Standard Operating Procedure for Minor Oral Surgery

During recovery phase of COVID 19 pandemic @ JR and CH

Authors Mr. Anand, Vindhya Bangalore Channakrishna and Sarah Kirchheimer

Introduction
The Covid-19 pandemic has restructured the way that we live and work. Evidence for
transmission is emerging, but we know it spreads by droplets, aerosol and surface contact.

Scope of document
This document provides advice and guidance for delivery of oral surgery care for people
during the COVID-19 pandemic easedown at John Radcliffe Hospital and Churchill hospital.

General Principles
 Non-urgent dental care should be deferred to minimise risk to patients, staff and the
public
 Urgent dental care falls in 2 x categories
1) Non-Aerosol Generating Producers (Non AGP’s)
2) Aerosol Generating Procedures (AGP’s)
 Aerosol generating procedures (AGP) present a higher risk of transmission of the virus
and should only be undertaken to provide urgent care where no other option is
available
 Operators may be concerned at the ‘splatter’ that is created by dental procedures, but
this is droplet contamination which universal precautions will guard against
 Each patient should be assessed and managed on their own merit, taking
into account the patient’s best interests, professional judgement and the prioritisation of
the most urgent care needs

Index
A. Booking
B. Arrival
C. Procedure
D. Discharge

A. Patient booking pathway

1) Referral (GDP, GP, Other Specialities)

2) Patient groups (Red, Amber, Blue)
3) Triage Virtual consultation: Video or telephone
Face to face consultation : Outpatient clinic, One stop clinic
4) MOS procedure list
5) COVID-19 assessment
6) OUH Visitor policy

Patient groups
Red Patients who are possible or confirmed COVID-19 patients- including patients with
symptoms or those living in their household
Amber Patients who are shielded, vulnerable / at increased risk from COVID-19

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Categories of shielded patient groups
People falling into this extremely vulnerable group include:
1. Solid organ transplant recipients
2. People with specific cancers:
o people with cancer who are undergoing active chemotherapy
o people with lung cancer who are undergoing radical radiotherapy
o people with cancers of the blood or bone marrow such as leukaemia, lymphoma or
myeloma who are at any stage of treatment
o people having immunotherapy or other continuing antibody treatments for cancer
o people having other targeted cancer treatments which can affect the immune system,
such as protein kinase inhibitors or PARP inhibitors
o people who have had bone marrow or stem cell transplants in the last 6 months, or who
are still taking immunosuppression drugs
3. People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe
COPD
4. People with rare diseases and inborn errors of metabolism that significantly increase the risk of
infections (such as SCID, homozygous sickle cell)
5. People on immunosuppression therapies sufficient to significantly increase risk of infection
6. Women who are pregnant with significant heart disease, congenital or acquired

Categories of vulnerable patient groups

This group includes those who are:
1. Aged 70 or older (regardless of medical conditions)
2. Under 70 with an underlying health condition listed below (i.e. anyone instructed to get a flu jab
as an adult each year on medical grounds):
o chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary
disease (COPD), emphysema or bronchitis
o chronic heart disease, such as heart failure
o chronic kidney disease
o chronic liver disease, such as hepatitis
o chronic neurological conditions, such as parkinson’s disease, motor neurone disease,
multiple sclerosis (MS), a learning disability or cerebral palsy
o diabetes
o problems with your spleen – for example, sickle cell disease or if you have had your
spleen removed
o a weakened immune system as the result of conditions such as HIV and AIDS, or
medicines such as steroid tablets or chemotherapy
o being seriously overweight (a body mass index (BMI) of 40 or above)
3.Those who are pregnant
Blue Patients who do not fit one of the above categories
MOS procedure list

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COVID-19 assessment:
Patients are advised to complete COVID-19 screening questionnaire and contact the
department by email oral.surgery@ouh.nhs.uk or phone 01865743112 to provide further
information. Patients are advised to respond 48 to 72 hours before their appointment date.

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OUH Visitor policy
From June 2020, OUH hospitals are following the ‘rule of one’ – one visitor, per patient, for one
hour per day
 The patient should attend the treatment appointment alone if possible.
o If an escort or additional attendee will be attending the appointment, patient
must inform us of the escort’s: name, relationship and their phone number
o If a parent/carer is attending they should be risk assessed for COVID-19 prior
to patient’s treatment appointment. Additional attendee may attend when a
patient is unable to consent or the patient is under 18 years old.
o Additional attendee must complete COVID-19 screening questionnaire ideally
prior to patient’s appointment and contact the department by email

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 oral.surgery@ouh.nhs.uk or phone 01865743112 to provide further
information. Patient and additional attendee are advised to respond 48 to 72
hours before their appointment date. If not, on the day of patient’s treatment
appointment - upon arrival, additional attendee to ask reception staff for
COVID-19 questionaire and fill them
o Upon arrival on the day of treatment a nurse will guide patient and additional
attendee to a designated seat in the waiting room and re-check the COVID-19
Screening Questionnaires
o Additional attendee is advised to observe social distance markings, ensure
hands are washed and must wear face covering (unless you are a child under
11years of age)
Elderly patients can be accompanied by one relative/carer/guardian if required
Patients with mobility problems or with learning disabilities can be accompanied by one
relative/ carer/ guardian
Others
 Patients are given ‘Pre-op MOS information pack’ which are sent via email, postage
or both
 Patients are advised to eat and drink as normal before the procedure and take their
normal medications unless instructed to do otherwise
 The patient should attend wearing a face covering (unless they are a child under
11years of age)
 The patient should arrive on time
o If arrival is more than 10 to 15 minutes early, the patient will be asked to leave
and return on time
o If arrival is more than 5 minutes late then the appointmnet will be cancelled in
accordance with hospital policy
 Patients are advised to bring their own pen
 Patients are advised not to bring in any items that are not required eg coats, bags

B. On arrival

1) The patient should visit reception for registration. Patients are advised to observe social
distance markings and ensure hands are sanitised on arrival

2) A nurse wearing Level 1 PPE

 will meet and guide the patient to a designated seat in the waiting room
 will re-check the COVID-19 Screening Questionnaire
 will check the patient’s temperature (Temp checks NOT carried out at CH)
If high (>37.8C) : will discuss with the clinician
If normal (36.1 to 37.8C) : proceed
 A face covering may be provided
 The patient will be asked to use hand sanitiser
 An ID band will be attached to the patient’s wrist
3) Patients are strongly advised to maintain social distancing whilst in the waiting area.
The waiting area will not have magazines, toys or games as these are difficult to
disinfect

4) Only the patient will be allowed into the clinical area of the department (Patients are
advised to contact us using the above details if they need an escort for additional

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 support). If there is no space in the waiting area, the escort may be asked to wait in the
main hospital foyer or potentially in their car.

C.Procedure
 A Nurse will guide the patient to the treatment room and where he/she will be met
by clinicians wearing PPE (Level 1 or 2)
The escort or chaperone will not be allowed into the treatment room unless clinically necessary

 Patient’s belongings will be kept by the door and covered

 Patient details will be checked (PPID)
 The patient will be asked to sign a consent form with their own pen
 Treatment will be completed in one visit wherever possible
Treatment room:
 The clinical room must be set up for the clinical procedure BEFORE the patient is
admitted
 The clinical surfaces must be clear of clutter and non-essential items not related to
the planned treatment episode
 If not washable, the keyboard and mouse should be covered with single-use clingfilm
(SARS-CoV-2 remains viable for 24 hours on cardboard)
 No paper records should be retained in the surgery during high risk AGEs or during the
fallow period

 Copies of radiographs should be placed in a clear plastic sleeve that can be

disinfected or disposed off as infectious waste into Orange clinical bin

 The treatment room door must remain closed and windows kept open for the duration of
the clinical procedure

AGP (JR):

3 2

Window Window
Non- AGP Surgery 3 or Surgery 4 at JR
Room 7 at CH
PPE:
All clinical staff should have
a) Fit testing and checking of FFP3 / Force 8/ Force10 masks
b) Attended Level 1 and 2 PPE donning and doffing training

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For COVID-19 OUH documents and resources including PPE policy follow
https://www.oxstar.ox.ac.uk/covid-19/personal-protective-equipment-ppe
Level 1 PPE: Non-AGP Level 2 PPE: AGP

1) Gloves 1) Gloves (Base layer + Top layer)

2) Disposable plastic apron
3) Fluid repellent surgical mask (FFP2/FFP3
may be considered in the case of a
prolonged intra-oral procedure, Pt with gag
reflux, soft palate biopsies)
4) Eye protection (full face visor)
5) Surgical/Clinical shoes (wipeable)
2) Long sleeved fluid repellent gown
3) Appropriate fit tested FFP3 / Force
8 / Force 10/ Powered respirator
4) Eye protection (full face visor)
5) Surgical/Clinical shoes (wipeable)

Non-AGP:
During soft tissue biopsies we use suction. High volume suction is not AGP as it actually
reduces the amount of aerosol generated particle.
Level 1 PPE should be used. After the procedure Level 1 PPE should be removed and
hands washed.The nurse will clean the surgery ready for the next patient.(There is a lack of
evidence to give an accurate time required for clearance of infectious aerosols/droplets
after a particular procedure i.e. Fallow Period.No fallow time is currently required for non-
AGP)
AGP:
Level 2 PPE should be used.
Doff in the allocated room (Surgery 2/ Recovery room @JR): The surgical gown, FFP3
mask, visor, gloves to be removed, and shoes wiped with clinell wipes, the PPE to be
disposed off in the clinical orange bin. Hands must be washed and dried or hand gel used,
and clinician+Dental nurse to exit
Fallow time is 1 hour: The Clinician will inform the nurse what time the procedure
finished.The nurse should calculate the time by adding 1 hour and writing when the room
can be used again on the door sign i.e. if the Clinician comes out of the room at 10:35 and
the procedure finished at 10:30 the safety time on the sign would be 11:30. The room must
be left for 1 hour and the cleaning will be completed by the nursing team wearing level 1
PPE.
Paper records should be completed in a clean area following doffing of PPE and hand
hygiene
 The patient will be given a bag containing printed post- operative instructions, a
copy of the consent form and some gauze
 The treatment will be provided and the patient be given time to recover before
leaving the room
 The patient will be asked to use hand sanitiser and to wear a face covering before
leaving the treatment room.
D.Discharge
 The patient will be discharged into the care of a Nurse/HCA wearing a mouthmask. We
will phone the escort to return to the department to meet the patient if necessary.
 The patient will be escorted out of the department and instructed to leave the Trust site
in a timely manner.
 We strongly advise patients not to go back to OMFS reception as future appointments
will not be made on the day. These will be arranged by letter / email / telephone call in

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 due course as necessary. The patient will need to contact us if they need to make any
changes to follow up appointments.

Scrubs should not be worn outside the hospital.Hospital issued scrubs should be placed in
the dirty laundry area. If they should be taken home for washing after a day’s wear in a
sealed plastic bag, pillowcase or dissolvable single-use bag. They should be washed
separately from other clothing at the highest possible temperature in a half-full load and then
tumble dried or ironed.
Clean your phone (particularly touch screen) using disinfecting wipes (check with the maker of
your phone).Frequency of cleaning will vary depending on your habits and the likelihood of
exposure.
BDA Returning to Work Toolkit 2nd June 2020
https://bda.org/advice/Coronavirus/Pages/returning-to-work.aspx
Office of Chief Dental Officer England – Standard operating procedure – Transitioning to
recovery 4th June 2020
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-
transition-to-recovery-SOP-4June.pdf
ouh covid 19 documents and resources
https://www.oxstar.ox.ac.uk/
Recommendations for Oral Surgery during COVID-19 pandemic
References https://www.rcseng.ac.uk/dental-faculties/fds/coronavirus/
COVID 19 SPL:
https://digital.nhs.uk/coronavirus/shielded-patient-list#overview
https://www.ouh.nhs.uk/covid-19/faqs.aspx
FGDP Guidelines:
https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/Implications%20of%20COVID-19%20for
%20the%20safe%20management%20of%20general%20dental%20practice%C2%A0-%20a
%20practical%20guide.pdf
PHE for PPE
https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-
aerosol-generating-procedures
Helpful videos:
1) Removal of Level 1 PPE : https://www.youtube.com/watch?v=u02WJaZHf0s
2) Removal of Level 2 PPE: https://www.youtube.com/watch?v=Tl93QUmxlyU
https://www.youtube.com/watch?v=MNXgElEBADA&feature=youtu.be
3) Handwashing : https://www.youtube.com/watch?v=wJ74h1t-DB0
https://www.youtube.com/watch?v=IisgnbMfKvI
4) Donning : https://www.youtube.com/watch?v=kKz_vNGsNhc
5) Doffing: https://www.youtube.com/watch?v=oUo5O1JmLH0
Doffing Force 8 and 10 mask: https://www.youtube.com/watch?v=HQ9UID1n4Y8

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