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COVID 19 Guideline( Draft) Of Bangladesh Dental Society

Method · May 2020

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Ibrahim Khalil
Bangladesh University of Professionals
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 COVID-19
Guideline
[Draft]

For Dental Practice in

Pandemic situation

President Secretary General

Prof. Dr. Md. Abul Kasem Prof. Dr. Humayun Kabir
Bulbul

Focal Research Person and

COVID-19 Coordinator
Prof. Dr. Ibrahim Khalil
email: ibrahimps@yahoo.com
 2

This guideline (draft) is prepared on the basis of

internationally trusted Authority. Any changes or tested
result published from WHO, ADA, FDA,CDC, SDECP or any
trusted Authority we will update this guideline.
 3

Background:

The mischievous weapon of nature, against which the world is fighting

together. Most unpredictable new Coronavirus (nCOVID-19) appears as a
beating reed which induce overwhelming pandemic situation all over the
world since December 2019. Dental surgeons are first grade risk group then
other health professionals. An occupational risk group survey was carried
out based on American bureau of statistics data with scoring 0 to 100. Dental
professionals risk score consequently Dental hygienist 99.7, Dentist, General
and Specialist except Oral and Maxillofacial Surgeon 92.5, Oral and Maxillo-
facial Surgeon 92.3 which indicates high score than any health professional
and other jobs1. For bearing a high occupational risk score due to aerosol
generating procedures (AGPs), every dental surgeon should follow a
reasonable trustworthy protocol during their practice in private chambers
and hospitals.

Purpose:
The purpose of protocol construction is –
 To introduce a reasonable protocol during COVID-19 outbreak for every
dental professionals, so that they can continue their practices with life
safety.
 To escape dental professionals and their dental offices from being a power
house of community transmission of COVID-19.
 To ensure the infection control in community.

*** Our Objective is not to teach treatment procedure rather than COVID-19
protective national guideline for Dental Surgeon.
 4

Basic Protocol for patient management:

Scottish Dental Clinical Effectiveness Programme (SDCEP) 2, American Dental

Association (ADA) 3 and ‘CDC guidelines’4 - focused on primary patient
selection before coming at dental chamber/Hospital for dental treatment as
follows:
 COVID-19 negative patient should comprise in AGPs Dental treatment.
Limitations of disease profile and availability of test, Patient would be
referred to ‘point of care test’ at Clinic or Hospital. ( Described in Page -13)
 Who has no recent travel history.
 Since 21 days has no history of fever, common cold, cough, headache or
difficulty to breath.
In Dental clinic or hospital outdoor has to maintain COVID-19 Suspected ‘Case
Record Form’- provided by Institute of Epidemiology, Disease Control and
Research (IEDCR) Bangladesh 5.
Triaging of patients to classify into emergency and risk group and advised to
dental surgeon to reassure their patients verbally with appropriate analgesia and
antimicrobial in spite of AGPs treatment except emergency cases in this crisis
period.

Recommendation for Dental Clinic or Hospital Dental OPD/IPD Design:

 According to SDCEP, ADA, CDC we suggested that, During COVID-19
outbreak Clinic/ OPD Hospital should be as ‘Designated Urgent Dental
Care Centre’ which should have well equipped emergency services
including anti-viral (0.5% Chlorine dioxide or 1.5% hydrogen peroxide
or (Ozone) fumigation fogger machine or Ozone/UV disinfectant fumigation
tunnel at doorway3,4,11,13.
 5

 Negative pressure room/Air born infection isolation rooms (AIRs) should be

needed for betterment of infection control 6, 7.
 During Dental operative but aerosol generating procedures (AGPs) Air
Condition (AC) should be switched off 8, 9.
 Should maintain rational use of personal protective equipment (PPE) WHO,
CDC 10, 11, 12.
 Doff and donning training is very important for every person related in
dental treatment to control the infection transmission. After use disposal
should be maintain properly according to CDC FDA WHO guideline.

[To see Video scan QR code ]

 Scarcity of PPE including mask is prominent due to Worldwide pandemic
crisis, so if needed should reuse Mask, Gown and other PPE accessories by
maintaining proper disinfection procedure. (see page-14)

Triaging by Tele-screening:
Scheduled the appointments for patients through tele-screening is the best
option in this pandemic situation, based on a pre-tested structured
questionnaire and categorizing patients for proper counseling and treatment
(Figure1)2. Most specifically should record their medical history and travelling
history according to CDC, USA guidelines4 before appointments fixing. Patients
who are selected for emergency and urgent treatment should be instruct about
the necessary protective measures they have to follow before entrance in the
dental clinic and hospital. Every time fumigate whole room after exit of
Each patient4.
 6

Figure 1: Questionnaire for Tele-Screening of patients 2.

After Triaging how to attend a patient in private chamber/ clinic/ hospital:

On arrival patient Preparation: Should be allowed maximum one visitor

with a patient. Disinfection protocol should maintain strictly. Whole body
and shoes of a patient and visitor should be disinfected before entrance in
clinic or hospital with fumigation by fogger machine or disinfectant
fumigation tunnel13. Patient including visitor should remove and disposal
their used gloves and mask into disposal bag and provide disposable shoe
cover** then ensuring hand wash with soap or sanitizer. Provide personal
protective equipment’s including gown, cap, hand gloves, facial mask, eye
protection (goggles) for patient14 and surgical mask, gown, gloves for
visitor11.

**]
[Scan QR code
 7

‘Point of care test’ for COVID-19: Diagnosis COVID-1933at chamber or hospital is

essential. Rapid test kits for Antigen or IgM/IgG antibody to COVID-19 or
other sensor device should be available according to Bangladesh government
approval (see page-10). Should avoid higher rated false negative related
rapid test.

Dental Assistant Preparation with Primary Patient Management: A trained den-

tal assistant should wear disposable surgical mask, gown, gloves, eye
protection (goggles or face shield) before receiving patients11 and taken
initiative to measure the patient’s body temperature by placing a
non-contact thermo scanner or infrared thermal sensors on patient’s
forehead from 6 feet distance. CDC recommended a guidelines mentioned
that individuals with suspected COVID-19 infection with fever (>100.4°F = 38°
C) or above should be seated in a separate and well ventilated waiting area at
least 6 feet from the unaffected patients, instruct to follow proper respiratory
hygiene, such as covering the mouth and nose with a tissue or cloths before
coughing and sneezing then discard immediately into disposal bag9.

Dental Surgeons Preparation: Should wear personal protective equipments

(PPE) before attending the patients including gloves, gown, Respirator
KN95,N95 or FFP2-standard along with eye protection goggles or should wear
full covered face shield along with approved surgical masks11. After that

patient should go through the pre-structured questionnaire related to medical

history as well as assessment of severity of pain on pre-designed pain scale
should be done 6(Figure 2). Radiograph should be taken aseptically according
to diagnostic demand.
 8

Oral Cavity preparation immediate before treatment for patient: Before clinical
screening all patients should instruct mouth rinsing with 0.12% percent
chlorhexidine or essential oil–containing mouthwash or 1% hydrogen peroxide
or 1-2% povidone iodine by holding one minute in mouth. Rubber dam
isolation technique reduces airborne droplets arround the operational field by
70%15, 16.
Protective measurement in Operative
Room:
A. For Dental Surgeon’s Self Protection
(during treatment procedure):
After primary consultation put on a
conventional sterile OT dress over PPE
overall then takes another sets of Gloves,
take surgical mask including full covered
Figure 2: Predesigned Pain assessment scale6. Face shields instead of protective Goggles
and mask N95 or KN95 etc.

B. For Dental Assistant and helping-hand Self Protection:

 Ensure Personal Protective Equipments (PPE) including overall gown, Gloves,

Surgical Mask Full covered Face shields and protective Goggles.

C. For Patient’s Self Protection:
 Nose-ear protective materials or sanitizer soaked cotton pellet (Figure-3) with
previously worn PPE including Gloves, protective Goggles.
D. Prevention of COVID-19 Cross infection from Droplet containing AGPs:
 Rubber dam isolation with High volume suction followed by Extra Oral vacuum
aspirator (EOVA) or Extra-oral aerosol suction machine to absorb the aerosol
generated during the treatment process to prevent cross infection34, 35
( figure 4.1).
 9

 Aerosol Box designed for ENT, Anesthesia Intubation. Would be suitable for
Dentistry, made using acrylic or transparent polycarbonate sheet17 (figure 4.2).
 Disposable Dental Scaler Hand-piece cover sleeves (figure 4.3).

Figure 3: (a) (b) (c) (d) Nano Material super ventilation, Effective filtration (PM2.5) of Bacteria,

Figure 4.1: Extra-oral aerosol suction machine.

 10

Figure 4.2: Aerosol Box which is design for ENT, Anesthesia Intubation
.
 11

Figure 4.3: Disposable Dental Scaler Hand-piece cover sleeves.

Protective Treatment Protocol:

Management of patient in pandemic situation is challenging for all dental
Surgeons. So, a best reasonable protocol of management is essential in this adverse
COVID-19 situation. On the basis of clinical experiences and trusted authorities
guideline dentist could follow the management protocol mentioned below2:-

AGPs Dental treatments are:

Access Cavity Preparation for Root Canal treatment, Pulpotomy, Pulpectomy,
Apexogenesis, Apexification, Root End filling, Acute apical abscess, Acute perio-
dontal abscess/Perio-endo lesions, Pulp involving tooth fracture or crack etc.

Procedure: If patient refuse to extraction then Root canal or other Endodontic

procedure should be done by rubber dam isolation with High volume suction.
Additional extra protection should be needed for safety measure by using
Extra-oral aerosol suction machine or transparent aerosol Box. After removal of
enamel portion (2-2.5mm) with high speed handpiece for short time, then EDTA in
dentinal portion with low-speed protaper or endo or RCT machine or manual file
 12

with EDTA and 5-6% sodium hypo chlorite irrigation is might be Protective34, 35, 36.
Then proceed as per clinical demand.
** Noted that: Single Sitting RCT Strongly Recommended as an option where
clinically appropriate to reduce frequent clinical contact36.

Cavity/Surface preparation for all type Restoration, Pulp capping, Fractured loose
or displace restoration, Inlay, Onlay, Overlay, crown, veneer prosthesis, tooth
preparation for Denture placement and Reduction for Difficult Extraction etc.

Procedure: Should use rubber dam isolation with High volume suction. Additional
extra protection should be needed for safety measure by using Extra-oral aerosol
suction machine or transparent aerosol Box.
**Atraumatic Restorative Treatment (ART) or Chemotherapuatic Caries Removal
recommended as an option where clinically appropriate36.

Scaling for essential periodontal disease

Procedure: Should use High volume suction, additional extra protection should
be needed for safety measure by using Extra-oral aerosol suction machine or
transparent aerosol Box.
** Otherwise advice and self help by recommend optimal analgesia, chlorhexi-
dine or hydrogen peroxide mouthwash. Give oral hygiene instruction, Advice
oral solution 5% rhubarb + 1% salicylic acid or benzydamine mouthwash or spray
may make toothbrushing less painful). Zinc oxide+eugenol+anesthetic
gel+fluride gel containing periodontal dressing*** may resolve lots of periodon-
tal problems which would clinically appropriate to reduce frequent clinical con-
tact. Consider antibiotics (metronidazole 200mg TDS, 3days).

[Scan QR Code → ***]

 13

Non-AGPs Dental treatments are:

Dental surgeon could treat Non AGPs dental treatment as their own method to
follow this guideline carefully but always should remember to use High volume
suction with Rubber dam isolation and Additional extra protection should be
needed for safety measure by using Extra-oral aerosol suction machine or
transparent aerosol Box36.

Patient referred for testing:

Though COVID-19 is occurred both symptomatic and asymptomatic pattern rapid
diagnosis of Covid-19 is the only option to eradicate the risk of Dentist. Along with
Laboratory test Rapid test kits also available now in so many countries. In this
aspect-Therapeutic Goods Administration (TGA), Health Department Australia
Government approved more than 55 rapid kits along with few laboratory test for
12 month due to undertaking an expedited assessment process based on the
information and performance data currently available at the time of application
for inclusion. All COVID-19 tests that is included on the subject to additional
non-standard conditions, which makes it easier for assessments of experience and
knowledge around COVID-19 diagnostic testing grows33.

[To see TGA Test list Scan the Code: ]

‘Point of care test’ -Corner needed for diagnosis COVID-1933 at chamber or

hospital. Rapid test kits for Antigen or IgM/IgG antibody to COVID-19 or other
sensor device should be available in Dental Chamber or Hospital according to
Bangladesh government approval.
But rapid chair side diagnosis approaches is still on experimental trial. According
to CDC, USA guideline to priorities of COVID-19 patients testing4, 18. WHO19 and
FDA approved COVID-19 rapid testing tools 20 and laboratory test are:-.
 14

 RT-PCR19, 21.
 Serological Test or Antigen-Antibody immunoassay22, 21.
 New ‘saliva test’ to instantly detect COVID-19 with lasers23, 24.
Some other test options are on clinical trial for rapid testing approval. This will be
very trustworthy for dental professionals.
 Bosch rapid COVID-19 test proved to diagnose COVID-19 in a sample within
two and hours. So it may be consider as quick diagnostic tool25.
 Iran Government approved a smart sensor system is able to detect COVID-
19 from 100 meters radius by creating a magnetic field and using a bipolar
virus inside the device possible 80% positive result26,27.

After legal approval of Bangladesh government, Dental Surgeon may advocate

the rapid saliva testing or infrared sensor system as the confirmatory chair
side diagnostic tools, which will be beneficial.

Suggested Mask, Respirator and protective gear:

N95 (US NIOSH-42CFR84), FFP2 (Europe EN 149-2001), KN95 (China GB2626-

2006), P2 (Australia/New Zealand AS/NZA 1716:2012), Korea 1st class (Korea
KMOEL - 2017-64), DS (Japan JMHLW-Notification 214, 2018) including some
protective gear were suggested by WHO, FDA and CDC with fit testing for such
materials is essential12.

Reuse mask:

Re-using of Mask, face shield, gown and eye protection also recommended by the
CDC28, 29. All mask reuse procedure by authentic reliable way shows in30.
(Figure-5.4)
 15

Reuse of N95/KN95 mask:

Expired N95 respirators remain as effective as the new ones, researcher claimed,
respirators that were as far as 11 years behind the expiration date. While the
respirator may still filter particles as good as new, elastic bands that may
deteriorate30, 32. CDC suggested that N95 mask can be used after 72 hours because
after 3 days COVID-19 loses their viability. Some suggestive sterilization technique
of N95 mask are Hydrogen Peroxide Vaporization, UV treatment, Moist
heat - heating at 60-70°C and 80-85% relative humidity and Dry heat- heating of
the mask at 70°C for 30 minutes29,30,31.

Procedure of reuse a surgical mask:

Due to minimal availability all the trusted authorities supported to reuse the surgi-
cal musk with some strategies (Figure showing some technique of surgical musk
reuse mentioned below. (Figure 5.1, 5.2, 5.3)

5.1: Cross-section view of surgical mask 5.2: In lab 10 min in boiled water
Under electron Microscope (500×)
 16

5.3: No fiber distortion after 10 minutes boiling (2000×).

5.4: after 7 days Re use Procedure 30, 31.

 17

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 18

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19

Special Note:
Bangladesh Dental Society will not
carry any responsibilities of the
Covid-19 affected doctors due to
follow the guidelines. So please take
proper personal protection for your
own safety.