Infection Control Unit

Faculty of Dentistry

The British University in Egypt

2020

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BUE Organization of Infection Control Unit in Faculty of Dentistry

Professor Tarek Abbas Faculty Dean

Prof. Reham Magdy Faculty vice Dean for community service & Head of Infection Control Unit

Prof. Ibrahim Yehia Director of infection control unit

Dr Engy Farag Hospital infection control coordinator for personal infection protection means

Dr Shereen Nader Awareness coordinator for infection prevention & protection

Departments Coordinatorsʼ :

Dr. Dina Mostafa Teaching assistant in Medical Science ( Microbiology )

Dr. Farah Mohey Demonstrator in Medical Science (Microbiology)

Dr. Cindrella Mamdooh Assistant Lecturer in Crown and Bridge Dep.

Dr. Raneem Mustafa Clinician in Crown and Bridge Dep.

Dr. Sara Tarek Demonstrator in Endodontics Dep.

Dr. Heba Metwally Assistant Lecturer in Endodontics Dep

Dr. Norhan Youssef Demonstrator in Pediatric dentistry Dep.

Dr. Yasmine Mohamed Demonstrator in Pediatric dentistry Dep.

Dr. Ahmed Hesham Assistant Lecturer in Surgery Dep.

Dr. Basma Abalkader Assistant Lecturer in Surgey Dep.

Dr. Ahmed Abd El Hady Assistant Lecturer in Orthodontics Dep.

Dr. Abd El Rahman Alaa Demonstrator in Prosthesis Dep.

Dr.Adham Youssef Demonstrator in Prosthesis Dep

Dr. Nada Ashraf Demonstrator in Medicine, Perio and Diagnosis , X Ray Dep.

Dr. Rana Tantawy Demonstrator in Medicine, Perio and Diagnosis , X Ray Dep.

Dr. Amr Shalby Demonstrator in Operative Dep

Dr. Nermeen Hamada Demonstrator in Operative Dep .

Administration support:

Ms Elhaam Abd El Hameed Head of Nurses

Mr. Maher Mansoor Hospital building manger

Ahmed Abd El Latif Administration support

Shaimaa Hamed

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*Background…………………………………………………………….P.5

*I-Strategies to prevent transmission by patient evaluation

and assessment ……………………………………………………….P.6

A-Patient selection……………………………………………………..P.7

B-Patient evaluation…………………………………………………...P.9

*II-Strategies to prevent transmission in waiting area & upon

arrival to dental clinic………………………………………………….P.10

*III- Strategies to prevent transmission by preparing dental room

& clinic settings……………………………………………………....P.15

*IV-Strategies to prevent transmission by personal protective

equipment (PPE)………………………………………………….….P.20

*V-Strategies to prevent transmission during dental

treatment……………………………………………………………...P.26

* VI-Strategies to prevent transmission after dental

treatment……………………………………………………………...P.32

*References…………………………………………………………...P.37

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Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2). Common symptoms include fever, cough,

and shortness of breath . As of 19 April 2020, more than 2.34 million cases have been reported

across 185 countries and territories, resulting in more than 161,000 deaths. The current

tendency of COVID-19 epidemic is increasing and spreading in the world.

The virus is primarily spread between people during close contact, often via small droplets

produced by coughing, sneezing, or talking. While these droplets are produced when breathing

out, they usually fall to the ground or onto surfaces rather than being infectious over long

distances. People may also become infected by touching a contaminated surface and then

touching their eyes, nose or mouth.

In most instances, coronaviruses, including SARS-CoV-2, are transmitted from person to person

through large respiratory droplets produced during normal conversation or when coughing and

sneezing, either by inhalation or deposition on mucosal surfaces. Other routes implicated in

transmission of coronaviruses include contact with contaminated fomites (e.g. frequently

touched surfaces) and inhalation of aerosols produced during aerosol generating procedures

(AGPs). Viral RNA has also been detected in blood specimens, albeit rarely, but there is no

evidence of transmission through contact with blood.

Recent evidence suggests that even someone who is not symptomatic can spread COVID-19

with high efficiency, and conventional protective measures, such as face masks, provide

insufficient protection; suggesting that people can be infected by patients with subclinical

infection, either by droplets or by direct contact with secretions from infected cases, followed

by subsequent inoculation into the mucous membranes .

Dental professionals are at high risk for nosocomial infection and can become potential carriers

of the disease. These risks can be attributed to the unique nature of dental interventions, which

include aerosol generation, handling of sharps, and proximity of the provider to the patient’s

oropharyngeal region. In addition, if adequate precautions are not taken, the dental office can

potentially expose patients to cross contamination.

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1-Tele screening via telephone

- any exposure to a person with

known or suspected COVID-

19

- any recent travel history to an

area with high incidence of

COVID-19

- presence of any symptoms of

febrile respiratory illness such

as fever or cough

* A positive response: dental care

should be deferred for at least

2 weeks or more & patients

should be encouraged to

engage in self-quarantine

2- Upon arrival, screening

questionnaire

- In the past 14 days, have you

had a fever (> 37.5°C), cough,

sore throat, or breathing

problems ?

- Any loss of taste or smell?

- Have you had close or family

contact with a suspected or

confirmed case of COVID-19 ?

- Does it come from areas with a

higher risk of COVID-19 in the

last 14 days?

(Figure 1)

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. COVID screening & Chest CT

. Contact &airborne precaution

. Report to local health care agency

Signs/Symptoms of

COVID-19

Travel

history/Epidemiological

link

Suspected COVID-19

patient Perform dental

treatment

Elective Care Urgent Care (Acute pain) Emergency Care

- Defer treatment for 2 weeks

& more

- Follow up using telephone

- Pharmacologic Management

Antibiotics

Analgesics

- Follow using telephone

Recommendation

- Perform dental

treatment in negative

pressure room/Air

borne infection

isolation rooms

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-Dental professionals should measure the patient’s body

temperature using a noncontact forehead thermometer or with

cameras having infrared thermal sensors.

- Patients should be seated in a separate, well-ventilated waiting

area at least 6 ft apart.

-Removing Carpets for easier floor cleaning and magazines,

Antiques, curtains, or anything that may be touched by others and

which are not easily disinfected.

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-Arranging chairs in the waiting area with social distancing 2

meters apart.

- Avoid crowding by proper patient scheduling and contact patient

by mobile phone when it’s their turn.

-Visual signs as posters for hygiene instructions and standard

recommendations should be hanged.

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-The patient should put disposable shoes cover or disinfect the

shoes at the clinic door.

-Patients are to sanitize their hands immediately after they arrive.

-Patients should wear a surgical mask and follow proper

respiratory hygiene, such as covering the mouth and nose with a

tissue before coughing and sneezing and then discarding the

tissue.

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-Disinfection of elevator, handles, doorbell switches, doorknobs,

leather chairs, tables, pens, computer mouse and keyboard and

other frequently touched objects with surface disinfectant e.g 70%

alcohol.

-Provide alcohol hand rub tissues 70-95% and automatic hand

sanitizer dispenser.

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-Use of disposable (single-

use) devices such as mouth

mirror, syringes, and blood

pressure cuff to prevent

cross contamination is

encouraged.

-Clinical contact surfaces are

surfaces that can be touched

frequently with gloved hands

during treatment or that can

become contaminated with blood.

Protective barrier covers (eg, clear

plastic wrap) can be used for these

surfaces, particularly those that are

difficult to clean.

-Only essential items and instruments

available on dental cabinets

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-Protected surfaces should be

disinfected at the end of each day

and between patients. Most clean

surfaces should be cleaned only

with water and detergent. While,

for superficial and non-critical

disinfection of patient care

equipment, 0.05 % chlorine solution

( 1: 100 ) dilution is currently being

used. All surfaces and objects in a

distance 2 meter from the patient

head or touched by the patient

should be disinfected with 0.1 %

chlorine solution (1: 50 dilution) or

75% ethanol.

-Make sure to flush

waterlines at beginning of

workday and between

each patient.

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-The floor of the clinical

area must be cleaned at

least 3 times/ day with

0.5% sodium hypochlorite

(1:10 dilution) and avoid

vacuum cleaners.

-Sterilization methods that can

be used for critical or semi-

critical dental instruments and

materials can be sterilized

with high pressure steam

(autoclave) & chemical steam

(formaldehyde).

-Ventilation systems that

provide air movement from a

clean to contaminated flow

direction should be installed.

Relying on natural air

ventilation through open

windows and natural air flow

is preferred. Air conditioning

filter and air water pipes

should be cleaned by

peracetic acid 0.2%

(recommended every 12 Hrs)

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-Bio-decontamination unit

high output, short cycle

time, and ease of

operation with high

capacity hydrogen

peroxide vapor

catalyzation unit shortens

decontamination cycles in

rooms

-Untouchable waste bins

must be available.

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1-GOWN

-FULLY COVER FROM NECK TO

KNEES

,ARMS TO END OF WRISTS &WRAP

AROUND THE BACK &FASTEN IN

BACK OF NECK &WAIST

2-MASK OR RESPIRATOR

-SECURE TIES OR ELASTIC BANDS AT

MIDDLE OF HEAD &NECK

-FIT FLEXIBLE BAND TO NOSE

BRIDGE

-FIT SNUG TO FACE & BELOW CHIN

-FIT-CHECK RESPIRATOR

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SURGICAL MASK

*Protects from splashes &large particles

*Not properly sealed & may leak up to

80% in aerosolized areas

*Can be worn for 6-8 hours a day

*Preferred to be used on top of respirator

to minimize its contamination

N95 MASK OR EQUIVALENT

*PROPER FIT ON THE FACE

*PROVIDES 95% PROTECTION TO

SMALL PARTICLES

*Can be worn for the whole working

day (except for aerosol producing

procedures must be changed after

each patient)

N95 MASK WITH VALVE

*Prevent inhalation of small particles but will

not prevent particles from spread to

surrounding environment thus not

recommended to be used in dental settings

by medical staff . Valved respirators make it

easier to exhale air and do not filter the

wearer’s exhalation. This one-way protection

puts others around the wearer at risk.

Elastomeric Half Facepiece Respirator

*Reusable device made of synthetic or rubber. *May be equipped with filters that block 95%, 99%, or 100% of very small particulates. Also may be equipped to protect against vapors/gases. *When properly fitted, minimal leakage occurs

around edges of the respirator when user inhales.*Reusable and must be cleaned/

disinfected and stored between each patient interaction

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3-GOOGLES & FACE SHEILD

-PLACE OVER FACE AND EYES AND

ADJUST TO IT

4-GLOVES

- EXTEND TO COVER WRIST OF

ISOLATION GOWN

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GOOGLES

*Tight fit over &around eyes (or

glasses)

*Have anti-fog coating

*Have adjustable elastic strap

FACE SHEILD

*Protection to eyes ,nose ,lips

*Cover forehead, extend below

chin & wrap around sides of the

face

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NEEDS

Waiting

area

Patient

Diagnosis

Non-

AGPs

AGPS

Gloves * * * Non-Water resistant

gowns * *

Water resistant gowns

*

Surgical Mask * * *

N 95 * Face shield /Goggles * *

Sealed Googles * Hand Hygiene * * * *

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1-Doors of dental room clinics should be kept closed all the time

to confine the aerosol generated during dental procedures within

limited area.

2-Supply the patient with a head cap and disposable apron

before entering the examination room to avoid getting his clothes

and hair contaminated.

3-Preprocedural mouth rinse with 0.2% povidone-iodine might

reduce the load of corona viruses in saliva for 30 seconds. Another

alternative would be to use 0.5-1% hydrogen peroxide mouth

rinse, as it has non specific virucidal activity against corona viruses.

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4-Based on the assessment of emergency questionnaire, clinicians

can gauge the severity of the dental condition and make an

informed decision to either provide or defer dental care.

4-Radiographs: extraoral imaging such as panoramic

radiography or cone-beam computed tomographic imaging

should be used to avoid gag or cough reflex that may occur with

intraoral imaging.

5-When intraoral imaging is mandated, sensors should be double

barriered to prevent perforation and cross contamination.

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6-Dentists should use a rubber dam to minimize splatter

generation. It may be advantageous to place the rubber dam so

that it covers the nose.

7-Dentists should minimize the use of ultrasonic instruments, high-

speed handpieces, and 3-way syringes to reduce the risk of

generating contaminated aerosols

8-Recommended: Negative-pressure treatment rooms/ airborne

infection isolation rooms (AIIRs): it is worth noting that patients with

suspected or confirmed COVID-19 infection should not be treated

in a routine dental practice setting. Instead, this subset of patients

should only be treated in negative-pressure rooms or AIIRs.

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9-Avoid aerosol-generating procedures (AGP) whenever possible

and if mandatory let the appointment be the last in the day. It is

recommended to avoid entering to the clinic from 15-30 minutes

after finishing aerosol generating procedures so that to settle

down before disinfecting the clinic.

10-High volume suction and four-handed dentistry are

recommended.

11- Use patients shields with Dental aerosol production if possible.

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12-All dental work (impressions, …….) after receiving or before

sending to dental lab should be cleaned with soap and water, and

sterilized or disinfected in impression disinfectant solution then

wrap it.

• Metal ceramic restorations can be safely sterilized in the

autoclave in separate sterilization pouches.

All items must be thoroughly rinsed under running tap water

following disinfection

*Ethyl alcohol 70% :-Spraying Some rubbers may harden.

-Items should be spraying till saturation then covered to reach total

contact time of 10 minutes.

*Chlorine solution 0.5% (1:10 dilution):-Immersion Zinc oxide eugenol impression.

-Preferably prepared daily

and kept in covered dark

containers.

*All chlorine dilution solutions that are used ,are prepared from 5% sodium hypochlorite.

*Glutaraldehyde 2% : Dental alginate & polyether impressions may distort after 10 minutes.

- Extremely irritating.

*70% alcohol (Ethanol): highly effective against most common viruses

*peracetic acid 0.2%: to sterilize medical, surgical, and dental instruments chemically, function

as oxidizing agents ,recommended by CDC

*0.5% sodium hypochlorite: used for disinfecting areas contaminated with body fluids,

including large blood spills (the area is first cleaned with detergent before being disinfected

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“Management of ... medical waste must also be done according

to routine procedures”

(a) The use of a single leak-resistant bag is usually adequate for

the containment of medical waste, provided the bag is resistant

and the waste does not contaminate the outside of the bag.

(b) Contamination or perforation of the bag requires its placement

in a second biohazard bag.

(c) All bags must be tightly closed for disposal.

(d) A rigid container must be used for sharps.

(e) For waste transportation, plastic bags are required to be

contained in a rigid container

(f) Regulated medical waste is decontaminated to reduce

microbial load and to make by-products safe for further handling

and elimination.

(g) The treatment need not render the waste “sterile”.

(h) Treatment processes may include autoclaving, incineration,

chemical disinfection, grinding/crushing/ disinfection methods,

energy-based technologies (eg, microwave or radio wave

treatments) and disinfection/encapsulation methods

(i) The bags containing waste can be disinfected with a solution

containing chlorine at 1000 mg/L, before transport.

(j)For household waste generated by the treatment of patients,

double-layer yellow bags with “gooseneck” ligation should be

used.

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-Centers for Disease Control and Prevention. Transmission of

coronavirus disease 2019 (COVID19). Available at:

https://www.cdc.gov/coronavirus/2019-

ncov/about/transmission.html.

-Symptoms of Coronavirus (2020) U.S. Centers for Disease Control

and Prevention (CDC). Link: https://bit.ly/3bC6bnx

-Coronavirus Update (live) (2020): 1,001,069 Cases and 51,378

Deaths from COVID-19 Virus Outbreak-Worldometer. Link:

http://www.worldometers.info.

-Q&A on Coronaviruses (2020) World Health Organization.

-Chang D, Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting

health-care workers from subclinical coronavirus infection. Lancet

Respir Med. 2020; 8: e13

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Disease 19 (COVID-19): Implications for Clinical Dental Care. JOE

2020;46

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on COVID-19. https://www.who.int/dg/speeches/detail/who-

director-general-s-opening-remarks-at-the-media-briefing-on-

covid-19—3-march-2020.

- Peng X, Xu X, Li Y, et al. Transmission routes of 2019-nCoV and

controls in dental practice. Int J Oral Sci 2020;12:9.

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clinical features of the emerging 2019 novel coronavirus

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pneumonia (COVID-19) implicate special control measures. J Med

Virol 2020. https://doi.org/10.1002/jmv.25748.

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severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

https://www.cdc.gov/coronavirus/2019-ncov/infection-

control/control-recommendations.html.

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bactericidal and virucidal efficacy of povidone-iodine

gargle/mouthwash against respiratory and oral tract pathogens.

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coronaviruses on inanimate surfaces and its inactivation with

biocidal agents. J Hosp Infect 2020;104:246–51.

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direct digital radiography barrier sheaths and finger cots. J Am

Dent Assoc 2000;131:463–7.

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surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-

CoV-1. N Engl J Med 2020 March 17. https://doi.org/

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-ADA recommending dentists postpone elective procedures.

Available at: https://www.ada.org/ en/publications/ada-

news/2020-archive/march/ada-recommending-dentists-

postponeelective-procedures. Accessed March 18, 2020.

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-ELEVATORS SANITIZATION CHECKLIST – ELEVATORS GERMS PROTECTION

https://blog.droom.in/elevators-sanitization-checklist

-Peng, X., Xu, X., Li, Y. et al. Transmission routes of 2019-nCoV

and controls in dental practice. Int J Oral Sci 12, 9 (2020).

https://doi.org/10.1038/s41368-020-0075-9