As I am sure we are all aware Covid-19 is a coronavirus, it is a respiratory infection. It is possible that patients may be infected and totally unaware or may be unaware that their symptoms may due to a coronavirus infection. The disease spreads via infected aerosol (coughing, sneezing and breathing). This aerosol can be inhaled or can settle on various surfaces. If you touch these surfaces and then touch your face, you can become infected.
Coronavirus is one of several respiratory diseases that as a dentist we deal with day to day (caused by bacteria, viruses and spores). The Coronavirus is easy to kill compared with some other pathogens we successfully deal with.
Dentists are highly regulated. We are inspected on a yearly basis and any deficiencies must be dealt with before a second practice inspection. Under this new scheme, Crescent Dental Health has had 4 inspections and in the last three we passed on the first inspection with no action needed. This is not to downplay the seriousness of Covid-19, but we are very good at treating patients safely and our record is excellent.
Deciding how to make the practice as safe as possible, part of the solution has been in how we operate (our SOP) and part has been investing in new equipment.
To oversimplify if all the staff members are Covid free and our patients are Covid free, we are completely safe. As we restart all patients and staff will be screened for possible infection and asked to reappoint/stay at home if there are any symptoms that may suggest possible infection.
However, the problem arises when someone is infected, but without any symptoms and so I need to protect against infection between staff members as well as between staff and patients.
In the absence of a vaccine or near instant and accurate testing, we are into the area of risk reduction and management. There is no single action I can take that removes all risk, but I can take measures to reduce the risk to as small as possible.
As a small practice we are at an advantage and will strive to have only one patient in the surgery at any time. The measure we plan to take are as follows:
- We will also screen all staff and patients for that day.
- We will ask patients where possible come by themselves or in a small family group only
- We will ask patients to ring the surgery when you arrive to let us know and when the surgery is ready, we will ring you back so that you can be taken straight into the surgery.
When you arrive, you will notice all staff will be wearing masks and full-face visors. We will offer you hand gel and disposable non latex gloves to wear when you are in the practice. We will also record your temperature.
As soon as you are in the chair we will ask you to rinse with an antimicrobial mouthwash, this has been shown to decrease the bacteria/virus load in the mouth and is effective for 35 minutes.
Covid-19 is spread by aerosol (the patient’s breath) and so to control aerosol is to control the spread of the disease.
During the initial period of lockdown, I sourced and bought in supplies of PPE, all the companies I have dealt with are longstanding trusted companies
Our dental drills and scalers produce aerosol and so the spray produced, while it dilutes the patient’s saliva, once mixed with a patient’s breath and saliva can cause a problem.
If we are to do a filling, we will use a rubber dam. Our patients will already be used to rubber dams, these are placed over the teeth to be worked on and so isolates the tooth. We have used dams as they protect the patient from the mercury fillings and allow us to place a stronger filling. We will now use them for all fillings as they protect both the patient and staff from spread of Covid-19, by greatly limiting any infected aerosol.
Whenever we are doing fillings, we will use our micro motor drills. These newer drills are driven my electric motors and not compressed air, so while they still produce aerosol, it is much less than the older air turbines. We will also use the drill as little as possible.
When scaling your teeth, it is impossible to use a rubber dam, again we will take measures to reduce the aerosol. We can use hand scalers to remove a lot of the tartar. Anytime we need to use a scaler, we will use an antimicrobial fluid as the coolant. So, as we work the teeth and gums the coolant will kill virus/bacteria instead of just water.
Moving forwards, we will be using Hypochlorous Acid (HOCL) as an antimicrobial, for mouthwashes, to clean surfaces and as a coolant in our scalers.
HOCL is naturally produced by the body and is part of the first wave of our immune response to fight infections.
Because it is produced naturally in the body it is very safe and completely non-toxic, unlike bleach. HOCL is 10 times more powerful than pure bleach in killing microbial particles.
We are buying our HOCL in from a British company that makes and produces HOCL for the pharmaceutical industry, it is 99.98% pure and very stable. There are many companies supplying HOCL or you can buy a machine to allow us to make it in the surgery. But by paying a little more and buying it in bulk, we are getting a far superior and stable pharmaceutical grade product.
As I have said, controlling the aerosol allows us to control the spread of the disease. Anytime we work my nurse uses a high-volume suction to clear any water, saliva and spray, this is very effective and can reduce the aerosol by up to 95%
When we carried out our last refurbishment, we moved to a suction motor that is in a garage outside the surgery, so the exhaust doesn’t present a danger. Our suction motor is designed to service four dental chairs, our practice has only two chairs and usually only one is running.
I have also invested in a second, high volume suction unit. This is in addition to the nurse’s suction. The arm sits above the patient’s face/torso and is present to help further reduce the aerosol spread. The air removed passes through a series of filters and then passes into an inbuilt UVC chamber. This destroys all Bacteria/Virus/Spores so that the exhaust is 99.97% pure.
This sort of extra oral suction unit is widely used in dental surgeries in Singapore and Asia, the motor is very powerful and effective at clearing the aerosol in the operating field and so will remove the aerosol produced by all in the surgery.
In the surgery I had previously placed air filter units, these monitored and purified the air. All these have been upgraded to units that contain HEPA and Charcoal filters but more importantly a UVC chamber. I have bought three of these air filter units, one for each of the surgeries and one for the reception/waiting room.
The units in the surgery are very powerful, as I have chosen units suitable for much larger rooms. Operating at a mid-range setting they will exchange all the air in the surgery every 4-5 minutes. The UVC chamber contains 16 UVC bulbs to give a 99.999% first pass kill rate on airborne pathogens.
Our last purchase has been wall mounted UVC tubes for each surgery and sterilisation room.
UVC light is a high energy, short wavelength part of natural sunlight. Luckily for us it is filtered out by the earth’s ozone level as it is highly destructive. UVC light is widely used in many industries and in hospital operating theatres as an effective and proven method of sterilising.
We will use these UVC lights to sterilise the surgery rooms between patients. The room must be empty, as the UVC is so powerful, and 8 minutes of UVC light exposure will destroy all pathogens in the air or on exposed surfaces. This will be used as well as a thorough cleaning with HOCL.
Both our dental chairs have an in-built automatic cleaning cycle and this will be used to cleans all waterlines between each patient.
In deciding how to move forward I wanted to try and future proof the practice and make it safer against all pathogens. With the current testing and lack of vaccines for Covid-19 it is impossible to remove all risk. I do not feel it is possible or desirable to enter another period of prolonged lockdown if there is a second wave. And there is always the possibility of a new pathogen in the future.
I wanted to develop a multi-layer approach, each layer reduces the risk to all members of the practice, and the multiple layers together reduce the risk to negligible levels.
I have invested heavily in the practice as well as the new equipment above, I had already planned to replace some of the sterilisation equipment and have moved forward with this. All the dental equipment in the practice is under 4 years old and so using the most up to date cross infection control technology available.
I have gone much further than any of the recommendations provided for dentists in England, Scotland or Wales and hope this demonstrates my commitment to all the people who make up this practice.
We at Crescent Dental Health hope to see you soon and hope you all stay safe!