GUIDANCE FOR REOPENING DENTAL SERVICES IN … · This guidance was issued to help all governmental...

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GUIDANCE FOR REOPENING

DENTAL SERVICES IN GOVERNMENTAL

AND PRIVATE SECTORS DURING

COVID-19 PANDEMIC

Edition 1, version 2

June 5, 2020


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CONTENT

1. Introduction………………………………………………………………….….…. 2. Purpose …………………………………………………………………………… 3. Terms and Definitions ……………………………………………………….…… 4. General Considerations …………………………………………………….….… 5. Infection Control Measures in Dental Settings During COVID-19 Pandemic

5.1 Dentist and Dental Team Preparation ………………....…...…………..…. 5.2 Hand Hygiene …………………………………………………...…………...

5.2.1 Pre-washing considerations………….………………...………… 5.2.2 Types of hand washing ………….……………….………………. 5.2.3 Indications for Hand Hygiene ………….……………….………… 5.2.4 Hand Hygiene Techniques …………….………...……………….

5.2.4.1 Hand Hygiene Technique with Alcohol-Based Formulation (Appendix 1&2) 5.2.4.2 Hand Hygiene Technique with Soap and Water (Appendix 1 & 2)

5.3 Personal Protective Equipment (PPE) ………………………...…………… 5.4 Air Control ………………………...…………………………………………. 5.5 Cleaning and Disinfection ...……………………………………...…...……. 5.6 Sterilization ………………….………………………...………...…...……… 5.7 Engineering Control ……………………...….…………...……………….... 5.8 Respiratory Triage (Figure 2) ……………………………………….……...

5.8.1 Types of respiratory triaging applied for dental setting ……....... 5.8.1.1.1 Distant Triaging by Telephone (13) 5.8.1.1.2 Triaging Upon Patient Arrival (Visual Triage)

5.8.2 Requirements of Visual Triage Station………………………….… 5.8.3 Triaging for Primary Healthcare (PHC) and Hospitals ……..…… 5.8.4 Triaging for non-hospital based dental center “Specialized Dental Centers” (Figure 2) ………………………………......……

5.9 Additional Measures and Instructions …………………………………..… 6. References ………………………………………...……..……….……….……... 7. Appendices ………………………………………………..…………..…….…….

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Guidance for Reopening Dental Services in Governmental and Private Sectors During COVID-19 Pandemic

1. Introduction

Novel coronavirus (COVID-19) is a new and emerging infectious disease that is rapidly spreading

worldwide and reported cases have grown impressively over time. Transmission of COVID-19 is

likely to occur through direct contact with respiratory mucosa or conjunctivae primarily through

respiratory droplets and secretion, either by direct exposure or by transfer on hands from

contaminated surfaces. The current evidence does not support airborne transmission, except

during aerosol-generating procedures (AGPs) (1-3). Due to the proximity of individuals during

dental procedures and the generation of aerosols, dentists, staff, and patients are at high risk of

transmission of COVID-19 (Figure 1).

Figure 1. Illustration of transmission routes of COVID-19 in dental clinic


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On March 20th, 2020, the Ministry of Health (MOH) restricted the governmental and private

dental facilities to manage only the emergency/urgent dental care. In addition, “Dental

Emergency Protocol during COVID-19 Pandemic” was issued by the General Directorate of

Dentistry, (MOH) to facilitate the safest practice during the current pandemic. In its efforts to

control the spread of COVID -19. The MOH started gradually some of its clinical and medical

services for routine cases. The national epidemiological status of COVID -19 as well as the

negative impact and consequences for delayed management cases were taken into

consideration.

This guidance was issued to help all governmental and private dental health facilities and

Dental Healthcare Workers (DHWs) to reopen and resume their routine services in a gradual

manner until further notice from the MOH. It comes in line with other documents previously

issued by the MOH and must be carefully read, understood, and applied. All relevant

documents can be reached through the MOH website in conjunction with other instructions,

which can be found on the Ministry’s website.

https://www.moh.gov.sa/Ministry/MediaCenter/Publications/Pages/covid19.aspx

The (manual of Infection Prevention &Control in Dental settings, 2nd edition) can be downloaded

through the link

005.pdf-22-11-https://www.moh.gov.sa/Ministry/MediaCenter/Publications/Documents/2018

2. Purpose

This document targets all dental facilities, clinics, and DHWs working in governmental or private

sector in Saudi Arabia. The guidance is based on the best latest available scientific evidence and

will be reviewed periodically according to the recommendations and updates of the MOH and

relevant authorities, and according to the epidemiological status of the virus outbreak. The overall

goals are to provide necessary instructions and guidelines for the management of safe routine

dental care during COVID-19 pandemic in Saudi Arabia.


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3. Terms and Definition

HVAC System: Heating, ventilation, and air conditioning system. Neutrally air-ventilated room: This is a room that contains an air conditioner or naturally ventilated. It has not been intentionally designed with a unidirectional airflow as a positive or negative pressure. AIIR: Airborne Infection Isolation Room. HEPA Filter: High-efficiency particulate air (HEPA), also known as high-efficiency particulate absorbing and high-efficiency particulate arrestance. Common standards require that a HEPA air filter must remove—from the air that passes through—at least 99.95% (European Standard) or 99.97% (ASME, U.S. DOE) of particles equal to 0.3 μm; with the filtration efficiency increasing for particle diameters both less than and greater than 0.3 μm.

PAPR: Powered air-purifying respirator is a battery-powered blower that provides positive airflow through a filter, cartridge, or canister to a hood or facepiece. The type and amount of airborne contaminant will dictate the type of filter, cartridge or canister required for the PAPR (4). It is used by those who failed the N95 size determination test, cannot find a fit-tested N95 or who have a beard.

Aerosols: A mixture of different sizes of particles which are differentiated as splatter (> 50 µm), droplet (≤ 50 µm), and droplet nuclei (≤ 10 µm). Most of the aerosols produced in dentistry are extremely small (0.5 to 5 µm). Inhalation of these small particles inflects infectious hazards for DHWs (5-7). Aerosol-Generating Procedures (AGPs): A procedure capable of generating hazardous droplet nuclei (≤ 10 µm). AGPs have been associated with increased risk of transmission of viruses (e.g., SARS-CoV and MERS-CoV) such as nasopharyngeal swabbing, the use of dental handpiece and ultrasonic handpiece, tracheal intubation, non-invasive ventilation, tracheotomy, and cardiopulmonary resuscitation. Standard Precautions: Are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes (8). Standard Precautions include:

1- Hand hygiene

2- Use of personal protective equipment (e.g., gloves, masks, eyewear

3- Respiratory hygiene/cough etiquette

4- Sharps safety (engineering and work practice controls) & waste management


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5- Safe injection practices (i.e., aseptic technique for parenteral medications)

6- Sterilization of instruments and devices

7- Cleaning and disinfection of environmental surfaces

Transmission-Based Precautions: Measures to be used in addition to Standard Precautions for patients who may be infected or colonized with specific infectious agents for which these additional precautions are needed to prevent infection transmission (8). Clinical contact surfaces: Are touched frequently with gloved hands during patient care, or may become contaminated with blood, saliva, or other potentially infectious material and then encounter instruments, devices, hands, or gloves (9). Housekeeping surfaces: (e.g., floors, walls, and sinks) do not encounter hands or devices used in dental procedures. Proper treatment of clinical contact surfaces is required before they become involved in the care of the next patient (9). GDIPC: General Directorate of Infection Prevention and Control. BICSL: Basic Infection Control Skills License, BICSL has five components:

1- Hand Hygiene

2- Personal Protective Equipment

3- Respirator Fit Testing

4- Safe Injections

5- Vaccinations

Emergent care: In dentistry, all potentially life-threatening situations need immediate treatment by the hospital emergency centers. It includes uncontrolled bleeding, significant infection (e.g. space infection, cellulitis), facial swelling and oro-facial trauma potentially compromising the patient's airway. Urgent dental care: It focuses on the management of severe or uncontrolled symptoms that cannot be managed by the patient and require the patient to be seen by a dentist in a dental care center/clinic. Non-urgent dental care: It includes all routine and elective dental and /or maxillofacial procedures. Advice care: Mild or moderate symptoms managed remotely by the dentist (by phone) providing advice and help, which may involve analgesics and antimicrobials.


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4. General Considerations

● For all dental procedures, DHWs should consider the risk factors associated with demographics, general health, and medical history.

● Providers who do not fall into one of the following categories (older age, presence of chronic medical conditions, including immune-compromising conditions and pregnancy) should be prioritized to provide care for patients. Consideration should be given to delaying non-essential procedures to older otherwise healthy adults (65+) and medically compromised patients.

● When performing assessment to the patient, consider the patient and staff safety, prioritization of the previously scheduled appointments, urgent care needs, professional judgment, patient’s preference, and the availability of the supply for the dental care centers.

● Dentists should exercise professional judgment and carefully consider the risks of the disease transmission. However, the possible risks should be considered against any benefit to the patient, the DHWs, and the community.

● Provide appropriate clinical judgment on pharmaceutical management and follow-up as

needed. MOH E-prescription services can help to dispense medication from the commercial pharmacies.

● Patients with non-urgent dental conditions are encouraged to postpone the dental visit and maintain proper oral hygiene by consuming a healthy diet, avoid hard or sticky food, and keep good oral hygiene practices to preserve their status.

● Schedule appointments far enough apart to minimize possible contact with other patients in the waiting room. Patients may also be asked to wait in their cars or outside the facility until they are asked to come in.

● DHWs should continuously update their knowledge about COVID-19 and its high-risk areas

in the kingdom.


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5. Infection Control Measures in Dental Settings

During COVID-19 Pandemic

Infection control measures during the COVID-19 pandemic must be accompanied by all

standard precautions in a normal situation. These include hand hygiene, Personal Protective

Equipment, their sequence of donning and doffing, covering high touchable clinical and

housekeeping surfaces, utilization of high-volume suction and saliva ejector, flushing the dental

lines and all others which are offered in previous local policies and guidelines (please refer to

The GDIPC’s manual of infection prevention and control for dental settings).

In this guideline, additional infection control measurements are explained and obligated in the

presence of COVID-19 to prevent cross-infection to/from DHWs. 5.1 Dentist and Dental Team Preparation

• All dental health care facilities/clinics must gradually operate to maintain public safety and prevent infection.

• Staff preparation and education is an absolute must, prior to opening your facility, an assessment of staff concerns and ability to adhere to these guidelines is a priority. Enough training in this regard must be carefully provided, evaluated, and guaranteed.

• Each facility must make sure that all DHWs are familiarized with these guidelines and assess their ability to adhere to them, in addition to all other relevant MOH guidelines and protocols in this regard.

• All dental health care facilities/clinics must adhere to the start and closing times of the clinic according to instructions issued by the Ministry of Interior and the Ministry of Health.

• Ensure that the safety and infection control guidelines of staff housing are strictly followed and monitored. Including the housing of housekeepers, if any. Necessary arrangements and coordination with the cleaning and maintenance companies must also be made to guarantee their adherence to the guidelines in this aspect. Follow the link for more information: https://drive.google.com/open?id=1zlx88kLXzev6lkjPqoOMBWwxSY1bQx78

• All facilities are encouraged to use electronic payment methods whenever possible and avoid cash payment at the present and future time.


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• A visual screening area for staff, patients, and their companions at the facility entrance should be established. DHWs and all other employees experiencing any of these signs (fever ≥ 38°c / cough/ sore throat/ shortness of breath) should not come to work and report to his / her healthcare facility/provider to seek medical care.

• DHWs are not allowed to resume working unless completely cleared as per MOH instruction

• Dental facilities should develop a plan whom to contact if an employee develops fever or respiratory symptoms to determine whether the medical evaluation is a necessary by a Call to (937) for assistance.

• All precautions and guidelines regarding the use and disinfection of elevators and other facility areas must be strictly monitored and followed.

• All dental facilities/clinics need to prepare a plan for the use of available personal protective equipment (PPE) - for example, surgical masks, surgical clothing, gloves, and face protectors, assuming that supplies may not be available sufficiently in the near future.

• To avoid viral cross-contamination, remove all unnecessary items from the work surfaces in the clinics and ensure all equipment, materials and disposable items in sight should be minimized to only that which is strictly necessary.

• Remove magazines, reading materials, toys, and any non-essential furniture (other than chairs) that may be touched by others and which are not easily disinfected. Place a transparent barrier in front of the check-in desk. Arrange chairs to optimize physical distancing of at least 1.5 m.

• The patient waiting areas should have chairs that are separated by 1.5-2 meters preferably with medical HEPA filter, alcohol dispensers, tissues touchless waste container and signs or media screens for cough etiquette and hand hygiene techniques.

• For suspected COVID-19 patients (score ≥4): 1. If available, let them wait in a separate waiting area preferably equipped with HEPA filter,

have chairs that are separated by 1.5-2 meters, medical alcohol dispensers, tissues, touchless waste container and signs or media screens for cough etiquette and hand hygiene techniques.

2. Otherwise after triage, ask the patient to wait in their cars until they are contacted by phone to enter the clinic directly (refer to Visual Triage 5.8).

• To prevent transmission to DHWS, other staff members and patients, contact (937) immediately if you suspect a patient or staff member has COVID-19.


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5.2. Hand Hygiene

Hand hygiene is extremely important to prevent the spread of the SARS CoV-2 virus. It also

interrupts the transmission of other viruses and bacteria, thus reducing the overall burden of

disease.

5.2.1 Pre-washing considerations

1- Remove jewelry, ring, watches, or bracelets 2- Remove artificial nails if present. 3- Cover skin cuts, abrasions, breaks or cracks with waterproof adhesive dressings. 4- Use running water; avoid dipping or washing hands in a basin of standing water. 5- Use hand lotions to prevent skin dryness.

5.2.2 Types of hand washing

1- Routine hand washing: washing hands with plain (i.e., non-antimicrobial) soap and water.

2- Antiseptic Hand Wash: Washing hands with antimicrobial soap and water for any surgical procedure.

3- Alcohol-based hand rub: An alcohol-containing preparation designed for application to the hands to reduce the number of viable microorganisms on the hands.

4- Surgical hand antisepsis. For more details, please refer to GDIPC’s Manual of Infection Prevention and Control for Dental Settings, 2018. https://www.moh.gov.sa/Ministry/MediaCenter/Publications/Documents/2018-11-22-005.pdf

5.2.3 Indications for Hand Hygiene

● Wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids or after using the toilet.

● If exposure to potential spore-forming pathogens is strongly suspected or proven, hand washing with soap and water is the preferred means.

● Use an alcohol-based hand rub as the preferred means for routine hand antisepsis in all other clinical situations if hands are not visibly soiled.

5.2.4 Hand Hygiene Techniques 5.2.4.1 Hand Hygiene Technique with Alcohol-Based Formulation (Appendix 1 & 2) A. Duration of the entire procedure: 20-30 seconds B. Apply a palm full of alcohol-based hand rub and cover all surfaces of the

Hands


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C. Rub hands palm to palm D. Right palm over left dorsum with interlaced fingers and vice versa E. Palm to palm with fingers interlaced F. Backs of fingers to opposing palms with fingers interlocked G. Rotational rubbing of left thumb clasped in right palm and vice versa H. Rotational rubbing, backwards and forwards with clasped fingers of I. Right hand in left palm and vice versa J. Once dry, your hands are safe

5.2.4.2 Hand Hygiene Technique with Soap and Water

(Appendix 1 & 2) A. Duration of the entire procedure: 40-60 seconds B. Wet hands with water C. Apply enough soap to cover all hand surfaces D. Rub hands palm to palm E. Right palm over left dorsum with interlaced fingers and vice versa F. Palm to palm with fingers interlaced G. Backs of fingers to opposing palms with fingers interlocked H. Rotational rubbing of left thumb clasped in right palm and vice versa I. Rotational rubbing, backwards and forwards with clasped fingers of J. right hand in left palm and vice versa K. Rinse hands with water. L. Dry hands thoroughly with a single-use towel M. Use towel to turn off faucet N. Your hands are now safe

5.3 Personal Protective Equipment (PPE)

PPE is specialized clothing worn by an employee for protection against a hazard (e.g., gloves,

masks, protective eyewear, and gowns). It is crucial for the protection of DHWs versus infection.

Regularly, the protection against aerosolized droplet nuclei is not recommended. However, the

N95 respirator/PAPR, along with the rest of other PPE, is mandatory during COVID-19 pandemic

when there is any attempt to perform an aerosol generating procedures (10). Moreover, Surgical

gown is preferred to be used with AGP as it provides more protection than an isolation gown

because it covers more areas of the body.


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The GDIPC’s manual of infection prevention and control for dental settings provides information

on the PPE and its use in dentistry. Fit testing and appropriate training to use the respirators

should be documented and trainees must be given cards to remind them of the appropriate size

for each one of them. The previous information is mainly available in the basic infection control

skill license (BICSL) training program, which is provided at the infection control office of each

hospital. If the facility does not offer BICSL training, please contact the local/regional infection

control office. N95 respirators should be approved by the National Institute for Occupational

Safety and Health (NIOSH) and/or the Occupational Safety and Health Administration (OSHA). A

substitute for the N95 respirator is available as an FFP3 respirator, which also needs fit testing

before use. This type of respirator should meet the EN 149:2001+A1:2009 standard for the

European Committee for Standardization (CEN).

NB: PPE must be removed regularly inside the clinic except for respirators, which should be taken off outside the clinic and disposed of in an infectious-waste basket (yellow bag) (11). 5.4 Air Control

Heat, Ventilation and Air Conditioning (HVAC) System and Air Handling Options for Any Dental

Aerosol-Generating Procedure for Suspected or Confirmed

COVID-19 Patients include:

A- Dental clinic with a negative pressure HVAC system (1).

B- Portable dental clinic inside AIIR in a hospital setting.

C- Dental clinic with a portable HEPA filter with airborne precautions.

D- If only N95 respirator is used as an airborne precaution in the absence of the previously

mentioned air-handling systems, it is not recommended to perform AGP for suspected

(score ≥4) or confirmed COVID-19 patients because the aerosols might be suspended in

the air for hours which increase the risk of infection.

5.5 Cleaning and Disinfection

After performing any dental procedure during the COVID-19 pandemic, a thorough terminal

cleaning and disinfection should be done for the whole housekeeping and clinical surfaces.

However, delaying the process of terminal cleaning and disinfection is mandatory before re-using

the same treatment room in order to allow the HVAC system or the HEPA filter to remove the

aerosols since the air remains contaminated after the dental procedure (12-14). The


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recommendation for this matter can be found in (Table 1) below (2, 10, 15). It is preferable to use

disposable mop heads and disposable non-woven cloth with freshly prepared cleaning/cleaning-

disinfecting solutions for non-clinical surfaces. Clinical surfaces are wiped utilizing hospital-level

disinfecting wipes (wipe-discard-wipe technique) or a spray-wipe-spray technique with hospital-

level disinfection spray and non-woven cloth. Beware that full PPE with surgical masks during

cleaning and terminal disinfection is extremely important to maintain the safety and protection of

the person performing the process. Some of the recommended disinfectants in the literature are

shown in (table 2) (12). However, all disinfection products should be approved for SARS CoV-2

by the Environmental Protection Agency (EPA) then the Saudi Food & Drug Administration

(SFDA). MOH approval is essential if the product is going to be used inside its facilities. It is

essential to follow the manufacturer’s instructions regarding the concentration and contact time.

Please refer to the GDIPC’s Manual of Infection Prevention and Control for Dental Settings for

more elaboration on the cleaning and disinfection steps and techniques.

Table 1. Recommended Time-Lapse Before Starting Terminal Cleaning and Disinfection

Type of Air Handling Recommended Time to Delay

Cleaning and Disinfection Negative pressure room Minimum 20 minutes HEPA-filtered neutral air-ventilated room According to the manufacturer’s instruction for

complete air filtration Neutrally air-ventilated room Minimum one hour

Table 2. Recommended Disinfectants for SARS CoV-2

Disinfectant Concentration Ethanol (Ethyl Alcohol) 62%–71%

Hydrogen peroxide 0.5%

*5% sodium hypochlorite (50,000 ppm chlorine)

0.1% (1,000 ppm chlorine) 1 measure 5% sodium hypochlorite to 49 measures water

*Attention should be taken as this concentration can be corrosive to the metallic surfaces. 5.6 Sterilization

There is no special recommendation for the sterilization process during COVID-19 pandemic.

The standard procedure for sterilization should be followed as usual in dental centers with the


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central sterile supply department (CSSD)/central sterile supply unit (CSSU) and for the solitary

dental clinics that contain sterilization rooms as in primary healthcare centers. However, the

emphasis on handling the dental instrument with full PPE is essential.

5.7 Engineering Control Engineering controls are technologies and innovations utilized to protect DHWs by removing

hazardous conditions or by placing a barrier between the worker and the hazard. Examples

include local exhaust ventilation to capture and remove airborne emissions or machine guards

to shield the worker. Engineering controls should not interact with the primary procedure,

personal comfort and affect the results of the treatment. Instead, they can be highly effective

in protecting workers and hazard prevention. As previously noticed, dental aerosols are the

most hazardous concern during COVID-19 pandemic. One of the engineering control

measures is the extra-oral suction or the extra-oral vacuum. Though there is no substantial

evidence to support the significant role of these measurements in the prevention of

occupationally acquired diseases, their practical effectiveness in reducing hazardous aerosols

is worthy of being mentioned.

5.8 Respiratory Triage (Figure 2) The goal of respiratory triage is to Identify persons with a potential respiratory infection and

thus reduce the chance of spreading the infection inside the facility and through the community.

5.8.1 Types of respiratory triaging applied for dental setting 5.8.1.1 Distant Triaging by Telephone (13)

● In case the patient called the dental clinic for an appointment or called 937; a dentist or well-trained dental personal will fill the triage form for COVID-19 and evaluate the patient if he needs clinical advice/pharmacological management (Appendix 3 & 4).

● Instruct the patient to visit the dental clinic in case of further evaluation or treatment is required. Guide patients who scored ≥ 4 according to triage form to wear a mask and visit hospital ER or refer him to 937 (Figure 2).


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5.8.1.2 Triaging Upon Patient Arrival (Visual Triage)

● A well-trained dental assistant will fill the triage form (Appendix 5), and the patient will be asked if he/she has any respiratory symptoms then the triage nurse should measure the patient’s body temperature using a non-contact forehead thermometer (14).

● All DHWs must be triaged twice daily, once before the entrance and the second before leaving the facility with measuring body temperature.

● After triage, both the patient and DHWs must take a signed pass-card or approve that they have been triaged.

● Fever in the absence of respiratory symptoms could be associated with an emergency or urgent dental condition (e.g., dental infection) if dental settings are to be used (14).

● Prevent patients from bringing companions to their appointment, except for instances where the patient requires assistance (e.g., pediatric patients, people with special needs, elderly patients, etc.). If companions are allowed for patients receiving treatment, they should also be triaged for signs and symptoms of COVID- 19 during patient check-in and should not be allowed to enter into the facility if signs and symptoms are present (e.g., fever, cough, shortness of breath, sore throat).

● Companions should not be allowed in the dental office if perceived to be at a high risk of contracting COVID-19 (e.g., having a pre-existing medically compromised condition).

5.8.2 Requirements of Visual Triage Station

1. The location of the triage station must be as close as possible to the facility entrance 2. Designated area or table with a clear poster of triage 3. A well-trained dental assistant on the triage form and how to score the patient 4. The following supplies are provided in the triage station:

• Facemasks, tissues, touchless waste container and dispensers of alcohol-based hand rub.

• An updated triage form must be available. 5. Allow for safe distance between people who well be triaged (approximately 1.5-2

meters).


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5.8.3 Triaging for Primary Healthcare (PHC) and Hospitals

Both PHC and hospitals already have respiratory triage stations which are based on MOH guidelines, after filling the triage form:

the patient has almost no risk for transmission of COVID-19. Start dental procedure using full PPE, gown, surgical mask, goggles/face shield and clean gloves) in a neutral ventilated room.

the patient has a low risk for transmission of COVID-19. If AGP is to be performed, it is preferable to follow the previously mentioned air handling options with full PPE. Otherwise, start a dental procedure using full PPE and N95 N95/PAPR respirators in a neutral air-ventilated room.

N.B: After AGP dental treatment, the DHWs must maintain proper ventilation before the terminal cleaning & disinfection and utilization of the dental clinic for another patient (Table 1).

The patient has a high risk of transmission of COVID-19 the patient will be referred as suspected COVID-19 case to hospital emergency and evaluate the need for isolation based on COVID-19 case definition. After that, the patient will receive urgent/emergency dental treatment in hospital with full PPE & N95/PAPR and in the presence of the previously mentioned air handling options for the dental procedures. N.B: Any elective treatment for patient Score ≥ 4 must be delayed until the patient is cleared from suspicion according to MOH regulations.

ScoreZero

Score<4

Score≥4


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5.8.4 Triaging for non-hospital based dental center “Specialized Dental Centers” (Figure 2)

the patient has almost no risk for transmission of COVID-19. Start dental procedure using full PPE, gown, surgical mask, goggles/face shield and clean gloves) in a neutral ventilated room.

If the Patient requires AGP Start dental procedure using full PPE and N95/respirator or PAPR in a neutrally ventilated room. N.B: After the AGP dental treatment, the DHWs must maintain good ventilation for a minimum of one hour before terminal cleaning and disinfection then utilizing the dental clinic for another patient. PPE options: 1) Surgical gown if possible or isolation gowns, N95 respirator/PAPR, hair cap, face shield/tight-fit goggles and clean gloves. 2) Gown, PAPR and gloves.

-If AGP will not be performed, start dental procedure using full PPE (Gown, Surgical Mask, Goggles/Face Shield, and clean gloves) in a neutral ventilated room.

-If the patient does not have a dental urgency/emergency and needs elective treatment only delay elective dental treatment. - Let the patient perform hand hygiene and wear a surgical mask report to infection control in the facility then refer him to Hospital ER-as suspected COVID-19 case.

ScoreZero

Score<4

Score<4

Score≥4


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-If the Patient has dental Urgency/emergency and AGP procedure will be performed treat the patient with Standard, Contact & Airborne precautions if one of the following air controls is available: 1- Dental clinic with a negative pressure HVAC system.

2- Portable dental clinic inside AIIR in a hospital setting.

3- Dental clinic with portable HEPA filter with airborne precautions.

PPE options: 1) Surgical gown if possible or isolation gowns, N95 respirator/PAPR, hair cap, face

shield/tight-fit goggles and clean gloves. 2) Gown, PAPR and clean gloves.

o If AGP will not be performed, start an urgency/emergency dental procedure using full

PPE (Gown, Surgical Mask, Goggles/Face Shield, and clean gloves) in a neutral ventilated room. N.B: Refer to Table 1 for the minimum time-laps recommended before cleaning and disinfection procedure then utilizing the room for another patient.

o Any employee in the facility scored ≥4 has to perform hand hygiene, wear a surgical mask

and report to the infection control department in the facility then be referred to hospital ER for evaluation and not allowed to enter the dental facility.

o For suspected cases with a dental urgency/emergency if he/she will be treated in the specialized dental center the patient will be asked to do hand hygiene and wear a mask. It is preferred to enter immediately to the treatment room. If it is not possible, let the patient wait in a special waiting area separate from the regular patient area if possible with HEPA filter and at least 1.5 m distance between each chair or ask the patient to wait in their cars until they are contacted by phone to enter the clinic directly.

Score≥4

Score≥4


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Figure 2. Infection Control Measures Flow Chart for Dental Treatment During COVID-19 Pandemic


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5.9 Additional Measures and Instructions

1- Once an aerosol producing procedure is started, every effort should be made to take that procedure to completion. Upon completion, disposable PPE should be disposed of within that operatory in yellow bags. PPE that is reusable should be left in the operatory and disinfected along with the operatory or sterilized. Consideration should be given to utilizing two operatories if possible. Disinfect the operatory upon completion of the procedure allowing it to set while the other operatory is in use. Disinfect again before reusing.

2- When Going Home After a Workday, DHWs should change from scrubs and shoes to

personal clothing before returning home. Upon arriving home, DHWs should take off shoes, remove and wash clothing [separately from all other household laundry], and immediately shower. Office attire should not be worn outside the office.

3- For Patient score ≥ 4 any extra-oral radiograph better to be delayed, otherwise follow the

MOH guidelines for radiology departments in the link below. For patients score < 4 or score zero and going for an “extra-oral dental radiographs such as panoramic radiographs or cone beam CT, let the patient perform hand hygiene and wear surgical mask, the x-ray technician has to wear full PPE (Gown, Surgical Mask, Goggles/Face Shield and clean gloves) and follow proper cleaning and disinfection of radiology department. Follow the link for more information: MOH Radiology Departments Preparedness Plan for COVID-19 V1.0

4- Reduce aerosol production as much as possible, as the transmission of COVID-19 seems to occur via droplets or aerosols and DHWS should prioritize the use of hand instrumentation.

5- If your mask is damaged or soiled, or if breathing through the mask becomes difficult, you should remove the face mask, discard it safely, and replace it with a new one.

6- DHWs should use rubber dams or isolating systems (i.e., dry shield, isolite, etc.) along with high volume suction if an aerosol-producing procedure is being performed to help minimize aerosol or splatter.

7- Consider using a 4-handed technique for controlling aerosolization or splatter. 8- Anti-retraction functions of handpieces may provide additional protection against cross-

contamination through the water line. 9- high-volume evacuator must be used as close as possible with AGPs. It is effective in

removing up to 90 % of the aerosols directly at the operation site if it is used properly within 15 mm (16).


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10- DHWs should be aware that in certain situations, when patient close his mouth on saliva ejector, backflow could occur, and this backflow can be a potential source of cross-contamination.

11- DHWs should use resorbable sutures when possible (i.e., sutures that last 3 to 5 days in the

oral cavity) to eliminate the need for a follow up appointment. 12- DHWs should minimize the use of a 3-in-1 syringe as this may create droplets due to forcible

ejection of water/air. 13- DHWs should adhere to the standard sequence of donning and doffing of PPE. 14- There are no clinical studies supporting the viricidal effects of any pre-procedural mouth

rinse against SARS CoV-2, however its recommended to be used due to its long-lasting antibacterial activity with a broad-spectrum of action.

15- If Suspected Unintentional Exposure, first aid must be done:

A- Remove contaminated clothing (if necessary). B- Irrigate the affected area with copious amounts of water (10 minutes). C- Reporting to the infection control department for guidance or Call (937). Follow MOH guidelines for Coronavirus-Disease-2019-Guidelines (17) in the event of suspected unintentional exposure (e.g., unprotected direct contact with secretions or excretions from the patient). Follow the link for more information: CDC/MOH guidance in COVID-19 (V. 1. 2)

16- As the pandemic progresses, some patients will recover from the COVID-19 infection. The patient should have a written document from the hospital that he has recovered from COVID-19 to receive regular dental treatment.

17- Dental treatment for Confirmed COVID-19 Patients must be only for an emergency dental

condition and must be done in AIIR in the hospital setting (e.g., Portable dental clinic inside the AIIR). o If dental AGP will be conducted it has to be in AIIR with the following PPE options:

1- Surgical gown if possible or isolation gowns, N95 respirator/PAPR, hair cap, face shield/tight-fit goggles and clean gloves 2- Gown, PAPR and clean gloves

o If non-AGP will be conducted, it must be in AIIR with the following PPE (Gown, Surgical Mask, Goggles/Face Shield, and clean gloves)


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18- DHWs must follow the proper practice for cleaning and disinfection for impressions and impression trays as mentioned in the Manual of Infection Prevention & Control in Dental Settings.

19- Considering the controversy regarding whether ibuprofen should be used for patients with a COVID-19 infection, it is recommended to use ibuprofen as normally indicated when managing any type of pain. For example, for the management of pulpal- and periapical-related dental pain and intraoral swelling in immune-competent adults, it is recommended that NSAIDs in combination with acetaminophen (i.e. 400-600 milligrams ibuprofen plus 1,000 mg acetaminophen) can still be used.

6. References

1. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19

(COVID-19): Implications for clinical dental care. Journal of Endodontics. 2020. 2. Su J. [Aerosol transmission risk and comprehensive prevention and control strategy in

dental treatment]. Zhonghua Kou Qiang Yi Xue Za Zhi. 2020;55(0):E006. 3. Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 outbreak: what we know. Int J Infect Dis.

2020. 4. Nancy Bollinger MS. NIOSH Respirator Selection Logic. In: Services USDoHaH, editor.

DHHS (NIOSH) Publication: NIOSH Publications Dissemination; 2004. 5. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and

infection control implications. Journal of the American Dental Association (1939). 2004;135(4):429-37.

6. WHO Guidelines Approved by the Guidelines Review Committee. In: Atkinson J, Chartier Y, Pessoa-Silva CL, Jensen P, Li Y, Seto WH, editors. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization World Health Organization.; 2009.

7. James R, Mani A. Dental Aerosols: A Silent Hazard in Dentistry! Int J Sci Res. 2016;5:1761-3.

8. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Committee HCICPA. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. American journal of infection control. 2007;35(10):S65.

9. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings-2003. 2003.

10. Guideline and Guidance for COVID-19 - Annex 1: infection prevention and control in urgent dental care settings during the period of COVID-19 Scotland: Health Protection Scotland 11 April 2020.

11. <APIC_DosDonts_Respirators_hiq.pdf>. 12. Ge Z-y, Yang L-m, Xia J-j, Fu X-h, Zhang Y-z. Possible aerosol transmission of COVID-19

and special precautions in dentistry. Journal of Zhejiang University-SCIENCE B. 2020:1-8. 13. <ADA_COVID_Int_Guidance_Treat_Pts.pdf>. 14. ADA_Int_Guidance_Mgmt_Emerg-Urg_Dental_COVID19.pdf. 15. Apic Text of Infection Control and Epidemiology

The Association for Professionals in Infection Control and Epidemiology; 2014. p. Chapter 18 – Isolation Precautions, page 4/3.


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16. Narayana TV, Mohanty L, Sreenath G, Vidhyadhari P. Role of preprocedural rinse and high-volume evacuator in reducing bacterial contamination in bioaerosols. J Oral Maxillofac Pathol. 2016;20(1):59-65.

17. Ministry of Health. (2020). Wegaya COVID 19 Coronavirus Disease Guidelines. Retrieved from https://covid19.cdc.gov.sa/wp-content/uploads/2020/05/COVID-19-Coronavirus-Disease-Guidelines-en.pdf [Accessed on 30 May 2020].

18. Ministry of Health. (2018). Manual of Infection Prevention & Control in Dental Settings. Retrieved from https://www.moh.gov.sa/Ministry/MediaCenter/Publications/Documents/2018-11-22-005.pdf [Accessed on 30 May 2020].

7.Appendices

Appendix 1. Five Moments of Hand Hygiene, English.


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Appendix 2. Combined Hand Hygiene Technique, English.


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Appendix 3. The most common urgent dental problems and the recommended care

during the COVID-19

Orofacial problem

Recommended management

Advice care Urgent dental care Emergent care

• Acute apical abscess

• Acute periodontal abscess

• Perio-endo lesions

-Recommend analgesics -Prescribe antibiotics if there is concern about swelling or if there is sign and symptoms of systemic infection -Advice patient to call the local center after 2 days if the symptoms do not resolve

In case of spreading infection without airway obstruction refer to the local dental clinic for extraction or drainage

If spreading infection with airway obstruction refer to medical emergency

• Acute pericoronitis -Recommend analgesics -Recommend anti-septic/ salt-water mouthwash -Prescribe antibiotics if there is concern about swelling or if there is sign and symptoms of systemic infection -Advice patient to call the local center after 2 days if the symptoms do not resolve

In case of spreading infection without airway obstruction refer to dental clinic in the local area for possible extraction

If spreading infection with airway obstruction refer to medical emergency

• Dry socket -Recommend analgesics -Advice for warm salt-water mouthwash -In case of signs of spread of infection or immunocompromised patient prescribe antibiotics

If pain is severe and uncontrollable, preventing sleep refer to the local dental clinic for dressing

• Irreversible pulpitis -Recommend analgesics -Advice patient to call the local center if the symptoms get worse

1- If pain is severe and uncontrollable, preventing sleep refer to the local dental clinic for possible initial endodontic therapy or extraction


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• Reversible pulpitis

• Dentine hypersensitivity

-Recommend analgesics if needed -Avoid stimuli (cold, hot and acidic drinks or food) -Apply desensitizing toothpaste regularly to the sensitive area with finger -Advice the patient to call back if symptoms get worse

If pain is severe and uncontrollable refer to the local dental clinic for temporary filling or initial endodontic therapy

• Oral ulcer If less than 3 weeks: -Advice for anti-septic mouthwash (> 7 years old) -Recommend analgesics (topical-systemic) -If due to denture, advice to keep the denture out where possible -In case of herpetic gingivostomatitis or herpes zoster, if the symptoms are severe or immunocompromised, prescribe anti-viral agents

- if more than 3 weeks: refer to the local dental care

If the patient is severely dehydrated, refer to emergency medical care

• Post extraction hemorrhage

• Uncontrolled bleeding in the orofacial region

-Advice the patient not to spit - Advice to place a rolled piece of gauze or cotton over the socket or injured area and press firmly for 20 minutes - Avoid drinking hot drinks or smoking for 24 hrs.

-If the bleeding fails to stop but is not brisk and persistent refer to the local dental care for management

If the bleeding fails to stop and is brisk and persistent, or the patient is taking anticoagulant medication refer to medical emergency care

• Dento-alveolar trauma Including (Avulsed, displaced, or fractured tooth)

If patient didn’t need emergency care advice to: -Clean the affected area gently with mild antiseptic and remove any foreign object if it is present -Apply ice pack to the soft tissue and swelling -Recommend analgesics if needed

Refer to the local dental care in case of: -Large wound laceration - Permanent tooth fracture involving the pulp, moved out of its place, or knocked out

If bleeding is severe and will not stop in 15-30 min, and/or significant facial trauma and/or loss of consciousness and/or tooth inhaled refer


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- If tooth is knocked out, follow the guideline of management *

immediately to the medical emergency care

• Fracture/loose tooth fragments or restorations (Tooth-Crown-Bridge)

For sensitive tooth -Recommend analgesics -Advice to call the local dental clinic if the symptoms are worsened

Refer to the dental clinic if the symptoms are worse or temporary restoration is lost, or broken or causing gingival inflammation for temporary restoration or cementation

For inhaled tooth, crown or bridge refer immediately to the medical emergency care

• Ill-fitting or loose denture

-If painful, recommend analgesic -Advice to remove the denture whenever possible

When function is impeded refer to the local dental care for adjustments

• Suture removal -Advice to keep good oral hygiene -Mouth wash with salt-water -Dissolvable sutures can stay longer than 2 weeks

If nonabsorbable suture was used refer to the The local dental center for suture removal

• Trauma from wire digging in (ortho-or prosthodontic appliance)

-If thin and possible patient or a family member use scissors or clippers to adjust -Advice to cover the wire with wax/silicone

If not possible to manage by patient refer to dental care for adjustments

• Broken bonded retainers

If possible, patient or a family member use tweezer and push wire back towards the tooth, adjust or remove as possible -Advice to cover the wire with wax/silicone -Advice use of removable retainer if present**

If not possible to manage by patient refer to the local dental care for adjustments


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• Temporomandibular disorders (TMD)

-If mild to moderate pain or limited movements advice for: -Warm hot-pack -Avoid hard or sticky food - Recommend analgesics - Jaw exercises -Oral parafunction awareness - To call again if the symptoms are worsened

If pain is severe and uncontrollable with/without limited movements preventing sleep refer for The local dental clinic for management

Reference: Management of Acute Dental Problems, Guidance for healthcare professionals. In: Programme SDCE, editor. March 2013 ed. Scotland: NHS Education for Scotland.

* Ram D, Cohenca N. Therapeutic protocols for avulsed permanent teeth: review and clinical update. Pediatric dentistry. 2004;26(3):251-5.)

** BOS COVID 19 Guide to the Management of Orthodontic Emergencies: British Orthodontic Society (BOS); [Available from: https://www.bos.org.uk/Portals/0/Public/docs/Advice%20Sheets/COVID19%20FACTSHEETS/Flow%20and%20Protocol.pdf.

Appendix 4. Most common recommended medication used in dental emergencies


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Appendix 5. Respiratory Triage Checklist for Specialized Dental Centers

This checklist is following MOH and Weqaya guidelines (Last Update: 5 May 2020) but after triaging the pathway for dental centers patient is different. Its updated regularly on: www.covid19.cdc.gov.sa

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