Art-6-4-2020
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INFLUENCE OF THE COVID-19 PANDEMIC ON DENTAL
Review Article
PRACTICE: WHY MEASURES TO BE TAKEN -
THE EXPERIENCE OF AN EUROPEAN UNIVERSITY
HOSPITAL (PART 2)
Constantinus Politis1a* , Annette Schuermans2b , Katrien Lagrou3c , Mia Vande Putte4d , Jean-Pierre Kruth5e
1
Department OMFS, Department Imaging and Pathology, Faculty of Medicine, Leuven University Hospitals, Leuven, Belgium
2
Department of Hygiene, Infection Control and Epidemiology, Faculty of Medicine, Leuven University Hospitals, Leuven, Belgium
3
Department of Laboratory Medicine, Faculty of Medicine, Leuven University Hospitals, Leuven, Belgium
4
Hospital Hygiene and Infection Control Department, Faculty of Medicine, Leuven University Hospitals, Leuven, Belgium
5
Wet Engineering Department, Technical Service, Faculty of Medicine, Leuven University Hospitals, Leuven, Belgium
a
MD, DDS, MM, MHA, PhD, Full Professor & Chairperson OMFS; e-mail: constantinus.politis@uzleuven.be; ORCIDiD: https://orcid.org/0000-0003-4772-9897
b
MD, PhD, Professor; e-mail: annette.schuermans@uzleuven.be; ORCIDiD: https://orcid.org/0000-0002-0998-8241
c
PharmD, PhD, Full Professor KU Leuven; e-mail: katrien.lagrou@uzleuven.be; ORCIDiD: https://orcid.org/0000-0001-8668-1350
d
Infection Control Practitioner, Expert of the Higher Health Council; ICP; e-mail: mia.vandeputte@uzleuven.be;
ORCIDiD: https://orcid.org/0000-0003-0556-5345
e
Eng, Ir; e-mail: jean.kruth@uzleuven.be; ORCIDiD: https://orcid.org/0000-0003-0362-8875
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(4).art.6
Background The COVID-19 pandemic does not leave the dental practice unattended. In Part 1 the reason
why measures should be taken was explored.
Objective The objective is to review the measures that can be taken to minimize the risk of tranmission in
the dental practice.
Data Sources These measures can be classified according to the guidelines of the National Institute for
Occupational Safety and Health (NIOSH).
Study Selection A qualitative approach explores the applicability of these guidelines to the dental practice.
Data Extraction In order to prevent aerosol transmission in the dental practice a large number of changes
are needed. It concerns hygiene protocols, organizational protocols and architectural changes, none of
which are backed by a legal framework.
Conclusion Until a vaccination program is introduced to counter the COVID-19 pandemic in a country, the
dental society will need to take measures to prevent aerosol transmission in the dental office. The pyramid of
measures according to NIOSH offers a suitable frame to classify all measures. Any legal regulatory intervention
could use this framework.
KEYWORDS
COVID-19; Aerosol; SARS-2-COV; Personal Protective Equipment; Respirator.
1. INTRODUCTION influence of the COVID-19 pandemic on the general
dental practice could be expected in the absence of
After the outbreak of COVID-19 in Wuhan, China, the a vaccination program. The second part tries to list
virus spread to the rest of the world and on March all measures that could be taken (hygiene measures,
11, 2020, the COVID-19 pandemic was formalized organisational and architectural changes) and to
by the World Health Organization. Part 1 of the provide a framework according to NIOSH pyramid
manuscript did answer the question why a lasting which is well-known in the industry [1].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Politis C, Schuermans A, Lagrou K, Vande Putte M, Kruth JP. IInfluence of the COVID-19 pandemic on dental practice: measures to be taken -
the experience of an European University Hospital (part 2). Stoma Edu J. 2020;7(4):275-285.
Received: September 13, 2020; Revised: September 18, 2020; Accepted: September 27, 2020; Published: September 29, 2020
*Corresponding author: Prof. Dr. Constantinus Politis, MD, DDS, MM, MHA, PhD; Full Professor & Chairperson Oral & Maxillofacial Surgery
Kapucijnenvoer 33B, BE-3000 Leuven, Belgium
Tel. +32 16 341780; Fax: +32 16 332437; e-mail: Constantinus.Politis@uzleuven.be
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Figure 1. "Aerosolised" after light signals in recording studios.
Figure 2. Between patients,
a "transition time" should be
observed to disinfect the treatment
room at the most sensitive points
of contact.
2. METHODOLOGY: CLASSIFICATION OF dental chair cannot be achieved conclusively, but in
MEASURES the hierarchy of measures it is preferable that it takes
place as close as possible to the source, in fact as
When considering COVID-19 as a new infectious close as possible to the potentially infected patient.
agent for dental practice, it seems wise to follow the In concrete terms, the production and diffusion
pyramid of basic interventions that apply to every of aerosols must be tackled and contamination
workplace, the “hierarchy of controls” as defined through direct and indirect contact with the source
by the National Institute for Occupational Safety of contamination must be avoided or prevented.
and Health (NIOSH) in the United States. Infection The following measures, under the heading of
control measures can also be tested against this elimination, will appear in infection control protocols
criterion in order to arrive at practice-oriented in the future, if they are not already present :
recommendations [2]. - as soon as possible: vaccination
Five questions are asked: - questionnaires to prevent potentially infected pati-
- Can the agent be eliminated? ents coming into the dental practice
- Can the agent be replaced by a less harmful agent - point-of-care PCR testing
(substitution)? - other point-of-care diagnostic testing for COVID-19
- Can the employee be isolated from the agent (tech- - measuring the patient’s temperature: if >37.3°C, the
nical controls)? patient should contact the general practicioner.
- Can the working method be adapted (administrative - The patient washes his hands with soap and water
control)? and, after drying them with pure paper wipes,
- Is personal protective equipment (PPE) possible? disinfects them with an alcohol hand solution (>
70%) when entering the practice.
3. RESULTS - the patient must wear a mouth mask up to the office
chair
3.1. Elimination - the patient enters the practice alone (unless super-
Elimination means no exposure to the COVID-19 vision is required)
virus. This is the purpose of the lock-down, of the - contactless access to the practice chair
quarantine measures and PCR testing. By ensuring - rinsing the mouth with 1% hydrogen peroxide or
that, no COVID-19 positive patients in the dental 1% povidone iodide mouthwash before any inter-
practice undergo any aerosol generating procedure. vention causing aerosol production
Dental treatments in COVID-19 positive have been - use of the rubber dam whenever possible
assigned to treatment centres equipped for this - use of surgical suction with a flow rate of 300 l/min
purpose if the treatment could not be posponed. where possible
Another means is a vaccination schedule for the - patients with drooling: scopolamine or atropine
population that cancels out the virus spreading. patch
However, in the absence of a vaccine and systematic - the use of mobile extra-oral fog extraction systems
PCR screening, each patient must be considered as - the use of disinfectants in tap water of rotating
a possible source of infection for the COVID-19 virus instruments or ultrasonic instruments.
and, mutatis mutandis, for all aerosol-transmitted All current measures for cleaning and disinfecting
germs (chicken pox, influenza, tuberculosis, measles, surfaces remain valid both inside and outside the
etc.). The elimination of the source of infection in the splash zone; in this case, the surface is first cleaned
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Figure 3. From left to right: a surgical nasal mask, an FFP-2 nasal mask
with valve, an FFP-2 nasal mask without valve.
Figure 4. Prolonged wear-
ing of an FFP-2 mask causes
pressure sores on the facial
of visible dirt and only then disinfected following the skin.
guidelines for the correct use of disinfectant; as an
example, but not exhaustively [3,4,5,6,7,8,9,10,11,12, 3.3. Technical measures
13,14,15,16]: The main innovation that will be triggered by the
- Alcohol-free wipes (wipes) based on a mixture of COVID-19 virus is air treatment in dental practices.
several different quaternary ammonium compounds Hospitals have had to invest in this area for several
and a biguanide have a broad biocidal spectrum; decades, both for general air quality and for treat-
this intermediate degree of disinfection is sufficient ment rooms or operating theatres [21,22,23].
for the COVID-19 virus. We expect measures to be taken in both dental
- A higher degree of disinfection can be achieved intervention rooms as in the general dental practice.
with concentrated sodium hypochlorite, but beware 3.3.1.Treatment area
of chlorine applications on stainless steel: in the long Hospitals have different “classes” of surgery or
term, stainless steel will be affected; especially with treatment rooms [24,25].
lower quality stainless steel, this effect will be more - A “treatment room” in a Belgian hospital has no
quickly noticeable. “class”, no clean or limited ventilation system, no
- Surfaces can be disinfected with more than 70% HEPA air filtration, if possible, a ventilation rate of
alcohol after cleaning. 6 is achieved. It is impossible to measure over- or
- Electrical or electronic appliances are rubbed underpressure because these treatment rooms
with alcohol-based disinfectants to prevent are often not airtight. Ventilation can be achieved
damage. Computers, keyboards and accessories are by opening the windows or using a ventilation
disinfected with 70% isopropyl alcohol to prevent device if there are no windows. Usually an ISO class
damage to the LCD screen. 8 according to ISO14644 is obtained at rest (i.e.
In a hospital context, experience is gained by making maximum 3520000 particles > 0.5 μm and maximum
the treatment room reusable during the transition 29300 particles > 5 μm). It is these particles or dusts
period : that can serve as carriers for possible bacteria and
- Nocolysis: this involves atomisation with an 8% viruses, just as aerosols can serve as carriers for the
hydrogen peroxide solution; this hydrogen peroxide COVID virus. The number of colony-forming units
is transformed into oxygen radicals which inactivate allowed is < 500 CFU/m3. This is in fact also the
viruses and bacteria; this mist is toxic; for a 50 m3 situation in most dental practices.
room, a spraying time of 3 minutes and an average - Class 2 operating theatres (also called performance
waiting time of one hour (exposure time, ventilation requirement 2) have a mixed ventilation system,
time) is required; this solution is expensive. HEPA air filtration, a multiple ventilation factor of 6
- There are systems for disinfecting treatment rooms to 30 times (criterion for new buildings). Usually an
and entire operating theatres based on UV-C light, ISO class 7 according to ISO14644 is imposed at rest
but they are not used in general dental practice (i.e. max. 352000 particles > 0.5 μm and max. 2930
because the UV-C light for this application is particles > 5 μm). The permitted number of CFU/m3
unprotected and toxic, but also because of the high is < 200. The operating theatre (zone 1) is normally
cost of these devices [17]. over-pressurised compared to the rest of the hospital
The infectivity of the air depends on the size of the (zone 2) in order to protect the operating area from
room, the number of air changes, the procedure environmental contamination. Overpressure in
(aerosol or not), the number of people in the room the room is possible if it is constructed in a sealed
(coughing or not): allowing natural ventilation by manner. Different rooms can be operated by a
opening the windows wide always has an important common ventilation system. The exhaust air is
place in the prevention of infections [18,19,20]. always blown outside (no air recovery).
- A class 1 operating theatre (or performance
3.2. Substitution requirement 1) is equipped with an unmixed
Substitution of the infectious agent by a less harmful ventilation system, laminar flow integrated in the
agent is not possible for COVID-19. plenum, HEPA filtration, a ventilation rate of between
30 and 60x per hour (criterion for new buildings),
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Figure 5. Procedure under local anaesthesia in a PCR negative patient Figure 6. Procedure under local anaesthesia in a PCR-negative patient
with low aerosol production; no drilling. On the right, an FFP-2 mask is with high aerosol production; drilling takes place. In this case, it is preferable
worn with a valve. A conventional surgical mask would have sufficed in this to wear safety glasses, an FFP-2 mask without a valve and a disposable
situation (PCR negative). apron. The FFP-2 mask of the person on the right side of the operating ta-
ble has an exhalation valve and is therefore defective.
an ISO class 5 system at rest below the plenum and because it is located in the aerosol production area.
ISO class 7 at the periphery and a maximum of only An ordinary saliva aspirator does little to control the
10 CFU/m3 allowed. The operating theatre (zone 1) production of aerosols. Surgical suction does have
is located in an operating room (zone 2) which is an effect on the transmission of droplets and droplet
separated from the rest of the hospital (zone 3). nuclei [27,28]. An extra-oral saliva aspirator may
The air flow is from zone 1 to zone 3. This type of be effective in some situations, but it is designed
operating theatre usually has one ventilation unit for industrial use and is very bulky and intrusive in
per operating theatre. The extracted air can be practice. As COVID-19 likes humidity, the installation
partially recirculated and re-injected through the of a dehumidifier can be defended on a theoretical
HEPA- filters in the plenum. basis [29]. A stand-alone dehumidifier is usually
- Fungal infections are not allowed in classrooms or sufficient for a space of 100 m2. Humidity in a dental
treatment rooms. practice comes from the aerosols created during
- Operations under general anaesthesia usually take the dental treatments, from evaporation after
place in class 1 or class 2 operating theatres, while disinfection of surfaces and spaces and from the
oro-maxillo-facial surgery and dental treatments autoclave. However, if regular natural (windows) or
which can be performed under local anaesthesia or mechanical (ventilation devices) ventilation takes
IV sedation are located in treatment rooms. place, the room will already be dehumidified in this
The operating theatres operate with an overflow of way. The added value of a stand-alone dehumidifier
air from the room to the environment to prevent will then be much more limited or even non-existent.
pathogens from entering the operating room These are devices designed to purify the air quality
from outside and compromising the sterile field. and reduce the number of particles circulating in
This is achieved by blowing more air into the room the air, but without any effect on the transmission
than is sucked in. The excess air escapes from the of droplets :
room through the door slots or grilles. If the room - Air disinfection systems based on UV-C light
is sufficiently sealed, the air flow can be properly with a peak emission wavelength of 253.7 nm; the
controlled and even measured with differential contaminated air is sucked into the unit where it
pressure meters. This is called positive pressure. is irradiated by a number (often 4) of UV-C lamps
In the case of an infected patient in the operating which inactivate all biological particles by damaging
room, the patient is the source of the pathogens and the DNA. These units can be operated during active
to maintain the source of infection in the operating dental treatment and do not allow UV-C radiation to
room, it is necessary to modify the air flow from the escape thanks to the good shielding of the housing.
environment to the operating room, or to create a There is no production of ozone or other by-products.
negative pressure [26]. More air is then extracted These devices are suitable for killing bacteria, viruses
than is blown in. If possible, the contaminated air and fungi. Care must be taken with UVC as UVC is
is diverted to the outside by a powerful extraction harmful to plastics.
system with a double filter (pre-filter and HEPA filter). - Air disinfection systems based on HEPA filtration
If the air is recirculated anyway, as in class 1 operating are realistic for the general dental practice because
rooms, it is returned through the HEPA filters into the of the affordable price, the absence of any toxicity
plenum before entering the operating room again. and because they do not require any interruption of
In the dentist’s treatment room, only the surgical practice. HEPA filters are well known in the hospital
suction is able to draw in the aerosol most powerfully sector where they are integrated into the plenum of
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Review Article
Figure 7. PPE in the form of PAPR when entering the operating room to Figure 8. Even if a dentist takes maximum personal protective measures,
perform an aerosol-producing procedure on a COVID-19-positive patient he or she cannot prevent consecutive patients from becoming mutually
in the contagious phase. infected with aerosols; additional ventilation measures are necessary.
operating theatres. The room air flows over a HEPA to inactivation by cold plasma. Natural ventilation by
filter and an activated carbon filter with a filtration opening windows can achieve up to 10 air changes
efficiency > 99.9% for all particles between 0.3 μm per hour, but depends on a number of important
- 0.4 μm. Simple commercial stand-alone units are parameters such as wind, outside temperature,
generally suitable for treatment areas of 75 m3 and window type, surface area, room orientation and
allow about 4 to 6 air changes per hour, depending opening duration of the windows. In order to
on the filtration rate. The main disadvantage of these reduce air contaminants by 90%, 2.5 air changes are
units is noise. The position of the unit must prevent required [36,37,38]. The time required depends on
aerosols from being sucked into the dentist. the number of air changes per hour achieved. For
- mobile or wall-mounted air purifiers based on the calculation of the required change time (= time
ionisation are extremely effective and broad- needed between the last aerosol production and the
spectrum and are capable of removing viruses, entry of the next patient into the treatment room),
bacteria, prions and odours [30,31,32]. The particles any scientific studies carried out in a real dental
are, so to speak, electrocuted and collected in an practice environment are still missing. As a rough
activated carbon collector. In addition to pulverising estimate, without a rocksolid scientific basis, it is
the aspirated particles with negative electrons, the assumed that the time required for 2.5 air changes
ioniser also creates reactive oxygen radicals. The with closed windows without mechanical ventilation
cartridges of these air purifiers must be replaced can vary between 5 and 25 hours, whereas widely
regularly. These devices can also be installed in open windows on either side of the treatment room
rooms where there is over- or underpressure. These can complete the work in 5 minutes. Open windows
devices have a low air flow rate. Approximately 2.5 and mechanical ventilation seem to achieve this in
air changes per hour are achievable for commercially 15 to 30 minutes. In rooms producing aerosols, the
accessible units. Larger units are available with more World Health Organization does not recommend 2.5
air changes per hour, but less suitable for general air changes per hour, but 6 to 12. A unit with a flow
practice. It is important to check that the unit does rate of 400 m3/h placed in a standard 40 m3 box will
not produce ozone as an end product. Most ionizers provide 10 air changes per hour [39,40].
on the market are also equipped with some filters 3.3.2. General dental practice
to stop coarse particles before the residue passes In contrast to class 1 or 2 operating theatres, where the
through the ionizer. large amount of ventilation air is cooled and filtered
- Devices that inactivate micro-organisms on the in the ventilation system, in treatment rooms or in
basis of cold plasma (= ionised gas) and HEPA- most dental practices, autonomous air conditioning
filtration work by generating a high electric field of 10 units are required to achieve pleasant temperatures
kV/cm in the cold plasma vacuum reactor by means all year round. Harmful micro-organisms can escape
of dielectric barrier discharges in which oxygen through such systems [41,42]. It is therefore important
radicals disinfect the air, and the filters ensure that no to ensure that rooms, windows and doors are well
particles leave the device [33,34,35]. These are fast- sealed and to use air filters and air conditioners that
acting devices (less than 2 minutes for a treatment are regularly maintained and replaced. In practice,
room) with an inactivation efficiency of >99.9% filters should be replaced at least once a year and
for particles greater than 0.3 μm without leaving drip pans should be cleaned. For more sensitive
residues. The disadvantage is their weight (around operations, it is even recommended several times
200 kg) and the high cost of their maintenance. This a year. Ventilation through natural or mechanical
technology was originally developed for the MIR extraction works. Contamination of a dwelling
space station. Fungi such as Aspergillus are resistant adjacent to the practice by a collective ventilation
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Figure 9. Most outpatient dental and oral surgery facilities are currently not equipped for aerosol control or ventilation, nor for physical separation or
separate walking routes for patients and the provision of care.
system is unlikely, but it is recommended that, if Since using the toilet also causes hand disinfection
possible, a distance of 5 to 10 metres should be kept by touching the glasses, the creation of an aerosol
between the discharge grille and open windows or after flushing the toilet will also require technical
the suction grille. The movement of impure air from innovations, e.g. the installation of UV-C light for
central rooms to service rooms (garages, cellars, etc.) decontamination, and the invitation to wash hands
may be insufficient if, for example, the windows of thoroughly after each use of the toilet should be
these service rooms are open. displayed [45,46,47,48,49]. Pets will be left in the car
park and personal belongings will remain at home
3.4. Organisation of the practice or be stored in a locker. The practice is organised
Many trends already present in the hospital sector in such a way that contact with people and objects
will accelerate their entry into the general dental is kept to a minimum, including doorbells, door
practice: digital appointment management, handles, payment terminals and other points of
numerous smartphone applications for contactless contact. Video consultations can be useful in general
payment, filling in questionnaires, access and dentistry for triage, questionnaire completion,
completion of one’s own dental record [43]. follow-up and assessment of problems that do not
A treatment room where an aerosol is produced will necessarily require an intra-oral examination.
remain closed with an indicator light to prevent entry Existing guidelines on waste management are
during treatment (Fig. 1). At the reception perspex sufficient [50]. Although less critical than not
creates a safe partition between the patient and the respecting deadlines in the legal profession, the
receptionist. In between two successive patients, expiry of storage periods for disinfectants should
there should be time for a complete cleaning of the be monitored with the establishment of systems
unit and the contact points of the patient and the to record regular maintenance, cleaning, toilet
practitioner (door handle, lamp, chair, keyboard). In cleaning. Water-based disinfectants may be stored
a conventional hospital environment, the “transition for 7 to 14 days once opened; in the case of alcoholic
times or change-over time” in an operating theatre solutions, no storage period is used unless limited
are known (Fig. 2) [44]. by the manufacturer. Maintenance contracts and
Wall posters, patient leaflets with instructions and cost-benefit analyses and vaccination schedules for
guidelines, digital wall signs with information, signs, auxiliaries should not be missed.
indicators and markings on floors and walls are
among the possibilities. 3.5. Personal protection measures
In places where patients come, it should be possible As far as personal protective measures are
to disinfect their hands and obtain a mouth mask. concerned, all guidelines on hygiene and hand
The decoration of the rooms should be very sober; washing remain fully in force [51]. Nothing has
drinking fountains should be avoided. changed with regard to gloves in dental practices
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either. It should be emphasised that hands must be mask under the surgical mask and behind the face
Review Article
washed or disinfected (alcohol > 70%) before and shield or goggles during every aerosol-generating
after wearing gloves. This is because the gloves are procedure, or will wear the FFP-2 mask only if he
not completely sealed. The penetration of the virus or she considers himself or herself to be one of the
was demonstrated in 8-14% of the sterile gloves groups at risk of suffering from a potentially severe
examined. Sterile gloves must also be changed form of COVID-19 and therefore wishes to have
every hour during critical medical procedures. The additional protection during aerosol-generating
three reasons for regularly changing gloves are lack treatments in the absence of PCR screening or
of complete occlusion, damage to the gloves by vaccination (Fig. 5, Fig. 6). The usefulness of surgical
sharp objects (instruments) and contamination of masks and FFP-2 masks is lost if they get wet or are
the hands when removing the gloves. poorly fitted. A face shield or face mask can reduce
Sciensano reports that it is necessary to wear short-term exposure to large infectious particles
professional clothing, including shoes. As aerosols and thus reduce contamination of nasal mouth
can precipitate on clothing, contact contamination masks, but after 1-30 minutes, the total reduction
is possible afterwards. To avoid this, one of the in contamination is only ± 23% according to some
following choices is recommended (Sciensano) [38]: publications [56]. Face shields are less effective
- Wear a disposable long-sleeved apron and replace against small particles. After all, these particles can
it between patients. stay in the air longer and can easily get behind the
- Wear a long-sleeved overshirt made of washable face mask. Nasal masks and splash goggles or face
fabric and replace it between each patient, and wash shields should not be touched by the healthcare
it at 60°C before the next use. Waterproof aprons are provider in the infected area [57].
ideally made of polypropylene with a density of at Dentists who prefer to wear a surgical mask rather
least 25g/m2. than an FFP2 mask should preferably choose an
- Wear a washable short-sleeved fabric apron and FFP2 mask with a valve, which allows much more
wash the forearms between each patient. comfortable exhalation.
- The aerosol-infected apron should be removed Reuse of surgical masks is not possible. Watering or
before leaving the treatment area and placed in the moistening surgical mouth masks is not a good idea.
appropriate garbage bag or dish basket. FFP-2 masks can be reused twice after resterilization
It makes sense to wear a surgical cap or headgear. with hydrogen peroxide and low pressure gas
Overshoes are not useful. Wearing professional sterilization [58,59]. Goggles and face shields are
silver-impregnated aprons makes no sense because washed with soap and water and, after drying,
silver usually disappears after about ten washes disinfected with disinfectant alcohol or treated in
along with the supposed protection [52]. the instrument washer. PAPRs (Powered Air-Purifying
For patients who are known to be COVID positive Respirators) are breathing apparatus in the form of
and need urgent treatment, long-sleeved splash a bonnet or full face mask with a battery-operated
aprons and washable shoes should be worn. fan that conducts a positive air flow through a filter
The existing guidelines of the High Council of Health to the bonnet [60]. The filter is the equivalent of a
(Publication no. 8363) concerning the wearing of HEPA filter that retains 99.7% of the particles in 0.3
nasal masks, corrective glasses, splash goggles and μm. This type of maximum protection is justified
face shields remain unchanged, with the difference for the treatment of a COVID-positive patient in
that in addition to tuberculosis, COVID-19 can now the contagious phase, but it is almost impossible
be added [51]. The masks stop the drops that carry to use in an ambulatory dental setting because
the virus [53,54]. An FFP-2 mask must be CE-certified communication with the patient is completely
and must not have an exhaust valve, as the health disrupted. There is also a high risk of infection if this
care provider is then protected, but not the patient PAPR is taken off (Fig. 7) [61]. Even if a dentist takes
(Fig. 3) . Mouth masks are exorbitantly expensive in maximum personal protective measures, he cannot
corona time: about 55 cents for a surgical mouth mask prevent consecutive patients from infecting each
and about 10 euros for an FFP-2 mask. Theoretically, other through aerosols contaminating the air in the
FFP3 masks offer better protection than FFP-2 masks treatment room; additional ventilation measures are
with regard to COVID-19, but in practice FFP2 masks necessary (Fig. 8). An under-exposed chapter is one
will suffice, also in the hospital sector. FFP stands of the many mistakes made when putting on / taking
for Filtering Facepiece Particle (filtering particle of off / removing personal protective equipment (PPE)
the mask). FFP-2 is the European (EU) standard and [62]. It is almost impossible to carry out donation
the equivalent of the N95 nasal mask certified by the and removal protocols correctly without training.
US National Institute for Occupational Safety and Wearing a beard under a mask is a common mistake.
Health (NIOSH). An FFP mask has the disadvantage Keeping gloves on between surgeries or touching
of causing pressure ulcers at pressure points and a clean surfaces with soiled gloves or touching the
common complaint is that it is difficult to breathe or surface of a mask with the hands explain why PPE
work when worn for long periods of time (Fig. 4) [55]. does not figure prominently in the hierarchy of
In practice, this means that a dentist wears an FFP-2 measures.
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4. INSTRUMENTS cleanability and disinfection.
Review Articles - Screens must be hidden without cables
With regard to dental instruments, no changes - The spit bowl should be redesigned to be extremely
have been made to the policy described in policy easy to clean and replace
document No. 8363 of the High Council of Health - Automated pipe flushing.
in 2011. The 1957 E.H. Spaulding risk categories It is not inconceivable that accreditation will be
continue to stand the test of time, even in coronary required in the long term for surgery rooms. This
periods [63]! To grind bite plates and other tips on concept will have to take into account the existing
the chair, simply immerse them in 3% hydrogen ISO standards for clean rooms in order to keep
peroxide for 30-60 seconds before sharpening. pace with current regulations. ISO standards do not
It is also recommended not to allow unused determine the number of air changes, but rather the
instruments in the splash area or aerosol area to maximum number of particles that can be found in
prevent contamination. the air in the room in question per cubic metre. This
can be done by ventilation, filtration or both.
5. ARCHITECTURAL INNOVATION Again, it is possible to differentiate between
orthodontic practices with many children where
There is no doubt that the new surgeries to be transmission problems (for COVID-19) have less
created offer great opportunities for architectural consequences and less aerosol production compared
innovation, as most oral and dental surgeries are not to general dental practices where the practitioner
equipped for aerosol and ventilation control (Fig. 9) and 28 patient are almost always connected at a
[64]. Several options exist to improve ventilation,air short distance by an aerosol spray during intra-oral
quality and air disinfection in dental practice, apart healing procedures.
from other architectural interventions influencing
patient flows: 6. CONCLUSION
- The treatment cabinets could be designed to
obtain negative pressure by extracting more air than The COVID-19 pandemic highlighted aerosol
it enters transmission in the chain of infection. Using the
- Good natural ventilation of the practice NIOHS pyramid of interventions a systematic
- Air changes of at least 6 to 12 changes per hour approach can be utilized to combat aerosol
- Ventilation ducts that do not lead to another room transmission in dental practice. The development
where people are sitting of new practices to be implemented is an excellent
- Control of air inlets and outlets opportunity for architectural renewal. In addition,
- Installation of HEPA filters COVID-19 provides an impetus towards the
- Working with several practices that allow for a time development of new technologies that generate
interval between practices less aerosols and towards new concepts to facilitate
- Conversion of a parking space into a workspace for the disinfection of dental facilities and practices.
waiting and recharging electric cars Extensive digitisation of the dental practice
- Good connectivity between the practice and the was a trend that is now becoming a necessity.
car park with the necessary remote surveillance and, Universities offer good education and training in
if necessary, automatic license plate recognition at PPE. Professional associations will be needed to
the car park entrance or in the outside waiting area. maintain economically viable dental practices in the
- The necessary facilities for maximum digitisation of health care field, accessible to all social strata of the
the practice population.
- If waiting rooms are still provided, taking into
account the rules of physical distance CONFLICT OF INTEREST
- Concept allowing gateways with minimal contact The authors declare no conflict of interest.
- Use of non-porous work surfaces and sinks impreg-
nated with a homogeneous distribution of copper AUTHOR CONTRIBUTIONS
oxide (Cu-O). Copper is bactericidal and virucidal.
In dental practices, closed shelves are preferred All authors contributed to this paper. CP: contributed to its
to open shelves because open ones can be concept and writing. AS and MVP: contributed to the protocol. KL:
contaminated by aerosols. contributed to the data gathering and analysis. JK: contributed to
Innovation will also be needed in the treatment critically revising the manuscript.
unit to allow for quick and proper cleaning between
patients: ACKNOWLEDGMENTS
- Swivel arms should be avoided as much as possible.
None.
- Redesign of drill pipes, air syringe, suction for
282 Stoma Edu J. 2020;7(4): 231-241 pISSN 2360-2406; eISSN 2502-0285
Influence of the COVID-19 pandemic on dental practice
www.stomaeduj.com
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54. Arellano-Cotrina JJ, Marengo-Coronel N, Atoche-Socola KJ,
Constantinus POLITIS
MD, DDS, MM, MHA, PhD
Full Professor & Chairperson
Oral and Maxillofacial Surgery Department
Faculty of Medicine
University Hospitals Leuven, KU Leuven
Leuven, Belgium
CV
Dr. Politis is an Oral and Maxillo-Facial Surgeon. He is currently a Full Professor and Chairperson of the Department of OMFS at
Leuven University Belgium. He is an invited Lecturer at EHSAL in Brussels. He graduated from the Catholic University of Leuven
in medicine (MD) and dentistry (DDS), also specializing in oral and maxillofacial surgery at the same university. He defended his
doctor’s thesis on the subject of complications of orthognathic surgery (PhD). He followed additional postgraduate training in
Arnhem (Stoelinga), Aachen (Koberg), Copenhagen (Pindborg), Göteborg (Bränemark) and San Francisco (Marx). He also holds
a master degree in management (MM) and a master degree in Hospital Management (MHM). He is Secretary General of the
Professional Union of Belgian Oral and Maxillofacial Surgeons. He is acknowledged trainer of OMFS trainees. Clinical research
projects include prevention and repair of iatrogenic trigeminal nerve injury, transplantation of teeth and orthognathic surgery.
284 Stoma Edu J. 2020;7(4): 231-241 pISSN 2360-2406; eISSN 2502-0285
Influence of the COVID-19 pandemic on dental practice
www.stomaeduj.com
Questions
Review Article
1. An operating room under negative pressure: which of the following is a correct
statement?
qa. Has no plenum;
qb. Needs no HEPA-filtration;
qc. Is the de facto standard in hospitals with COVID-19 wards;
qd. Is the standard when operating on COVID-19 patient.
2. Which of following is not true or applicable when discussing humidity in a dental
practice:
qa. Humidity in a dental practice comes from the aerosols created during dental treatments;
qb. Humidity in a dental practice comes from the autoclave;
qc. The added value of a stand-alone dehumidifier is only present if enough regular natural (windows) or
mechanical (ventilation devices) ventilation takes place;
qd. The added value of a stand-alone dehumidifier is limited or even non-existent if enough regular natural
(windows) or mechanical (ventilation devices) ventilation takes place.
3. Which of the following parameters does NOT fit the following statement: "Natural
ventilation by opening windows can achieve up to 10 air changes per hour, but depends
on a number of important parameters such as:"
qa. Outside temperature;
qb. Circadian rhythm;
qc. Window type;
qd. Surface area.
4. PAPR (Powered Air-Purifying Respirator): which of the following statements is
unjustified
qa. Is synonymous for a FFP3 mask;
qb. Is a breathing apparatus in the form of a bonnet or full face mask with a battery-operated fan that
conducts a positive air flow through a filter to the bonnet;
qc. Has a filter with the equivalent of a HEPA filter that retains 99.7% of the particles in 0.3 μm;
qd. Carries a high risk of infection for the dentist when treating Covid-19 patients if this PAPR is taken off.
Stoma Edu J. 2020;7(4): 231-241 pISSN 2360-2406; eISSN 2502-0285 285