Phone Appointments

All patients requiring dental care must request an appointment by phone in advance. During the call the patient’s risk should be assessed with questions regarding the presence of possible symptoms such as fever, cough, respiratory distress, and if the patient has been any contact with any suspicious or person confirmed as having COVID-19.^{Reference Pereira, Pereira and Murata13} Appointments should be staggered to avoid patients accumulating in the waiting room.

Waiting Room and Patient Arrival

The whole environment should be considered as being of high risk. Therefore, it is recommended that the dental office provide masks, disinfectant alcohol, and that magazines, ornaments, and objects that may spread the virus contagion be removed.^{Reference Spagnuolo, De Vito and Rengo9,Reference Ather, Patel and Ruparel14} In addition, the temperature of the patient should be taken with a contact-free infrared digital thermometer.^{Reference Wu and Qi15} A questionnaire should be given to identify patients with potential COVID-19 infection before dental care (Table 2).

TABLE 2 Questionnaire for Patients Before Dental Care

Patients answering “yes” to the questionnaire but without a temperature higher than 98.6°F or 37°C are to be instructed to remain quarantined at home and under surveillance for 14 d. In the case of symptomatic patients, these must promptly contact the nearest health center for evaluation. In the event of any symptoms, the appointment is postponed until after 14 d and the patient is advised to undergo a medical evaluation. Patients answering “yes” to the questionnaire and with a temperature higher than 100.4°F or 38°C should be immediately quarantined and the nearest health center should be contacted. If patients answer “no” to the questionnaire, dental care will proceed.^{Reference Valenzuela3,Reference Ather, Patel and Ruparel14}

Personal Protection and Transmission Precautions

Dental health personnel must take measures to protect both the patients and themselves. Before any procedure, the clinician must perform hand washing and use different garments to enhance biosecurity in the following order: disposable surgical cap, breathing mask (N95 or FFP2), disposable long-sleeved gown with elasticized wrist cuffs, lenses, facial visor, disposable gloves, and boots.^{Reference Pereira, Pereira and Murata13,Reference Ather, Patel and Ruparel14}

Dental units and work tables must be covered with single-use plastic (film) for each patient.¹⁶

Patient Apparel and Management

The patient should be given a hydrogen peroxide rinse with 1% distilled water to decrease the salivary viral load and should be fitted with disposable boots, a disposable cap, and protective glasses.^{Reference Araya6}

Instrumental and Clinical Material

Handpieces, micromotors, and ultrasound parts must be disinfected with 96% alcohol, sodium hypochlorite. Rotary systems must have an anti-return system.^{Reference Spagnuolo, De Vito and Rengo9,Reference Wu and Qi15}

To minimize the spread of aerosols, a rubber dam should be used in all procedures in addition to performing minimally invasive techniques, such as atraumatic restorative therapy.^{Reference Odeh, Babkair and Abu-Hammad17,Reference Baghizadeh Fini18}

When auxiliary exams such as X-rays are needed, panoramic X-rays or CT scans are recommended, and if a surgical suture procedure is performed, a resorbable material should be chosen to reduce clinical appointments.^{Reference Meng, Hua and Bian4,Reference Araya6}

In addition to following these measures, a disinfection method should be used for any material extracted from the mouth and sent to the laboratory (eg, prints, bite register, and prosthesis) to prevent cross-contamination.^{Reference Baghizadeh Fini18,Reference Warnakulasuriya19}

Suspected Fluid Exposure

When there is suspicion of exposure, microbiological testing should be performed, and if the diagnosis of COVID-19 is confirmed, the patient should be quarantined and supervised.^{Reference Izzetti, Nisi and Gabriele20}

Cleaning and Disinfection of the Office

It is recommended that the handpiece, micromotor, and any equipment that can be removed from the unit be sterilized and/or autoclaved between each patient, depending on the manufacturer’s specifications, and the same considerations should be taken with nondisposable instruments. In addition, X-ray equipment, lights, and the dental chair must be disinfected according to the manufacturer’s instructions.^{Reference Lucaciu, Tarczali and Petrescu24}

Surfaces such as door handles, chairs, desks, elevators, and bathrooms, among others, must be frequently cleaned and disinfected. Disinfectants such as 0.1-0.5% sodium hypochlorite, 62-71% ethanol, or 2% glutaraldehyde can be used for surface decontamination, as well as 62% ethanol or 2% glutaraldehyde in freshly prepared solutions and adequate concentrations.^{Reference Kampf, Todt and Pfaender25}

Protective barriers should be used to cover clinical contact surfaces, especially those that are difficult to clean such as switches on dental chairs, computer equipment, screens. These barriers should be changed between each patient.^{Reference Sexton, Wilson and Sassi26}

Waste Management

In relation to the residue discarded, this should be disinfected with a 0.5% sodium hypochlorite solution and then placed in a double-layered bag with a “swan neck” knot which should only be filled to 80% capacity to allow proper closure. Sharp objects should be placed in a double bag.^{Reference Baghizadeh Fini18,Reference Mayo, Cique and Cascante23}

All waste originating from the care process is to be considered as dangerous, and disposable personal protection elements should also be considered as hazardous waste. For biocontaminated waste, red bags should be used, while common waste should be discarded in black bags, and special residue should be placed in yellow bags (Table 3).^{Reference Haralur, Al-Qahtani and Al-Qarni27,Reference Agarwal, Singh and Bhansali28}

TABLE 3 Waste Management in the Dental Office

Abbreviation: PPE, personal protective equipment.