|Year : 2020 | Volume
| Issue : 3 | Page : 131-138
A memory-recall checklist for dental services during the COVID-19 outbreak: A clinical recommendation
Amal A Al-Khotani1, Haila A Al-Huraishi2, Dalia E Meisha3
1 Dental Division, East Jeddah Hospital, Ministry of Health, Jeddah, Saudi Arabia; Scandinavian Center for Orofacial Neurosciences, Malmö/Huddinge, Sweden
2 Scandinavian Center for Orofacial Neurosciences, Malmö/Huddinge, Sweden; Department of Orofacial Pain and Jaw Function, Riyadh Specialized Dental Center, Ministry of Health, Riyadh, Saudi Arabia
3 Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Submission||15-Jul-2020|
|Date of Decision||20-Aug-2020|
|Date of Acceptance||19-Sep-2020|
|Date of Web Publication||12-Nov-2020|
Dr. Dalia E Meisha
Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, P. O. Box: 80209, Jeddah 21589
Source of Support: None, Conflict of Interest: None
The epidemic coronavirus disease 2019 (COVID-19) has infected millions of people and put a huge amount of stress on the health-care system. Health-care professionals, including dental professionals, are at a high risk of acquiring COVID-19. Therefore, extra precautions need to be implemented for routine dental infection control procedures. It is encouraged to have a written reminder in the form of a checklist to recall these crucial steps, especially when nonroutine procedures must be followed. The aim of this special communication is to present a proposed mnemonic or memory-recall, user-friendly checklist to be used in the dental clinic during the COVID-19 outbreak. The checklist was created following the guidelines for reopening dental services in governmental and private sectors during the COVID-19 pandemic that were published by the Ministry of Health on June 5, 2020. Based on the patient's score and the urgency of the dental situation, specific steps should be followed. When the patient's score is ≥ 4 and needs an emergency aerosol-generating procedure, REDS steps should be recalled. Further, MRS steps must be followed if the patient's score is < 4. For both groups, GAMES can be followed when personal protective equipment is needed before the patient examination and HD steps should be applied after finishing the dental procedure. In conclusion, this written reminder in the form of a checklist can be helpful for a safe dental practice during pandemics to recall the crucial nonroutine steps. We recommend that the dental staff place those steps as a written reminder in an accessible, visible place.
Keywords: Checklist, COVID-19, dental, guidelines, infection control, pandemic
|How to cite this article:|
Al-Khotani AA, Al-Huraishi HA, Meisha DE. A memory-recall checklist for dental services during the COVID-19 outbreak: A clinical recommendation. Saudi J Oral Sci 2020;7:131-8
|How to cite this URL:|
Al-Khotani AA, Al-Huraishi HA, Meisha DE. A memory-recall checklist for dental services during the COVID-19 outbreak: A clinical recommendation. Saudi J Oral Sci [serial online] 2020 [cited 2021 Jan 28];7:131-8. Available from: https://www.saudijos.org/text.asp?2020/7/3/131/300594
| Introduction|| |
The coronavirus disease 2019 (COVID-19) is an infectious disease caused by the novel coronavirus (2019-nCOV), also known as the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). It is classified as a new strain of the coronaviruses family that targets the airways and has not been detected in humans before.,,, COVID-19 causes respiratory infections that range from common cold-like symptoms to the more severe illnesses similar to the Middle East respiratory syndrome (MERS-CoV) and SARS-CoV., In addition, it can also cause dyspnea, severe lung congestion, arrhythmia, acute myocardial injury, acute liver injury, and multiorgan failure such as respiratory failure.
As of August 2020, the COVID-19 pandemic represents an extraordinary public health crisis that has affected over 22 million of the population worldwide.
COVID-19 can spread by mucus or droplets that are expelled through the nose or mouth when an infected individual coughs or sneezes. In addition, it can be indirectly transmitted via contact between the hands/oral mucosa and the contaminated surfaces. More importantly, as a case report of COVID-19 infection in Germany revealed, the transmission of the virus can occur via contact with asymptomatic patients as well., Furthermore, other studies indicated that COVID-19 infection could be transmitted through fecal–oral route. Studies also suggested that medical/dental procedures such as aerosol-generating procedures (AGP) can transmit COVID-19 infections. Therefore, everyone in the sustained transmission phase of COVID-19 needs to consider that anyone might have the virus and act accordingly.
Countries' first action toward COVID-19 was the implementation of curfew laws toward the pandemic, including school closures, shopping malls' closures, plane groundings, and business/major event lockdowns. Furthermore, people have been instructed to stay at home, but are allowed to leave home for necessities such as food, medical reasons, or for work. Due to the escalating numbers of cases, many countries were providing ample tests for free to people with symptoms and are conducting active screening in crowded areas where there is a high number of confirmed cases. On August 15, 2020, the total number of cases reached 297,315 since the start of the outbreak in Saudi Arabia. In addition, the number of recovered cases and fatalities reached 264,487 and 3369, respectively [Figure 1].
In many countries, all routine medical/dental care and elective surgical procedures were postponed until further notice to avoid sustained transmission of COVID-19.,,, In March 16, 2020, the American Dental Association recommended postponing elective procedures until April 18, 2020, when they released the new interim guidance to help dentists during the reopening process to help reduce the risk of exposure to infection. In the case of Saudi Arabia, the Saudi Ministry of Health (MOH) recommended that all essential dental procedures, including emergencies, during the COVID-19 pandemic, must be provided with a high level of infection control protocol supported by suitable personal protective equipment (PPE). In particular, the MOH recommended avoiding AGPs, unless they fall under the category of dental emergencies, and published a guideline regarding dental emergencies during the COVID-19 outbreak. On June 5, 2020, the MOH published guidance for the reopening of dental services in governmental and private sectors – as the COVID-19 pandemic continues. In response, this special communication aims to present a proposed mnemonic, or memory-recall, user-friendly checklist to be used in dental clinics during the COVID-19 outbreak.
Dental practitioners are at a biological risk of infection due to the exposure to pathological microbes from the patient's oral cavity and respiratory tract. Studies have shown that face-to-face contact and day-to-day exposure to contaminated saliva, blood, and conjunctival/nasal mucosa could transmit respiratory infections., Moreover, dental staff is at possible extra risk of infection from the handling of sharp instruments. Studies have suggested that respiratory infection can be directly transmitted through the inhalation of airborne microbes that are present in the air, or indirectly transmitted by contact with contaminated instruments or inanimate surfaces.,,
AGPs, which include the use of high-speed handpieces, ultrasonic scaler, and triple syringes during dental procedures, can cause the spread of infection through the production of a significant amount of droplets and aerosols mixed with a patient's blood or saliva., It is recommended that the dental clinic environment must be under the highest infection control standards as part of dental care workers' routines to prevent the transmission of microbiological contaminations. This cannot be emphasized enough especially during a public health crisis.
It has been documented that extended exposure to AGP along with poor infection control could be associated with an increased risk of acquired infections. Moreover, inadequate handwashing, inadequate social distancing, and inadequate use of PPE can contribute to an increased risk of infection. A study conducted in China reported that a large number of medical staff became infected with COVID-19 during this pandemic.
Several guidelines provide recommendations to minimize or prevent the risk of transmission associated with AGP during the COVID-19 outbreak.,,, To prevent the spread of COVID-19, dental staff must not only be aware of the way that COVID-19 is transmitted but also be able to identify patients at risk and implement appropriate infection control measures in the dental practice.
The need for the development of a mnemonic checklist
It is important for health-care workers during the COVID-19 pandemic to follow the recommended guidelines in both emergencies and routine dental care to decrease the chance of possible unfavorable consequences and improve standards of patient care., Moreover, it has been documented that during stressful conditions such as the COVID-19 outbreak, memory, awareness, and cognitive functions could be adversely influenced. Hales et al. suggested that the development of a checklist might be required to not only help staff and minimize the risk of medical errors but also ensure patient safety. Hence, a useful checklist should improve performance in stressful environments by increasing mental competence to perform important tasks correctly.
A checklist is a directory of actions, procedures, or behavior that highlights the essential measures of a particular task or a set of tasks., It aims to assist in recalling critical criteria, ensure standardization of practice, and maintain reproducibility in assessments., Studies recommend one of the two main types of checklists: evaluative or mnemonic. An evaluative checklist is used to standardize evaluation by using specific guidelines for assessment while maintaining further authority and uniformity among the evaluators. A mnemonic checklist is used as a reminder system not only to help standardize routine or complex procedures but also to provide an organizational structure for a quick memory recall of crucial information during periods of stress or crisis. It is suggested that medical mnemonic checklists can be designed to support a medical/dental team through a process with a standard outline. At the same time, the mnemonic checklist should be concise and condense the number of bits of knowledge to help focus on the most critical areas.
| Discussion of the Checklist|| |
The proposed checklist [Appendix 1] was obtained from the guidelines for reopening dental services in governmental and private sectors during the COVID-19 pandemic that was published by the MOH. However, this checklist highlights the important procedures that must be undertaken in the dental clinic, starting from the patient evaluation until the dismissal from the clinic during the COVID-19 outbreak. These procedures are divided into three main stages: before the patient enters the clinic, while the patient is in the clinic, and after the patient leaves the clinic. Based on the respiratory triage checklist (RTC) score, the checklist is further divided into two main sections: protocol A is followed when the RTC score is ≥4 and protocol B is followed if the RTC score is <4. Each patient must be carefully triaged and scored before the dental examination.
The RTC score consists of a number of questions about the exposure risk to COVID-19 and the clinical signs and symptoms. Each question has an assigned score. The total score should be calculated by adding the patient's score for each question. According to the patient score, the responsible dentist must evaluate the urgency of the dental condition and decide whether to provide or defer dental care. For example, febrile patients with respiratory symptoms will fall under section A and should not receive dental treatment unless it is urgent. According to the checklist, if the emergency AGP dental procedure was necessary when the patient's score is ≥4, REDS steps should be recalled, whereas MRS steps must be retrieved if the patient's score is <4. However, for both groups, we suggest that GAMES be followed when PPE is needed before examination, and HD steps should be used after finishing the dental procedure [Appendix 1]. Because those mnemonic checklists are meant to facilitate easy recall, the mnemonic abbreviations are explained as follows: The REDS steps denote Rubber dam, Emergency dental procedure, Dental clinic, and Suction, whereas MRS steps stand for Mask, Rubber dam, and Suction; GAMES steps indicate Gown, Anti-septic mouthwash, Mask, Eye protection, and Shoes and protective head covering; and HD steps denote Hand hygiene and Doffing of PPE.
Standard infection control guidelines, including the use of PPE, are well known by dental professionals. Unlike normal dental settings, the current checklist emphasizes two levels of PPE that depend on the patient's RTC score. The first level includes standard PPE, comprised of an isolation gown, surgical mask, eye protection (such as goggles or a face shield), and protective headcover, which is recommended for use when examining a patient with an RTC score <4. The second level of PPE is comprised of a surgical gown, N95 mask with eye protection, and protective headcover, which must be used during the examination of a patient with an RTC score ≥4. Of note, a power air-purifying respirator can be used instead of the N95 mask as the second level of PPE when the RTC score is ≥4 – especially when AGP is needed during the COVID-19 outbreak.
Although hand hygiene is considered a standard requirement in dental practice, studies have shown low hand-hygiene compliance (35%–56%) among dental health workers, thus hand hygiene was also included in the checklist,,, followed by wearing gloves, which should be worn at all times. The checklist also includes patient's hand hygiene to minimize the risk of surface area contamination in the dental clinic and possible cross-contamination.
Evidence regarding the effectiveness of preoperative use of antiseptic mouth rinse is controversial. On one hand, several studies suggested the use of a 0.2% chlorhexidine gluconate mouthwash to decrease oral microbes before AGP, especially when a rubber dam cannot be used.,, On the other hand, few studies stated that the use of a preprocedural chlorhexidine gluconate mouth rinse is ineffective in reducing bacterial contamination during AGP. Other studies have shown that a 0.2% povidone-iodine mouth rinse is effective in reducing viruses, including SARS-CoV and MERS-CoV.,, Ather et al. recommended using povidone-iodine mouth rinse before dental emergencies during the COVID-19 pandemic.
Dentists should minimize the use of AGPs during the pandemic and if needed, a rubber dam along with AGPs can be used as presented in the checklist. Studies strongly recommended the use of rubber dam together with high-volume suction as it significantly minimizes aerosols by >70%., For a dental patient whose RTC score is ≥4 and requires AGPs for emergency reasons, it is recommended that the treatment takes place in a negative-pressure room in the dental practice or medical high-efficiency particulate air filter/airborne infection isolation room for the duration of the public health crisis. Regarding AGP, Baumann et al. stated that airborne aerosols could remain in the air from 30 min up to 2 h. van Doremalen et al. have shown that SARS-CoV-2 survived up to 3 h in aerosols and remained viable for 3 days on inanimate surfaces. Hence, a 3-h time lapse is suggested between patients with an RTC score >4 for maximum precaution. Two hours is recommended before the next use of dental clinic when AGP is performed on patients with an RTC score <4, whereas only a 30-min time lapse is necessary before the next use of dental clinic when non-AGP procedures are performed on patients with an RTC score <4.
| Conclusion|| |
Because dental health-care workers are considered a part of the “very high exposure risk” category during COVID-19, they need to take proper precautions to protect themselves and prevent cross-contamination. Thus, having a written reminder in the form of a checklist to recall the important and new nonroutine steps could be helpful. This will improve the safety of dental practice in this critical time during the COVID-19 pandemic. Furthermore, we recommend that dental health-care providers receive good training to be able to recall the checklist steps. It is recommended that dental clinics have those steps printed, laminated, and placed in an accessible visible place to support the implementation process.
The authors would like to thank Dr. Ali M. AlAhdal, BDS, MHSA, MBS-IC, American Board certified in infection control and epidemiology, from the Dental Administration, Makkah Health Affairs, Ministry of Health, Saudi Arabia, for his help in revising the checklist. Also the authors would like to thank Mr. Mahdi Bathallath for his help with graphics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al
. A new coronavirus associated with human respiratory disease in China. Nature 2020;579:265-9.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al
. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8:420-2.
Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al
. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579:270-3.
Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology 2020;5:536-44. DOI: 10.1038/s41564-020-0695-z.
Paules CI, Marston HD, Fauci AS. Coronavirus infections-more than just the common cold. JAMA 2020;323:707-8.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Du Y, Tu L, Zhu P, Mu M, Wang R, Yang P, et al
. Clinical features of 85 fatal cases of COVID-19 from Wuhan. A retrospective observational study. Am J Respir Crit Care Med 2020;201:1372-9.
WHO. Novel-Coronavirus-2019 Available from: www.who.int/emergencies/diseases/novel-coronavirus-2019. [Last accessed on 2020 Jul 15].
Yu IT, Li Y, Wong TW, Tam W, Chan AT, Lee JH, et al
. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N
Engl J Med 2004;350:1731-9.
Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al
. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N
Engl J Med 2020;382:970-1.
Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Surveill 2020;25(5):2000062.
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al
. First case of 2019 novel coronavirus in the United States. N
Engl J Med 2020;382:929-36.
Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67:568-76.
Centers for Disease Control and Prevention. “CDC Guidance for Providing Dental Care During COVID-19.” Centers for Disease Control and Prevention. Available from: www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html. [Last accessed on 2020 Aug 15].
Coulthard P. Dentistry and coronavirus (COVID-19)-moral decision-making. Br Dent J 2020;228:503-5.
Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:9.
Weber DJ, Rutala WA, Schaffner W. Lessons learned: Protection of healthcare workers from infectious disease risks. Crit Care Med 2010;38:S306-14.
Cleveland JL, Gray SK, Harte JA, Robison VA, Moorman AC, Gooch BF. Transmission of blood-borne pathogens in US dental health care settings: 2016 update. J Am Dent Assoc 2016;147:729-38.
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.
Liu L, Wei Q, Alvarez X, Wang H, Du Y, Zhu H, et al
. Epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques. J Virol 2011;85:4025-30.
Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.
Wei J, Li Y. Airborne spread of infectious agents in the indoor environment. Am J Infect Control 2016;44:S102-8.
Carlson AL, Budd AP, Perl TM. Control of influenza in healthcare settings: Early lessons from the 2009 pandemic. Curr Opin Infect Dis 2010;23:293-9.
Gamage B, Moore D, Copes R, Yassi A, Bryce E, BC Interdisciplinary Respiratory Protection Study Group. Protecting health care workers from SARS and other respiratory pathogens: A review of the infection control literature. Am J Infect Control 2005;33:114-21.
Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:145-51.
Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust 2004;181:428-31.
Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med 2011;26:50-6.
Hales BM, Pronovost PJ. The checklist – A tool for error management and performance improvement. J Crit Care 2006;21:231-5.
Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20:22-30.
Thomassen Ø, Espeland A, Søfteland E, Lossius HM, Heltne JK, Brattebø G. Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med 2011;19:53.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al
. An intervention to decrease catheter-related bloodstream infections in the ICU. N
Engl J Med 2006;355:2725-32.
Scriven M. The Logic and Methodology of Checklists [Dissertation]. Claremont, CA: Claremont Graduate University; 2000.
Koeckeritz JL, Hopkins KV, Merrill AS. ILEUM: Interactive learning can be effective using mnemonics. Nurse Educ 2004;29:75-9.
Saudi Ministry of Health. COVID-19 Coronavirus Disease Guidelines; 2020 V. 1.3.
Cheng HC, Peng BY, Lin ML, Chen SL. Hand hygiene compliance and accuracy in a university dental teaching hospital. J Int Med Res 2019;47:1195-201.
Resende KK, Neves LF, de Rezende Costa Nagib L, Martins LJ, Costa CR. Educator and student hand hygiene adherence in dental schools: A systematic review and meta-analysis. J Dent Educ 2019;83:575-84.
Gupta G, Mitra D, Ashok KP, Gupta A, Soni S, Ahmed S, et al
. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: A pilot study. J Periodontol 2014;85:562-8.
Shetty SK, Sharath K, Shenoy S, Sreekumar C, Shetty RN, Biju T. Compare the efficacy of two commercially available mouthrinses in reducing viable bacterial count in dental aerosol produced during ultrasonic scaling when used as a preprocedural rinse. J Contemp Dent Pract 2013;14:848-51.
Toroǧlu MS, Haytaç MC, Köksal F. Evaluation of aerosol contamination during debonding procedures. Angle Orthod 2001;71:299-306.
Eggers M, Koburger-Janssen T, Eickmann M, Zorn J.In vitro
bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens. Infect Dis Ther 2018;7:249-59.
Eggers M, Eickmann M, Kowalski K, Zorn J, Reimer K. Povidone-iodine hand wash and hand rub products demonstrated excellentin vitro
virucidal efficacy against Ebola virus and Modified Vaccinia virus Ankara, the new European test virus for enveloped viruses. BMC Infect Dis 2015;15:375.
Eggers M, Eickmann M, Zorn J. Rapid and effective virucidal activity of povidone-iodine products against Middle East respiratory syndrome coronavirus (MERS-CoV) and Modified Vaccinia virus Ankara (MVA). Infect Dis Ther 2015;4:491-501.
Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): Implications for clinical dental care. J Endod 2020;46:584-95.
Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child 1989;56:442-4.
Baumann K, Boyce M, Catapano-Martinez D. Transmission precautions for dental aerosols. Decisions Dent 2018;4:30-2, 5.
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al
. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N
Engl J Med 2020;382:1564-7.
Occupational Safety and Health Administration. Guidance on Preparing Workplaces for COVID-19: Department of LaborOccupational Safety and Health Administration. Available from: https://www.osha.gov/Publications/OSHA3990.pdf
. [Last accessed on 2020 Jun 20].