COVID19/CORONA VIRUS Safety Protocol for Dental Practice

Dental Protocol

• Patient Protocol
• Reception Protocol
• Operatory Protocol
• Housekeeping Protocol
• Sterilization Protocol

Patient Protocol

• Only appointments/ no walk in
• Brief history(travel history, quarantine/connection with covid patient, fever, cold, cough)
• Thermal scanning
• Only one attender
• Extra cost/payment
• Enter the reception

Patient Protocol/Emergency Assessment

Thermal Scanning

PPE Requirement At Different Levels Of Employee Setting In A Dental Office

Operatory Protocol

• Doctor and assistant wear PPE (donning)
• Make the patient sit in the chair
• Maximum single visit dentistry
• Patient to gargle with providing iodine/ h202
• Use a rubber dam
• High Vaccum suction
• Doffing of PPE

Doctors and Assistant PPE Polyproplene-100gsm

Mask and Face Shield FFP-2/FFP-3 3M-8210/N 95 Niosh Approved

Mask and Face Shield FFP-2/FFP-3 3m-8210/N 95 Niosh Approved

Important points to be noted:
• Single-use refers to the disposal of disposable PPE or decontamination of reusable items e.g.
eye protection or respirator, after each patient and/or following completion of a
procedure on a patient or session;
• Respirators can be used safely within their design specifications for
8 hours of continuous or intermittent use.
• Discard N95 respirators following use during aerosol-generating procedures or those
contaminated with blood or other body fluids.
• Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and
after touching or adjusting the respirator
• Ensure that areas for donning and doffing are designated as separate from the patient
care area (e.g., patient’s room)

Extended Use & Reuse of N95 Mask

Exposing contaminated N95 respirators to vaporized hydrogen peroxide (VHP) or
ultraviolet (UV) light appears to eliminate the SARS-CoV-2 virus from the material
and preserve the integrity of the masks’ fit for up to three uses, a National
Institutes of Health (NIH) study shows.
Dry heat (70° C) was also found to eliminate the virus on masks but was effective
for two uses instead of three.

Povidine Iodine/h2o2 2% Povidine Iodine 0.1% Hydrogen Peroxide

Intra Oral High and Low Vaccum Suction

Donning and Doffing Procedure In Clinical Practice

• Dorn PPE before entering the operatory https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
• Surgical gown or coverall
  Disposable surgical gown/coverall including shoe cover of quality that meets or exceeds ISO 16603
  class 3 exposure pressure, or equivalent (63 to 69 GSM)
  https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf
• Mask – N95 respirator: NIOSH N95, EN 149FFP2, or equivalent
  Perform fit test to select the right size
  https://www.osha.gov/video/respiratory_protection/fittesting_transcript.html
• User seal check must be performed each time after wearing the mask
  https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
• Single extended use of 6-8 hours if it does not become contaminated.
  Protect N95 with a surgical triple-layered mask which must be changed after every patient
  Ref link for extended use or limited reuse of N95 masks
  https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
• Wear Goggles with the flexible frame to ensure a good seal to the skin compliant with or equivalent to EU standard directive 86/686/EEC, EN 166/2002 or ANSI/SEA Z87.1-2010
• Disposable or cloth head cap in the absence of a hood
• Put on face shield compliant with or equivalent to EU standard directive 86/686/EEC, EN 166/2002 or ANSI/SEA Z87.1-2010
• Non-sterile nitrile gloves complying with any of the below standards
  1. EU standard directive 93/42/EECClassI, EN 455
  2. EU standard directive 89/686/EECCategory Ill, EN 374
  3. ANSI/SEA 105-2011
  4. ASTM D6319-10

Donning and Doffing Procedure Inclinical Practice

Step-by-step doffing of PPE after clinical procedure

• Doff the PPE after exiting the operatory
• Follow doffing sequence https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
• Provide ABHR ( Alcohol-based hand rub) in the doffing area
• Dispose of PPE appropriately according to biomedical waste disposal regulations
• Reusable autoclavable cloth gown and head caps if used must be immersed in domestic detergent for 20-25 min, washed at 70 degrees and then autoclaved

House Keeping Protocol

• FOGGING OPERATORY ROOM
• MOPPING THE FLOOR/SURFACES
• CHAIR CLEANING AND WRAPPING
• MAKING READY FOR THE NEXT PATIENT

Chair Wraping

Sterilisation Protocol

• SOILED INSTRUMENTS IN SEPERATE TRAY
• CLEANING THE INSTRUMENTS WITH GLOVES
• ULTRASONIC CLEANING
• DRYING THE INSTRUMENTS
• POUCHING THE INSTRUMENTS
• AUTOCLAVE-B CLASS
• DATE OF AUTOCLAVE
• STORE IN RACKS

Recommended Disinfection and Sterilization Protocols For Dental Clinics Treating

Area Reception and patient waiting area
(Housekeeping surfaces)

Specifications:

• Avoid sweeping with a broom
• Use wet mopping with warm water and detergent (eg. 1:50 dilution of 5.25-6.15% Sodium
  hypochlorite)
• High touch surfaces (eg. doorknobs, handles, elevator buttons)
  must be cleaned more frequently with hospital grade
  detergent/disinfectant.
• Toilets, washbasins, sinks must be cleaned with detergent and
  disinfected with 1% sodium hypochlorite

Treatment area/patient care area
(Standard recommendation )

• Floor – Use Wet Moping- Multi Bucket Technique –
  Water/Detergent/Low Level Disinfectant like 3% hydrogen peroxide,
  1% sodium hypochlorite or EPA approved agents
• High touch/clinical surfaces within 3 feet diameter of the dental
  chair that are difficult to clean must be covered using a physical
  barrier for every patient or disinfected between patients using a
  wipe (Eg. 0.5% to 0.1% sodium hypochlorite or 70% alcohol for
  sensitive surfaces)
• Wet dust all non- critical/ non touch surfaces horizontal surfaces
  with freshly prepared disinfectant solution once a day unless visibly
  soiled (Eg. 0.5-1% Sodium hypochlorite or 3% hydrogen peroxide)
• Walls, window blinds, frames cleaned and disinfected when visibly
  soiled or end of the day
• Mop heads and cleaning cloths must be discarded in biomedical
  waste bins appropriates or decontaminated regularly by laundering
  (heat disinfection) with detergent, 1:1000 dilution of sodium
  hypochlorite and drying at 80 °c. Must be changed frequently

Aerosol adjuncts
(additional recommendations)

• Identify a closed room to perform Aerosol Generating Procedures(AGP) if available
• 1: 100 dilution of 5.25- 6.15% i.e., 0.01% of sodium hypochlorite for
  Dental Unit Waterline.
• Air should be filtered with High-Efficiency Particulate Air (HEPA 13 o14)- if recirculated or otherwise exhausted to the outside effectively
• Temporary use of a strategically placed portable, an industrial-grade HEPA filter may expedite the removal of airborne contaminants https://www.abatement.com/learning-center/patientisolation/faqs/
• Ultraviolet germicidal irradiation (UVGI) 252 nm, duct irradiation or upper-room air irradiation(30-40
  Watts/100 sq feet) can be used as an adjunct air-cleaning measure but it cannot replace HEPA filtration
• Allow adequate time for sufficient ACH to remove 99% of airborne particles and to perform
  environmental disinfection of min 20minutes after non-AGP and 30 minutes after AGP between
  patients
• Hydrogen peroxide vapor fumigation with 30% hydrogen peroxide
  can be performed

Note:

• Disinfectants approved by the Environmental Protection Agency, Disinfectant List
  Coronavirus Disease 2019
  (COVID-19) 03/13/2020 are recommended for surface disinfection procedures.
  https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
• Do not use disinfectants spray-on potentially highly contaminated areas (such as toilet bowl
  or spitoons) as it
  may create splashes that can further spread the virus.
• 70% of Alcohol can be used to wipe down surfaces where the use of bleach is not suitable, e.g.
  metal.
  (Chloroxylenol (4.5-5.5%)/ Benzalkonium Chloride or any other disinfectants found to be
  effective against
  coronavirus may be used as per manufacturer’s instructions)
• Always use freshly prepared sodium hypochlorite solution and discard remnant diluted
  solution

Conclusion

• Self-quarantine till further instructions
• Social distancing in reception
• Face mask to everyone
• Avoid aerosol practices till June
• Single-visit treatments
• Use sodium hypochlorite
• Use proper PPE
• Use proper sterilization & disinfection
  protocols
• Practice safe dentistry & stay safe

Unity Is Our Strenght