Coronavirus Pandemic: Coronaviruses are a large family of viruses that are common in humans and in many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people such as with SARS-CoV, MERS-CoV, and now with SARS-CoV-2. The SARS-CoV-2 is the official term and classification for the COVID-19 Coronavirus. The Coronavirus has now been classified by the World Health Organization officially as a Pandemic and has been shown to the at least 10 times more deadly than the common flu. The dental office setting has the potential to be a highly contagious setting and may prove to be an environment that breeds cross exposure to the COVID-19 due to the lack of preparation and access to effective protocols.
Dental care settings invariably carry the risk of 2019-nCoV infection due to the specificity of its procedures, which involves face-to-face communication with patients, and frequent exposure to saliva, blood, and other body fluids, and the handling of sharp instruments. The pathogenic microorganisms can be transmitted in dental settings through inhalation of airborne microorganisms that can remain suspended in the air for long periods, direct contact with blood, oral fluids, or other patient materials, contact of conjunctival, nasal, or oral mucosa with droplets and aerosols containing microorganisms generated from an infected individual and propelled a short distance by coughing and talking without a mask, and indirect contact with contaminated instruments and/or environmental surfaces. Infections could be present through any of these conditions involved in an infected individual in dental clinics and hospitals, especially during the outbreak of 2019-nCoV
Published and early reports suggest spread from person-to-person most frequently happens during close exposure to a person infected with COVID-19. Person-to-person appears to occur similar to other respiratory viruses, mainly via respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs. While it may not be currently identified as the predominant mode of transmission, it has been established that touching a surface contaminated with the virus and then touching the mouth, nose, or eyes contributes to transmission. The virus can remain on surfaces for up to 9 days and infect other unsuspecting individuals long after the aerosols land on those surfaces.
Dental offices are in short supply of masks and dental supply companies are limiting the supply of masks to dental offices moving forward. Even the N95 dental masks cannot fully protect dental professionals from the virus as the particle size of the virus is smaller than the filtration size of the masks. Dental professionals will have to make some proactive decisions moving forward on how to protect their patients and staff.
Published and early reports suggest spread from person-to-person most frequently happens during close exposure to a person infected with COVID-19. Person-to-person appears to occur similar to other respiratory viruses, mainly via respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs. While it may not be currently identified as the predominant mode of transmission, it has been established that touching a surface contaminated with the virus and then touching the mouth, nose, or eyes contributes to transmission. The virus can remain on surfaces for up to 9 days and infect other unsuspecting individuals long after the aerosols land on those surfaces. Dental offices are in short supply of masks and dental supply companies are limiting the supply of masks to dental offices moving forward. Even the N95 dental masks cannot fully protect dental professionals from the virus as the particle size of the virus is smaller than the filtration size of the masks. Dental professionals will have to make some proactive decisions moving forward on how to protect their patients and staff.
Since 2019-nCoV can be passed directly from person to person by respiratory droplets, emerging evidence suggested that it may also be transmitted through contact and fomites. In addition, the asymptomatic incubation period for individuals infected with 2019-nCov has been reported to be between 1–14 days, and after 24 days individuals were reported, and it was confirmed that those without symptoms can spread the virus. Live viruses have been found present in the saliva of infected individuals by viral culture method. This means that non symptomatic patients may transmit the virus to others through their saliva landing on various surfaces in the dental office long after they leave the dental offices.
Studies have shown that respiratory viruses can be transmitted from person to person through direct or indirect contact, or through coarse or small droplets, and 2019-nCoV can also be transmitted directly or indirectly through saliva. Dental patients and professionals can be exposed to pathogenic microorganisms, including viruses and bacteria that infect the oral cavity and respiratory tract.
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WASH YOUR HANDS REGULARLY
Good hand hygiene is the most important protection for dentists and their staff:
- Thoroughly wash hands with soap and water for at least 20 seconds
- Lather hands with soap
- Lather the back of hands, between the fingers and under the nails
- Scrub hands for at least 20 seconds
- Rinse off
- Dry hands with a clean disposable towel or air dry
USE HAND SANITIZER BUT DON’T OVER USE
- Thoroughly wash hands with soap and water for at least 20 seconds
Personal Protective Equipment
Dentists, Dental Professionals and all Dental Staff
Dental professionals are used to wearing a mask, gown and gloves. Because the coronavirus is an airborne virus, conventional surgical masks are not adequate. Most mask companies and dental supply companies have either limited the number of masks dental offices can purchase or have run out of the masks themselves. Depending upon potential exposure, dental professionals and staff should consider wearing the following personal protective equipment:
An N95 Mask/Respirator
- Ordinary surgical masks have pores of about 2-10 microns and will NOT protect you in any fashion from the Coronavirus which has a diameter of .12 microns
- N95 masks have pores of about 0.3 microns and will also not fully protect you from the coronavirus that has a diameter of .12 microns but will greatly reduce your exposure
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HIDE YOUR MASKS! MANY DENTSITS HAVE REPORTED STOLEN MASKS FROM PATIENTS, ASSISTANTS, AND EVEN CLEANING CREW!
Some offices have reported autoclaving and sterilizing masks for repeated use but this may not be recommended by OSHA and other governing bodies.
Face shield protection:
Full cover face shield protection is recommended as aerosols will likely be able to land on the face
Goggles are highly recommended with a full seal eliminating any potential aerosols from entering the eyes. Loupes are not adequate to protect the eyes and Coronavirus exposure
The common transmission routes of novel coronavirus include direct transmission (cough, sneeze, and droplet inhalation transmission) and contact transmission (contact with oral, nasal, and eye mucous membranes). Although common clinical manifestations of novel coronavirus infection do not include eye symptoms, the analysis of conjunctival samples from confirmed and suspected cases of 2019-nCoV suggests that the transmission of 2019-nCoV is not limited to the respiratory tract4, and that eye exposure may provide an effective way for the virus to enter the body.
Gown: It is imperative that gowns be purchased and used to avoid contaminating the dental professionals clothing. Gowns should ideally be changed after each patient and disposed of before leaving the office.
Head and hair covers should be used as aerosols can land on hair, scalp and skin
Gloves should be used not only during patient care but during cleaning and decontamination of operatories. At this point the traditional latex and nitrile gloves used in dental offices provide sufficient protection against the Coronavirus.
It’s also important to not touch your face. Be careful not to touch your face when taking masks and shields off.
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A preoperational antimicrobial mouthrinse is generally believed to reduce the number of oral microbes. However, as instructed by the Guideline for the Diagnosis and Treatment of Novel Coronavirus Pneumonia (the 5th edition), chlorhexidine, which is commonly used as mouthrinse in dental practice, may not be effective to kill 2019-nCoV. Since 2019-nCoV is vulnerable to oxidation, mouthrinse containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone is recommended, for the purpose of reducing the salivary load of oral microbes, including potential 2019-nCoV carriage. A preoperative mouth rinse would be most useful in cases when rubber dam cannot be used.
Based on various recommendations by prominent dental clinicians one may also choose to dilute 1 part Sodium Hypochlorite and 20 parts water as a mouth rinse. This may also be used as a mouthwash for home use.
AThe use of rubber dams can significantly minimize the production of saliva- and blood-contaminated aerosol or spatter, particularly in cases when high-speed hand pieces and dental ultrasonic devices are used. It has been reported that the use of rubber dam could significantly reduce airborne particles in ~3-foot diameter of the operational field by 70%. When rubber dam is applied, extra high-volume suction for aerosol and spatter should be used during the procedures along with regular suction. In this case, the implementation of a complete four-hand operation is also necessary. If rubber dam isolation is not possible in some cases, manual devices such as a caries excavator and hand scales are recommended for caries removal and periodontal scaling, in order to minimize the generation of aerosol as much as possible.
The high-speed dental handpiece without anti-retraction valves may aspirate and expel the debris and fluids during the dental procedures. More importantly, the microbes, including bacteria and virus, may further contaminate the air and water tubes within the dental unit, and thus can potentially cause cross-infection. Studies have shown that the anti-retraction high-speed dental handpiece can significantly reduce the backflow of oral bacteria and HBV into the tubes of the handpiece and dental unit as compared with the handpiece without anti-retraction function. Therefore, the use of dental handpieces without anti-retraction function should be prohibited during the epidemic period of COVID-19. Anti-retraction dental handpiece with specially designed anti-retractive valves or other anti-reflux designs are strongly recommended as an extra preventive measure for cross-infection. Therefore, the use of dental handpieces without anti-retraction function should be prohibited during the epidemic period of COVID-19. Anti-retraction dental handpiece with specially designed anti-retractive valves or other anti-reflux designs are strongly recommended as an extra preventive measure for cross-infection.
Dental and medical institutions should take effective and strict disinfection measures in both clinic settings and public area. The clinic settings should be cleaned and disinfected. Chlorox wipes and Caviwipes as well as cavicide sprays are effective against the Coronavirus. Public areas and appliances should also be frequently cleaned and disinfected, including door handles, chairs, and desks. The elevator should be disinfected regularly. People taking elevators should avoid direct contact with buttons and other objects.
The medical waste (including disposable protective equipment after use) should be transported to the temporary storage area of the medical institute timely. The reusable instrument and items should be pretreated, cleaned, sterilized, and properly stored in accordance with the Protocol for the Disinfection and Sterilization of Dental Instrument (WS 506-2016) released by the National Health Commission of the People’s Republic of China. The medical and domestic waste generated by the treatment of patients with suspected or confirmed 2019-nCoV infection are regarded as infectious medical waste. Double-layer yellow color medical waste package bags and “gooseneck” ligation should be used. The surface of the package bags should be marked and disposed according to the requirement for the management of medical waste.
Ozone generators can be used to help bring down the level contaminants within the office and on surfaces. Systems reports that since ozone has been proven to kill 99.999 percent of pathogens in the air, including SARS Coronavirus and influenzas such as H5N1, researchers anticipate that it may be an important tool in preventing the spread of the Coronavirus Disease 2019 (COVID-19). Viruses are small particles made up of crystals; ozone destroys viruses by attacking the nucleic acid core, thus damaging the viral RNA. After destroying these particles, ozone dissipates and leaves breathable oxygen as its only byproduct. It is very important to note that ozone is very damaging to lung tissue so while it may help kill viruses it should not be breathed in by anyone during the use of the ozone generator. It is recommended to utilize the generators based on the square footage of the office and turn them on upon leaving the office and giving ample time upon the return to properly air out and ventilate the office before returning.
UV sanitizing wands and lights can clean germs and odor-causing bacteria found on hard surfaces and several claim that they may safely eliminate 99.9% of germs and viruses, (even MRSA and H1N1), bacteria, allergens, and flea and dust mite eggs found on places like counter tops and fabrics. This may prove to be helpful in dental offices after procedures as an additional modality to minimize cross contamination. Please do not use the UV light on humans or skin and do not stare directly at the light.
The utilization of telehealth and tele-dentistry specifically can prove to be very helpful in preventing cross-contamination and allowing dental office to maintain continuity of care should quarantines become necessary and should patients have symptoms requiring them to stay away from the dental office. Tele-dentistry can be utilized in a variety of ways by dental practitioners to serve their patients. Over 2.2 million emergency visits are made to urgent care centers and hospitals annually for dental related emergencies. It is not recommended a dental emergency patients continue to visit hospitals and urgent care centers for any dental related issues since hospitals are not only short of supplies but also can be places where cross-contamination become rampant. Emergency patients should be seen by tele-dental visits and telemedicine visits with participating dentists who can evaluate the patient’s emergency and provide prescriptions, recommendations, and even same-day appointments in a dental office.
Patients who receive advice and recommendations may not necessarily become established patient’s records but can legally become a patient of records should the dentist choose so. Dentists should take the same precautions and review the patient’s medical history, chief complaint, and the appropriateness of the medications being prescribed should the dentist be establishing the patient as a patient of record through tele-dental visits.
Dentists should check with their state and local governing bodies as well as their insurance company to determine the specific legalities and coverage of tele-dentistry in their respective states. Dental offices can greatly benefit from Dentulu’s tele-dentistry platform allowing dentists to maintain continuity of care by following up with patients after surgery through video conferencing, charts, filesharing, and a number of other features highlighted by Dentulu’s tele-dentistry software. Dentulu has waived all setup fees and monthly subscription fees during the coronavirus outbreak in an effort to help minimize the financial burden on the dental profession and professionals who are already taking a massive due to cancellations and no-shows in their dental offices.
Dentulu also provides the world’s first consumer intraoral camera priced at $25 which can be sent home with patients who require postoperative monitoring allowing dentists to view inside the patient’s mouth remotely from any location of their choice.
Dental professionals and staff can download the Dentulu mobile app on android and iPhones in addition to iPads and their desktop computers. Users can also register and become credentialed directly on the Dentulu website by following the link below.
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