🎯 Decision making processes in patient management
🎯 What can dentists do to protect themselves and patients?
- Hand hygiene has been considered the most critical measure for reducing the risk of transmitting microorganism to patients
- SARS-CoV-2 can persist on surfaces for a few hours or upto several days. This reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within dental clinics.
- Every surface in the waiting room must be considered at risk; therefore in addition to providing adequate periodic air exchange, all surfaces, chairs, magazines and doors that come into contact with healthcare professionals and patients must be considered “potentially infected”
- It may be useful to make alcoholic disinfectants and masks available to patients in waiting rooms. The entire air conditioning system must be sanitized very frequently.
1. How to wear and remove your mask?
Wearing a mask is mandatory for the clinician and support staff, the N95 has become a necessity. The most important requirement is to avoid touching the surfaces of the mask, if at all it is required to touch it for the first time, make sure it is with sterile gloves.
2. How to re-use N95?
We all know that the surgical masks should be disposed after each use. However these days it’s necessary for and supporting staff to use N95. Since the N95 is more expensive than the masks we wear on a regular basis, to dispose after each use may not be very economical.
So here’s how you can store your N95 if it is not soiled, you can label each box/bag with the name of the doctor who it belongs to and the days (as shown in the image below) and use it accordingly.
3. Are you wearing your mask right?
It is advisable to wear the mask before wearing the head cap so that the ears are completely covered, if the mask is worn over the head cap the elastic that goes behind the ear may tug on the cap and expose your ears.
4. A small tip on which masks you can avoid and/or wear in your clinics?
Nowadays a variety of masks are available, right from single to ten layers. Cloth masks are not surgically approved to be worn by a clinician based on its filteration capacity, and it is advisable not to use a single or two ply mask. The least you need is a two, 3 ply surgical mask worn one on top of the other.
The preferred choice always would be an N95 over which you can wear a 3 ply mask so that your N95 is protected from any splatter or aerosol and can be reused.
5. Are you using cloth masks while working at your clinics?
The four layer cloth masks are not scientifically proven for clinical use, these are good for general use, but not suitable for clinical use as there are no studies that have proven their effectiveness in clinical use.
6. Select the mask that fits you well!
Make sure the nose clip is fit well. Blow air to check if there is any leakage of air, the rim should be perfectly sealed. Poorly fit N95 can drastically reduce the filteration capacity to 30%. It is always better to wear your mask in front of a mirror.
7. Is it advisable to wear masks with filters?
The filter in the mask is a feel good factor for getting fresh air inside, but in conditions, where there is an active virus around it is advisable not to use, especially in clinical conditions.
8. Wearing a mask may cause a lot of symptoms right from the marks from the mask which is a sign that your mask has a good seal, to sweating, breathlessness, dizziness, increased heart rate and blood pressure, fatigue and increased CO2 saturation.
We recommend clinicians to start working with lesser number of hours and increase the work time gradually till you get accustomed to the new conditions.
9. Are masks with shields effective for use in clinical practice?
They are not scientifically proven because of the lack of fit and are not recommended for clinical practice.
10. Which shield are you using?
Shields have been proven to have adequate protection when worn over the N95, it acts as a second line of defence and avoid any splatter or aerosols on the exposed part of the face. Hence its strongly recommended to incorporate a shield while practicing by the clinicians. Pick the one that best suits your needs!
Its best to have separate shields for everyone working in the clinic, label the shields and use 4-5 times and disinfect the shields in between uses with a disinfectant.
11. Wearing protective glasses in such times is very important, for the clinician and the supporting staff. Make sure to have different glasses for each person. The glasses should seal the area around the eyes and protect them from any aerosols. A good fit ensures tight seal and no fogging, in addition check the quality to see the visibility too.
12. Are you providing your patients with protective eyewear?
It is of utmost importance to provide your patients with protective eyewear too. There are various kind of eyewear available that can be given to the patient depending on the treatment being carried out. Store the glasses in a box or ziplock bag after disinfection in between uses.
13. Are you washing your hands thoroughly?
14. WASH YOUR HANDS!
Earlier considered as a luxury, these days using sensor based soaps/sanitizer dispensers and automatic taps are better, more safe in these times and quite affordable as well. If the installation of automatic taps and soap dispensers is not possible, we recommend taps which have push buttons that can be used with the non-dominant part of the hands. For sanitizers use dispensers which have foot pedals to avoid contact.
15. Virtual Care:
Its best to make sure first a TELECONSULTATION is done and then the patient is called in only if absolutely necessary. Level 1 includes consultation and planning if treatment of level 2 or 3 is required. Teleconsultation is also known as level 0 treatment. Make sure to check with the patient before giving an appointment if they have or had any symptoms in the past 10-15 days.
16. The New Normal:
If there is a chance to space your appointments it is a good idea, it would be better to donn and doff after each patient and go back to scrubs specially when you are performing procedures involving aerosols. The idea being if you are in a PPE the whole day you may end up touching surfaces that could be avoided. Once exposed to the patient you must assume that there is some microbial or viral load on your PPE. Therefore to reuse your PPE through the day donning and doffing with inter-spacing between appointments would be an intelligent idea.
17. Are you disposing your PPE the right way?
At the end of the day or whenever you deem fit to dispose the PPE follow a protocol in such a way that you don’t end up touching the front surfaces of the PPE which may have been exposed to aerosols. Pull through the sleeves catching the inner surface and then roll inside out always with a pair of gloves and dispose the PPE.
18. Four main chemicals will make all the difference
- a) Ethyl Alcohol: Ethyl Alcohol comes in various concentrations, make sure to be close to 70% if not 80%
- b) Hydrogen Peroxide: The dilution of hydrogen peroxide as recommended of 1% for mouth rinse
- c) Sodium hypochlorite: Commercially available in different percentage, the most common being 3% and 5%. Please do not buy large quantities of sodium hypochlorite, more than required per month as it will dissociate into hypochlorous acid, chlorine and then water in no time. Dilutions of NaOcl vary from 1, 0.1 and 0.01 depending on the intended usage. 1% can be used to clean floors and/or 0.1% for disinfecting surfaces.
- d) Povidone Iodine
19. Hypochlorous acid:
HOCl is the most effective disinfectant in the chlorine family and has been proven to be more efficient than NaOCl. HOCl’s lack of electrical charge allows it to penetrate the protective lipid membrane of an organism and quickly inactivate the viral protein. Hypochlorous acid is also known as electrolyzed water is considered by the FDA to be “the form of free available chlorine that has the highest bactericidal activity against a broad range of microbes” including MRSA, M.Tuberculosis, E.coli, Corona virus and many more.
The Management practice of the operating area:
The management practice of the operating area should be quite similar to what happens with other patients affected by infectious and highly contagious diseases. As often as possible, the staff should work at an adequate distance from patients; furthermore, handpieces must be equipped with anti-reflux devices to avoid contaminations, improving the risk of cross-infections.
Dentists should take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols. The 4-handed technique is beneficial for controlling infection. The use of saliva ejectors with low or high volume can reduce the production of droplets and aerosols.
The operatory may be contaminated with micro-aerosols that can stay in air for upto 15 minutes, make sure to open the windows in the operatory to facilitate air circulation before you take the next patient.
Transmission routes of 2019-nCoV and controls in dental practice
It is crucial for dentists to refine preventive strategies to avoid the COVID-19 infection by focusing on patient placement, hand hygiene and all personal protective equipment (PPE)
Due to the characteristics of dental settings, the risk of cross-infections may be high between dental practitioners and patients. Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection.
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