What steps should you take to reopen your dental clinic?

What steps should you take to reopen your dental clinic?

This week we want to share with you information provided by the General Council of Dentists in Spain. This organization established a “Dental Action Plan for the post-epidemic period COVID-19” (version 1/05/2020). The objective of this plan is to design lines for the protection and reduction of transmission risks in any dental clinic (public or private) after the stage of the epidemic. The purpose of this project is to provide the dentist with the scientific evidence available to attend to patients and keep the office staff protected.

Bader, as a company and brand in the dental sector, have the responsibility to actively collaborate in the control of this disease. For this reason, today we want to help the dissemination of this information. Below we explain in a brief summary the most important points of this plan.

The current situation is known to all of us. Our country and the whole world is suffering from a type of highly pathogenic coronavirus originating in Wuhan (China) that produces Covid-19 disease. This virus has caused a pandemic that affects the entire population, therefore, to prevent its spread and contagion, generic measures are established in the dental field through the use of personal protective equipment such as: masks, gloves, eye protection and work clothes.

We want to emphasize the issue of masks since it is the one that is causing the most controversy. There are several types of masks: FFP3, FFP2, resistant surgical, surgical and hygienic.

Current protocols recommend the use of FFP2 masks without an exhalation valve. These types of masks are designed for single use but due to the scarcity of them and the high demand from the public, studies have been carried out that provide satisfactory data on their reuse. It is the case of Delft University in Holland that has carried out a study where it establishes that the sterilization with steam of hydrogen peroxide, by means of dry heat at 70ºC for 30 minutes or by humid heat (121ºC for 15 minutes) maintains the efficiency of the FFP2 with a maximum of 2-3 sterilizations always that the mask is clean and without breakage. In this type of studies, its limitations must be taken into account, since Covid-19 is a recent disease and therefore, there is no scientific evidence (on reuse) demonstrated over an extended period of time. The Ministry of Health in Spain has established guidelines for the cleaning and disinfection of reusable hygienic masks and the Spanish Agency for Standardization has published the technical specifications for its manufacture.

The Dental Action Plan for the post-epidemic period COVID-19 made by the General Council of Dentists establishes a series of generic and specific measures that we explain below:

Before starting activity in any dental clinic it is essential:

- Check the health of the staff. The protocols for reincorporation to the job will be consulted with the respective occupational health services.

- Basic training of all clinic staff on the new protocols to adopt. All workers must receive basic training as well as a simulation of the new protocols adopted prior to the restart of the activity with patients.

- Planning, start-up and supervision of new protocols. The clinic manager must ensure the correct implementation of all the new protocols and measures adopted. It will also ensure that all staff have understood the true scope of the new protocols.

Once the dental clinic activity has resumed, it is recommended to carry out a prior telephone triage of the patients before being treated in the office. The purpose of this triage is to know the general health status regarding the Covid-19 and to find out the reason for the patient's consultation. In case you have to be attended in the clinic, you will be given a series of guidelines to follow to avoid contagion: come alone (in the case of a child or person in need of help, the ideal is to leave the patient in the clinic and wait outside except in exceptional case), without decorations (without earrings, rings, bracelets), at the time of the appointment and pay by card.

The dental clinic agenda will be organized always prioritizing the first morning appointments for elderly patients, as well as those with previous medical conditions. It is also recommended to add 15 or 20 min to each appointment time, that is, if an appointment is 45 min, leave 60min reserved.

Once in the consultation, the patient will find a series of specific measures such as: methacrylate in the reception area, signs with safety distances, hydro-alcoholic gels to disinfect hands, and the person who receives it will have a mask and glasses to your protection.



Also in the waiting room any unnecessary material (board games, magazines, books, vases, TV remote control, etc.) will be removed and the minimum possible chairs will be left, and in any case always keeping the safety distance of at least 2 meters from one to another.

Regarding the common spaces of the dental clinic, the following will be avoided:

- Towels in the bathroom. It will be replaced by blotting paper.

- Pictures, posters, certificates... hanging on walls.

- Patient movements around the clinic. They should remain in the waiting room and the clinic staff should disinfect the site after each patient.

- Air conditioning if it is centralized and connects common areas and clinical area.

In addition, liquid soap with a dispenser will be provided in the bathroom and the common spaces will be kept ventilated every hour (between 5-10 minutes).

Before the patient goes to the clinical area, dental treatment will be planned to organize the strictly necessary materials and instruments, as well as the placement of the appropriate PPE by the health personnel. Dental equipment and areas of more contamination can be protected with plastic film.

When the patient enters the clinical area, the following instructions must be followed:

- Close the door.

- Ask the patient to disinfect their hands again with hydroalcoholic gel before sitting in the dental chair and not to touch anything.

- Put on a waterproof plastic bib.

- Put eye protection on the patient.

- Give the patient a mouthwash of 1% hydrogen peroxide, 0.2% povidone iodine or cetyl pyridinium.

During dental treatment, healthcare professionals will take into account the following indications:

- Use high powered aspiration to decrease the spread of aerosols. The vacuum cleaner nozzle should be as close as possible to the area to be treated.

- Avoid using the equipment's air-water syringe because it generates aerosols: dry if possible with gauze and refrigerate (when feasible) with a manual syringe of water or saline (depending on the treatment).

- Use a rubber dam in surgery: it reduces the viral load by 70%.

- Use disposable covers in rotary appliances, polymerization lamp, intraoral cameras, etc.

- If X-ray is required: extraoral (orthopantomography) is preferable to intraoral.

- If a suture is required: pre-absorbable suture is preferable.

In high-risk interventions:

- Use low-speed instruments with refrigeration, manual irrigation, manual tartrectomy (curettes), minimally invasive dentistry.

- Use of FFP2 masks.

- Double pair of gloves.

- Hat and shoe covers.

- Waterproof disposable gown.

- Eye protection or face shield.

In reduced risk interventions:

- FFP2 mask.

- Gloves (double pair).

- Hat and shoe covers.

- Disposable eye gown or face shield.

Disinfection of impressions:

Dental impressions require special treatment against the coronavirus as glutaraldehyde is not effective against it. We remember that before disinfection of any impression it is necessary to clean it with water. After disinfecting, clean it again with water.

- Alginate impressions: it is recommended to better use the spray with 1% sodium hypochlorite disinfectant and place in a sealed bag for 10 minutes. Important: for the prepared solutions of sodium hypochlorite they have an efficacy of 24 hours (for which it is necessary to prepare them daily and throw away the excess).

- Elastomer impressions (silicones and polyethers): immersion in 1% sodium hypochlorite for 15-20 minutes. Once the impressions are disinfected, they must be rinsed and placed in a sealed bag for shipment to the laboratory, indicating how it has been disinfected (product) and the disinfection time.

- 30ml of 5% common bleach for every 100ml of water.

Prosthesis disinfection:

- Metal-ceramic and skeletal prostheses: immersion in 70% alcohol (until a new virucide revision is currently underway) for 5 minutes and subsequent rinsing.

- Acrylic prostheses: immersion in 1% sodium hypochlorite for 10 minutes and subsequent rinsing.



Cleaning and disinfection protocol of the clinical area

At the end of the dental treatment, all the material and instruments will be taken to the disinfection and sterilization area (it is mandatory to wear the PPE). The plastic film that we had recommended to put in the areas of greatest contamination of dental equipment, bibs, cloths and all contaminated material will also be taken to the disinfection area and deposited in the pedal-operated hardcover container.

Afterwards, a thorough cleaning and disinfection of surfaces, areas of contact with the patient (armrests, headrest), spittoon, instrument tray, equipment lamp handle, chair actuation buttons, aspiration system, etc. will proceed. A disposable cloth or non-sterile pad will be used. Do not use a spray as there is a risk of viral spread. The surfaces are rubbed / rubbed, distributing the product well on the surface to be treated, from the cleanest to the dirtiest areas. It is important not to pass twice through the same area with the same face of the pad or cloth.

The floor of the clinical area must be cleaned at least 3 times: at the beginning in the morning, at noon and at the end of the working day.

It is essential that the dirty area is outside the clinical area.

- The products commonly used in the clinic for disinfection are effective against the coronavirus. You just have to let it work for 2 minutes.

- Ventilate the clinical area by closing the door (5-10 minutes). For those interior cabinets that do not have the possibility of natural ventilation, methods such as: ozone purification, chlorine dioxide purification, use of hypochlorous acid, etc. can be used.

- For the disinfection of the instruments, the usual procedures in the clinic will be followed. Phenolic compounds, per acetic acid, or 10% sodium hypochlorite, among others, are good options for the coronavirus.

- Goggles and protective screens must be disinfected between patients, to do this, place the glasses in the disposable tray and spray with 70º alcohol or immerse in water with bleach (25ml 5% bleach in 1 liter of water). In case of screen, deposit in a disposable tray, spray it with alcohol at 70º.

- Individual Protection Equipment and other contaminated material will be deposited in the hardcover container for this purpose.



After the treatment, some tips for the next appointment will be explained to the patient:

- Come alone.

- Remove bracelets, rings, earrings and report the appearance of any general sign (fever, cough, digestive sign or any other indicated) or if you come into close contact with a confirmed case of Covid-19.

- Pay by card and not in cash.

- Transfer with hydroalcoholic solution to the dataphone after use.

Cleaning and disinfection of the clinic at the end of the day:

- Common areas: they must be cleaned and disinfected daily. For soils, sodium hypochlorite solution (30 ml per liter of water) is recommended (whenever feasible). Do not use a vacuum cleaner or broom. Ideal the use of mop impregnated in disinfectant. Clean and disinfect all door and window knobs, railings, tables, armrests for chairs and armchairs, switches etc. Metal door knobs can be damaged by bleach (use 70% alcoholic solution).

- Reception area:

  • Cleaning and disinfection of: work table; protection screen; computer and telephone screen and keyboard; printer and dataphone.

- Bathing area:

  • Cleaning and disinfection of: sink, switches, toilet and bathroom floor.

- Disinfection and sterilization area:

  • Cleaning and disinfection of work areas, autoclave and heat sealing and container.

- Clinical areas:

  • Cleaning and disinfection of: work surfaces, dental chair, equipment lamp, spittoon area (let disinfectant act 2-3 minutes before unloading spittoon), suction system, furniture, clinic switches, computer screen and keyboard, knobs door and windows and floor (scrubbing with bleach if possible).

At the end of the working day, the health personnel must follow a series of instructions:

1. When you return home and before washing your hands with soap and water, you should not touch anything in case they are contaminated with the virus.

2. When you get home, you should disinfect the soles of your shoes or take them off. The soles of the shoes may be contaminated and do not forget that children often play on the ground, and may become contaminated

3. Keys, wallet, purse, may have viruses attached to their surfaces. That is why it is convenient to leave them in a box at the entrance and add disinfectant.

4. It is advisable to take off your clothes when you get home and put them in a washing machine in a high temperature cycle at least 60º, if possible, use bleach.

5. Viruses have been found to accumulate on the lenses of glasses and on mobile phones. It is essential to clean them well and disinfect them as soon as you get home and every so often.

6. Careful hand washing on returning home, with soap and water, cleaning between the fingers and palms of the hands is very important. Showering on arrival is essential to eliminate fomites and risk of contagion.

7. The use of the dishwasher is recommended. First, avoid handling plates and cutlery, and second, because they usually work at a temperature of 70ºC.

8. Before storing the items when you return from the street, it is advisable to disinfect them well to avoid accumulating possible viruses.

Lastly, the Dental Action Plan for the Post-Epidemic Period COVID-19 provides all dental professionals with checklists that can be downloaded in their presentation (click here - page 27). This way it will be easier to follow the protocols and avoid possible infections.

In addition, this same document includes some health education infographics on protocols when leaving and returning home as well as living with a person risk.

As we know that all this information is tedious, the "Association Dentaire Française" has produced a very visual, practical and didactic guide to follow all the recommendations previously explained. This guide, originally in French, has been translated by the General Council of Dentists of Spain and released with the authorization of the ADF, so we want to share it with you. At the following link you can download it:

GUIDE COVID-19

If you have any questions about the coronavirus or its action protocols, the Council of Dentists makes all the information available to health professionals and citizens on its website. For our part, we hope that this information has been of great help to you and, if you have any questions, you can contact us through this blog by writing a comment (in the "Leave a reply" section) or on those Networks Social in which we are present (Facebook, Instagram, Twitter, Youtube y LinkedIn). In any case, you can also call us at 986 190 307 (+351 211 156 082 from Portugal), write to us on WhatsApp at +34 698 91 72 78 or send us an email to info@bader.es

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      I am also willing to reopen my clinic as I am a dental surgeon and also an assignment writer in Dubai. During this current pandemic COVID-19 situation I have temporary closed my clinic but I am available online. I am specialized in dentistry and I am totally inspired by the guide you have shared to reopen the clinic.

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