Routine personal protective equipment in COVID-19 pandemic: What dentists need to know

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.

COVID-19 in endoscopy: Time to do more?

Firmly establishing oral health care professionals’ roles as vaccinators within the health care system

the global spread of the new Coronavirus has caused concerns in the medical community. According to the Department of Occupational Safety and Health, dentists and their staff are in the list of jobs with high exposure risk. The provision of dental services has been affected by this pandemic and attention to oral health in the community has diminished due to the anxiety of acquiring the infection. In the following, the effects of this pandemic on dentistry, and strategies for providing better dental services in these conditions, have been suggested.COVID-19, is the disease caused by infection with Coronavirus. The main symptoms of this disease are headache, fever, cough, sore throat, fatigue, shortness of breath, and intestinal inflammation. Patients may also show symptoms of acute respiratory distress syndrome (1). Asymptomatic patients are a potential source of spreading the infection. Thus, it is necessary to fully analyze the ways in which the virus spreads. The virus mainly spreads through direct or indirect contact with the mucous membranes of the eyes, nose, or mouth (2). Following the COVID-19 pandemic, dental clinics (public and private), were temporarily closed and elective dental treatments were suspended. Dental school clinics were also closed due to the suspension of classes and clinical education activities (3). As a result, paying attention to oral health declined.Poor oral health can increase the complications of systemic diseases such as diabetes, chronic kidney disease, and liver disease. Improving oral health can reduce oropharyngeal colonization and the risk of respiratory complications. Besides, by decreasing the risk of developing systemic diseases, it can reduce the severity of COVID-19 disease and its symptoms (1). Based on a study carried out by Gonzalez et al. (2), the tongue is the main organ which acts as a reservoir of COVID-19 in the mouth, and brushing the tongue is important for reducing the viral load in a virus carrier. Therefore, the relation between oral health and the severity of COVID-19 symptoms seems logical. However, to prove this relation, more research is required (1).As the severity of the pandemic increases, the anxiety and fear of acquiring COVID-19 infection may cause people to underestimate the importance of serious oral disease symptoms and avoid receiving services necessary for the diagnosis of oral lesions. Nevertheless, despite the discontinuation of dental services, chronic diseases with significant clinical effects still occur. Therefore, COVID-19 can be an additional aggravating factor in delaying the diagnosis of serious diseases such as oral squamous cell carcinoma, and lead to more complications and worse prognosis (3).Oral squamous cell carcinoma is a disease with the highest clinical significance. Delays in the diagnosis of the disease are common and most cases are diagnosed at an advanced stage. As a result, the mortality rate ofthis disease is generally high. It is most likely that pemphigoid is poorly diagnosed or not diagnosed at all during the COVID-19 pandemic. To minimize this effect, it is necessary for the social and dental media to play a role in remote diagnosis of oral diseases as well as in raising public awareness during the course of the pandemic, especially about lesions suspicious for malignancy (3).Digital instruments can replace some of the common services such as counseling and monitoring patients. Instead of three times going to the dentist (for giving history, treatment, and symptom monitoring), using digital programs, patients can receive dental treatment with only one visit (4). However, it is better to limit elective treatments at this stage of the pandemic. The number of people suffering from diseases and the health system capacity are of high importance. People should be encouraged to use oral hygiene methods in the best way, so that the cases of dental emergency and worsening of oral health reduces as far as possible. In cases where the patients are suffering from pain, spontaneous bleeding, and dental trauma, doing dental treatment in dental clinics is inevitable. In these circumstances, providing biosafety protection isa fundamental principle. However, the usual biosafety protection methods are probably not enough and one must provide instructions based on the best available evidence. Patients receiving dental services need to be informed of the status quo, and written consent must be obtained from them (5).Actions which involve using rotatory tools such as hand pieces and scaling with ultrasound, produce aerosols. Therefore, a better understanding of transmission mechanisms, clinical features, and viral detection tests is essential. These help to provide dental treatment protocols and are useful in identifying cases and preventing further spread of the infection in patients and dental staff (4). The recommendations of the American Dental Association (ADA) and Centers for Disease Control on how to provide dental services include making phone calls with patients for screening COVID-19 before treatment, avoiding non-emergency treatment of patients who have COVID-19 symptoms, limiting the number of patients’ companions (if possible), minimizing the number of patients in the waiting room, and checking the body temperature of patients before their treatment (5). For all of the staff, using face masks and eye protectors (goggles / face shields), gowns, and disposable gloves as personal protective equipment (PPE) is recommended. All surfaces should be cleaned and disinfected after each patient and the floor of the treatment environment should be cleaned 2 to 3 times a day. This disinfection may be done by the chlorine-based hypochlorite solutions or alcohol (%60-70). Clinical waste needs to be disposed in accordance with the legislations. It is recommended that PPE and other contaminated disposable materials, be put in containers with rigid lids for disposal. A proposed method for disinfecting is washing with H2O2, of which there is no clear evidence available. The potential of H2O2 in reducing viral load is an example of using the precautionary principle and needs more evaluation (5).Studies in this area are ongoing. It is hoped that dentistry will adapt to the current situation as soon as possible and appropriate dental services will be provided in the community during the pandemic.

The EU Response to COVID-19: From Reactive Policies to Strategic Decision-Making.

We welcome Professor Cook's article clarifying the use of personal protective equipment (PPE) in protecting staff during the current COVID-19 pandemic 1. There remains considerable debate about the extent to which airborne spread of SARS-CoV-2 occurs. Small droplets (< 5 μm) are thought to remain suspended in the air and could theoretically be inhaled into the lungs causing infection 2. Loose fitting 'surgical' masks will not prevent such inhalation and only a tight-fitting filtering mask is adequate. Conversely larger (> 5 μm) particles do not remain suspended in the air 2 and can only cause infection if they are immediately inhaled, or after contact with a surface they land on. We applaud the clarity brought to the complex issue of PPE, but we have concerns about the relative proportion of particles generated during a normal cough or sneeze. Nicas et al. is cited as evidence that 99.9% of the fluid volume ejected during a cough is in large particles 3. We believe that this should be interpreted with caution because there is also evidence suggesting that a much higher proportion of particles emitted are in the small, potentially airborne, range 2. Given the uncertainty regarding the infectivity of SARS-CoV-2 and the inoculum required to cause infection, it is possible that the sheer number of small particles is more relevant than the weight of the larger droplets. The World Health Organization (WHO) has defined a number of healthcare-related aerosol generating procedures (AGPs) 4 but we believe this list is outdated in the context of COVID-19. Much of the evidence used by WHO is epidemiological, based on SARS and other respiratory outbreaks 5. Many of the procedures, which were defined as aerosol generating, may in fact be a risk precisely because they generate coughing. Bronchoscopy and physiotherapy would likely fit this description. Cook points out that air accelerating across a wet surface generates aerosols 1, 4. Typically, the faster the airflow, the more aerosols are generated. Although we agree there is some evidence supporting tracheal intubation as an AGP, in our experience, very few airway procedures generate rapid airflows unless they cause coughing (e.g. at tracheal extubation). Many of the other AGPs listed do not generate high airflows and we question why they are considered a higher risk than coughing. Procedures such as manual ventilation and suctioning the airway (unless coughing) are unlikely to generate high gas flows. Manual ventilation, continuous positive airway pressure and non-invasive ventilation may generate a leak around a mask but high gas flows in the airway itself seem unlikely. There are many other factors other than particle size (such as viral shedding) which might affect spread of SARS-CoV-2. However, we believe that if airborne spread can occur, it is likely to occur with coughing and not solely during AGPs. We agree that PPE carries cost and resource implications and should be applied in a logical manner based on the likely risk from any source of airborne particles. If airborne spread does occur, then it would make sense to apply airborne precautions when staff are exposed to infectious patients who are coughing rather than solely in the intensive care unit (ICU)/anaesthetic context. This may be why some major bodies (the Centers for Disease Control and Prevention and the European Centre for Disease Prevention and Control) have advocated the use of respirators for healthcare workers with any contact with patients with COVID-19. It is arguable that PPE should be directed towards ward-based healthcare workers exposed to infected, coughing patients as much as to the controlled environment of ICU or the operating theatres.

Analyzing The Ebola ViruAnalyzing The Impact That The Ebola Virus Disease Has on Children

COVID-19 drive through testing: An effective strategy for conserving personal protective equipment

The aim of this study was to examine safety-related contamination threats and risks to health-care workers (HCWs) due to the reuse of personal protective equipment (PPE) among emergency department (ED) personnel. We used a Participatory Design (PD) approach to conduct task analysis (TA) of PPE use and reuse. TA identified the steps, risks, and protective behaviors involved in PPE reuse. We used the Centers for Disease Control and Prevention (CDC) guidance for PPE donning and doffing specifying the recommended task order. Then, we convened subject matter experts (SMEs) with relevant backgrounds in Patient Safety, Human Factors and Emergency Medicine to iteratively identify and map the tasks, risks, and protective behaviors involved in the PPE use and reuse. Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE ties and materials. TA was helpful revealed that the procedure for donning and doffing of re-used PPE does not protect ED personnel from contaminant spread and risk of exposure, even with protective behaviors present (e.g., hand hygiene, respirator use, etc.). Future work should make more apparent the underlying risks associated with PPE use and reuse.

What should I do when a patient just wants antibiotics?

Introduction: In response to the 2014 Ebola outbreak, MedStar Washington Hospital Center established the Biocontainment Unit (BCU) to provide safe treatment of patients infected with special pathogens. Through federal funding for infectious disease preparedness from the Administration for Strategic Preparedness and Response and the Centers for Disease Control and Prevention, the MedStar BCU became one of thirteen Regional Emerging Special Pathogen Treatment Centers in the United States. The Medstar BCU is designed to deliver safe and effective clinical care for patients infected with high-consequence infectious diseases. Methods: Providers, including physicians, advanced practice providers, and registered nurses, underwent quarterly simulation-based training that focused on donning and doffing personal protective equipment (PPE) including a powered air purifying respirator, coverall, isolation gown, two layers of elbow-length gloves, one layer of examination gloves, foam clogs, and boot covers. All post-training surveys included two primary outcomes related to PPE, and the distributions of these responses were summarized. Results: 89% of participants were comfortable, very comfortable, or extremely comfortable with donning and doffing PPE, while 11% of participants were still not comfortable after training. Training proctors monitored for PPE breaches. Of 100 respondents, 4 responded that a PPE breach had occurred during training. 87% of participants were comfortable, very comfortable, or extremely comfortable with caring for patients in full biocontainment PPE, however, 12% of responders were extremely uncomfortable or not comfortable. Distributions in post-training comfort level did not vary significantly between training sessions, suggesting that each session had a relatively consistent impact on these two measures. Conclusion: Simulation-based medical training can increase provider preparedness in high-level isolation unit settings by improving PPE proficiency and self-efficacy. PPE proficiency and competency are integral to the low-frequency, high-consequence events of providing safe care for patients infected with special pathogens.

How to Manage Pediatric Orthopaedic Patients: Strategies to Provide Safer Care During the COVID-19 Outbreak in Wuhan, People's Republic of China.

Coronavirus disease (COVID-19) is responsible for a global pandemic. It is important to balance the need for access to healthcare services, including testing and treatment for sexually transmitted infections. Sexually transmitted infection programs must consider how to use limited resources and implement novel approaches to provide continued access to care.

The aerosol transmissibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has impacted the delivery of health care and essentially stopped the provision of medical and dental therapies. Dentistry uses rotary, ultrasonic, and laser-based instruments that produce water-based aerosols in the daily, routine treatment of patients. Abundant aerosols are generated, which reach health care workers and other patients. Viruses, including SARS-CoV-2 virus and related coronavirus disease (COVID-19) pandemic, continued expansion throughout the USA and the world. The virus is spread by both droplet (visible drops) and aerosol (practically invisible drops) transmission. The generation of aerosols in dentistry—an unavoidable part of most dental treatments—creates a high-risk situation. The US Centers for Disease Control and The Occupational Safety and Health Administration consider dental procedures to be of “highest risk” in the potential spreading of SARS-CoV-2 and other respiratory viruses. There are several ways to reduce or eliminate the virus: (i) cease or postpone dentistry (public and personal health risk), (ii) screen patients immediately prior to dental treatment (by appropriate testing, if any), (iii) block/remove the virus containing aerosol by engineering controls together with stringent personal protective equipment use. The present work takes a novel, fourth approach. By altering the physical response of water to the rotary or ultrasonic forces that are used in dentistry, the generation of aerosol particles and the distance any aerosol may spread beyond the point of generation can be markedly suppressed or completely eliminated in comparison to water for both the ultrasonic scaler and dental handpiece.

The aerosol transmissibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has impacted the delivery of health care and essentially stopped the provision of medical and dental therapies. Dentistry uses rotary, ultrasonic, and laser-based instruments that produce water-based aerosols in the daily, routine treatment of patients. Abundant aerosols are generated, which reach health care workers and other patients. Viruses, including SARS-CoV-2 virus and related coronavirus disease (COVID-19) pandemic, continued expansion throughout the USA and the world. The virus is spread by both droplet (visible drops) and aerosol (practically invisible drops) transmission. The generation of aerosols in dentistry—an unavoidable part of most dental treatments—creates a high-risk situation. The US Centers for Disease Control and The Occupational Safety and Health Administration consider dental procedures to be of “highest risk” in the potential spreading of SARS-CoV-2 and other respiratory viruses. There are several ways to reduce or eliminate the virus: (i) cease or postpone dentistry (public and personal health risk), (ii) screen patients immediately prior to dental treatment (by appropriate testing, if any), (iii) block/remove the virus containing aerosol by engineering controls together with stringent personal protective equipment use. The present work takes a novel, fourth approach. By altering the physical response of water to the rotary or ultrasonic forces that are used in dentistry, the generation of aerosol particles and the distance any aerosol may spread beyond the point of generation can be markedly suppressed or completely eliminated in comparison to water for both the ultrasonic scaler and dental handpiece.