Endodontic and Dental Practice during COVID-19 Pandemic:

Position Statement from

International Federation of Endodontic Associations (IFEA)
& Indian Endodontic Society (IES)

Jogikalmat Krithikadatta1, Ruchika Roongta Nawal2, Kurinji Amalavathy3,

William McLean4, Velayutham Gopikrishna5

1
Associate Professor, Department of Conservative Dentistry & Endodontics
Faculty of Dentistry, Meenakshi Academy of Higher Education and Research,
Chennai, India. [email protected]

2
Associate Professor, Department of Conservative Dentistry & Endodontics
Maulana Azad Institute of Dental Sciences , New Delhi, India.
[email protected]

3
Prof and Head, Department of Conservative Dentistry and Endodontics,
Sathyabama Dental College & Hospital,Chennai, India.
[email protected]

4
Senior Lecturer, Glasgow Dental College,
University of Glasgow, Scotland. [email protected]

5
Adjunct Professor, Faculty of Dentistry, Sri Ramachandra University, Chennai, India.
Chairman - Education Committee, International Federation of Endodontic Associations
(IFEA) [email protected]

Corresponding author:
Dr. Velayutham Gopikrishna, [email protected]

1
Abstract:
The emergence of COVID-19 pandemic poses an immense global health challenge. As
dental care providers, we are faced with significant responsibilities both to the dental
team and our patients to limit exposure to the virus. Due to the nature of our work, the
team are at a high risk of contracting the virus and potentially transmitting the virus. One
of the prime modes of containing this pandemic is in enforcing effective social
distancing. However, as dental care providers we face the twin challenge of protecting
ourselves and our patients from community transmission and at the same time ensuring
patients continue to have access to urgent/emergency dental care. Whilst it is
recognized that practitioners from different countries will be subject to the governing
authorities and directives of their country, nevertheless this general position statement is
for the benefit of endodontists and dentists and provides an objective method of
streamlining their dental practices based on need and evidence based disease
containment protocols.

Keywords: COVID-19, SARS-CoV-2, Coronavirus, Aerosol, Nosocomial, Virus, Disease

transmission, Dentistry, Endodontics.

Introduction:
Coronaviruses are enveloped single-stranded RNA viruses that are zoonotic in
nature and cause symptoms ranging from those similar to the common cold to more
severe respiratory, enteric, hepatic, and neurological symptoms[1]. Other than SARS-
CoV-2, there are six known coronaviruses in humans: HCoV-229E, HCoV-OC43,
SARS-CoV, HCoVNL63, HCoV-HKU1, and MERS-CoV. Coronaviruses have caused
two large-scale pandemics in the last two decades: SARS and MERS[2].
On 29 December 2019, the first four cases of an acute respiratory syndrome of
unknown etiology were reported in Wuhan City, Hubei Province, China. It appears that
most of the early cases had some sort of contact history with a seafood market[1]. Soon
afterwards, a secondary route of transmission was found to be via human-to-human
close contact. The World Health Organisation (WHO) announced the official name of
the 2019 novel coronavirus as coronavirus disease - COVID-19[3]. The current reference
name for the virus is Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-
2). The disease was recognized as a pandemic on 11 March 2020, with global spread
affecting 5,97,283 individuals with 27,365 deaths at the time of writing. Most of the
evidence for understanding the disease process comes from the epidemiological
findings from China, Korea, Italy, USA and United Kingdom. The information from these
countries have helped researchers model and draw inference for the rest of the world.

2
 The nature of the dental setting puts both the dentist/dental team and the patient
at high risk of cross-infection. The COVID-19 pandemic, has led to the absolute
requirement for strict and effective infection control protocols beyond those that already
exist within the dental setting. The purpose of this position statement is to establish a
standard operating protocol for endodontic and dental practice in the current climate.
This document presents the essential knowledge about COVID-19 and nosocomial
infection in dental settings along with recommended management protocols for
institution-based and private clinical practices.

Routes of transmission:
The three most common transmission routes[4] of novel coronavirus include:
i. Direct transmission (through cough, sneeze or droplet inhalation),
ii. Contact transmission (through oro-nasal-ocular route) and
iii. Aerosol transmission.

Asymptomatic carriers of the infection are equally capable of transmitting the

virus as symptomatic patients[5]. The SARS-CoV-2 virus can be detected in aerosols
up to 3 hours post operatively, and can persist on surfaces for extended periods.
The nature of the surface alters the persistence of the virus. On copper surfaces the
virus can persist for up to four hours, on cardboard up to 24 hours and on plastic and
stainless steel up to 2-3 days[6]. The droplet and aerosol transmission of SARS-CoV-
2 are the most important concerns in dental clinics and hospitals[7], because it is
hard to avoid the generation of large amounts of aerosol and droplet mixed with
patient’s saliva and even blood during dental procedures[8].

Symptoms of COVID-19 and related co-morbidities:

A systematic review and meta-analysis of 19 studies and 36 case reports
concluded that, for 656 patients the most prevalent symptoms include:
• Fever (88.7%),
• Cough (57.6%)
• Dyspnea (45.6%).
Among these patients, 20.3% required admittance to an intensive care unit (ICU),
32.8% presented with acute respiratory distress syndrome (ARDS) and 6.2% with
shock. Some 13.9% of hospitalized patients had fatal outcomes[9]. The presence of
comorbidities like hypertension, diabetes, cardiovascular diseases and respiratory
system disease are identified as major risk factors[10]. The mean incubation period of
COVID-19 is around 6.4 days, but can range from 0-24 days. Males were generally
affected more (60%) and the patients had a discharge rate of 42% and the fatality
rate was 7% [11].

3
Disease progress and containment:
A study from China CDC showed the majority of patients (80.9%) were
considered asymptomatic or had mild pneumonia but released large amounts of viruses
during the early phase of infection, which poses enormous challenges for containing the
spread of COVID-19. Asymptomatic carriers that were calculated based on the data
from the Diamond Princess cruise ship was as high as 17.9% [13].The basic reproductive
number (R0) denotes the number of people who can contract the disease from a
contagious person. The R0 of COVID-19 ranges from 2.6 - 4.7. Importantly, this is
higher than that of SARS or MERS[2].

Hence, social distancing has been encouraged/expected by many nations as a

single primary factor to reduce the rate of infection spread and to “flatten the curve” of
numbers of those infected over a period of time. Along with social distancing, other
measures taken to limit the doubling time and rate of infection is constantly updated by
the Center for Disease Control, USA[14]. This minimizes the potential for people to
contract the disease from a contagious person. For example, a recent report based
upon available data, projected the death of 260,000 individuals in the UK with the
absence of social distancing. In fact, this model not only advocates social distancing but
also recommends self-isolation for individuals 70 years of age and above. The
Indian Government have imposed restrictions on public gatherings beyond fifty and also
recommends self-isolation of the elderly population[15].

With vaccines and effective drugs still under trial, Imperial College London has
outlined several public health measures to slow down the disease progress[16]:
i.Home isolation of cases – whereby those with symptoms of the disease (cough and/or
fever) remain at home for 7 days following the onset of symptom.
ii.Home quarantine – this involves all household members of the individual(s) with
symptoms of the disease remain at home for 14 days following the onset of symptoms.
iii.Social distancing – this is a broader policy that targets to lower the overall contacts
that one makes with other people by three-fourths. This involves contacts made
outside the household, school or workplace.
iv.Social distancing of those over 70 years – as for social distancing but just for those
over 70 years of age who are at highest risk of severe disease.
v.Closure of schools and universities

4
 However, social distancing creates significant challenges for the provision of
dental services. Dental practitioners and in particular endodontists are health care
providers with a major role in management of dental emergencies including
symptomatic pulpitis, acute dental infections and dental traumatic injuries. Hence
complete closure of clinical practice/dental institutions is not recommended.
Dentists also can participate in health education services by extending the information
on prevention measures issued by their respective national and refer suspected COVID-
19 patients to government authorised institutions[17,18].

Providing Dental Care during COVID-19 Pandemic: Challenges

i.Dental care settings invariably carry the risk of SARS-CoV-2 infection due to the
nature of procedures performed7. Virus can be transmitted in dental settings through
inhalation of airborne viral particles that can remain suspended in the air for long
periods. Direct contact with blood, oral fluids, or other patient materials present a risk.
Contact of conjunctival, nasal, or oral mucosa with droplets and aerosols containing
virus particles generated from an infected individual can lead to infection. These can
be propelled a short distance by coughing and talking without a mask, and indirect
contact with contaminated instruments and/or environmental surfaces.
ii.Droplet and aerosol transmission of SARS-CoV-2 are the most important concerns
in dental clinics and hospitals. Most dental procedures involve the use of high speed
air rotors with water cooling; which generate large amounts of aerosol and droplet
mixed with patient’s saliva and even blood during dental practice. The aerosols are
small enough to stay airborne for an extended period before they settle on
environmental surfaces or enter the respiratory tract. Thus, SARS-CoV-2 has the
potential to spread through droplets and aerosols from infected individuals in dental
clinics and hospitals.
iii.The asymptomatic incubation period for individuals infected with SARS-CoV-2 is
variable but can be protracted. It has been confirmed that those without symptoms can
still spread the virus. This makes it extremely difficult to identify those individuals that
pose a risk[7]. Owing to the contagious nature of the disease, while we take a history
and carry out an examination of the patient and assess for urgency of dental need, an
asymptomatic patient could have acted as a potent source of infection for others.
iv.Risk of Nosocomial Infection: Since the health care workers themselves fall in the
high risk group for infection, exposure to them and to the health care settings is best
avoided or postponed to control community spread. As per an earlier report in the early
stage of the epidemic, on an analysis of hospitalized patients with SARS-CoV-2 41%
were presumed to have been infected in hospital, including 29% health care workers
and 12% patients [19].

5
Providing Dental Care during the COVID-19 Pandemic: Recommendations
As health care professionals it is our duty to mitigate the community spread of
this disease through responsible and informed actions. We need to fulfill our
professional duty towards our patients, and in particular obtain informed consent from
the patient of the proposed treatment(s), while keeping ourselves, our staff and
environment safe. The International Federation of Endodontic Associations (IFEA)
and Indian Endodontic Society (IES) recognizes and recommends the need for
immediate postponement of all elective dental procedures while keeping
emergency services operational. Concentration on emergency care will take care of
immediate patient needs for true dental emergencies while also reducing the load of
such emergencies on hospital emergency departments. The situation in hand is fluid
and not time limited, but may persist for some time and will require close monitoring.
The governing bodies and local governments are continuously providing timely updates
regarding the situation that needs to be closely monitored.
In this position statement, we intend to answer the following questions for the practicing
dentist: .
1. Specific Recommendations for dentists to triage patients to decide, what is a
dental emergency and when and how to schedule such patients
2. Recommendations regarding a work flow and steps to be followed in a dental
setting to reduce exposure while keeping the services functional for
emergency care
3. Infection prevention and control recommendations
4. Specific Dental Procedure Related Recommendations

1. Specific recommendations for dentists to triage patients to decide, what is a

dental emergency and when and how to schedule such patients.

1.1: Emergency Severity Assessment – An objective triaging tool has been

suggested to facilitate the scheduling of the patients based on the level of need. This is
based on the adaption of recommendations given by the American Dental Association
on 18th March 2020[20]. The operating question in this situation may be "How long can
each patient safely wait?"
The purpose of this triage is to limit incoming patients and to identify those who
cannot wait to be seen. It also will help in prioritizing the scheduling of patients as and
when we restore normal functioning in our dental set ups. This may be preferably
done by trained staff or dentists themselves through audio or video
communication channels. The following triages the patients into 3 categories (Table 1
and 2):

6
• Emergency Care
• Urgent Care
• Scheduled Care / Elective Care

Table 1 . Emergency Severity Assessment – Decision Making Tool

7
Table 2 : Recommended medications for Emergency Care Patients reporting with
severe dental pain during Covid-19 Pandemic

• The most recommended drugs of choice24,25,26 for treating acute pulpitis are:

✓ Acetaminophen 1000 mg (every 6 – 8 hours) OR

✓ Ketorolac Tromethamine 10mg (every 6 hours) OR
✓ Piroxicam 20 mg (every 12 hours) OR
✓ Ibuprofen 600 mg (every 6 hours) [Use with caution]*

• The pain felt by patients diagnosed with symptomatic irreversible pulpitis may be
also alleviated by administering 4 mg dexamethasone either orally Or through
intraligamentary and mainly supraperiosteal injections27.

• A Cochrane Review 28 illustrates that there is not enough evidence to recommend

the use of antibiotics to reduce pain in cases with irreversible pulpitis. (Kindly note
that if patient reports with signs and symptoms of acute apical abscess / cellulitis
then appropriate antibiotic medications has to be given)

• Current WHO guideline29 has not contraindicated the usage of Ibuprofen during
COVID -19 Pandemic as on 27th March 2020. However with conflicting research
in this issue this position statement would recommend the usage of alternative
medications to ibuprofen given in this table above.

8
2. Recommendations regarding a work flow and steps to be followed in a dental
setting to reduce exposure while keeping the services functional for emergency
care.
Certain specific measures are discussed here regarding general work flow for
dental patient management during this period.

2.1: Patient triaging and tele-screening:

To minimise the risk of exposure and community spread it is critical to reduce
physical walk-ins in the dental setting. This can be done effectively by tele-screening
and triaging by phone. Triaging is the process of determining the priority of patients'
treatment needs based on the severity of their condition. In telephone triage, decision
makers must effectively assess the patient's symptoms and provide directives based on
the urgency. This should be done in a timely fashion while meeting standard guidelines
in order to prevent symptoms from worsening[21].

The front-desk staff members should to be trained to triage callers based

on their emergency severity assessment of the dental condition and the exposure
risk categories related to COVID-19. Effective triaging of the emergency calls will
enable the practice to apply social distancing within the practice and plan the treatment
of dental emergency or urgent care more effectively[22]. Before physically appointing a
patient or attending to a walk-in patient in the dental setting, it is necessary to ascertain
the following:
• Exposure Risk Categories: Low/High based on a detailed medical history and
COVID-19 Questionnaire . (Annexure 1)
The main factors that may give vital insight into COVID-19 risk are (Table 3):
▪ Stage of disease spread in a particular geographic
location/state/country
▪ History of exposure to potentially infected persons or places
(through travel) - Positive COVID - 19 suspect
▪ Any respiratory illness symptoms (fever, coughing, difficulty in
breathing)
High risk patients should be directed toward the local authorities for assessment
and management. For the purpose of the dental setting, as a rule of thumb, all
patients should be considered as potential asymptomatic carriers, if not already
a known case of COVID-19. Dentist can track COVID-19 spread by accessing their
respective Ministry Of Health And Family Welfare website[23].

9
 Table 3: Covid-19 Risk Assessment Chart *

Geographical
location – Areas History of Temperature/Resp Risk Category
Stage 3 of exposure iratory symptoms
outbreak
(Community
Transmission )

+ + +

+ + - HIGH RISK

+ - -

- + +

- + -

- - + LOW RISK

- - -

*The risk assessment is based on the evidence gathered upto 27th March 2020. Since
the disease dynamics is constantly changing, the reader is referred to their respective
health bodies to keep abreast of the situation.

10
 • Emergency Severity Assessment of the associated dental condition
(discussed in Section 1.1) Only patients which fall under Emergency/Urgent Care
should be attended to or scheduled immediately for management. While others
may be tele-counselled, put under pharmacological management if needed
(Table 2) and kept on a telephonic follow up for any exacerbation of symptoms.

2.2: For physical walk-ins :

Direct walk-ins in the clinics should be greatly discouraged other than life
threatening dental conditions. Educating and informing the patients before-hand using
digital and mobile applications and messages and setting up of tele-consultation
avenues may prove to be effective tools for the same.
Pre-check Triage: Dental clinics are recommended to establish pre-check triages to
measure and record the temperature of every patient as a routine procedure (this
should also be carried out for all dental team members). As outlined above, all patients
on arrival should be questioned and a detailed medical history form should be
completed to identify patients at high risk from infection. A COVID-19 related
questionnaire completed to identify potential asymptomatic carriers and those that are
infected.
Only Emergency Cases should be attended to while others should be counseled
and appointed for a later date and may be kept on a telephonic follow up if needed.

3. RECOMMENDATIONS FOR INFECTION PREVENTION AND CONTROL

3.1. GENERAL RECOMMENDATIONS

As outlined previously, the triaging of patients is an essential step in

reducing the risks of COVID-19 transmission through reduction in the numbers of
patients attending and identification of symptomatic carriers.

Once a patient has access to the dental setting due to an identified

urgent/emergency treatment need the dental team can further limit the potential
impact of a dental visit. The patient if possible can be encouraged to avoid public
transport or travel alone. Upon arrival at the dental set-up, facilities should be
made available for patients to wash or disinfect their hands (see Box 1). Efforts
should be made to minimize the number of patients in the dental setting at any
one time. Patients should be seen promptly to limit waiting times. If possible
patients should not wait in waiting rooms.

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 Box 1: GENERAL RECOMMENDATION CHECKLIST
FOR DENTAL CENTRES BEFORE TREATING PATIENTS
DURING COVID 19 PANDEMIC*

• Place Visual Alerts for patient awareness using posters on COVID-

19 pandemic awareness, cough etiquette and hand hygiene
practices
• Modify existing patient waiting area seating arrangement to
enforce social distancing of 1 to 2 meters
• Insist on use of Alcohol Based Hand Rub (ABHR) for ALL upon
entry into your dental practice.
• Provide face mask for all patients prior to consultation.
• Tissue paper dispenser and foot operated waste bin mandatory in
patient waiting room
• Mandatory provision for hand washing with soap and water
• Avoid usage of commercial split/ centralized / window air
conditioners unless equipped with High Efficiency Particulate Air
(HEPA) filters
• It is recommended to use natural and mechanical ventilation using
fans and exhaust
*Adapted from National guidelines for infection prevention and control in
healthcare facilities, National Centre for Disease Control, Directorate
General of Health Services. Ministry of Health and Family Welfare,
Government of India. January 2020

*https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html
Guidelines for Environmental Infection Control in Health-Care Facilities
Recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee (HICPAC)

12
As outlined previously droplet and aerosol transmission are significant risks in the dental
practice setting. Due to the potential risk of asymptomatic COVID-19 patient presenting
in the dental setting appropriate measures to limit risk should be taken. The use of
personal protective equipment (PPE) in line with guidance should be used (see section
3.1.2). Generally, certain endodontic emergencies that necessitate the use high speed
handpiece to gain access to the root canal system should be performed under dental
dam and high volume aspiration[30, 31]. However, ALL aerosol generating procedures
should be avoided (see section 4.1).

If aerosol generating procedures are undertaken, operators should wear appropriate

personal protective equipment ideally comprised of a fluid-resistant mask, visor and
apron. It is important to remember to put on and remove PPE in an order that minimizes
the risk of contamination.

Even when not using aerosol generating procedures, it is important that robust
infection control measures are employed. In non-clinical areas such as reception
and waiting areas thorough cleaning should take place. Ideally all non-essential items
should be removed from these areas and surfaces free of clutter. (See section 4.5)

3.1.1 HAND HYGIENE

The WHO guidelines on hand hygiene in healthcare (2009) suggest that hand
hygiene is the single most important measure for prevention of infection.

• Hand washing with soap and water is preferred when hands are visibly dirty or
soiled with blood or other body fluids or after using the toilet.
• Use alcohol-based hand rubs (ABHR), when hands are not visibly soiled or tap
and running water is not available
Hand hygiene must be performed:
• Before patient examination
• Before dental procedures
• If gloves are torn or compromised during the procedure
• After removing gloves
• After touching the patient
• After touching surroundings or equipment that are not disinfected

Dental professionals should avoid touching their own eyes, mouth and nose[32].

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3.1.2 Use of PERSONAL PROTECTION EQUIPMENT:
The use of PPE, including protective eyewear, masks, gloves, caps, face shields, and
protective outerwear, is strongly recommended for all healthcare givers in the
clinic/hospital settings during the COVID-19 pandemic [19].
a. A triple-layered surgical mask can be worn by all health care providers when within
1–2 meters of patient.
b. Particulate respirators (N-95 masks authenticated by the National Institute for
Occupational Safety and Health or FFP2-standard masks set by the European Union)
are recommended for routine dental practice[33,34].
c. If available an FFP3-standard mask should be used and in COVID-19 positive
patients this would be considered essential.

4. RECOMMENDATIONS FOR SPECIFIC DENTAL PROCEDURE

Table 4: RECOMMENDATIONS FOR SPECIFIC DENTAL PROCEDURE:

No. SUBJECT RECOMMENDATION REASON

AVOID ALL AEROSOL PRODUCING

PROCEDURES PROCEDURES To prevent aerosol
4.1
TO BE AVOIDED Avoid tooth preparation with air turbine or production
electric handpiece
Avoid use or ultrasonic or sonic scalers

PROCEDURES They tend to

4.1.1 TO BE Avoid Intraoral radiographs or should be stimulate saliva
MINIMIZED performed cautiously secretion & induce
coughing [29] [35].

Avoid use of three way air- water syringe(43-45]. To minimize aerosols

14
No. SUBJECT RECOMMENDATION REASON

GENERAL Patient escorts should be discouraged. and

4.2
MEASURES patient should be instructed to maintain social To avoid disease
distancing from others. transmission.
Preferable to give non-overlapping
appointments.

Provide the patient with a surgical mask at the

entrance of the clinic

These are strongly

PERSONAL Prior to meeting the patient, the dentist should recommended for
4.2.1 wear all PPE, including : ALL healthcare
PROTECTIVE
providers and
EQUIPMENT Protective eyewear, Masks (N-95/ FFP 2 / support staff in the
(PPE) FFP 3 equivalent), Gloves, Head cap, Face clinic/hospital
shields and protective outerwear. settings [19].

4.3 PRE- 1% hydrogen peroxide

PROCEDURAL To reduce the
or
MOUTHRINSE salivary load of oral
0.2% povidone-iodine microbes, including
potential
(Chlorhexidine is ineffective against SARS-CoV-2
SARS-CoV-2) carriage[36,37].

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No. SUBJECT RECOMMENDATION REASON

✓ Preoperative administration of
MANAGEMENT
4.3.1 any nonsteroidal anti-inflammatory drug (NSAID)
PROTOCOL 1 h prior to the local anesthesia injection (Table 2)
FOR ACUTE
PULPITIS ✓ Local anesthesia with 2% lidocaine with 1:
WITHOUT 100,000 epinephrine (1.8ml).
GENERATING • Allow sufficient time (15 mins) for anesthesia to
AEROSOL take effect
• If required use supplemental buccal infiltration
To achieve
with 4% Articaine with 1: 100,000 epinephrine
optimal
(0.9 – 1.2ml) at the apex of the tooth to be
anesthesia
treated[38-40] OR Intraligamentary injection
0.2ml of 2% lidocaine with 1: 100,000
epinephrine[41]
• Buffered (alkanising) LA solution[42]

✓ Mechanical/ Chemomechanical caries

excavation methods -
• Dental dam isolation with high volume saliva
To prevent
ejectors.
aerosol
• Four handed technique[19]
production
• Caries excavation with sharp spoon excavator
to remove soft caries or Carisolv+ spoon
excavator
• Slow speed micromotor handpiece without
water spray until pulp is exposed (19]

✓ Perform Partial/complete pulpotomy.

• Arrest bleeding with sterile cotton or soaked
with 3% NaOCl applied with slight pressure. To provide
Place sterile dry cotton and provide temporary interim relief
seal.[46]
• If bleeding is not arrested, place arsenic-free
pulp devitaliser and temporary filling.[19]
• Prescribe NSAIDs approved by the local
government health authorities for post-
operative pain management (Table 1B)

Where indicated, extraction followed by suture

Promote
placement.
hemostasis.

16
No. SUBJECT RECOMMENDATION REASON

EMERGENCIES 1. Any procedure which would

4.3.2
THAT REQUIRE involve aerosol production; should
AEROSOL ONLY be done in dental/medical
PRODUCING set-ups equipped with negative
PROCEDURES pressure or AIIR (AIRBORNE
INFECTION ISOLATION ROOM)
treatment rooms which allow for
complete disinfection to prevent
cross-contamination.(19]. To avoid disease
transmission
2. If the concerned dental set-up is
not prepared with same, then
patient should be directed toward
equipped dental centre in his
area / the local medical
authorities for assessment and
management [46].

4.4 DISINFECTION General areas - frequently clean and disinfect, including door
OF THE CLINIC handles, chairs, and desks.
SETTINGS[44,47] Disinfectants - Isopropyl alcohol, 0.5 % sodium hypochlorite
Reusable instruments - pretreated, cleaned, sterilised, and properly
stored. (Refer Table 4)

4.5 WASTE Medical and domestic waste should be marked and disposed in
MANAGEMENT accordance with the Biomedical Waste Management and Handing
Rules 2016, 2018[48,49].

17
Box 2: RECOMMENDED DISINFECTION AND STERILIZATION PROTOCOLS
FOR DENTAL CLINICS TEATING PATIENTS DURING COVID-19 PANDEMIC
A. Treatment area/patient care area
• All critical, heat resistant semi critical instruments and handpieces should
be cleaned and sterilized after each use or discarded.
• Heat sensitive semi-critical items can be processed with high-level
disinfection eg. 2% Gluteraldehyde.
• High touch/clinical surfaces that are difficult to clean must be covered using
a physical barrier for every patient or disinfected between patients.
(Eg: 1 % Sodium hypochlorite or 70% alcohol)

• Use moistened wipe / cloth to clean all surfaces with freshly prepared
disinfectant solution. (Eg: 1 % Sodium hypochlorite or 3% hydrogen
peroxide). Always Discard remnant diluted solution

• Floor - Use Wet Moping- Multi Bucket Technique : (i) Water followed by
(ii) Detergent followed by (iii) Low Level Disinfectant like 3% hydrogen
peroxide, 1% Sodium hypochlorite or EPA approved agents

• Mop heads and cleaning cloths must be decontaminated regularly by

Laundering (heat disinfection) with detergent and drying at 80 °c and
changed frequent

• Do not perform disinfectant fogging

B. Reception and patient waiting area

• Avoid sweeping with broom
• Use wet moping with warm water and detergent or hospital disinfectant (eg.
1 % Sodium hypochlorite).
• High touch surfaces must be cleaned more frequently with detergent/
disinfectant.

Note: Disinfectants approved by the Environmental Protection Agency,

Disinfectant List Coronavirus Disease 2019 (COVID-19) 03/13/2020 are
recommended for surface disinfection procedures. https://www.epa.gov/pesticide-
registration/list-n-disinfectants-use-against-sars-cov-2 LAST UPDATED ON
MARCH 13, 2020.

18
 TABLE 5 : PREPAREDNESS CHECKLIST TO VERIFY
BEFORE TREATING A PATIENT IN YOUR DENTAL SET-UP*

POINTS TO BE CHECKED YES / NO

✓ Does the Patient need Emergency Dental Care and cannot be

managed by pharmacological management as given in Table 1
and Table 2?

✓ Are the required dental procedures non-aerosol producing

procedures or can be managed with alternative options (Micro motor /
Chemo-mechanical) ?

✓ Is your dental practice equipped with Personal Protection

Equipments including protective eyewear, masks (N-95/FFP2/FFP3
standard), gloves, head caps, face shields, shoe cover and
protective outerwear ?

✓ Does your dental practice comply with the disinfection and

sterilization protocols given in Box 2 ?

✓ Do you know where and how to report a potential COVID-19

case or history of direct exposure for quarantine in your
geographical area ?

✓ You and your team members DO NOT have any history of direct
exposure to COVID 19 and DO NOT have high temperature or
respiratory symptoms ?

* IFEA and IES strongly recommend that a dental practitioner should not treat patient in
his clinic UNLESS he/she is able to comply with ALL points in the above Checklist. In
case a dental practitioner does not comply with all six parameters of above check list

19
then he/ she should refer the patient to an equipped dental center / local medical
authorities.

Concluding Remarks:

Unprecedented challenges necessitate unprecedented solutions. As dental health

care providers our primary goal is to serve our patients during their times of need.
However, the current pandemic makes dentistry a potent channel of community
transmission of disease. Hence, current reality requires revised policy guidelines (Table
5) that provide clarity on the extent of dental services that can be provided by us safely.
This joint position statement from IFEA and IES is an attempt to provide a logical and
effective clinical decision making process that enable us to effectively screen, protect
and serve our patients.

References:

1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from

patients with pneumonia in China, 2019. N Engl J Med. 2020. https://
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Annexure

Annexure 1: COVID-19 Questionnaire

Questions to ask prior to patient attendance include
(1) Do you have a fever or have experienced fever within the past 14 days?
(2) Have you experienced a recent onset of respiratory problems, such as a cough or
difficulty in breathing within the past 14 days?
(3) In the past 14 days, have you or any household member traveled internationally to
the following areas China, Iran, Japan, South Korea, Italy or any other European
country) or domestically with documented COVID -19 transmission?
If so, please note location:
(4) Have you come into contact with people who have traveled internationally to China,
Iran, Japan, South Korea, Italy or any other European country, or people from the
neighbourhood with recent documented fever or respiratory problems within the past 14
days?
(5) Have you come into contact with a patient with confirmed COVID-19 infection within
the past 14 days?
(6) Have you recently participated in any gathering, meetings, or had close contact with
many unacquainted people?
(7) Do you want to schedule a dental visit later, or do you want to speak to/meet the
dentist for an emergency?

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