Considerations to Be Taken Before Dental Care

On any suspicion of viral infection, dental appointments must be canceled and the patient should be advised to immediately go to the hospital. On the other hand, in the absence of symptoms and with the need for a dental appointment, a questionnaire will give by phone to rule out a possible infectious process, and if the patient is considered virus-free, an appointment will be scheduled (Table 1). Once in the office, the temperature of the patient is measured with a digital thermometer on the forehead to identify possible fever. The thermometer must be disinfected with 70% ethyl alcohol after each use as recommended by the WHO.¹⁴ If the patient is in an acute febrile state, dental care will be stopped, the appointment rescheduled, and the patient will be advised to go to the doctor.^{14,Reference Peng, Xin and Yuqing15}

In the case of patients with a temperature below to 98.6°F, or 37.3°C, but with an affirmative answer on the questionnaire (Table 1), the treatment will be postponed to 14 days after the exposure event. The patient is instructed to initiate quarantine and report any fever or flu-like symptoms to the local health department.^{Reference Peng, Xin and Yuqing15} On the other hand, patients with a temperature above of 98.6°F, or 37.3°C, and an affirmative answer to the questionnaire will be considered as suspicious or at risk for COVID-19, and the appointment will be postponed, and the patient referred to emergency medical services for diagnosis.^{Reference Peng, Xin and Yuqing15}

Considerations for Patients to Take During the Dental Consultation

Hand Washing Before and After Dental Care

Hand washing with plenty of soap and water is an extremely important element for infection control for both patients and professionals alike.^{Reference Rabie and Curtis25} Several studies have confirmed that adequate hand washing can break the transmission cycle of respiratory diseases and reduce the risk of transmission by 6 to 14%.^{Reference Fung and Cairncross24} There have also been reports of fecal-oral transmission of COVID-19, further emphasizing the need for handwashing in dental practice. Although hand washing is a general requirement, compliance is relatively low, making infection control a great challenge during care.^{Reference Peng, Xin and Yuqing15}

Precautions to Consider During Dental Care

Currently, some researchers have considered pediatric populations as one of the most vulnerable to possible contagion by COVID-19. In addition to the transmission routes presented by this virus (inhalation of droplets, sneezing, direct contact, and saliva), additional risks in the care of pediatric patients involve the use of removable orthodontic devices and auxiliary elements. These devices induce a higher risk of contamination if biosafety protocols are not optimally followed. On the other hand, pediatric patients should always be accompanied by someone who will also be in close contact with the operator, increasing the risk of cross-contamination.

Due to the long incubation period of approximately 2 to 14 days, the signs and symptoms of infected pediatric patients may go unnoticed as the symptomatology may be mild.^{Reference Backer, Klinkenberg and Wallinga26} For this reason, both parents and infants should be considered potential carriers of COVID-19.

Upon arrival at the dental office, the child and the accompanying person should be asked to wash their hands and face, using alcohol gel for the hands. Preferably, disposable surgical footwear covers will be placed over the shoes. Before proceeding with the treatment, the previously mentioned mouthwash of choice will be used by cleaning with a gauze impregnated with the rinse to reduce the risk of ingestion.^{Reference Kumar, Innes and Procida27,28}

During the treatment, only the patient, operator, and assistant should be present, although if necessary, a maximum of 1 accompanying person will be allowed. The patient must be able to collaborate with the treatment being carried. Children unable to collaborate with the treatment should be referred for care under sedation or general anesthesia.²⁸

At the end of the treatment, the air space will be cleaned with a disinfectant spray, waiting 2 min before opening the door. The patient and accompanying person will leave the unit and will be instructed to wash their hands and face before leaving the dental office.

On the other hand, the generation of greater quantity of fluids and droplets during oral surgery procedure leaves dentists exposed to possible contagions of diseases that could be transmitted to patients if adequate protection barriers are not implemented.^{Reference Zhao and Gao23,Reference Ochoa29-Reference Parhar, Tasche and Brody31} It is important to emphasize that, in the absence of adequate safety elements, the health of both the patients and the work team cannot be guaranteed; therefore, dental procedures cannot be undertaken.^{Reference Chen, Ran and Liu30}

Several studies have suggested that a minimum distance of 1-2 m must be maintained, with no bodily contact, such as kissing or hugging. It has also been suggested to have a container at the entrance of the office to disinfect footwear using a bleach solution of 1/5 of sodium hypochlorite in 4/5 of water, 800 mL of water + 200 mL of sodium hypochlorite remaining at 10,000 ppm, which should be changed every 4 h.^{Reference González and Santos-Lopez17,Reference Chen, Ran and Liu30} All these considerations should be taken into account when preparing for a consultation to rule out any type of infection and decide whether to continue or cancel an appointment.

The recommendations state that patients should wash their hands with soap and water or antibacterial gel for a minimum time of 20 s. After that, documents requiring a signature, such as informed consent, medical records, and forms required by the insurers, can be handled.^{Reference Cleveland, Kolavic and Harte21} Electronic banking services should be used for payment because receiving bills or coins requires their placement in plastic bags and being sprayed with disinfectant. In addition, pens have also been described as possible vehicles of the spread of the virus^{Reference Parhar, Tasche and Brody31}; therefore, each worker and patient should have their own pen for individual use.

Subsequently, before entering the consultation, the patient should perform a new hand wash and thereafter remain with their hands on their chest and not touch anything.^{Reference Ochoa29} The literature recommends patients washing their hands twice before entering the procedure and three times thereafter. The patient is instructed where to stay, and if the office must be left, the entire protocol should be repeated upon reentry if the use of washrooms should be avoided, and if necessary, the area should immediately be disinfected.^{Reference Zhao and Gao23,Reference Chen, Ran and Liu30}

On the other hand, extraoral radiographic examinations such as panoramic radiography or cone beam computed tomography (CT) are considered good alternatives to reduce contact with the patient saliva. Nevertheless, the cost of these auxiliary examinations for the patient and their requirement by the clinician must be considered.^{Reference González and Santos-Lopez17}

Before starting the procedure, the dentist should ensure that an anesthetic boost is not necessary. It is ideal to consider the use of truncal anesthesia, plus an infiltrative supplement. According to the surgical technique to be used in the area to be treated, the use of resorbable sutures is recommended to decrease session time. The area is irrigated with needles, and aspirated to reduce the amount of spray. Patients with trauma or maxillofacial infections generally present an elevated temperature. However, according to the epidemiological history, etiology, clinical examination, blood test, and chest CT scan, this differs from that of COVID-19.^{Reference Meng, Hua and Bian16,Reference Ochoa29}

After the procedure, all disposable materials are removed from the patient and hand washing is requested. Recommendations for postoperative care and the prescription of medication are given to the patient,^{Reference Cleveland, Kolavic and Harte21} followed by another hand washing and exit from the dental office. When exiting, the patient should avoid touching office surfaces, and finally, hands should be washed with antibacterial gel.^{Reference Parhar, Tasche and Brody31}

Ideally, care in these cases should be carried out in rooms with negative pressure, such as wards, reducing the number of staff present.^{Reference Meng, Hua and Bian16,Reference Parhar, Tasche and Brody31} Alternatively, patients should receive care in an isolated room with good ventilation. In life-threatening cases, the patient should be immediately admitted to a hospital and chest CT performed, if available, because reverse transcription polymerase chain reaction testing takes a long time.^{Reference Carrillo, Méndez and Huertas32}

Dental emergencies are closely related to pain management, and endodontists are closely involved with the evaluation and treatment of odontogenic pain and inflammation. It is highly likely that dental practices can treat some patients with asymptomatic COVID-19 infections. A recent article described a set of recommendations for the management of dental emergencies, which concluded that the use of ibuprofen 600 mg with paracetamol 500 mg would be effective for symptomatic irreversible pulpitis, symptomatic apical periodontitis, acute apical abscess.^{Reference Watts, Balzer and Drum33-Reference Taggar and Wu35}