COVID-19: Review of the Best Recommendation Guidelines for a Secure Dental Practice

Angélica Braga de Oliveira¹, Giovanna Lopes Lanza² & Jôice Dias Corrêa^3*

¹DDS, Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais. Av. Dom José Gaspar, 500. Belo Horizonte, Minas Gerais, Brazil
²Grad Student, Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais. Av. Dom José Gaspar, 500. Belo Horizonte, Minas Gerais, Brazil
³PhD, Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais. Av. Dom José Gaspar, 500. Belo Horizonte, Minas Gerais, Brazil

*Correspondence to: Dr. Jôice Dias Corrêa, PhD, Graduate Program in Dentistry, Department of Dentistry, Pontifícia Universidade Católica de Minas Gerais. Av. Dom José Gaspar, 500. Belo Horizonte, Minas Gerais, Brazil.

Copyright © 2021 Dr. Jôice Dias Corrêa, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background
The COVID-19 pandemic has been the greatest one in the last century [1]. The causative virus was identified as SARS-CoV-2. In most cases, the virus causes mild-to-severe respiratory complaints [2]. Since humanity has not had contact with this pathogen before, we did not have antibodies to fight the virus. Besides, the virus is highly transmissible, with a transmission ratio of 1 to 2 people [3].

The virus that causes COVID-19 is thought to be spread primarily between people who are in close contact or by contaminated surfaces.

Infection control in dentistry is complex as we do not know who is contaminated. The pandemic demands important changes in dental practice. Dentists must be aware that additional biosecurity measures are necessary to avoid COVID-19 infection [4].

Methodology
This is a integrative review of the literature about the protocols for dental care during COVID-19 pandemics, A search was carried out in the literature (dental care and pandemic COVID-19) and in dental representative entities on the protocols indicated for the return of dental care worldwide. The article gathers all the information found, removing duplicates, in order to bring the most complete information about the protocols adopted in the world. It is important to remember that these protocols are being updated according to the evolution of knowledge on the topic.

Risks for Dental Workers
COVID-19 was included in group B of infectious diseases. However, the best protocols suggested that protection measures should be for group A infections (highly infectious pathogens [5]). This is because the COVID-19 transmission occurs via three modes: direct contact, saliva droplets, and airborne particles [6].

The practice of dentistry usually creates an aerosol that includes saliva, water, and pathogens, however, until now, there has not been a case of SARS-CoV-2 transmission during dental treatments7. It is important to remember that after the patient leaves the dental chair, aerosols are suspended in the air with a viable virus. Literature shows that the virus could survive on surfaces up to 7 days [7].

Recently, a study has reported the association between periodontitis and severity of COVID‐19 infection [8]. This data shows the importance of dental treatments to preserve oral health and avoid possible complications in COVID-19 patients in the future. Our work has the objective to resume the best available guidelines to provide safe dental care for patients and professionals.

Practice Preparation - Pre-Appointments and Reception Area

1. Contact All Patients Before the Dental Appointment
Pre-appointment contact with the patients is essential. A questionnaire for COVID-19 risk should be applied to any person that will be in the clinic [4,9]. If the patient reports symptoms or contact with someone positive for COVID-19 the only treatment should be to prescribe medication and, if the cases are emergencies, the treatment must be given with the maximum of precaution [4].

An individual with an acute respiratory condition is considered a suspected case of the new Coronavirus 2019 (COVID-19) when it is characterized by at least two (2) or more of these signs and symptoms: fever (body temperature higher than 37.8ºC), chills, sore throat, headache, cough, runny nose, olfactory or taste disorders [10]. It is necessary to consider the fever reported by the patient, even if not measured [11].

There are health questions to ask people, listed below, before they arrive in the clinic [4,9,12]:

1. Did you have a fever in the last two weeks (14 days)?
2. Do you have a cough? Breathing difficulty? Sore throat? Runny nose? Headache? Diarrhea? Nauseous? Vomiting?
3. Have you felt loss or disturbance in smelling or tasting?
4. Have you been in contact with any confirmed COVID-19 positive people?

It is also important scheduling vulnerable patients as the first appointments of the day, to decrease the risk of COVID-19 transmission among these people and:

2. Limit the Number of People Accompanying the Patient.

3. Measure the Patient’s Temperature.

4. Intervals between Appointments Should Be at Least 1 Hour. The patients should be taken directly into the dental chair as soon as they arrive at the facility [4,7,9,12].

5. Advise the Patients and Staff to wear a facemask and to perform hand hygiene with alcohol-based hand rub 70% alcohol [4].

6. Prepare the Clinic to Receive People: the chairs in the reception room should be placed 1 meter apart. Remove any objects that cannot be regularly cleaned or disinfected (magazines, toys, newspaper). Avoid the use of water fountains and provide disposable cups. Disinfect the room twice a day [4,7,13].

7. At the End of the Day: Cleaning floors with sodium hypochlorite 1%.

Use of the PPEs

1. Common Recommendations: Short nails without polish and no jewelry.

2. Working Uniform: Members of Dental Service should wear a surgical mask if the procedure does not generate aerosol and wear an N95 or PFF2 without valve if the procedure generates aerosol. It should be changed every 4 hours. It is possible to re-use the mask if not damaged. For eye protection, goggles, protective eyewear with solid side shields, or a full-face shield should be used, also a gown or protective clothing and gloves during procedures. Use of the Surgical hat or equivalent changed at maximum half day if not soiled (Table 1) [4,7,14].

Management of the Clinical Room and Dental Procedures
All working surfaces susceptible to be soiled by projection (1.5m around source) should be empty or covered with plastic covers to ease cleaning and disinfection. Paper records should be kept in drawers or boxes. Only the instruments needed for the dental treatment should be in the surgery room [4,15].

To perform hand hygiene use soap and water for at least 30 seconds. Or, you can use 70% alcohol if the hands are not soiled [4].

Always prefer four-handed dentistry, high power suction, and dental dams to minimize aerosols and avoid the use of spittoon [6].

Avoid intraoral radiographies and use extraoral techniques, such as panoramic radiography [4,16]. Impressions should be rinsed with cold water and disinfected with sodium hypochlorite 1% [12,14].

After Procedures

1. Advertise Patients:
The patient must inform the dental clinic if they develop symptoms or are diagnosed with COVID-19 in the next 2 days after the dental treatment [4,17].

2. Cleaning the Surgical Room (Table 2):
Ventilate the clinical room for at least 15mins with the window wide opened and the door closed. To clean and disinfect the dental operatory, professionals should delay the entry into the operatory until a sufficient time has elapsed for enough air changes to remove potentially infectious particles. There is a lack of evidence to give an accurate time required for clearance of infectious aerosols after a procedure. We currently accept that 30 minutes should be the recommended fallow period. However, this time can be affected by many factors including the layout of the room, the presence of ventilation, the type of procedure performed, the use of rubber dam, and the duration of the aerosol procedure. Floor cleaning should be at the end of each appointment [14].

Disinfection of the clinical environment surfaces must be carried out in the sequence below:

• From the area less contaminated to the area with more contaminant risk.
• From up to down.
• From the inside out [16].

3. Removing the PPEs Table 3.

4. Cleaning the Instruments: sterilization protocols do not change [18-21].

Conclusion
The COVID-19 pandemic has been present for more than one year now since the first case. What we know about the virus is that the transmission occurs after contact with body fluids, mainly saliva and respiratory droplets. The pandemic demands important changes in our daily lives and the dental practice as well. Dentists are among the professionals with a higher risk of contamination as the oral environment represents a great source of the virus and other respiratory pathogens. Dental workers should know and practice the best protocols to avoid COVID-19 transmission. This work brings the most recent guidelines to help clinicians in their preparation for this new era for dentistry (Supl 1).

Disclosure of Interest
The authors report no conflict of interest.

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