Philip F. Stahel divided elective procedures into “
essential”, which bear an increased risk of adverse outcomes if surgery is delayed indefinitely, “
non-essential” or “
discretionary”, in which the results are not time-sensitive to surgery and “
equivocal” which don’t fall clearly into one or the other category. He also projected a decision-making algorithm for deciding whether and when to proceed with an elective surgery, based on surgical indications and predicted requirement of critical resources [
25]. Similarly, based on the urgency of the situation, a dentist can take a call so as to provide emergency treatment or to postpone the treatment. Emergency dental conditions based on the risk factors include uncontrolled bleeding, symptomatic pulpitis and periodontitis, tooth fracture/avulsion/luxation, facial fractures, facial space infections compromising airways and biopsies related to abnormal tissue [
21,
22].
Operative Examination of the patient: Patients present in the clinical area for the examination should be set apart by at least one chair or 2 m distance. Care should be taken not to allow more than three patients in the clinical area. Operative examination should be done for only one patient at a time. Full complement personal protective equipment is recommended to be worn by the dentist. Centers for Disease Control and Prevention (CDC) has laid directions for donning and doffing of personal protective equipment when treating COVID-19 patients (
https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf) [
21,
26]. Pre-procedural oral rinse with 1% Povidone iodine is recommended to lower the viral load of in saliva. It is recommended to perform extraoral swabbing prior to examination with isopropyl alcohol. Safe distance to be maintained during the examination of the patient. Informed consent should be obtained from every patient as a routine procedure. Every patient treatment procedure is performed with prior appointments so to provide ample time disinfection of the clinical area. Patient drape should be immediately discarded, and the examination chair should be disinfected with 0.01% Sodium hypochlorite [
27]. It is highly recommended to use single use mouth mirrors, and probes, or the used instruments can be sprayed with ENZYMAX SPRAY GEL READY-TO-USE INSTRUMENT PRE-CLEANER to break the blood proteins and the bacteria and can be soaked in Septodont Quitanet Ultra or Glutapex solution for 15 mins to 20 mins.
Guidelines/precautions for Treatment Procedure: It is advisable to perform dental treatments in partitioned chambers to maintain safe distance and minimize contact. A modified concept of a “
corona-curtain” in this regard, has been designed by Hill et al. where they discussed a simple, cost-effective, and innovative intubation tent designed to protect staff from viral aerosolization during emergent intubations [
28]. Proper ventilation should be maintained with natural air by opening of windows and use of independent exhaust blower. Dental personnel (dentist and dental assistant) should wear the full complement personal protection equipment (PPE) during the treatment procedure. Every dental procedure should be performed under rubber dam with high volume evacuation to maintain the standard of care and to prevent splatter production. Extraoral HEPA (High efficiency Particulate air) suction with four handed dentistry can minimize the aerosol production [
29]. The use of high-speed handpieces and ultra-sonics should be prevented. Micromotor handpieces with intermittent breaks and syringe for water irrigation is recommended as an alternative. Extraoral imaging such as Orthopantomograph (OPG) or Cone beam computed Tomograhy (CBCT) is better preferred over intra-oral imaging to prevent cross contamination. When the usage of intraoral imaging is must, it is advisable to cover the sensor with two barriers to prevent cross contamination [
30]. Following treatment procedure. The patient drapes should be discarded immediately. It has been highly recommended to perform the treatment procedures in negative pressure treatment rooms or airborne infection isolation rooms [
29]. It is mandated to maintain 1-h gap between the patient appointments so that the operatory can be disinfected and made readied for the next appointment. Data has shown that COVID-19/ SARS-COV-2 remain viable on inert surfaces for up to 3 days and has greater preference for humid condition [
31]. It is recommended to vent off the air conditioning system in the operatory. In case of procedures involving use of general anesthesia (e.g. multiple extractions, fracture surgeries, rehabilitation treatment for pediatric patients etc.) a heat and moisture exchanger (HME) filter should be used on the expiratory limb of the circuit [
32].. Dental impressions if taken should be disinfected by immersion in chlorine compounds, phenols, iodophors, formaldehyde and glutaraldehyde. Immersion in NaOCl at concentration of 1:10 (0.525%) is advised for 10 min [
33]. The dentist/dental operating staff is recommended to perform five moments (Table
1) of hand hygiene recommended by World Health Organization (WHO) with Alcohol based hand rub (ABHR) [
34]. These include:
-
Moment 1. Before touching a patient
-
Moment 2. Before a clean/aseptic procedure
-
Moment 3. After body fluid exposure risk
-
Moment 4. After touching a patient
-
Moment 5. After touching patient’s surroundings
Table 1
Five moments of hand hygiene recommended by the World Health Organization