Indian Dental Association

Indian Dental Association

Public Safety Initiative

Powered by Indian Dental Association

PUBLIC SAFETY INITIATIVE

The Indian Dental Association (IDA) is the largest recognized body of dental professionals in India. Its vision is to attain optimal oral health for all in the country and improve overall health index of the people.

Public health safety in India has been greatly challenged due to COVID19. More organized infection prevention and control have become of prime importance to safeguard the interest of the patients as well as the dentists.

The Indian Dental Association (IDA) is highly concerned about the present health scenario created by the outbreak of COVID-19 and has been flooded with various queries and concerns on “public health and patient safety” related to dental treatment during this COVID19 Pandemic.

As a guardian of oral healthcare in India, IDA is advocating for safe dentistry for dentist, patient and community. Aa step in this direction, IDA is ready with “PUBLIC SAFETY INITIATIVE” – an online learning platform to empower its members with the required knowledge to deal with the clinic preparedness and standard protocols of patient management.

Guidelines for dental care provision during the COVID-19 pandemic are developed after considering the nature of COVID-19 pandemic, and grouping the patients according to condition and need, and considering the procedures according to risk and benefit.

All members are encouraged to study the online documents under COVID19 section of IDA website upon completion of which the members will receive a certification under the “Public Safety Initiative” along with safety and precaution posters, which can be displayed in the clinic to bring assurance in patients and public at large that their dental clinic are prepared to deliver care in an “safe “environment.

HEAD OFFICE BEARERS

  • Dr. President- Ravindar Singh
  • Dr. Imm. Past President- Janak Raj Sabharwal
  • Dr. Hon. Secretary General- Ashok D Dhoble
  • Dr. Hon. Joint Secretary- Sanjay Joshi
  • Dr. Hon. Assistant Secretary- Mukul Dabholkar
  • Dr. Treasurer- Deepak Muchhala
  • Dr. Editor - Journal- B. V. Ramana Reddy
  • Dr. Chairman CDE- Abhay P Kolte
  • Dr. Hon. Secretary CDE- Jatinder Singh Walia
  • Dr. Chairman CDH- Manish Verma
  • Dr. Hon. Secretary CDH- Sharif Firoz
  • Dr. Chairman-International Committee- (Capt.)R Bellie
  • Dr. Vice Chairman-International Committee- S. G. Damle
  • Dr. Chairman-ICCDE India Division- Dr.R K Bali
  • Dr. Secretary-ICCDE India Division- M C Mohan

CONTRIBUTORS LIST

  • Prof. O.P. Kharbanda - Dr. C G.Pandit National Chair ICMR, New Delhi
  • Dr. Deepak Muchhala, Treasurer, IDA
  • Dr. Sanjay Joshi, Hon. Jt. Secretary, IDA
  • Dr. Venkat Ramana Reddy, Hon. Editor, IDA
  • Dr. Suresh Kumar G.
  • Dr. Kumar Rajan
  • Dr. Eapen Thomas
  • Dr. Rajeev Chugh
  • Dr. Abhay Lamba
  • Dr. Yogesh Shah
  • Dr. Jayanto Mukherjee
  • Dr. Stuti Muchhala

DISCLAIMER

  • The advisory protocol and observations compliled in this document are based on evidence available at present
  • GOI and State Govt guidelines are being constantly updated and individuals need to keep themselves abreast with the latest developments and follow the same
  • We have made an attempt to compile the existing guidelines and protocols with points relevant to the dental practice based on current available evidence
  • This document can be freely distributed amongst dental fraternity for educational and information purpose only.
  • The information gathered from various sources is appropriately cited. IDA like to acknowledge the contribution and all sources of information such as MoHF-GOI, ICMR, DCI, WHO, CDC, OSHA, American Dental Association, Australia Dental Association etc. All efforts have been made to cite and acknowledge, however missed if any may please be considered as dually acknowledged.
  • This protocol shall get updated from time to time based on new developments and rules .
  • IDA takes no responsibility of any harm caused with the suggested protocol

Table of Contents

INTRODUCTION TO COVID-19

The new variant of the corona virus which caused SARS, but now in a mutated highly contagious version is called NOVEL CORONA VIRUS 2019, and the disease is called COVID -19.

  • Healthcare workers (HCW) are frontline warriors who have been guided by multiple guidelines for prevention and treatment
  • Those in Corporate and Government Hospitals have the advantage of colleagues with multispeciality skills as well as administrative and resource management personnel to assist.
  • Those having individual clinics have the advantage of probably yet not having to treat these patients directly but are no way immune to being exposed to these patients especially while performing their duties for the regular other patients who may / may not be covid suspect. Their disadvantage is increased by the fact that a single doctor has to perform multiple roles of clinician, administrator, resource management, etc.
  • An attempt is hence made to derive the best advice out of the existing guidelines from WHO, MoH&F (GOI) and other available literature.
  • This may help smaller set ups to provide care to at least the non COVID patients thereby reducing the load on the already stretched government infrastructure and healthcare system.

Mode of transmission

  • Person to person by respiratory droplets.
  • Face to face communication
  • Direct contact and fomites.
  • Directly or indirectly through saliva.
  • Contact with contaminated instruments and or environmental surfaces.
  • Poor respiratory hygiene and etiquettes
  • Inadequate sterilization protocols

What can we do as Dental Professionals

  • Access reliable information
  • Avoid panic and rumors
  • Take the recommendations from the local, state and government public health officials
  • Heed the call to temporarily suspend all non-urgent dental treatment until this crisis is over.

Why do we need to stop elective procedures

  • At this stage we cannot reliably identify who are asymptomatically infected
  • We need to limit our contact with people outside our immediate circle for some time, and make sure as health professionals that people do not leave their houses for non-essential purposes.
  • Many dental procedures produce aerosols, known to increase exposure, if the patient is infected.
  • Supplies of PPE’s for treating sick people in hospitals is low right now, if we use this for non-urgent treatment, we contribute to the risk of the front line health workers being left unprotected.

Dental Emergencies

Potentially life threatening and require urgent and immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection which includes the following:-

  • Uncontrolled bleeding
  • Severe uncontrolled pain
  • Cellulitis or a diffuse soft tissue bacterial swelling
  • Infection with intra oral or extra oral swelling that potentially compromises the airway.
  • Trauma involving the face or the facial bones.
  • Severe trismus
  • Persistent non healing ulcers

Urgent Dental Care

  • Severe dental pain from pulpal inflammation
  • Peri coronitis or third molar pain
  • Dry socket
  • Abscess or localised pain and swelling
  • Tooth fracture
  • Dental trauma with avulsion/ luxation
  • Final crown and bridge cementation if the temporary has been lost or broken
  • Restorations causing severe pain
  • Suture removal
  • Orthodontic wire or appliances piercing or impinging on the oral mucosa and causing ulcers
  • Biopsy of abnormal tissue.

Who should avoid practice in dental offices

  • Dentists and paramedical staff above the age of 65 years or those with the following underlying conditions
    • Diabetes Mellitus
    • Chronic Liver Disease
    • Heart and Kidney Disease
    • Chronic lung conditions like Asthma, COPD, etc.
    • Cancer
    • Pregnant women
    • Seropositive status cases.
  • Any Dentist or the Allied staff with a travel history in the last 28 days
  • Anyone suffering from cough/ cold/ fever

Patients that should be avoided for treatment

  • All symptomatic individuals who have undertaken international travel in the last 28 days
  • All hospitalized cases in the last 28 days
  • All individuals who come from a hotspot areas must be tested first
  • All healthcare workers in hospitals who are symptomatic
  • Patients with active fever, cough, cold, malaise, diarrhoea etc
  • History of direct contact with COVID +VE cases.

Testing strategies for Dentist and their staff

  • According to the CDC guidelines, not everyone needs to be tested for COVID-19, which includes dentists. It also suggests that the decision on who is to be tested is at the discretion of local and state health departments and individual clinics. ICMR guidelines also suggest in their revised testing strategy, dated 20/3/2020, that the following people need to be tested:

    • All symptomatic individuals.
    • All symptomatic contacts of laboratory confirmed cases.
    • All symptomatic health care workers.
    • All hospitalized patients with Severe Acute Respiratory Illness (fever and cough and/or shortness of breath)
    • Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.

    If the dentist and the clinical staff do not fall in these categories, getting tested for COVID-19 is not warranted. However, as suggested by CDC, it is at the discretion of the individual clinics. Also, since majority of clinical staff in the Indian context do not have health professional background and carry the risk of exposure from neighborhoods, it would be a wise idea to follow ‘Tele-screening and Triaging’ for clinical staff by conducting initial telephone screening using the screening questionnaire suggested for patients, before they resume their duties in the clinics.

    For patients, initial screening for symptoms should be done as a part of care provision, which is not only a risk reduction strategy but also boosts the confidence of the patients in availing care. If the clinician chooses to get the patients tested for COVID-19, tests may be sent to the private labs to avoid the burden on the state-run hospitals and labs. If the management of the clinic chooses to get the staff and consultants tested as a risk reduction strategy, it is advisable that the expenses are arranged for by the management.

  • Initial testing will help to boost practices as it will give a sense of confidence to the patients
  • Staff and all the associate Doctors, Consultants and assistants also should be tested by the owner of the practice.
  • Tests may be done with the private labs to avoid the burden on the state-run hospitals and labs
  • In event of active symptoms and/or suspected exposure to COVID +ve, retest as per the ICMR Guidelines.

CLINICAL MANAGEMENT DURING AND AFTER COVID 19 PANDEMIC

  • Before Dental Procedure

    1. Ensure safety of staff by getting them vaccinated, flu shots, and also arrange PPE for them.
    2. OFFICE SET UP – Remove all the clutter and things from the practice that cannot be disinfected easily, like magazines, reading materials and other objects.
    3. Ensure that there is sufficient quantity of PPE or disinfectants necessary for hygiene care.
    4. Print and place signage in dental office for instructing patients on standard recommendations for respiratory hygiene/cough etiquette and social distancing
    5. Schedule appointments with at least 30 mins between patients to minimise possible contact with other patients in the waiting room and disinfect the entire working area
    6. Request patients to come alone and accompanied only if the patient is a child/ compromised/ elderly patients who cannot come alone, however the accompanied person cannot wait in the operatory while the procedure is going on.
    7. History of travel or any exposure or symptoms related to COVID-19 must be discussed on phone or text before the patients comes into the clinic
    8. Instruct patients to brush their teeth just before they arrive for their appointments
    9. Instruct patients to update their Arogya Setu App at home prior to arrival for appointment
    OPD
    • Call only those whom you have screened and spoken on phone
    • Appointments to be scheduled and spaced to avoid crowding the waiting area
    • For walk in patients - Ask them to call first on your phone from outside the clinic and asses them as you would have in telephonic assessment before letting them in
    • For an emergency visitor - Arrange your staff to triage them at the gate with some physical barrier like glass or plastic if possible. The staff should wear a good quality mask, gloves and maintain a distance of at least 2 meters at the entrance.
    • Allow only one relative strictly inside the premises and avoid that too if feasible
    • Ensure all walking inside the clinic are wearing surgical mask or provide them with one. Ensure cough and sneeze etiquettes are followed
    • Prepare your waiting area in such a way where spacing for different patients can be maintained easily.
    • Remove all unnecessary items in the room like magazines, books etc
    • Ensure hand sanitization of all those coming in.
    • Avoid all unnecessary visitors including Medical Reps
    • “Keep clinic well ventilated at all times”
    • Ensure more frequent surface cleaning of waiting areas with sodium hypochlorite solution especially surfaces which are more often touched such as reception table top, door handles, etc.
  • Patient Arrival

    1. Ask patients to wait outside the clinic if possible or in their own vehicles and we will contact them when to come in
    2. Online registration form
    3. All patients if sitting in the waiting room patient must be wearing a mask and ask them to use a sanitizer on arrival
    4. Disposable shoe covers must be placed in the waiting room and all patients must remove shoes and wear them before entering the operatory
    5. Supply of tissues and no touch receptacles for disposal in the waiting room
    6. Insist on the patient to maintain the appointment time strictly
    7. No handshakes with patients
    8. Recor detailed history in waiting area
    9. Consent form for general and COVID19 to be taken in waiting area
    10. Front Desk /Staff should be separated from waiting room using transparent glass or barrier.
  • During The Dental Procedure

    • Hand Hygiene

      1. As part of essential quality requirements, training in hand hygiene should be part of staff induction and be provided to all relevant staff within dental practices periodically throughout the year.
      2. Hand hygiene should be practiced at the following key stages in the decontamination process so as to minimise the risk of contamination:

        • before and after each treatment session;
        • before and after the removal of PPE;
        • following the washing of dental instruments; need to use mechanical or ultrasonic washer/ disinfection.
        • before contact with instruments that have been steam-sterilized (whether or not these instruments are wrapped);
        • after cleaning or maintaining decontamination devices used on dental instruments; at the completion of decontamination work.
      3. Mild soap should be used when washing hands.
        • Bar soap should not be used.
        • Apply the liquid soap to wet hands to reduce the risk of irritation, and perform hand-washing under running water. Ordinarily, the hand-wash rubbing action should be maintained for about 20 seconds. After the exercise, the hands should be visibly clean. Where this is not the case, the hand hygiene procedure should be repeated.
        • Drying of hands: Effective drying of hands after washing is important because wet surfaces transfer microorganisms more easily than when they are dry, and inadequately dried hands are prone to skin damage.
        • To prevent recontamination of washed hands, disposable paper towels should be used.
        • Skin care: Hand cream, preferably water-based, should be used to avoid chapped or cracking skin. Communal jars of hand cream are not desirable as the contents may become contaminated and subsequently become an infection risk. Ideally, wall mounted hand-cream dispensers with disposable cartridges should be used. Any staff who develops eczema, dermatitis or any other skin condition should seek advice from general practitioner (GP) as soon as possible.
        • Fingernails should be kept clean, short and smooth. When viewed from the palm side, no nail should be visible beyond the fingertip. Staff undertaking dental procedures should not wear nail varnish and false fingernails.
        • Rings, bracelets and wristwatches should not be worn by staff undertaking clinical procedures. Staff should remove rings, bracelets and wristwatches prior to carrying out hand hygiene. A wedding ring is permitted but the skin beneath it should be washed and dried thoroughly, and it is preferable to remove the ring prior to carrying out dental procedures.
  • The Patient Treatment Area

    • Should be cleansed after every session using disposable cloth or clean microfibre materials even if the area appears uncontaminated.
    • Areas and items of equipment local to the dental chair that need to be cleansed between each patient with 1% sodium hypochloride or 70% alcohol these include: local work surfaces; dental chairs; curing lamps; inspection lights and handles; hand controls including replacement of covers; trolleys/delivery units; spittoons; aspirators; X-ray units.
    • Areas and items of equipment that need to be cleansed after each session include: taps; drainage points; splashbacks; sinks. In addition, cupboard doors, other exposed surfaces (such as dental inspection light fittings) and floor surfaces, and bathrooms, including those distant from the dental chair, should be cleaned daily with wet mopping containing a disinfectant . Spittoons and aspirating units need to be disinfected thoroughly at the end of a session according to manufacturers’ instructions.
    • Items of furniture that need to be cleansed at weekly intervals include: window blinds; accessible ventilation fittings; other accessible surfaces such as shelving, radiators and shelves in cupboards. Disposable single-use covers are available for many of the devices mentioned above, including inspection light handles and headrests.
    • For infection control reasons, in clinical areas, covers should be provided over computer keyboards
    • Intra-oral radiology film and devices used in digital radiology imaging are potential sources of crossinfection. Accordingly, where reusable devices are used, they should be decontaminated in accordance with the manufacturer’s instructions. For intra-oral holders, this will require the use of steam sterilization following washing and disinfection.
    • For blood spillages, care should be taken to observe a protocol that ensures protection against infection. The use of hypochlorite at 1000 ppm available chlorine is recommended. Hypochlorite should be made up either freshly using hypochlorite-generating tablets or at least weekly in clean containers. Contact times should be reasonably prolonged (not less than five minutes). A higher available chlorine concentration of 10,000 ppm is useful, particularly for blood contamination. The process should be initiated quickly and care should be taken to avoid corrosive damage to metal fittings etc. The use of alcohol within the same decontamination process is not advised. The use of these is encouraged but should not be taken as a substitute for regular cleaning. Covers should be removed and surfaces should be cleaned after each patient contact.
    • Keep the Airconditioning vent facing upwards, use of airpurifiers with HEPA filters is recommended
    • If the dental chairs are not six feet apart, then 2 patients should not be treated at the same time
  • How To Use / Remove ( PPE)

    Personal Protective equipment (PPE)

    The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be inadequate also. Surging global demand-driven not only by the number of COVID-19 cases but also by misinformation, panic buying, and stockpiling − will result in further shortages of PPE globally. The capacity to expand PPE production is limited, and the current demand for respirators and masks cannot be met, especially if widespread inappropriate use of PPE continues.48

    If basic PPE, including surgical facemasks are not available, do not proceed with any dental procedure, regardless of emergency/urgent patients.

    • What to wear and when to wear

      As dental treatments fall under high-risk category for airborne and droplet infections such as COVID-19 strict measures have to be followed to ensure operator and patient safety

      The use of personal protective equipment, including masks, gloves, gowns, and goggles or face shields, is recommended to protect skin and mucosa from (potentially) infected blood or secretion. As respiratory droplets are the main route of SARS-CoV-2 transmission, particulate respirators (e.g., N-95 masks authenticated by the National Institute for Occupational Safety and Health or FFP2-standard masks set by the European Union) are recommended for the routine dental practice.

      Recommended personal PPE during the outbreak of COVID-19 outbreak, according to the setting, personnel, and type of activity.

      Prerequisites

      • Separate places or areas for wearing and discarding PPE (closed rooms).
      • Thoroughly disinfected scrub area with sink and long handle water outlet
      • Contactless bins for disposing PPEs
      • PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting).
      • Display charts or guidelines proposed by CDC or WHO for wearing and removing PPEs in their designated areas.

        https://www.who.int/csr/resources/publications/PPE_EN_A1sl.pdf ,

        https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

      • Receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE.
      • Demonstrate competency in performing appropriate infection control practices and procedures.
      • Properly train your staff to adhere to the above-said principles

      • Setting Target personnel or patients Activity Type of PPE or procedure
        Health care facilities - Inpatient facilities
        Patient room Health care workers Providing direct care to COVID-19 patients Medical mask
        Gown
        Gloves
        Eye protection (goggles or face shield)
        Aerosol-generating procedures performed on COVID-19 patients Respirator N95 or FFP2 standard, or equivalent. Gown
        Gloves
        Eye protection
        Apron
        Cleaners Entering the room of COVID-19 Patients Medical mask
        Gown
        Heavy-duty gloves
        Eye protection (if risk of splash from organic material or chemicals)
        Boots or closed work shoes
        Visitors Entering the room of a COVID- 19 patient Medical mask
        Gown
        Gloves
        Other areas of patient transit (e.g. wards, corridors). All staff, including health care workers Any activity that does not involve contact with COVID-19 patients No PPE required
        Triage Health care workers Preliminary screening not involving direct contact Maintain spatial distance of at least 1 metre. No PPE required
        Patients with respiratory symptoms Any Maintain spatial distance of at least 1 metre. Provide medical mask if tolerated by patient.
        Patients without respiratory symptoms Any No PPE required
        Laboratory Lab technician Manipulation of respiratory Samples Medical mask
        Gown
        Gloves
        Eye protection (if risk of splash)
        Administrative areas All staff, including health care workers. Administrative tasks that do not involve contact with COVID-19 patients. No PPE required
        Health care facilities - Outpatient facilities
        Consultation room Health care workers Physical examination of patient with respiratory symptoms Medical mask
        Gown
        Gloves
        Eye protection
        Health care workers Physical examination of patients without respiratory symptoms PPE according to standard precautions and risk assessment.
        Patients with respiratory symptoms Any Provide medical mask if tolerated
        Patients with respiratory symptoms Any No PPE required
        Cleaners After and between consultations with patients with respiratory symptoms. Medical mask
        Gown
        Heavy-duty
        gloves
        Eye protection (if the risk of splash from organic material or chemicals).
        Boots or closed work shoes
        Waiting room Patients with respiratory symptoms Any Provide medical mask if tolerated. Immediately move the patient to an isolation room or separate area away from others; if this is not feasible, ensure the spatial distance of at least 1 meter from other patients.
        Patients without respiratory symptoms Any No PPE required
        Administrative areas All staff, including health care workers Administrative tasks No PPE required
        Triage Health care workers Preliminary screening not involving direct contact Maintain a spatial distance of at least 1 meter. No PPE required
        Patients with respiratory symptoms Any Maintain a spatial distance of at least 1 meter. Provide medical mask if tolerated by the patient.
        Patients without respiratory symptoms Any No PPE required
      • Checklist for isolation room or area trolley or table

        The following items should be kept on the trolley at all times so that PPE is always available for healthcare workers.

        S.No Equipment Stock Present
        1 Eye protection (visor or goggles)
        2 Face shield (provides eye, nose and mouth protection)
        3 Gloves
        • reusable vinyl or rubber gloves for environmental cleaning
        • nitrite single-use gloves for clinical care
        4 Hair covers (optional)
        5 Particulate respirators (N95, FFP2, or equivalent)
        6 Medical (surgical or procedure) masks
        7 Gowns and aprons
        • single-use long-sleeved fluid-resistant or reusable non-fluid- resistant gowns
        • plastic aprons (for use over non-fluid-resistant gowns if splashing is anticipated and if fluid-resistant gowns are not available)
        8 Alcohol-based hand rub
        9 Plain soap (liquid if possible, for washing hands in clean water)
        10 Clean single-use towels (e.g. paper towels)
        11 Sharps containers
        12 Appropriate detergent for environmental cleaning and disinfectant for disinfection of surfaces, instruments or equipment
        13 Large plastic bags
        14 Appropriate clinical waste bags
        15 Linen bags
        16 Collection container for used equipment
  • PATIENT PRECAUTION BEFORE STARTING DENTAL TREATMENT ON THE CHAIR

    • Ask patient to rinse the mouth with 1.5% hydrogen peroxide or 0.2% povidine iodine mouthwash for 1 minute
    • Reduce aerosol production by using rubber dam for all procedures.
    • 4 handed dentistry with high vaccum suction
    • Anti-retraction hand pieces may provide additional protection against cross contamination
    • Autoclave handpiece for every patient (recommended to keep 5-6 spare handpieces autoclaved)
  • AFTER DENTAL CARE

    • In between patients – cleaning and sanitizing surfaces and changing PPE as given above
    • Postoperative instructions for patients- it is recommended that NSAIDS in combination with acetaminophen can still be used for management of pulpal and periapical related dental pain and intraoral swelling

      https://www.sciencealert.com/who-recommendsto-avoid-taking-ibuprofenfor-covid-19-symptoms
    • Dental health care providers (DHCP’s) should change from scrubs to personal clothing before returning home. Upon arriving home, DHCP’s should take off shoes remove and wash clothing (separately from other household residents) and immediately shower

INFORMATION OF THE LEVEL OF THE PANDEMIC AND THE RECOMMENDATION OF THE LINE OF TREATMENT TO BE CARRIED OUT

  1. Proportionate, pre-planned response to the possible escalation of COVID-19 based on the evolving community context
  2. Staged restriction of dental services to reduce transmission risk for COVID-19
  3. Avoidance of likely burden on medical primary care and emergency services should address to urgent dental care

In all restrictions, urgent dental treatment for people who have been identified as either at moderate to high risk of COVID-19 or confirmed as COVID-19 case should be provided under transmission based on precautions using appropriate PPE

Services that can be performed Restricted services / defer treatment
No Restrictions All dental services No restrictions apply
Level 1 Restrictions All dental treatment using standard precautions for people who do not meet epidemiological or clinical risk factor for COVID-19 infection transmission

Defer non-urgent treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk.

Urgent dental treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk or confirmed as COVID-19 case

Level 2 Restriction

Provision for dental treatments that are unlikely to generate aerosols or where aerosols generated have the presence of minimal saliva / blood due to use of rubber dam. This includes

  • Examinations
  • Simple non-invasive fillings without use of high-speed handpiece
  • Restoration procedures using highspeed handpiece only provided with the use of rubber dam
  • Non-surgical extractions
  • Hand-scaling (no use of ultrasonic scalers)
  • Medical Management of soft tissue presentations (such as ulcers)
  • Temporomandibular dysfunction management
  • Denture procedures
  • Preventive procedures such as the application of topical remineralising agent e.g. fluoride
  • Orthodontic treatment

Defer all treatment that likely to be generating aerosols which may include the use of

  • High speed handpiece without the use of rubber dam
  • Ultrasonic scalers
  • Surgical handpieces

All surgical extractions should be referred to specialist oral surgeon who will undertake these procedures using transmission based precautions.

Elective implant treatment should be delayed.

Urgent dental treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk or confirmed as a COVID-19 case,

Level 3 Restriction

Only dental treatments that do not generate aerosols, or where treatments generating aerosols is limited to:

  • Management of dental patient with acute dental pain, e.g., endodontic treatment under rubber dam or extractions
  • Management of significantly damaged upper front teeth (e.g. due to trauma, with restorative treatment provided under rubber dam)
  • Soft tissue pathology, e.g., ulcers
  • Management of complex medically com promised patients with dental concerns which may compromise their systemic disease
  • Management of those at higher risk of rapid progression of dental disease due to socioeconomic or cultural factors
  • Management of patients referred by medical practitioner for medically necessary dental care

Defer all routine recall examinations and dental treatments for patients not fitting the risk categories identified in the left who present with the following concerns

  • Extraction of asymptomatic teeth without swelling
  • Broken or chipped tooth/teeth
  • Bleeding or sore gum, halitosis
  • Loose teeth without aspiration risk
  • Denture concerns
  • Crown and bridge
  • Scales & clean
  • Clicking/grating in jaw joint

Urgent dental treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk or confirmed as a COVID-19 case

Level 4 Restriction

Only the following dental treatment to be managed:

  • Swelling of the face, neck or mouth
  • Dental trauma causing change in the position of teeth, soft tissue damage and/or significant pain
  • Significant bleeding
  • Difficulty opening the jaw and/or swallowing
  • Referral from a specialist medical practitioner for assessment or management of a patient receiving urgent medical care for medically necessary dental care
  • Dental pain causing loss of sleep
  • Ulcers persisting for 3 + weeks

Defer all dental treatments for patients not fitting the risk categories identified on the left.

Urgent dental treatment for people who DO meet epidemiological or clinical symptom criteria for COVID-19 risk or confirmed as a COVID-19 case,

Level 5 Restriction No routine dental treatment provided. All patients with acute dental concerns to be directed to emergency care centres. Any dental treatment without expressed permission from the public health authorities.

PSYCHOLOGICAL MANAGEMENT OF DENTAL CLINIC STAFF:

Keeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfill their roles. Be sure to keep in mind that the current situation will not go away overnight and you should focus on longer-term occupational capacity rather than repeated short-term crisis responses. Ensure that good quality communication and accurate information updates are provided to all staff. Rotate workers and partner inexperienced workers with their more experienced colleagues. The buddy system helps to provide support, monitor stress and reinforce safety procedures. Support all staff in taking care of themselves at this time. Encourage them to use helpful coping strategies such as:

  • sufficient rest and respite during work or between shifts
  • eating sufficiently and choosing healthy foods

Encourage staff to avoid using unhelpful coping strategies such as:

  • use of tobacco, alcohol or other drugs.

The COVID-19 outbreak is a unique and unprecedented scenario for many workers. Prepare them mentally as this is not a sprint; it’s a marathon. Provide clinical staff with refresher training in infection prevention and control.

DECONTAMINATION AND WASTE MANAGEMENT

  • Follow all OSHA and the local municipal guidelines for biohazard waste.
  • Burn sharps immediately. Store in closed container.
  • Clean/ SPRAY/ SWAB DOWN EQUIPMENT WITH APPROVED DISINFECTANTS.
  • Fogging at the end of the day.
  • Ensure safe waste management.

Treat waste contaminated with blood, body fluids, secretions and excretions as clinical waste, in accordance with local regulations. Human tissues and laboratory waste that is directly associated with specimen processing should also be treated as clinical waste.

Discard single use items properly

GUIDELINES FOR DIFFERENT TREATMENTS IN DENTISTRY

  • Treatment to be given according to the level of the pandemic.
  • Initially emergency treatment only
  • Intra oral sensors to have double barriers. Avoid placing sensors too deep to induce gag/ cough reflex.
  • Preferably take OPG/ CBCT.
  • For routine treatment Gloves, triple layer mask, foot covers , face shields, for the Dentist as well as the chair side assistant.
  • PPE’S for aerosol generating and surgical work.
  • Wherever possible aviod using air rotors and instead use micro motors with external irrigation to minimise aerosol.
  • ART preferred
  • Endo treatment under rubber dam and single use files.
  • Fillings to be done under rubber dam

GUIDELINES FOR CONSULTING ROOM AND WAITING ROOM

  • All clutter to be removed from the consulting + waiting room.
  • Anything which cannot be disinfected easily should be removed.
  • Strict appointment scheduling
  • No crowding in the waiting room.
  • Patient should be encouraged to come alone. If they are accompanied then the accompanying persons history, address, contact number need to taken.
  • Mask, foot covers, and hand sanitisers for the patient as well as the accompanying person.
  • The front office manager/ secretary in mask and gloves.
  • Sanitise pen / discard used for consent
  • Take history orally and record it and then store it to be later entered into your respective files.
  • Respiratory/ coughing etiquettes , with disposable tissues and foot controlled waste disposal unit in the waiting room also.
  • Washroom etiquettes to be followed rigidly. All contact areas to be sanitised, and the washroom to be fumigated.
  • Visual alerts posters issued by CDC can be accessed here:

    https://www.cdc.gov/flu/pdf/protect/cdc_cough.pdf

    https://www.cdc.gov/coronavirus/2019-ncov/downloads/stop-the-spread-of-germs.pdf

    https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html

PAYMENT GUIDELINES.

  • Digital maximum
  • Non-contact methods, Rupay, UPI, NEFT, etc.
  • Keep currency handling to bare minimum

TELECONSULTING

Telehealth refers to a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery. Teledentistry refers to the use of telehealth systems and methodologies in dentistry. Teledentistry can include patient care delivery using, but not limited to, the following modalities:

  • Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology.
  • Store-and-forward (asynchronous): Transmission of recorded health information (for example, radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a practitioner, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction
  • Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA)

During this pandemic our goal as dental care providers is to use telecommunication technology to triage patients and conduct problem-focused evaluations to limit office visits to urgent or emergency care. This can facilitate providing advice and performing triage. It can also facilitate planning for in-person interactions should they become necessary.

Applications to use:
  • Take control of appointments in your own hands
  • Talk to all patients on phone prior to calling them to the clinic
  • Depending on symptoms ask for some basic investigations done before the patient is called to the clinic. It will serve to come to an early diagnosis and also prevent further traffic for showing reports.
  • Preferably use OTC drugs.
  • Make all attempts to screen these patients for symptoms / signs of COVID infection and refer appropriately if suspected.
  • Audio record the conversation with prior consent of the patient.
  • Record all personal details of the patients as spoken by the patient
  • If not audio recorded than make an entry in your diary stating time of conversation, name, age, contact details plus clinical details and advice given like you would do if patient was seen by you physically.

Contacts…

References:

  1. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine [published online ahead of print, 2020 Mar 12]. J Dent Res. 2020;22034520914246. doi:10.1177/0022034520914246
  2. To, K. K.-W. et al. Consistent detection of 2019 novel coronavirus in saliva. Clin. Infect. Diseases10.1093/cid/ ciaa149 (2020).
  3. Centers for Disease Control and Prevention. Coronavirus Disease 2019. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19). Available from:

    https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

    [accessed on 9th April, 2020]
  4. Government of India. 2020. March 17. Guidelines on clinical management of COVID-19. Available from:

    https://www.mohfw.gov.in/pdf/GuidelinesonClinicalManagementofCOVID1912020.pdf

    [accessed on 6th April, 2020]
  5. Centers for disease control and prevention. 2020. ‘Coronavirus disease 2019 (COVID-19)’ (Testing for COVID-19). Available from:

    https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html

    [accessed on 6th April, 2020]
  6. Indian Council of Medical Research. 2020. March 20. ‘Revised Strategy of COVID19 testing in India (Version 3, dated 20/03/2020)’. Available from:

    https://icmr.nic.in/sites/default/files/upload_documents/2020-03-20_covid19_test_v3.pdf

    [accessed on 6th April, 2020]
  7. ADA Interim Guidance for Management of Emergency and ....

    https://www.ada.org/~/media/CPS/Files/COVID/ADA_Int_Guidance_Mgmt_Emerg-Urg_Dental_COVID19.pdf

  8. World Health Organization. Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19 March 2020. World Health Organization; 2020.
  9. World Health Organization, Pandemic and Epidemic Diseases, World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. [Internet]. 2014 [cited 2020 Apr 8]. Available from:

    http://apps.who.int/iris/bitstream/10665/112656/1/9789241507134_eng.pdf?ua=1

  10. Australian Dental Council. ADA Dental Council Restrictions. Available from:

    https://www.ada.org.au/Campaign/COVID-19/Managing-COVID-19/Practice-Resources/Dental-restriction-Levels/ADA-dental-restriction-levels-inCOVID-19-Publishe.aspx

    [accessed on 9th April, 2020]
  11. World Health Organization. 2020. Mental health and psychosocial considerations during the COVID-19 outbreak. Available from:

    https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf

    [accessed on 9th April, 2020].
  12. World Health Organization. Coronavirus disease (Covid-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. Available from: https://www.who.int/ docs/default-source/coronaviruse/who-rights-roles-respon-hw-covid-19.pdf?sfvrsn=bcabd401_0 [accessed on 9th April, 2020].
  13. American Dental Association. Coding and billing interim guidance. Available from:

    https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf

ANNEXURE II - Rational Use of PPE Kit - Additional Guidelines

Ministry of Health and Family Welfare Directorate General of Health Services [ Emergency Medical Relief ]

Novel Coronavirus Disease 2019 (COVID-19): Additional guidelines on rational use of Personal Protective Equipment (setting approach for Health functionaries working in non-COVID areas)

  1. About this guideline

    This guideline is for health care workers and others working in Non COVID hospitals and NonCOVID treatment areas of a hospital which has a COVID block. These guidelines are in continuation of guidelines issued previously on ‘Rational use of Personal Protective Equipment’

    ( https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf ).

    This guideline uses “settings” approach to guide on the type of personal protective equipment to be used in different settings.
  2. Rational use of PPE for Non COVID hospitals and Non-COVID treatment areas of a hospital which has a COVID block
    The PPEs are to be used based on the risk profile of the health care worker. The document describes the PPEs to be used in different settings.

2.1. Out Patient Department

S.No Setting Activity Risk Recommended PPE Remarks
1 Help desk/ Registration counter Provide information to patients Mild risk
  • Triple layer medical mask
  • Latex examination gloves
Physical distancing to be followed at all times
2 Doctors chamber Clinical management Mild risk
  • Triple layer medical mask
  • Latex examination gloves
"No aerosol generating procedures should be allowed."
3 Chamber of Dental/ ENT doctors/ Ophthalmology doctors Clinical management Moderate risk
  • N-95 mask
  • Goggles
  • Latex examination gloves
+ face shield
Aerosol generating procedures anticipated.



Face shield, when a splash of body fluid is expected
4 Pre- anesthetic check-up clinic Pre-anesthetic check-up Moderate risk
  • N-95 mask
  • Goggles*
  • Latex examination gloves
* Only recommended when close examination of oral cavity/dentures is to be done
5 Pharmacy counter Distribution of drugs Mild risk
  • Triple layer medical mask
  • Latex examination gloves"
Frequent use of hand sanitizer is advised over gloves.
6 Sanitary staff "Cleaning frequently touched surfaces/ Floor" Mild risk
  • Triple layer medical mask
  • Latex examination gloves"

#All hospitals should identify a separate triage and holding area for patients with Influenza like illness so that suspect COVID cases are triaged and managed away from the main outpatient department.

2.2. In-patient Department (Non-COVID Hospital &Non-COVID treatment areas of a hospital which has a COVID block)

S.No Setting Activity Risk Recommended PPE Remarks
1 Ward/ individual rooms Clinical management Mild risk
  • Triple layer medical mask
  • Latex examination gloves"
Patients stable. No aerosol generating activity
2 ICU/ Critical care Critical care management Moderate risk
  • N-95 mask
  • Goggles
  • Nitrile examination gloves
+ face shield
Aerosol generating activities performed.



Face shield, when a splash of body fluid is expected"
3 "Ward/ICU /critical care" Dead body packing Low Risk
  • Triple layer medical mask
  • Latex examination gloves"
4 Ward/ICU/ #Critical care (Non-COVID) Dead body transport to mortuary Low Risk
  • Triple layer medical mask
  • Latex examination gloves"
5 Labor room Intra-partum care Moderate Risk
  • Triple Layer medical mask
  • Face shield
  • Sterile latex gloves
N-95 mask*

Patient to be masked in the Labor room

*If the pregnant woman is a resident of containment zone
6 Operation Theater Performing surgery, administering general anaesthesia Moderate Risk
  • Triple Layer medical mask
  • Face shield
  • Sterile latex gloves
+ Goggles

Already OT staff shall be wearing

For personnel involved in aerosol generating procedures
7 Sanitation Cleaning frequently touched surfaces/ floor/ changing linen Low Risk
  • Triple Layer medical mask
  • Latex examination gloves

2.3. Emergency Department (Non-COVID)

S.No Setting Activity Risk Recommended PPE Remarks
1 Emergency Attending emergency cases Mild risk
  • Triple Layer medical mask
  • Latex examination gloves"
No aerosol generating procedures are allowed
2 Attending to severely ill patients while performing aerosol generating procedure High risk Full complement of PPE (N-95 mask, coverall, goggle, Nitrile examination gloves, shoe cover)"

2.4 Other Supportive/ Ancillary Services

S.No Setting Activity Risk Recommended PPE Remarks
1 Routine Laboratory "Sample collection and transportation and testing of routine (non- respiratory) samples" Mild risk
  • Triple Layer medical mask
  • Latex examination gloves
Respiratory samples Moderate risk
  • N-95 mask
  • Latex examination gloves
2 Radio-diagnosis, Blood bank, etc. Imaging services, blood bank services etc Mild risk
  • Triple Layer medical mask
  • Latex examination gloves
3 CSSD/Laundry Handling linen Mild risk
  • Triple Layer medical mask
  • Latex examination gloves
4 Other supportive services incl. Kitchen Administrative Financial Engineering** and dietary** services,etc. Low risk Face cove ** Engineering and dietary service personnel visiting treatment areas will wear personal protective gears appropriate to that area

2.5. Pre-hospital (Ambulance) Services

S.No Setting Activity Risk Recommended PPE Remarks
1 Ambulance Transfer to designated hospital Transporting patients not on any assisted ventilation Low risk
  • Triple Layer medical mask
  • Latex examination gloves
Management of SARI patient High risk Full complement of PPE (N-95 mask, coverall, goggle, latex examination gloves, shoe cover) While performing aerosol generating procedure
2 Driving the ambulance Low risk
  • Triple Layer medical mask
  • Latex examination gloves
Driver helps in shifting patients to the emergency

POINTS TO REMEMBER WHILE USING PPE

  1. Standard precaution to be followed at all times
  2. PPEs are not alternative to basic preventive public health measures such ashand hygiene, respiratory etiquettes which must be followed at all times.
  3. Always follow the laid down protocol for disposing off PPEs as detailed in infection prevention and control guideline available on website of MoHFW.

In addition, patients and their attendants to be encouraged to put on face cover.

In case a COVID-19 patient is detected in such Non-COVID Health facility, the MoHFW guidelines for the same has to be followed

(Available at:

https://www.mohfw.gov.in/pdf/GuidelinestobefollowedondetectionofsuspectorconfirmedCOVID19case.pdf)