8.0 DENTAL SURGERY / OPERATORY PROTOCOLS

  • CODE has already has strict dental surgery and operatory protocols as part of its day-today functioning. These will continue as normal. 

  • However, in addition we will be introducing the following protocols whilst the Covid19 pandemic is still at significant levels in the UK. 

8.1 Aerosol generating procedures (AGP)s

  • Aerosol Generating procedures are listed below:

    • Use of high-speed handpieces for routine restorative procedures and high-speed surgical handpieces

    • Use of ultrasonic or other mechanised scalers 

    • High pressure 3:1 air syringe  

  • CODE would reiterate that we regard all patient contact generates some level of droplet or aerosol production. 

  • Our normal dental suction removes over 90% of aerosol generated during dental procedures. 

  • If patients and staff are at lower risk of exposure to SARS-CoV-2 based on pre-attendance questionnaires and maintenance of social distancing and self-monitoring, we maintain that there is scant evidence to suggest that aerosol generated by dental instrumentation in any way increase the risk of viral transmission. The references given at the end of this Standard Operating Procedure document referred to potential risk of aerosol- borne infection from dental procedures but have documented no such confirmed case. 

  • However, to mitigate any potential risk we will have adopted at least FFP2 reusable half face mask P3 Stealth fit tested, valved respirators as well as face visors, hair nets and protective waterproof gowns plus eye protection as normal. 

  • It should be remembered that most of the aerosol produced by dental instrumentation will be virucidal and have a diluting effect on droplets and on any aerosol from the patient. This will include 10% hydrogen peroxide-based (H2O2) and hypochlorous acid (HOCl)-based solutions which are safe for ingestion but are potently virucidal. 

  • Air-conditioning units will not operate on recirculation mode and alternative solution will be looked into to improve the mechanical ventilation of the surgeries.

  • Immediately after each operative procedure, the surgery will be vacated for aerosol settling time

8.2 Operatory preparation protocols  

  • Normal surgery preparation at the start of each day and at the end of each session will continue as normal as per our established protocols based on HTM 01-05 protocols and standard protocols for running through and disinfection of dental water lines. 

  • All non-essential items have been removed from the surgeries and placed into cupboards or into storage. 

  • All treatment is planned well in advance and any laboratory work that has been received from the laboratory will have been processed as under item 10 below. 

  •  All items to be used for a procedure should be prepared in advance on the worktop to avoid having to open drawers or cupboards during operative procedures. 

  • All computers and other equipment that cannot be removed should be covered with disinfected or disposable covers such as polythene for items such as the operating microscope and disposable clingfilm for computers and photographic and video cameras.

  • The operatory nurse should not leave the surgery during treatment and should, similarly to the patient, be well hydrated and have visited the bathroom prior to donning PPE for that session.

  • Nobody should enter the surgery where patient treatment is continuing without donning suitable PPE even if it is for only a very short period. Similarly, the PPE should be removed upon exiting the surgery. All nurses and clinicians should ensure that they have everything they need and should not need to enter another surgery during a procedure.

8.3 Clinical protocols

  • Following a full clinical assessment, we have found very little to change in our normal clinical protocols. It is our opinion that differentiating between aerosol generating and non-aerosol generating procedures is not realistic and has no scientific basis when considering risk of cross infection. It is not realistic to open the dental practice and expect to be able to treat patients without generation of aerosol droplets in one form or another. This is therefore a relative risk that has to be faced when a dental practice is in operation.  

  • However, the following points should be considered when treating patients: 

  • Rubber dam should be used for all restorative operative procedures as normal. This is already something that is carried out at CODE as routine. 

  • The spittoon tap should be turned on prior to patients rinsing to reduce the amount of droplet or aerosol deflected from the spittoon. The number of times a patient needs to rinse should be minimised to reduce droplets and spatter. We do not feel it is realistic to stop patients rinsing entirely but they should be made aware of the need to minimise this activity. 

  • High-volume suction with or without additional saliva ejector should be used for all procedures

  

 

9.0 POST-TREATMENT PROTOCOLS, DECONTAMINATION AND STERILISATION  

  • As soon as the patient has completed treatment, the infection control nurse will guide the patient outside of the operatory room, provide alcohol hand gel rub and accompany patients towards the exit of the practice which will be made via fire exit back door, together with the personal belongings.

  • The assistant nurse should maintain all of their current PPE and remain in the surgery for the moment.

  • The dental surgeon should remove their gloves only and also wash and disinfect their hands remembering that the remainder of their PPE remains contaminated. 

  • The dental surgeon should exit the surgery closing the door behind him or her 

  • They should also then immediately don a clean PPE. 

  • The runner/greeting nurse should then wipe down the exit door handle inside and outside the front door and also the entry phone button and grille by the front door. The wipes and disposable gloves should be immediately disposed in clinical waste.

  •  In the meantime, the surgery nurse should also have removed her gloves and thoroughly washed and disinfected her hands. 

  • For AGP procedures the buffer time allowed until the next appointment will be 1 hour. The 60 minutes period starts at the moment of ceasing AGP procedure and not after patient leaves the surgery.

  • All non AGP appointments have been extended by 15 minutes to include 15 minutes fallow time

  • The dental surgeon should then use this time to write up contemporaneous notes, right up lab dockets, check emails, optimise name and tag photographs from the previous session or day and carry out all the administrative tasks required by standard CODE protocols. This is still regarded as an integral part of the patient’s appointment. 

  • After each treatment session, the surgery nurse will then re-enter the operatory 10 minutes before the next patient is due. She will don new PPE plus plastic apron and heavy duty gloves and wipe down all surfaces using regular proprietary antimicrobial cleaning solution and wipes, changing and replenishing as required, starting at high level and working downwards to include the following in order:

    • All clinical items to be decontaminated and sterilised to be placed into a lidded lockable box, normally stored in the sterilisation room and brought to the surgery by the runner/infection control nurse at the end of the session.

    • Any small items or material containers or equipment to be put away at the end of the procedure (e.g. Implant motor, endodontic motor, dental loupes etc) removing all clingfilm on items such as computers and cameras with the contaminated surface being collected inwards and the clingfilm discarded into clinical waste.

    • Light, camera and light arm on the dental chair

    • Dental chair bracket table and arm

    • Handpiece motors and cabling

    • Nurses station and spittoon

    • Dental chair and base and foot pedals

    • Clinician and dental nurse tools

    • Wall cabinet façades and handles, work surfaces and base cabinet façades and handles

    • Wall mounted x-ray

    • Alcohol and soap dispensers

    • Paper towel dispenser

    • Sharps bin surface taking care that no sharps project out of the bin

    • Computers and mouse ensuring no excess fluid gets under the keys onto the screen and PC speakers

    • Trios scanner 

    • Taps and hand wash basins

    • Light switches and x-ray machine switches

    • Door glass (inside and on other side of door facing outwards)

    • Floor 

  • Discard all cleaning items and solutions as clinical waste.

  • Doff all PPE at the end of the cleaning session into clinical waste. 

  • Carry out full hand hygiene prior to the next procedure.  

  • Plug-in clinical camera to upload photographs from the surgery to the clinician’s folder. 

9.1 Sterilising room procedure

No changes should be required to normal HTM 01-05 protocols apart from the following considerations:

  • All non-essential small items in the decontamination and sterilisation room should be removed from the work surfaces and place into cupboards or drawers wherever possible. 

  • The disinfected outside of the instrument container brought from the sterilisation room to the surgery by the runner/infection control nurse should be regarded as clean and held by the runner/infection control nurse just at the door to the surgery.

  • The assisting nurse who has just finished the procedure should place all instruments to be sterilised directly into the box taking care not to allow contamination of the outside of the box. 

  • The runner/infection control nurse should then place the box onto the floor and replace and lock the lid and transport the box of contaminated instruments to the sterilising room whereupon normal decontamination and sterilisation processing should continue as normal.

  • The infection control nurse should don normal decontamination and sterilising room PPE in the absence of any droplet or aerosol within the sterilising room, including standard mask, eye protection, hairnet, plastic apron and thick protective gloves.

  • Special care should be taken not to allow spatter when emptying the box. 

  • All nurses must make doubly sure to doff all PPE in accordance with instructions above and go through full hand hygiene prior to exiting the decontamination sterilising room.

  • At the end of each session the sterilising room should be cleaned in the same fashion as the dental surgery.

 

10.0 LABORATORY PROTOCOLS

 

10.1 Outgoing work

  • Until now, outgoing dental laboratory work has been placed in into decontamination baths in decontamination room before being bagged, packaged and boxed and given to the receptionist to send to the laboratory. 

  • This procedure will be changed and the impressions will stay in the surgery until end of treatment. 

  • For alginates which cannot be left for 20 minutes exposed nor 20 minutes immersed. The protocol should therefore be: 

    • All laboratory work due to go to the laboratory should be placed on and covered by a disposable bib/surface cover for the duration of the aerosol settling 

    • The lab work should be left away from direct sunlight so that any wax records are not warped. 

    • The nurse entering the room with clean PPE to decontaminate the room after the aerosol settling should then immerse laboratory work into the decontamination solution for the 10 minutes it takes to wipe down the surgery.

    • Laboratory work can then be rinsed, dried, wrapped and boxed normally using new gloves and bags and boxes stored away from aerosol within the cupboards after surgery decontamination has been completed.  

    • A sticker to indicate decontamination of contents has been completed should be stuck to the packaging. 

10.2 Incoming work

Standard procedures apply for incoming work that will be re-disinfected by CODE prior to fitting in the clinical environment. No changes to protocols are required other than those for packages being received as below under Section 11.0.

 

11.0 CHANGES FOR CLEANING / WASTE DISPOSAL AND THIRD-PARTY CONTRACTORS

 

11.1 Cleaning services

  • Cleaning services should continue as normal. A minimum of one hour should elapse between the last patient being completed and the cleaner attending the practice

  • All clinical areas down to floor level will have been decontaminated by the assisting nurse in the surgeries. 

  • The colour-coded mops for clinical and non-clincal areas will remain and the efficacy of the floor cleaning solutions in being virucidal should be verified. 

  • Cleaning staff should be trained to be knowledgeable about the virus and wear fluid resistant masks while wiping the floors and carrying out cleaning of the common areas. 

  • They should be trained to minimise droplet and spatter when mopping clinical areas to reduce the risk of viable viral droplets being re-distributed around the surgery. 

11.2 Handling of packages to the practice

  • Delivery men including the postman should not enter the practice but leave all items just inside the front door on the main mat. The outside of the door and the door buzzer should always be regarded as contaminated and outside the practice.

  • It should be remembered that coronavirus can survive for up to a day on cardboard and paper and therefore all packaging coming to the practice should be regarded as being potentially contaminated. 

  • The runner/infection control nurse should undertake opening of all letters and boxes whilst wearing an FFP2 mask, protective gown and gloves as well as eye protection. When the boxes are opened the contents should be removed by a second nurse also wearing PPE and with alcohol wipes to disinfect or items that can be wiped down.

  • Paper or cardboard boxed items that cannot be read wiped down without causing damp damage to the box or wiping of surface ink due to the alcohol content should be transferred to a decontaminated really useful box and left for at least 24 hours for the virus to die before the items are removed from the box and distributed to their storage places in the practice. 

  • The runner/infection control nurse who first opened the delivery boxes or envelopes should place them into a recycling bag the back should then be sealed, the outside surface sprayed with hypochlorous vapour or alcohol wiped at the end of each day and left for the cleaner to dispose of. 

11.3 Information pack for third-party contractors attending the practice

A copy of this standard operating procedure and risk reduction recommendations document will be available on the website under our covert page and can be forwarded to any party working with CODE upon request 

 

11.4 Feedback mechanism for third party contractors

Any third-party contractor concerns or comments should be directed to the Practice Clinical Director, Dr Kushal Gadhia. We will endeavour to respond to them within 24 hours. 

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