Dental practice COVID-19 safety guidelines

In order to keep yourself, your dental practice and your patients safe, the Professional Board for Dental Assisting, Dental Therapy and Oral Hygiene has compiled a list of procedures and precautionary measures that you can implement.

1. Disinfection/Sterilisation

There are three principal modes of virus spread, all of which are relevant to the field of dentistry;

  • Airborne spread—owing to exposure to bodily fluids and generated droplets, spatter and aerosols;
  • Contact spread—owing to contact with bodily fluids, patient materials, contaminated dental instruments and environmental surfaces; and
  • Contaminated surface spread—since coronaviruses can persist on various surfaces for a prolonged time (depending on the type of surface) and could contaminate the entire dental practice.

Effective and strict disinfection measures in both dental practice settings and public areas should be rolled out. The practice should be cleaned and disinfected regularly in accordance with current safety protocols, as should the public areas and appliances, including door handles, chairs, desks and pens. Proper recirculation of reusable instruments and items should be undertaken, with appropriate instrument pre-treatment, cleaning, sterilisation and storage should be done in line with approved practices.

2. Patient evaluation

Screening patients using a standardised structured questionnaire, measuring the patient’s body temperature and then taking adequate steps to address the results. It is strongly recommended that a contact-free infra-red forehead thermometer be used.

The following set of screening questions can help identify potential infection. This list is not exhaustive, and should be adapted to suit your needs, in keeping with current research and guidelines:

  • Do you have a fever or have you experienced a fever within the past 14 days?
  • Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing, within the past 14 days?
  • Have you, within the past 14 days, travelled to areas with documented COVID-19 cases?
  • Have you come into contact with a patient with confirmed COVID-19 infection within the past 14 days?
  • Have you come into contact with people who had recent fever or respiratory problems within the past 14 days?
  • Have you recently participated in any gathering, meetings, or had close contact with many unacquainted people?

Following the screening questionnaire:

  • If the patient replies yes to any of the screening questions, and the body temperature is below 37.3°C, you can postpone the treatment until 14 days after the exposure event.
  • If the patient replies yes to any of the screening questions, and the body temperature is 37.3°C or higher, then the  patient should be advised on immediate quarantine, and you should report the case to the infection control department of the hospital or the local health department. The method and place of quarantine should be as per the current guidelines mandated by the government.
  • If the patient replies no to all the screening questions, and the body temperature is below 37.3°C, you can treat the patient with extra protection measures and do your best to avoid spatter or aerosol-generating procedures.
  • If the patient replies no to all the screening questions, but his or her body temperature is 37.3°C or higher, the patient should be directed to the nearest appropriate facility for further medical care.
3. Hand Hygiene

The Board recommends following, the two-before and three-after hand hygiene guidelines for dental professionals, which is:

  • before patient examination;
  • before dental procedures;
  • after touching the patient;
  • after touching the surroundings and equipment that have not been disinfected; and
  • after touching the oral mucosa, damaged skin or a wound, blood, bodily fluid, secretion or saliva etc.

NOTE: Everyone should take extra care to avoid touching their own eyes, mouths and noses.

4. Personal Protective Measures

The following protective measures are recommended:

  • Standard protection in the clinical settings: Disposable working caps, surgical masks and working clothes, protective goggles or face shields, and disposable latex or nitrile gloves.
  • Advanced protection for dental professionals: Additional disposable isolation clothing or surgical clothes over working clothes in addition to standard protection.
  • Strengthened protection for being in contact with patients with suspected or confirmed COVID-19.
5.  Pre-procedural mouth rinse

It is recommended that pre-procedural mouth rinses containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone-iodine be used for the purpose of reducing the salivary load of oral microbes. It must be noted that chlorhexidine may not be effective at killing the SARS-CoV-2 virus.

6.  Rubber dam isolation

The use of dental dams can significantly minimise the production of saliva- and blood-contaminated aerosol or spatter, particularly when high-speed handpieces and dental ultrasonic devices are used. The use of a dental dam could reduce airborne particles by 70% within a 1 m radius of the operational field. High-volume evacuators for suction should be used (for aerosol and spatter) during the procedures along with regular suction.

7.  Handpieces

High-speed dental handpiece with no anti-retraction valves may suck in and expel debris and fluids. Microbes may further contaminate the air and water tubes within the dental unit and thus potentially cause cross-infection as well.
Therefore anti-retraction high-speed dental handpieces which can significantly reduce the backflow of oral bacteria and viruses into the tubes of the dental unit. As a result, it is strongly recommended that dental handpieces without an anti-retraction function should not be used at this time.

8. Medical waste

Waste, including disposable PPE, should be regarded as infectious medical waste and should be appropriately and timeously discarded. Proper recirculation of reusable instruments and items should be done, with appropriate instrument pre-treatment, cleaning, sterilisation and storage should be done in line with approved practices. Refer to the Department of Health Practical Manual for Implementation of the National Infection Prevention and Control Strategic Framework.

9. Ventilation

The dental treatment room and other facilities, such as waiting rooms, should be adequately ventilated. Whilst the use of air conditioning is discouraged, but should they be a necessity then approved hospital-quality multi filtration systems (a filtration system that includes a pre filter, true HEPA filter, carbon filter and a UV-C light) should be sourced and regularly changed.

Whilst the Board acknowledges that none of these precautions can prevent or resolve COVID-19 on their own, all of them can contribute to keeping your dental practice, staff and patients safer and healthier—whether there is an ongoing viral epidemic or not.


References
  1. Centre for Disease control (CDC). https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
  2. Department of Health.COVID-19 Disease: Infection Prevention and Control Guidelines Version 1 – April 2020. http://www.health.gov.za/index.php/component/phocadownload/category/626
  3. Department of Health Practical Manual for Implementation of the National Infection. Prevention and Control Strategic Framework. http://www.health.gov.za/index.php/component/phocadownload/category/626#
  4. Department of Labour. https://www.labourguide.co.za/workshop/1773-covid-19-guideline-mar2020/file
  5. National Institute for Communicable Diseases. https://www.nicd.ac.za/diseases-a-z-index/covid-19/covid-19-guidelines/
  6. National Institute of Communicable Disease. Covid- 19 Guidelines. www.nicd.ac.za/diseases-a-z-index/covid-19/covid-19-guidelines/
  7. National Department of Health. Corona Virus (Covid-19) – Updated. www.health.gov.za/
  8. Medical Council of New Zealand. Current Standards. www.mcnz.org.nz/our-standards/
  9. General Medical Council. Ethical Guidelines. www.gmc- uk.org/ethical-guidance/ethical-hub
  10. Department of Health Practical Manual for Implementation of the National Infection. Prevention and Control Strategic Framework. http://www.health.gov.za/index.php/component/phocadownload/category/626#