical distancing, and disposal of contaminated items in trash cans.

• Install glass or plastic barrier at the reception desk, preferably with a two-way speaker system.

• Ensure availability of sufficient three-layer masks and hand sanitizers and paper tissue at the registration desk, as well as nearby hand hygiene stations.

• Ensure physical distancing between waiting chairs, preferably six feet (2 guj ki doori) apart.

• All areas to be free of all fomite such as magazines, toys, TV remotes or similar articles.

• Cashless/contactless payment methods are preferred.

• A bin with a lid should be available at triage where patients can discard used paper tissues, masks, etc.

2.5 Within Dental Operatory:

• Ensure spacing or barrier in multi-chair operatory. Separate areas for donning and doffing of PPE should be identified.

• In a multi-chair facility, the clinical area should preferably be divided into a screening and treatment area with separate dental chairs.

• The dental operator, assistant, and all personnel within two meters of patient care should wear impervious surgical gown/ scrub with a well-fitting N-95 mask.

• Sensor taps or taps with elbow handles should be preferred.

• Avoid the use of towels; Paper towels are preferred

• Pre-procedural mouthwash (povidone-iodine, chlorhexidine, chloride dioxide) for at least 15 seconds may be helpful in a transient reduction of viral load.

• Infection control guidelines with special considerations for aerosol or splatter generating procedures should be followed:

- High vacuum suction with a minimum suction capacity of 6.6 liters per minute.

- Use a face shield.

- Use a rubber dam wherever possible.

- Keep adequate fallow time in between two procedures.

- Clean and disinfect equipment and operatory surfaces with 1% sodium hypochlorite or 70% alcohol for appropriate contact times.

• The patient drape will be removed by the assistant, and the patient is asked to perform hand wash and guided out of the clinic towards reception and handed back his footwear and belongings.

• Remove soiled gown as soon as possible. The procedures and prescriptions are recorded only after doffing the PPE.

• Patient to perform hand hygiene and to be provided with review /follow up instructions

For the patient with COVID-19 symptoms/tested positive, it is advised that:

• The emergency procedures should be undertaken with level 3 PPE and standard COVID-19 protocol for surgeries

• The clinics which do not have the required infrastructure should refer such patients to higher centers for management.

3. Infection prevention control and waste management

3.1 Disinfection of Dental Clinic/ Dental facility

• After the patient leaves the treatment room, the Assistant will collect all hand instruments immediately, rinse them in running water to remove organic matter and as per standard sterilization protocol.

• All 3 in 1 syringe, water outlets, handpiece water pipelines, etc. should be flushed with the disinfectant solution for 30-40 seconds.

• Remove water containers and wash them thoroughly and disinfect with 1% sodium hypochlorite using clean cotton/ gauge piece and then fill with fresh 0.01% sodium hypochlorite solution and attach back to the dental chair.

• Then, disinfect the Dental Chair along with all the auxiliary parts within 3 feet of distance using 1% sodium hypochlorite and clean and sterilize the cotton/gauge piece using inner to outer surface approach and leave for drying. A new cotton/ gauge piece should be used for every surface. The areas include:

- Patient sitting area and armrests

- Dental chair extensions including water outlets, suction pipe, handpiece connector, 3 in 1 syringe, etc.

- Dental light and handle

- Hand washing area – slab and tap nozzle

- Clinic walls around the dental chair and switchboards

- Hand washing area – slab and tap nozzle

• Handpieces should be cleaned using a handpiece cleaning solution to remove debris, followed by packing in the autoclave pouches for autoclaving. Record to be maintained for the same.

• Delicate Electronic Equipment Should be wiped with alcohol-based rub/spirit (60- 90% alcohol) swab before each patient contact.

• Floors: 2 Step Cleaning Procedure (Detergent and freshly prepared 1% sodium hypochlorite with a contact time of 10 minutes. Mop the floor starting at the far corner of the room and work towards the door, two hourly or after a major splash.

• Rest of the surfaces: Freshly prepared 1% sodium hypochlorite (Contact Time: 10 minutes). Damp dusting should be done in straight lines that overlap one another. (Frequency: before starting daily work, after every procedure, and after finishing daily work).

3.2 Waste Management

• Treat blood, body fluids, secretions contaminants, and human tissues as clinical waste, in accordance with local regulations. Discard single-use items coming in contact with body fluids of COVID-19 patients with special caution.

Proper provision of covered bio-hazard bins for disposal should be made available.

Used PPEs, masks, etc. should necessarily be disposed of in accordance with the guidelines

issued by Central Pollution Control Board available at:

https://cpcb.nic.in/uploads/Projects/Bio-Medical-Waste/BMW-GUIDELINES-COVID_1.pdf)

4. Dental laboratory protocol

• Disinfect dental impressions, dental casts, prosthesis, appliances, etc. before handing over to laboratory/clinical staff and vice versa.

• Consider all the tissue specimen and body fluids samples collected for laboratory investigations as potentially infectious and recommendations for infection control in laboratories should be followed while handling them.

• Consider referral laboratories if unable to meet biosafety recommendations.

5. Dental imaging protocol

• Minimize intraoral imaging and prefer extraoral radiographs.

• Double barrier (impervious covers or sleeves) the dental X-ray film or RVG sensor.

• Disinfect the x-ray unit handle, tube, casing, computers, and monitors with bleach-free disinfectant twice daily.

6. Ventilation and air quality management in dental clinics

• Maintain air circulation with natural air through a frequent opening of windows and using an independent exhaust blower to extract the room air into the atmosphere.

• Avoid the use of a ceiling fan while performing procedures.

• Place a table fan behind the operator and let the air flow towards the patient. A strong exhaust fan is to be so located to create a unidirectional flow of air away from the patient.

• For air-conditioned facilities, the guidelines of CPWD shall be followed which mentions that the temperature setting of all air conditioning devices should be in the range of 24-30o C, relative humidity should be in the range of 40-70%, intake of fresh air should be as much as possible and cross ventilation should be adequate

• The window air condition system/ split AC should be frequently serviced, and filters cleaned.

• Use of indoor portable air cleaning system equipped with HEPA filter and UV light may be used.

7. Instructions to patients visiting Dental Clinics/ Hospitals

• Follow teleconsultation and visit the Dental clinic / Oral health facility only with prior appointment.

• Wear a facemask during transport and before entering the premises. Minimize or eliminate wearing a wristwatch, hand and body jewellery and carrying of additional accessories bags, etc.

• Minimize the number of people accompanying the patient.

• Use their own washrooms at home to avoid the need of using toilets at the dental facility.

• Have a mouth wash rinse with 10 ml of the 0.5% solution of PVP-I solution (standard aqueous PVP-I antiseptic solution-based mouthwash diluted 1:20 with water). Distribute throughout the oral cavity for 30 seconds and then gently gargle at the back of the throat for another 30 seconds before spitting out.

• To report if suffering from any symptoms suggestive of COVID-19 infection (fever, cough, cold, etc.).

• Maintain a physical distance of 6 feet while waiting for your turn for consultation.

• To be vaccinated as appropriate.

To read the full guidelines click on the following link