Neobook — clinical reference

Medical Pre-Assessment of Patients During COVID-19 Pandemic

Periodontology, Implantology and Oral Hygiene

Dental care during Level 3 includes procedures where aerosol can be generated. Hence, pre-assessment screening for COVID-19 is crucial. This should not be seen as a deterrent to offering treatment but instead as a way of assessing risk to the dental team, ancillary personnel and patients.

Medical Pre-Assessment of Patients During COVID-19 Pandemic

In addition to taking a standardised medical history, additional pre-assessment for COVID-19 needs to be done and categorised. Pre-assessments need to be done in all these cases:

Patient is asymptomatic, unsuspected but unconfirmed for COVID 19
Patient is symptomatic, suspected but unconfirmed for COVID 19
Patient is confirmed posit ive with active symptoms but stable
Patient is confirmed positive and unstable
Recovered COVID 19 patient

If a patient is confirmed positive for COVID-19, they should be treated in specialised environments such as laminar flow, HEPA filtered (H13, H14) hospital theatres or specially designed AIIR.

1. General Dentistry

Dental treatment is not limited at this stage. Dentists can continue with telephonic consultations to practise social distancing in the reception area. Face-to-face consultations can occur with correct PPE: head cap, eye protection, nose and mouth protection and water-resistant gown.

AGPs are allowed. However, these must be performed under rubber dam and HVE close to the tooth being worked on. Again, the operator should be equipped with the correct PPE.

Precautionary rinses or sprays: For all the procedures listed below, it is recommended that the patient rinse their mouth immediately with 1 % H2O2 (1% for 2 periods of 30 seconds each.) Povidone-iodine rinses (0.2%) as well as a nasal spray can also be of benefit, providing the patient is not allergic to iodine.

The operator should be equipped with the correct PPE (head cap, eye protection, nose and mouth protection and water-resistant gown). For all the procedures listed below, it is recommended that the patient rinse their mouths immediately with 1% H2O2 (1% for 2 periods of 30 seconds each). Povidone-iodine rinses (0.2%) preoperatively strongly advised.

General anaesthesia can be considered with the consultation of hospital protocols of AGPs.

Sedation (inhalation/ intravenous) can be considered with stringent care taken to use PPE and sterilise all equipment, including sedation machines, pipes and masks. No evidence is available on the safety of sedation or GA in COVID-19 positive patients.

Scope of Treatment

a. Diagnostics

Requires HVE and adequate PPE
Examination and assessment of patients can be done as part of an early diagnosis of possible disease and pathology. This includes essential intra-oral radiographs, which should be limited to diagnosis and treatment verification.
Extra oral radiographs are encouraged where they may assist in the diagnostic process.

b. Restorative

Requires limiting aerosol under rubber dam, with HVE and adequate PPE
Treatment of carious lesions that are approaching the pulp and may result in devitalisation of the tooth with subsequent pain and infection if left untreated.
Treatment of symptomatic and painful carious and crack lesions.
Treatment of broken or chipped teeth or restorations causing soft tissue trauma, even if the teeth are asymptomatic.

c. Fixed Prosthodontics

Requires limiting aerosol under rubber dam, with HVE and adequate PPE.
Indirect restorations are permissible (with the use of rubber dam, HVE and PPE).
Preparation and cementation of crowns and bridges are permissible (with the use of rubber dam, HVE and PPE).
Failed indirect restorations, crowns and bridges can be replaced at this stage. (The use of rubber dam, HVE and PPE is always advocated.)
Pro theses for implants are also permissible.

d. Removable Prosthodontics

Requires HVE and adequate PPE.
Denture repairs may be undertaken chairside or through laboratory processing.
New removable prostheses can be done at this stage, disinfection of impressions to follow protocols from the SADA COVID 19 protocol document.
All prosthodontic procedures that are related to the management of malignant and benign maxillofacial lesions can be done.
All necessary TMD adjustments of oral appliances used in the pain management of TMDs can be done.

e. Implants

Requires HVE and adequate PPE
Routine implants can be placed.
Prostheses for implants can be placed.

f. Trauma and Extractions

Requires HVE and adequate PPE.
The extraction of teeth due to trauma is allowed.
Teeth that have a poor prognosis and hopeless periodontally compromised teeth can be extracted.
Non elective extraction for orthodontic purposes can be done.
Extractions of teeth with pericoronitis that cannot be managed pharmacologically can be extracted by aerosol generating techniques
If extractions are done by surgical interventions, HVE and the correct PPE are essential.

g. Endodontics

Requires a rubber dam, HVE and adequate PPE.
There is no restriction on the level of care with regard to endodontics at this point.
Emergency root canal treatments can be done to resolve irreversible pulpitis, facial swelling and acute pain and infection.
Endodontic obturation after a preparatory visit or done as a single visit is at the discretion of the clinician.
Endodontic management of trauma can be done at this stage and should follow endodontic protocols.
Direct pulp capping and indirect pulp capping can be done.
Endodontic treatment on primary teeth (pulpotomy and pulpectomy) can be done at this stage. But where there is acute pain, abscess formation, facial swelling, and cellulitis, then extraction is the treatment of choice.

h. Paediatric Dentistry

Requires rubber dam, HVE and adequate PPE.
Treatment of cavities causing pain/trauma with direct restorations or paediatric preformed crowns with rubber dam placement.
Extraction i s the treatment of choice for primary teeth associated with acute pain/abscess formation/facial swelling/cellulitis.
Endodontic treatment on primary teeth (pulpotomy and pulpectomy). Discretion of the treating clinician should be used where multiple pulpectomies or pulpotomies are indicated as to whether treatment should be done in theatre, chair (under sedation) or multiple chairside visits.

i. Periodontal Treatment/Oral Medicine

At this level, ultrasonic scalers or lasers can be used with the appropriate PPE and HVE and with minimum permissible kHz and water coolant output.
Routine prophylaxis by minimum aerosol generation and aided by hand instrumentation for active and chronic periodontal patients.
Management of periodontal diseases or infection.
Supporting Periodontal Therapy not restricted to hand instrumentation for the periodontal maintenance of patients with a history of periodontal disease.
Oral medicine consultation and if needed relevant biopsies of oral lesions not responding to therapy, suspect ed of malignancy or where only a biopsy can determine the diagnosis and treatment required.
Palliative care for post radiation and post chemotherapy patients. Determine the diagnosis and treatment required.
Palliative care for post radiation and post chemo therapy patients.
Routine dental implant placement where a further delay of treatment will have a detrimental effect on treatment outcomes.
Augmentation procedures are allowed to site for planned implant placement.
Soft tissue grafts for root coverage procedures.
Mucogingival procedures: gingivectomy; crown lengthening and frenectomies.
Management of peri-implant diseases.

j. Oral Hygiene Related Procedures

Scaling with ultrasonic scalers and polishing with the use of low rpm and minimum permissible water coolant together with hand instrumentation can be explored under HVE.
Use of pit and fissure sealants under rubber dam for highly caries risk group.
Fluoride treatment where applicable.
Desensitisation of exposed roots where there are symptoms.
Vital bleaching.
Minimum invasive procedures, for example, ART.

2. Orthodontics

Scope of Treatment

Level 3 allows for further relaxation with respect to the scope of procedures that may be performed whilst still acknowledging the patient scheduling protocols outlined for Level 4.

AGPs should still be kept to a minimum where possible with strict adherence protocols outlined in Level 4 regarding appropriate PPE and HVE:

This includes procedures such as banding, and especially debanding and bracket re bonding the orthodontic procedures associated with the highest risk of aerosol generation.
Procedures should take cognisance of treatment protocols that acknowledge the best interest of the patient to ensure treatment continuity. It is imperative that the progress of treatment is not unduly delayed.

3. Periodontology, Implantology and Oral Hygiene

As a reminder: When treating patients, all patients should be treated as potentially being COVID-19 positive. Patients presenting with symptoms or are COVID-19 positive should only be seen with relevant PPE and only for the management of pain and sepsis.

During the delivery of emergency and essential services, all efforts must be made to eliminate and avoid aerosol-producing procedures, including the use of lasers. Strictest PPE guidelines should be followed by the clinician and supporting staff.

All procedures listed at Level 4 will be permitted in Level 3.

The reduction of aerosol production is advocated at all times. However, all aerosol-producing procedures that are allowed at this level must be performed with the correct PPE in place as well as correct surgery ventilation as set out in this document.

All procedures that fall under the scope of practice are allowed under this level, including the use of ultrasonic scalers. Again, it must be reiterated that water levels must be set at a minimum to reduce the amount of aerosol but enough not to damage any of the anatomical structures being worked on.

All implant-related procedures including any augmentation techniques
Any Mucogingival surgery both on implants and natural teeth, including crown lengthening and gingivectomies.
Any other procedure and related procedures that fall under the scope of the practice of the periodontist.
All elective procedures may be undertaken at this time.

Oral Hygiene Related Procedures

Ultrasonic instruments may be used but under the same guidelines as per periodontal procedures.

HVE and adequate PPE are standard requirements.
Fissure sealants under rubber dam
Vital bleaching procedures
Fluoride treatment, where applicable
Desensitisation of exposed roots where patients are experiencing symptoms.
Scaling and polishing with limited use of aerosol producing equipment
Any other procedures that fall under the scope of practice for an oral hygienist

4. Prosthodontics

The scope of treatment should be performed under the umbrella of Extensive Care. Where aerosols will be generated, it is especially important to work under a rubber dam where applicable, using PPE and HVE. Elective treatment can be done. Face-to-face consultations with the use of correct PPE are allowed, but telephonic consultations are especially important to gauge the level of need for treatment.

COVID-19-positive patients should be treated in specialised environments such as laminar flow, HEPA filtered (H13, H14) hospital theatres or specially designed AIIR.

Note: All prosthodontic work is to be performed, where appropriate. PPE sterilisation and patient preparation measures are adhered to strictly as defined in the preamble. All aerosol-producing procedures should be performed under a rubber dam. All prosthodontic patients must make use of preoperative oral rinses prior to any procedure being undertaken.

a. Fixed Prosthodontics

The use of a rubber dam is essential.
All fixed prosthodontic work required to comprehensively manage cases, where left untreated will compromise the quality of health (indirect or direct)
Exclude elective cosmetic procedures.

b. Removable Prosthodontics

Repair and fabrication of new of all prosthodontic prostheses.
Fabrication of all maxillofacial prostheses.

c. Implant Therapy

No restrictions on the scope of practice; all procedures are permissible.

d. Oncology and Craniofacial Trauma

All prosthodontic procedures that are related to the management of malignant and benign maxillofacial lesions that cannot be deferred

e. TMD

Management of cases that be otherwise managed pharmacologically.

f. Endodontics

The same as for the general practitioner under this level.

5. Maxillofacial and Oral Surgery

In Level 3, almost all maxillofacial surgical procedures can be offered. These procedures include all facial trauma, orofacial sepsis and associated inflammatory conditions, oncological resection and its appropriate immediate reconstruction, intra- and extra-oral implantology and associated augmentation procedures, orofacial pathology, dento-alveolar and associated oral surgery procedures, myofascial pain disorders and syndromic craniofacial procedures including cleft palate and urgent syndromic conditions and deformities.

Note: During a Level 3 lockdown, procedures that are still excluded are any semi-elective or elective surgery (other than oncology and reconstruction) that may require ICU/high-care management post-operatively as the standard of care or as a reasonable complication that may arise from such a procedure.