Indian Society of Oral Implantologists [ISOI], the premier and largest society of Oral Implantology in India, hereby issues its Guidelines for dental clinics in India during the current COVID-19 pandemic.
The recent COVID-19, is a viral pneumonia originated in Wuhan [China]. The virus is recognised as novel corona virus[2019-nCOV] which causes COVID-19. The signs and symptoms include fever, cough, shortness of breath and respiratory symptoms. In severe cases, the infection can cause pneumonia, severe acute respiratory symptoms and sometimes death. According to WHO, the incubation time for the COVID-19 infection can range from 1-14 days, and is commonly 5 days. It is suggested that the virus can stay virulent on infected surfaces from 3hrs to 9 days.
The typical routes of transmission for COVID-19 are either via a direct transmission via cough, sneezing or droplet infection or via contact transmission via oral, nasal and eye mucous membranes. Studies have shown that the disease can be transmitted directly or indirectly through saliva.
Dentists, dental clinic auxiliaries and dental patients can be exposed to viruses and bacteria that infect or are spread through oral cavity, saliva and respiratory tract. Dental care setups are always at risk of COVID-19 infection and its spread as our procedures involve face to face communication with patients and frequent exposure to saliva, blood and the oral cavity and respiratory system in general. Thus, dentist should protect themselves and their staff from acquiring this infection and the dental setup from transmitting the infection.
Thus, we at ISOI have formulated the guidelines to help prevent dentists and staff from acquiring the infection and our clinics from transmitting the infection from an infected patient.
The key recommendations for safety of patients, dentists and dental auxiliaries have been suggested in these Guidelines.
The recommendations are divided under 3 major headings-
1] Patient selection guidelines
2] Waiting/ Reception area Protocols
3] Operatory Protocols
1] PATIENT SELECTION GUIDELINES
A] Thorough medical history, preferably over the telephone when the patient calls for an appointment with relevant questions seeking travel history, history of close contact with any person who has travelled or has been sick. History should also include history of recent fever, cough, running nose, body ache, difficulty in breathing at rest and during routine activity, self-quarantine advisory given by competent authorities and COVID-19 testing if done.
If any of the above are answered in positive, please ask the patient to get himself checked for COVID-19 from a medical consultant before his dental visit is scheduled. In case the patient has arrived in the dental office please get the history form filled and signed along with the consent.
B] If the patient is suspected to be from a high-risk category from the history, treat the patient’s emergency problems with medication before he gets himself medically examined and proves to be COVID-19 negative.
Choice of drugs should be-
Analgesics– Any one of the following-
1] Diclofenac Sodium [50mg] with or without
2] Ketorolac Tromethamine 10mg QID
3] Acetaminophen [Paracetamol] 1000mg TID
In the current pandemic it has been advised by WHO in their guidelines to abstain from prescribing Ibuprofen. Thus, above mentioned analgesics should be of first choice. Choice of analgesics should be done after patient history and risk assessment.
Antibiotics are to be used in case of infections only. Cochrane Review suggests that there is not enough evidence to recommend the use of antibiotics to reduce pain in cases with irreversible pulpitis except for cases with acute periapical abscess and cellulitis. Appropriate choice of antibiotics should be used, if necessary.
C] Only emergency dental treatment should be performed. All elective procedures should be postponed. Treatments for uncontrolled bleeding, cellulitis and/or soft tissue swelling, swellings compromising patient’s airway, trauma and cancers should only be considered as emergency dental treatments.
D] Urgent dental care procedures include pain from pulpal involvement, pericoronitis, dry socket management, tooth fracture, treatment necessary before medical procedures, broken or dislodged definitive prosthesis, painful restorations, denture adjustments for soreness and oncology patients, adjusting appliances like orthodontic wires or prosthesis causing ulcerations to oral mucosa and biopsy. All these should be done to relieve pain and discomfort with temporary means only without definitive treatment goals and as far as possible without aerosol producing devices.
D] Patients with COVID-19 who have successfully completed home isolation can receive emergency dental treatment. At least 3 days should have passed since recovery and 7days have passed since symptoms occurred.
For individuals with Lab confirmed COVID-19 who have not had symptoms and at least 7 days have passed since diagnosis and have no symptoms can be treated for emergency dental work.
NO TREATMENT TO BE GIVEN TO COVID-19 POSITIVE OR SUSPECTED POSITIVE PATIENT IN ROUTINE DENTAL SETUP. REFER HIM TO A MEDICAL FACILITY FOR HIS COVID-19 TREATMENT.
2] WAITING/RECEPTION AREA PROTOCOLS
Prominently display the notice below in the reception:
- Fill medical and dental questionnaires and self-declaration forms and sign them
- Do not touch anything in the clinic unless unavoidable
- Ask questions or talk with the mouth covered with a mask.
- Avoid use of in-house toilets.
A] Patients entering into the receptions should be screened for body temperature first and should be given hand sanitizers to disinfect their hands upon entering the dental office along with a tissue for their use in coughing or sneezing. Disposal bags should be made available in the reception for ready disposal of used tissues. Mark distances in the reception with red tape and arrange the seating with 6 feet distance. Cover frequently touched objects like phones, mouse, keyboards, pens, etc with disposable covers or cling films so that they can be disinfected. The patient should be given a questionnaire to be filled regarding his exposure and travel history [ Sample form attached] to be filled before he enters the operatory. Any positive replies in the questionnaire shall defer his dental treatment.
B] Reduce wait time in dental reception and maintain spacing of 6 feet apart.
C] Have a smaller number of patients in reception and consider patients waiting in their cars till dental chair is made available for OPD based practises.
D] Use disinfection protocols for reception area like twice a day floor mopping with warm water, detergent and 1%Sodium Hypochlorite [ Called as the Three-bucket Technique]. [Source-ncdc.gov.in]. Broom sweeping should be avoided.
E] High touch surfaces like door knobs, reception chairs, furniture, etc should be disinfected after every patient with a disinfectant spray or detergent.
F] Remove all reading material from reception as it is hard to disinfect them.
G] Schedule appointments leaving sufficient time for staff for disinfection of equipment and surfaces.
H] Patients should be requested to have a mask or a nose protection worn in the reception till they are called in the operatory.
I] THE RECEPTION STAFF SHOULD BE WEARING HEAD CAPS, EYE PROTECTION GLASSES, MASKS AND FULL SLEEVED APRONS OR SCRUBS AND GLOVES. THEY SHOULD PERFORM HAND HYGIENE AFTER EVERY PATIENT IN THE RECEPTION AREA.
3] OPERATORY PROTOCOLS
the patient in the operatory and ask him to disinfect his hands and face by
thoroughly washing with soap and water.
2] Patient should be asked to gargle with 1% hydrogen peroxide and/or 0 .2% betadine solution to reduce viral load in the mouth and saliva. The commonly used 0.12% Chlorhexidine mouth rinse may not be effective to kill 2019-nCOV. Since 2019-nCOV is vulnerable to oxidation, pre-procedural mouth rinse with Hydrogen Peroxide or Povidone Iodine is recommended. [ Ref-Guidelines for the Diagnosis and Treatment of Novel Coronavirus Pneumonia [5th Edition] released by National Health Commission, China.
3] The dentist and assisting staff should perform thorough hand hygiene and be well protected with PPEs [Personal Protection Equipment] even before examining the patient.
The PPEs are classified into 3 categories-
Primary Protection– Standard protection for staff in the clinic which includes disposableworking cap, surgical mask, latex/nitrile gloves, white full sleeves coat, protection goggles or face shields.
Secondary Protection– Advanced protection for dental professionals.
Includes all primary protection plus face shield over eyewear and autoclaved isolation clothing or surgical clothing outside.
Tertiary Protection– Incase of contact with COVID-19 Positive patient or suspected positive foremergency dental treatment.
Although such a patient is not expected to be treated in dental office, if one has to.
This includes all secondary protection with addition of disposable outside wear, eyewear plus face shield and impermeable shoe covers. Ideally an N-95 respirator mask [ authenticated by National Institute for Occupational Safety and Health] should be worn, but in view of shortage of these a triple layered surgical mask with a face shield is proposed. A Hazmat Suit, if available should be used for COVID-19 confirmed cases.
4] The patient should be draped with a disposable or autoclavable drape after he performs rinsing.
5] The main aim should be to perform only essential dental procedures to relieve pain and discomfort of the patient. Elective and non-emergency procedures should be delayed.
6] Use of aerosol causing equipment like airotors, three-way syringes and ultrasonic devices should be avoided or minimised. Use of rubber dam with high volume suction can significantly minimize aerosol production when high speed or ultrasonic equipment are used. If use of rubber dam is not possible use low speed drilling equipment like air motor or micromotors for pulpal exposures and hand scalars for scaling.
7] The dentists and assisting staff should avoid touching other surfaces with saliva and or blood contaminated gloves.
8] All surfaces and equipment which cannot be autoclaved or chemically disinfected like knobs, hoses, electronic equipment, dental light grips, etc should be covered by barriers which should be changed after every patient.
9] All drilling handpieces, scaler handpieces, instruments, endo instruments, burs etc which can be autoclaved, have to be done so. Studies have shown that there is a possibility of retention of viral DNA and viable viruses in side high speed handpieces and scaler handpieces. The restricted access to cleaning internal provides challenges. The proposed method for disinfection is to discharge air and water for 20-30 secs after each patient, to flush out patient material that might have entered the turbine and air and water lines. Then manufacturers instruction for cleaning, lubrication and sterilization should be performed. Preferably use disposable three-way syringe tips or use autoclavable tips for each patient. Low vacuum saliva ejectors should be disposable and High Vacuum saliva ejectors could be disposable or autoclaved.
10] After the procedure is completed the dentist and assistants should thoroughly wash the gloved hands with soap and alcohol-based disinfectant. The disposables worn by the patient and the dentists should be removed and disposed with the washed gloved hands to avoid skin contact with possible aerosols on the disposables. The patient should be advised to wear his mask immediately after the procedure. Once the PPEs are taken off, remove the gloves and again perform hand hygiene.
The assistant should clear all used instruments, equipment and disposables with gloved hands and all PPE worn. The instruments should be left in covered tray with alcohol-based disinfectant for minimum 20-30 minutes followed by cleaning the instruments in an Untrasonic bath and finally autoclaving them. The equipment like handpieces, drills three-way tips, etc should be cleaned with soap and water, followed by chemical disinfection, before autoclaving. Use of Ultrasonic cleaning baths is compulsory. The disposables including used needles, syringes blades etc should be properly sealed in bio-medical waste bags and disposed on a daily basis.
All surfaces of contact on the dental chair, furniture suctions etc should be thoroughly cleaned and disinfected immediately with an alcohol-based disinfectant [ Bacilol etc] before the assistant removes his/her gloves.
The patient consulting chair and the dentist consultation table also should be disinfected after the patient leaves the office, before the next patient.
The floor of the operatory should be mopped with the Three-bucket technique or with 1%sodium hypochlorite and detergent after each patient. [ ncdc.gov.in]
The dental operatory and reception should be fumigated every day before closing down with commercial fumigators or with Liquid Formalin and potassium permanganate crystals. Liquid Formalin to be poured on the potassium permanganate crystals and the room to be closed overnight. The next day enter with mask and ventilate the room 30mins prior to usage.
Laboratory Work Protocols
All dental impressions going to the laboratory, ideally should not be more, as only emergency work has to carried out, should be disinfected thoroughly in the dental office before dispatch. Proposed disinfection protocol is-
1] Thoroughly wash the impression in running water after removing it from the mouth. [For all materials including alginates, polyethers and vinyl polysiloxanes.]
scrub with a camel hair brush and liquid detergent under running water. . [For
all materials including alginates, polyethers and vinyl polysiloxanes.]
3] Immerse the impression in a solution of 5.25% Sodium Hypochlorite with 1:10 dilution. The solution should be changed daily. [ Only for vinyl polysiloxanes.]
4] Alginates and Polyethers are generally sprayed to saturate for required time with an intermediary level disinfectant.
Hydrophobic materials should be immersed in disinfectant solution for 10 mins. There shall be minimal distortion. Hydrophilic silicones and alginates should be sprayed to avoid dimensional changes.
5] Packet of jobs received from the laboratory should be disinfected first with disinfectant spray and the prosthesis should be disinfected by immersing in Gluteraldehyde or any other suitable disinfecting solution for appropriate time.
BIO-MEDICAL WASTE DISPOSAL NORMS SHOULD BE STRICTLY ADHERED TO AND WASTE DISPOSAL SHOULD BE DONE DAILY AND STORED IN THE PREMISES.
CONCEPT OF FORCED MEDICAL LEAVE
If any of the clinic staff including the dentists develop symptoms or are tested positive for COVID-19, the clinic should be closed down with immediate effect and all the personnel should compulsorily go into a 14-day self-quarantine. If anyone develops symptoms within the quarantine window, inform the other clinic staff and seek medical advice and treatment immediately.
All personnel should get tested themselves for COVID-19 after the quarantine window is over and then resume the duties.
clinic staff should daily update the dentist about their health and their
These are the minimal and viable recommendations proposed by ISOI. Sky is the limit to incorporate methods and equipment like the aerosol removing air purifiers with HEPA filters, PPEs to be used in high risk categories, Z-kits for personal protection etc. These may not be financially viable or may not be available for us in these testing times.
POST PANDEMIC CONSIDERATIONS WHEN REGULAR DENTAL VISITS RESUME
When we get out of this pandemic and resume routine dental treatments, essentially, we must treat every patient visiting our offices to be COVID-19 positive and take all above mentioned precautions as Standard Operating Procedures henceforth.
Once the pandemic is over, dental clinics could be one of the most affected services with fear about spread from a dental clinic in patients mind. To alleviate these fears and build confidence in our patients the dentist and clinic staff should get themselves checked for COVID-19 and display the findings prominently in the reception area. Also make the patients aware about the protocols followed by your office for preventing spread of the disease and assure them of a safe environment in your office.
time where our practises are not running to optimal levels, we should utilise
this time in laying down plans and protocols for future. We should utilise this
period to train ourselves and our staff in following the protocols for our
offices. Training our staff for effective appointment planning and biomedical
waste management. This shall help all of us in streamlining the protocols and
SELF DECLARATION FOR THE PATIENT
I, _____________________________, aged ____years, resident of _______ (city/country), with my
present address ______________________________________________________
numbers _________________, ___________________, ________________ and email
____________________ have come to this clinic with the following complaints
I have / have not underlying medical conditions. If yes ______________________________.
I am giving an undertaking that I and any of my family members have / have not
- travelled to / returned from any foreign country / domestic cities in last two months.
- come in contact with someone from abroad in last two months
If yes, which countries and cities: _______________________________________________
I have the following symptoms (please tick )
dry cough / breathlessness / loose motions / body aches / any other symptoms
I have / have not come in close contact with a suspected COVID 19 case/s.
I have / have not been quarantined / hospitalized in last one month.
The above information is true to the best of my knowledge.
I am aware of the epidemiological risks of this disease and if I am an asymptomatic carrier or undiagnosed COVID 19 patient, I suspect I am endangering the clinicians, assistants and other personnel. I may also similarly get the infection from them. In either case it is my responsibility to take appropriate precautions and adhere to protocols prescribed by us. There may be additional costs to the said protocols. But I will not hold the clinic staff accountable if such infections occur to me or my accompanying persons.
Signature : ________________________________
Date and Time: ___________________________
1] CDC Guidelines for Infection Control in Dental Healthcare Settings-2003
2] International Journal of Oral Heath [IJOS] March 03 2020
3] ADA Covid-19 Infection Control Protocols and Procedures
4] CDC Coronavirus Disease 2019- Healthcare Professional Infection Control
5] NHS Advisory on NSAIDs
6] Journal of Dental Research- Coronavirus Disease 2019: Emerging and Future Challenges for Dental and Oral Medicine. March 12 2020.
7] Journal Of Zhejiang University
8] Canadian Dental Association Oasis.
Disclaimer: The contents of these recommendations are for informational purpose and are based onscientific references and literature as mentioned but do not constitute 100% guarantees. Hence, we disclaim any liability with the use of this information.