Oral Radiol. 2020; 36(4): 395–399. Dental professionals have always been meticulous about infection control due to high risk of cross-contamination during dental procedures. Nevertheless, there is an urgent need to review and revise our current practice of infection control and develop more strict protocols that will prevent nosocomial spread of infection during
COVID-19 outbreak and future pandemics. The risk of contamination is high during dental radiography if proper disinfection techniques are not applied. This document provides advice and guidance for infection control when practicing dental radiography during COVID-19 pandemic. Keywords: Dental radiology, COVID-19, Infection control The new coronavirus disease (COVID-19) caused by the
recently recognized SARS-CoV 2 virus is having devastating impacts on all aspects of life including economy, social life and health care [1, 2]. On the other hand, health care facilities are required to provide continuous service, treatment and relief for those in need and are rarely closed during any
crises [3]. The primary route for transmission of virus is through droplets and aerosols and therefore dental health care workers are among the medical professionals who are at extreme risk of getting infected and further spreading the virus
[4–7]. The long and unpredictable incubation period (up to 27 days) [1] of the virus and the high rates of asymptomatic carriers (80%)
[4] further challenges infection control measures during dental practice. There is no available universal guideline regulating the dental care provision during any epidemic or pandemic. However, dental pain is the most commonly encountered health problem among any given population and requires immediate care or treatment
[8]. This is proven by the fact that the demand for urgent dental treatment decreased by only 38% since the beginning of pandemic in China [9]. It is evident that patients applying for dental emergency treatment will likely require dental imaging. So far, several reports and articles
that focuses on screening, clinical features, patient management during surgical or endodontic procedures have been published [6, 7,
10–12]. Postponing all elective dental treatments and providing care for only emergency cases during the pandemic are recommended [6,
7, 10–12]. There are limited number of reports on dental radiography during COVID-19
[13–15], which is a critical component of diagnostic work-up and involves significant potential for cross-contamination through exposure to saliva and/or blood. The presence of SARS-CoV 2 virus has been revealed in both blood and saliva samples
[5] of COVID-19 patients, which necessitates reviewing our current practice of infection control during dental radiography to develop more strict protocols that will prevent nosocomial spread COVID-19. So far, Centre for Disease Control (CDC) Guidelines published in 2003 has been followed in dental radiology clinics
[16]. Provided that intraoral radiographs may stimulate gag reflexes, coughing and saliva secretion, it is recommended to prefer extraoral imaging techniques such as panoramic radiography and cone-beam computed tomography (CBCT) during the outbreak [6,
7, 12]. Although panoramic radiography can substitute for intraoral radiographs during these difficult times, CBCT is associated with much higher radiation doses and should not be used as an alternative to intraoral imaging
[13]. Additionally, there may be cases where dental practitioners require better radiographic image quality for a particular tooth (e.g. traumatized upper anterior incisor) or access to extraoral imaging techniques may not always be available, especially in low- and middle-income countries. In such, conditions intraoral imaging may be mandatory for dental practitioners. This document provides
advice and guidance for infection control when practicing dental radiography during COVID-19 pandemic. The recommendations are based on previous reports [17–22] and available data on SARS-CoV 2
[23–25]. Environmental surfaces in dental radiology clinics include furniture and other fixed items inside and outside of examination rooms (e.g. tables, floors and walls, chairs, light
switches). These surfaces are more likely to be contaminated and must be properly cleaned and disinfected. It should be kept in mind that SARS-CoV 2 virus can persist on inanimate surfaces for 4 h up to 7 days depending on the temperature, humidity, type of surface and virus load [24]. World Health Organization (WHO) suggests that outpatient/ambulatory care rooms,
particularly high-touch surfaces such as light switches, door handles, trays, sinks, tables, water/beverage pitchers, and floors should be cleaned and disinfected after each patient in visit, and low-touch surfaces should be cleaned daily. At least one terminal clean every day is recommended [23,
25]. Hypochlorite (0.5% for blood and body fluids, 0.1% for environmental disinfection), 70–90% ethanol and > 0.5% hydrogen peroxide can be used for disinfection [23, 25]. A minimum
of 1-min contact time with the disinfectant solution is advised. Some disinfectants can be inactivated in the presence of organic material; therefore, the surfaces (especially high-touch surfaces, in case of blood, saliva or other bodily fluids) should be thoroughly cleaned with soap/detergent or water using mechanical action (scrubbing) prior to the use of disinfectants [23,
25]. Cleaning equipment should be well maintained and the buckets containing detergent and/or disinfectant solutions must be discarded after each use in areas with suspected/confirmed patients with COVID-19. Fresh solutions must be prepared on a daily basis or for each cleaning shift
[23, 25]. Spraying or fogging of certain chemicals (e.g. formaldehyde, chlorine-based agents) is not recommended for COVID-19. Adjunct technologies using UV irradiation supplement but do not replace the need for manual cleaning procedures
[23]. Frequent ventilation of the examination rooms and cleaning of the air filters should be ensured. Infection control for staff and patientsDuring the previous SARS (SARS-CoV) outbreak, Seto et al. [26] reported that proper use of standard precautions is adequate to prevent the nosocomial spread of the disease in the absence of aerosol-producing procedures. Nevertheless, all patients must have surgical masks and coughing/sneezing manners should be briefly reminded to the patient prior to acceptance to the examination room.
Infection control for dental radiography: general considerationsPrevious research indicated that microorganisms can remain viable on radiographic equipment for up to 48 h and as long as 2 weeks in X-ray developer/fixer [21]. If proper disinfection techniques is not applied when taking any dental radiograph, the potential for cross-contamination of radiographic equipment with blood and/or saliva would be significantly high [17, 18, 21]. Most reusable items used in dental radiology are considered semi-critical (contact with mucous membrane) or non-critical (contact with intact skin). Reusable semi-critic items such as bite guides, film positioning devices must be sterilized with high-level disinfectants after each use or covered with plastic sheets, wraps or pieces with adhesive edges, if sterilization or barrier-protection is not possible, then disposable items should be used [17, 18, 21]. Non-critical items such as chin rest, hand grasps can be barrier-protected and the covers must be changed after each patient. Surface barriers provide adequate protection while eliminating the need for clean and disinfect surfaces between patients [17]. Lead-apron and thyroid collars should be disinfected with a low-level disinfectant (e.g. quaternary ammonium compounds) and should be suspended on a coat hanger after each use. Attention should be paid to minimize the positioning and exposure errors during radiographic examination in order to eliminate the need for repeated exposures which may additionally increase the risk of contamination. The working station (computers, screens, scanners etc.) should be kept remote from the patient examination rooms and the operator in charge of exposures should have limited access to the working station or to the dark room. The radiologists should have a separate room to interpret images and prepare the reports. On the basis of experience with SARS, the use of a remote satellite radiography center or utilization of mobile radiographic equipment are also recommended for patients with known COVID-19 disease [28]. Oral rinse with 1% hydrogen peroxide or 0.2% povidone solution prior to any dental procedure has been shown to reduce viral load [29]. Considering the close contact of mucous membranes during panoramic, CBCT and intraoral examination, we recommend oral rinsing for the patients before using these techniques. Panoramic radiography
CBCT imagingSame infection control measures also apply for CBCT. The only difference is the type of non-critical items on the device.
USG imagingSwellings and pain in masticatory muscles may also require ultrasound (US) imaging during COVID-19 pandemic. Transducers may carry pathogens, including viruses such as human papillomavirus (HPV), unless properly disinfected between examination sessions. The infection prevention and control recommendations of Ultrasound Working Group of the European Society of Radiology should also be followed for COVID-19 [30]. High level of disinfection should be applied for ultrasound transducers. The transducers must be used with protective covers such as medical gloves, or condoms during contact with mucous membranes or any body fluids (including interventional procedures, injections, tissue sampling, use in the theater, etc.). Sterile gel should be used inside and outside covers. The following specific measures are recommended by American Institute of Ultrasound in Medicine (AIUM) for COVID-19 [31].
Intraoral radiographyDuring intraoral radiography transmission of the disease is possible through either direct contact with saliva or cross-contamination. Cross-contamination may also occur when the clinician handles the digital sensors or opens film packets [17–21].
A majority of these infection control procedures have been already known as inseparable parts of everyday dental radiology practice, however, the new COVID-19 disease has dramatically altered our habits and the way we live our lives due to high transmission rate. More serious implementation and control of current infection control regulations is absolutely required to manage the disease and prevent the global spread of the virus. It is obvious that this pandemic will inevitably trigger a new era in dental profession both during normalization period and afterwards. Therefore, the present guide has been awarded for infection control when practicing dental radiography during this pandemic. These recommendations which are based on the previous reports and current data on the disease can be also be applied during possible future outbreaks. Compliance with ethical standardsConflicts of interest Betul Ilhan received no financial support and declare no potential conflicts of interest. Ibrahim Sevki Bayrakdar received no financial support and declare no potential conflicts of interest. Kaan Orhan received no financial support and declare no potential conflicts of interest. This article does not contain any studies with human or animal subjects performed by the any of the authors. FootnotesPublisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References3. Ahmed MA, Jouhar R, Ahmed N, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17:E2821. doi: 10.3390/ijerph27082821. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 4. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. Int J Antimicrob Agents. 2020;55:105924. doi: 10.1016/j.ijantimicag.2020.105924. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 5. To KK, Tsang OT, Chik-Yan Yip C, et al. Consistent detection of 2019 novel coronavirus in saliva. Clin Infect Dis. 2020 doi: 10.1093/cid/ciaa149. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 6. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99:481–487. doi: 10.1177/0022034520914246. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 7. Fallahi HR, Keyhan SO, Zandian D, Kim SG, Cheshmi B. Being a front-line dentist during the Covid-19 pandemic: a literature review. Maxillofac Plast Reconstr Surg. 2020;42:12. doi: 10.1186/s40902-020-00256-5. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 8. Cavalheiro CH, Abegg C, Fontanive VN, Davoglio RS. Dental pain, use of dental services and oral health-related quality of life in southern Brazil. Braz Oral Res. 2016;30(1):S1806–S83242016000100272. doi: 10.1590/1807-3107BOR-2016.vol30.0039. [PubMed] [CrossRef] [Google Scholar] 9. Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020 doi: 10.1016/j.jds.2020.02.002. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 10. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus disease 19 (COVID-19): implications for clinical dental care. J Endod. 2020;46:584–595. doi: 10.1016/j.joen.2020.03.008. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 11. Abramovitz I, Palmon A, Levy D, et al. Dental care during the coronavirus disease 2019 (COVID-19) outbreak: operatory considerations and clinical aspects. Quintessence Int. 2020;51:418–429. [PubMed] [Google Scholar] 13. Dave M, Coulthard P, Patel N, Seoudi N, Horner K. Use of dental radiography in the COVID-19 pandemic. J Dent Res. 2020 doi: 10.1177/0022034520923323. [PubMed] [CrossRef] [Google Scholar] 14. Saki M, Haseli S, Iranpour P. Oral radiology center as a potential source of COVID-19 transmission; points to consider. Acad Radiol. 2020 doi: 10.1016/j.acra.2020.04.040. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 16. National Center for Chronic Disease Prevention and Health Promotion (CDC). Guidelines for Infection control in dental health-care settings. 2003;December 19/52(RR17):1-61. [PubMed] 17. Infection control practices in dental radiology. In: SM Mallya, W Ernest, N Lam, editors. White and Pharoah’s oral radiology principles and interpretation 8th ed. Elsevier Publications, p. 798–802. 18. Bartoloni JA, Chariton DG, Flint DJ. Gen Dent. 2003;51:264–271. [PubMed] [Google Scholar] 19. Hubar JS, Gardiner DM. Infection control procedures used in conjunction with computed dental radiography. Int J Comput Dent. 2000;3:259–267. [PubMed] [Google Scholar] 20. MacDonald DS, Waterfield JD. Infection control in digital intraoral radiography: evaluation of microbiological contamination of photostimulable phosphor plates in barrier envelopes. J Can Dent Assoc. 2011;77:b93. [PubMed] [Google Scholar] 21. Palenik CJ. Infection control practices for dental radiography. Dent Today. 2004;23:52–55. [PubMed] [Google Scholar] 22. Bali RK, Chaudhry K. Maxillofacial surgery and COVID-19, The Pandemic !! J Maxillofac Oral Surg. 2020;19(2):159–161. doi: 10.1007/s12663-020-01361-8. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 24. Revel MP, Parkar AP, Prosch H, Silva M, Sverzellati N, Gleeson F, et al. COVID-19 Patients and the Radiology Department-Advice From the European Society of Radiology (ESR) and the European Society of Thoracic Imaging (ESTI) Eur Radiol. 2020 doi: 10.1007/s00330-020-06865-y. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 26. Seto WH, Tsang D, Yung RW, Ching TY, Ng TK, Ho M, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) Lancet. 2003;361:1519–1520. doi: 10.1016/S0140-6736(03)13168-6. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 27. European Centre for Disease Prevention and Control. Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19; 2020. https://www.ecdc.europa.eu/sites/default/. Accessed 23 Mar 2020. 28. Kooraki S, Hosseiny M, Myers L, Gholamrezanezhad A. Coronavirus (COVID-19) outbreak: what the department of radiology should know. J Am Coll Radiol. 2020;17:447–451. doi: 10.1016/j.jacr.2020.02.008. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 29. 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(1):1–6. doi: 10.1038/s41368-020-0075-9. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 30. Nyhsen CM, Humphreys H, Koerner RJ, Grenier N, Brady A, Sidhu P, et al. Infection prevention and control in ultrasound-best practice recommendations from the European Society of Radiology Ultrasound Working Group. Insights Imaging. 2017;8:523–535. doi: 10.1007/s13244-017-0580-3. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 31. Guidelines for cleaning and preparing external- and internal-use ultrasound transducers between patients, safe handling, and use of ultrasound coupling gel. American Instutite of Ultrasound in Medicine Offical Statement, May 2020. https://www.aium.org/accreditation/Guidelines_Cleaning_Preparing.pdf. 32. Choi JW. Perforation rate of intraoral barriers for direct digital radiography. Dentomaxillofac Radiol. 2015;44:20140245. doi: 10.1259/dmfr.20140245. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 33. Hokett SD, Honey JR, Ruiz F, Baisden MK, Hoen MM. Assessing the effectiveness of direct digital radiography barrier sheaths and finger cots. J Am Dent Assoc. 2000;131:463–467. doi: 10.14219/jada.archive.2000.0202. [PubMed] [CrossRef] [Google Scholar] What infection control measures are recommended for digital radiography sensors?With digital imaging, barriers must be placed on the sensors. Sensors cannot be sterilized. There are many types of plastic barriers available for indirect phosphor plate and hard sensors used in direct digital imaging. The wired direct sensors will need barriers over the fiber optic cables and hard sensor.
What infection control techniques are used for the environmental surfaces in dental radiography?Film barriers are the method of choice, especially when using daylight loaders. Their use eliminates almost all potential for equipment contamination. After the patient has been seated, hands can be washed, dried, and gloves placed.
When working with digital sensor which is a best practice for infection control?Digital sensors and intraoral cameras should be barrier protected, followed by the use of an intermediate-level disinfectant,4 and wiping the intraoral camera lens with gauze and isopropyl alcohol. Handpieces: Some cordless handpieces have a removable head, and heat sterilization is recommended after each use.
What unique infection control problems occur in dental radiography?Radiology Ch 40. |