COVID-19 pandemic: multilevel dental technical guidelines based on new scientific evidence

Andrade, Sérgio Araújo; Lima, Raissa Emanuelle; Varotti, Fernando de Pilla; Abdelwahab, Omar; Lwaleed, Bashir Abdulgader

doi:10.31744/einstein_journal/2022AE6307

Brasil

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Special Article • Einstein (São Paulo) 20 • 2022 • https://doi.org/10.31744/einstein_journal/2022AE6307 linkcopy

COVID-19 pandemic: multilevel dental technical guidelines based on new scientific evidence

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The COVID-19 pandemic imposed restrictive measures on dentistry in different regions of the world, ranging from stoppage of care to only permission for urgent and emergency dental services. Thus, new biosafety guidelines for resuming activities, whether in single dental offices, large clinics or dental education activities, are urgently required. In this sense, herein, guidelines that incorporate common points of the main protocols found in the literature for the resumption of dental activities at their different levels, whether in the scope of care or education, are presented. Furthermore, we present the incorporation of measures that allow an increase in the level of biosafety, such as the control of the dental team, the inclusion in the history of conjunctivitis as a possible alert for COVID-19, and the use of the pulse oximeter to assess the risk of silent hypoxemia, which may indicate a complication of COVID-19. In addition, new perspectives for directing research and innovation for biosafety in dentistry are discussed.

Keywords: Coronavirus infections; COVID-19; SARS-CoV-2; Pandemics; Betacoronavirus; Guideline; Dentistry; Dental care; Containment of biohazards; Telescreening, medical; Personal protective equipment

Advices	Description
Dental staff controls	Dental workers with comorbidities (hypertension, diabetes, cardiorespiratory and/or cerebrovascular diseases, and cancer) and/or elderly should be removed from the frontline of clinical care, undertaking only administrative activities or teletriage(⁴,⁸)
	Dental workers with suspected or confirmed case of COVID-19 should be removed from the clinical frontline and kept under medical care(³,⁶)
	Asymptomatic dental workers should be monitored and tested for COVID-19(³,⁶,¹¹)
Engineering controls	Installation of physical barriers that maintain a minimum distance of 2m between people, whether they are patients and/or professionals(⁶,⁸,¹¹)
	Adequate ventilation with air flow directed from clean to less clean(³,⁶,⁸)
	Allow 20 to 30 minutes between consultations to ensure sufficient time for cleaning, disinfection, sterilisation and renewal of ambient air. In the waiting room, social distancing should be observed and strictly adhered to, magazines should be removed, as well as ornaments and toys and, if possible, avoid the presence of escorts. Intelligent scheduling for the patient to arrive at the dental office and be cared for “just in time”(⁴,⁶–⁹,¹¹,¹⁹)
	Preferably, use an individualised dental office. In the case of dental clinics with a large number of chairs, a spacing between chairs of at least 2m should be promoted, which must be positioned parallel to the air flow, with physical barriers between chairs. If available, consider the use of a portable HEPA air filtration unit in all types of dental offices(⁶)
	Use of plastic film in handle-able locations (e.g. door handles, equipment hand-pieces, handles of reflectors and keyboards)(⁷,¹⁹)
	Avoid the use of a spittoon, prioritising, if possible, the use of high volume suction to minimise aerosol(³,⁶,⁷,¹¹,¹⁹)

Stage	Measures applied
Telephone or video conference triage	Perform anamnesis for assessment of the patient for the presence of signs and symptoms of COVID-19, with careful tracking of all professionals who were in contact with a COVID-19 positive individual.(³,⁵–⁹,¹¹,¹⁹) In this context, attention should be drawn to the suspicious signs of COVID-19: fever >37.8°C, conjunctivitis, chill, cough, shortness of breath, fatigue, muscle or body pain, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, or vomiting, diarrhea, which appear 2 to 14 days after exposure to the virus. The presence of indicative signs of severity for COVID-19 should be assessed, including breathing difficulties, persistent pain or pressure in chest, confusion, difficulty keeping awake and bluish lips(³,⁶,⁹,²⁵,³¹,³²)
	Check the real need for a face-to-face consultation, through a history taking focused on the basic concepts of: – Emergency: situations involving the risk of death of the patient, such as airway obstruction and uncontrolled hemorrhage – Urgency: refers to cases of severe pain and/or infection – Elective procedure: refers to the scheduled consultation where there is no setting that requires emergency(³,⁶,⁷,⁹,¹¹,²⁶)
	If available, use teledentistry, which includes remote patient assessment and medication prescription. This remote prescription includes analgesics, anti-inflammatory and/or antibiotics, according to the disease condition, patient preferences, possible complications, and the possibilities coming from the local public health departments(⁵,¹¹)
	Special attention should be given to elderly individuals and/or with comorbidities: if asymptomatic for COVID-19, only urgent or emergency care should be prioritised, and, if available, the possibility of home care should be considered. In turn, if infected with COVID-19, the elderly patient and/or with comorbidities should be referred to a hospital to assess the risk and benefit of urgent or emergency dental care(¹¹)
	History-taking should be repeated for each new patient consultation request(¹¹)
Care in the face-to-face appointment	Patient must wear a face mask and perform hand hygiene with soap or alcohol 70°(³,⁶,⁷,⁹,¹¹)
	Measure temperature, and, if >37.8°C, consider fever(⁶,⁷,⁹,¹⁹)
	Check oxygen saturation levels with pulse oximeter and, if <93%, refer to medical care due to the risk of silent hypoxemia(²⁷–²⁹)
	Repeat the triage history for COVID-19 before appointment(⁵,¹¹)
	Consider the use of a rapid test for COVID-19 since it has high specificity and sensitivity(⁶)
	Use of FFP2, N95 or FFP3 respirators for procedures with no generation of aerosols. However, in suspected or confirmed cases of COVID 19 and/or for any aerosol-generating procedure, it is ideal to use respirators, FFP3, N99 or N100 without exhalation valves(³,⁶,⁸,¹¹,¹⁹,³⁰)
	Priority should be given to emergency and urgent care, postponing elective procedures, avoiding adverse impacts on the patients’ conditions due to delayed care. If possible, carry out the entire treatment in a single consultation(³,⁶,⁹,¹¹,¹⁹)
	Preferably, perform minimally invasive procedures, such as using excavators, chemical agents for tooth decay removal, and rubber dam to minimize the spread of microorganisms(³,⁵,⁷,⁸,¹¹,¹⁹)
	Avoid procedures that produce aerosol (e.g. dental turbines, micro motor hand piece, ultrasonic scalers, air/water syringe and sodium bicarbonate powder jet), or procedures that lead to increased salivation, retching or coughing, such as an intraoral radiographic examination and impression. Otherwise, tomography or extra oral radiographic technique should be used(³,⁵–⁸,¹¹,¹⁹)
	Use PPE, such as goggles, face shields, gloves, apron, long-sleeved disposable fluid repellent coverall, surgical cap and, foot cover, in addition to adoption of work uniform (consider washing the uniform using the hospital services or specialised laundry facilities).(³,⁶–⁹,¹¹,¹⁹) Change PPE at each appointment to avoid cross-contamination and spread of infection(⁷,¹¹)

Modality	Features
Theoretical classes	Maintaining remote on-line activities, preferably with live classes to promote students/lecturers interaction(³,²⁶)
Theoretical classes	Use of education tools, such as participation in on-line seminars, case-based discussions or problem-based learning, and clinical videos(²⁶)
Laboratory classes	Pre-clinical didactic videos(²⁶)
	Use of PPE suitable for staff and students. Maintaining social distance of 2m, imposing physical barriers and insuring appropriate levels of air flow(²⁶)
	Use of virtual reality tools, if available(²⁶)
General measures	Insuring that preventive and therapeutic psychological support are in place for students against psychological stress, anxiety and fear caused by the uncertainties arising from the COVID-19 pandemic(³,²⁶)
Clinical practices	It should be understood that the techniques of provision of the clinical care is the main component in the training of students in dentistry.(²⁶) Thus, these activities can be postponed, but preparations should be made to deliver sufficient clinical training in an optimal way when it is safe to do so
	It should be acknowledged that there is no way that virtual, on-line or remote tools can replace face-to-face clinical care activities(²⁶)
	Consider the recommendations of PPE, engineering controls, proper social distancing and patient flow for cases of clinics with multiple chairs
	Whenever possible, face-to-face urgent and emergency care should be considered. Special measures should be put in place in case of infected or suspected patients with COVID-19, ensuring strict social distancing and anti-infection measures are taken. Another technique worthy of implementing is to divide the patients into groups based on the presence or absence of aerosol generation. They then should be directed into different areas within the practice room. The separation of patients should minimise the risk of spread of COVID-19 as well as enable tracking in case of contamination(³,²⁶)
	Similarly, the service teams should be separated to reduce the risk of infection and to facilitate contact tracking in the event of contamination. Thus, a lecturer should be kept in tutoring a specific and reduced number of students(¹¹)
	The temperature should be checked and history taken daily, regarding the signs and symptoms of COVID-19, maintaining confirmed and suspicious cases, as well as professors, students and patients from risk groups at home and, when necessary, under medical care(¹¹)
	Consider using rapid tests for COVID-19 on staff and patients(²⁶)
Continued education	Strong migration trend from traditional conferences to webinars and on-line courses(⁴,⁴²)
Continued education	Use of on-line tools that allow audiovisual interaction in real time(⁴²)

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Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
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[TFN1] HEPA: high efficiency particulate arrestance.