Such a document might be adopted or adapted to any regional and international organization that wants to use a revised professional guideline for infection prevention and control for dental services during the COVID-19 pandemic.

4.1. Dental Infection Control Practices in COVID-19 Pandemic

IPC science was defined as measures that are encountered in the surroundings and through practical operations. They aim to stop and manage the spread, acquiring, and cross of infectious agents within the health-care industry [8]. Therefore, the specifically proposed IPC measures at the COVID-19 pandemic have to be escorted with all previously known standard precautions in a normal situation to provide full protection for the DHWs and patients. These measures include hand hygiene, PPE, covering high touchable surfaces. In this document,moreIPCmeasures are detailed and compelled, especially for the COVID-19 pandemic.

4.1.1. Dental Health-care Workers Preparedness

DHWs are advised to steadily continue their duties to ensure public health safety and prevent infection. Their awareness and education are fundamentals before restart running the dental facility. An evaluation of the adherence to the IPC guidelines is mandated. Sufficient training on the guidelines must be carefully planned, executed, and guaranteed. Facilities must ensure that all DHWs understand these guidelines and assess their capability to stick to them.

According to the local governing body instructions, dental facilities/clinics have to comply with their working hours. It is an absolute necessity to make sure that IPC guidelines in staff residencies are strictly applied. Including those for housekeepers, if any. The in-need maintenance has to be arranged and coordinated with companies to ensure their compliance with these roles.

A visual triage point at the facility entrance should be established. Employees suffering from these fever ≥ 38°c, cough, sore throat and/or shortness of breath must not attend and have to report to the management to find medical care. They are not permitted back to duty without clearance from the medical side.

4.1.2. Personal Protective Equipment (PPE)

Usually, the safeguard gears against dentally-generated-aerosolized droplet nuclei are not recommended. However, it is mandatory to use the respiratory protection devices, e.g., non-oil resistant with 95% filtration capacity (N95) respirator or powered air-purifying respirator (PAPR) with other PPE for patients who score > zero during the pandemic when AGPs are decided to be performed [9].

Facilities have to register the fitting test and training of N95 respirators for their DHWs during the fitting test. The Occupational Safety and Health Administration (OSHA) and/or National Institute for Occupational Safety and Health (NIOSH) are agencies that approve the specifications for N95 respirators. Certified N95 should be used in health-care facilities to assure protection. Alternatively, the third class Filtering Facepiece Respirator (FFP3) can be used as a replacement of the N95 respirator, which follows the standard for the European Committee for Standardization (CEN) EN 149:2001+A1:2009.

NB: Users of PPE should be instructed to take them off normally in the clinic except for N95 or PAPR. They must be removed outside the clinic and discarded in acontaminated-wastecontainer [10].

4.1.3. Air Control

AGPs for patients are better to be performed under one of the following air control options, particularly for suspected patients or confirmed for COVID-19:

A- Heating, ventilation, and air conditioning “HVAC” system with negative pressure within dental settings [2]. B- Airborne infection isolation room (AIIR) in a hospital setting provided with portable dental gear. C- Portable high-efficiency particulate air “HEPA” filter in the dental clinic. 4.1.4. Decontamination of Dental Settings

Thorough terminal decontamination should follow dental procedures for all surfaces. Meanwhile, the postponing decontamination process is obligatory prior to reuse the dental clinic to eradicate aerosols as the surroundings stay contaminated due to AGPs [11-13]. The guidance for time-laps before begin decontamination is dependent on the type of air control (Table 1) [3, 9, 14]. It is recommended to use disposable mops and non-woven cloths incorporated in a fresh detergent or detergent combined with low-level disinfectants for non-clinical surfaces. For clinical surfaces, intermediate-level disinfectant wipes or sprays are. Be sure to put on full PPE [with regular masks] during decontamination. Some of the decontamination intermediate-level chemicals suggested in the literature are listed in Table 2 [11].

Table 1.

Guidance for time-lapse before beginning decontamination.

Type of Air Control Recommended Time to postpone
Decontamination Negative pressure HVAC* At least 20 minutes HEPA-filtered Room** Follow manufacturer's instruction for complete air filtration Neutrally air-ventilated room At least one hour

*HVAC: heating, ventilation, and air conditioning.
**HEPA: high-efficiency particulate air.

Table 2.

Guidance for disinfection chemicals for SARS CoV-2.

Intermediate-level Chemical formula Dilution Rate Ethyl Alcohol 62%–71% Hydrogen peroxide [H2O2] 0.5% 5% sodium hypochlorite*
[50,000 part per million chlorine] 0.1% [1,000 of chlorine]
1 volume of 5% sodium hypochlorite to 49 volumes of water

* Cause corrosion to the metallic surfaces in such concentration.

4.1.5. Engineering Control

It is important to eliminate the hazardous conditions to preserve DHWs by a barrier between the staff and the hazard by taking advantage of technology or innovation. For instance, expelling the airborne emissions by exhausted-local ventilation. The most important thing is that technologies and innovations do not intervene with the original procedure, comfort, and outcome. Rather, they must be of substantial impact on safeguarding the workers' health and preventing hazards. In the absence of unequivocal evidence to back up these measurements' significance, their clinical performance in reducing aerosols is worthy of being referred to.

4.1.6. Respiratory Triage and IPC Management Protocol

Respiratory triage aims to early detect persons who are potentially respiratory infectious and therefore decrease the chance of disseminating the infection inside the facility. A visual triage scoring form [respiratory triage checklist] is being used as issued from Saudi Center for Disease Prevention and Control (Weqaya).

Depending on the scores, the patients are considered as high risk of transmitting a respiratory disease, including COVID-19 if score ≥ 4, moderate risk if score between 1 and 4, finally low risk if score = 0.

4.1.6.1. Two types of Triaging could be Applied for Dental Setting

a- Triaging by Telephone [2]:

In case, the patient called the dental clinic for an appointment; in this case, a trained dental assistant will fill the triage scoring form Appendix 1, and ask the patient if he has any dental emergency after that inform him if he can come to the dental clinic for evaluation.

b-Triaging upon Arrival of the Patient:

A well-trained dental assistant will fill the triage scoring form Appendix 1, and the patient will be asked if he has any respiratory symptoms then the triage nurse should measure the patient’s body temperature using a non-contact forehead thermometer [15].

Illustration of IPC management protocol according to the patients given scores as per the respiratory triage checklist for COVID-19 can be found in Fig. (1).

4.1.7. Additional Measures and Instructions

• When AGPs started, effort should be made to finish the aim of the procedure. Upon completion, single-use PPE must be put in infectious waste bags. Consideration to operate two clinics, whenever feasible, is advisable.

• For those who score ≥ 4, oral radiographs are best to be postponed or adhere to the radiology department guidelines for extra-oral radiographs. If the patient's case score < 4 or score of zero, instruct the patient to doHH and put on a regular mask for taking anorthopantomogram.

• Using manual instrumentation is preferred and should be prioritized over the use of dental turbines.

• Whenever possible, use a rubber dam or any other appropriate isolation method, e.g., dry shield and isolite,along side high volume suction to reduce aerosol or splatter.

• The 4-handed technique is always useful for the management of aerosolization or splatter.

• Use High-volume evacuators appropriately, i.e., as near as it could be to the operation area within 15 mm. It effectively reduces the aerosols up to 90% immediately at the operation area [16].

• Backflow could occur when the patient closes his mouth on a saliva ejector, posing a risk of cross-contamination.

• Use resorbable sutures whenever possible to eliminate the need to suture removing appointments.

• Decrease the application of the 3-in-1 syringe to the minimum. Droplets might be generated as the water and air are forced through its narrow tip.

• Patients are eligible to receive dental treatment normally if they are cleared from the COVID-19.

Fig. (1). Illustration of the respiratory triage and IPC management protocol according to the patients given scores for COVID-19.
COVID-19: Coronavirus disease-2019
PPE: Personal Protective Equipment
HEPA: High-Efficiency Particulate Air
AIIR: Airborne infection isolation room
HVAC: Heating, Ventilation, and Air Conditioning