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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 8  |  Page : 93-97

Managing the oral and maxillofacial surgical patient during the SARS-CoV-2 pandemic: A review of guidelines


Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission17-Jul-2020
Date of Decision30-Aug-2020
Date of Acceptance06-Oct-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Sunil S Nayak
Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_243_20

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  Abstract 

Management of the oral and maxillofacial surgical patient during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is quite challenging. This paper assesses the impact of coronavirus disease-2019 (COVID-19) on oral and maxillofacial surgical practice and lays down various guidelines employed to counter the pandemic. Separate protocol and guidelines are formulated for examining the patients in the Outpatient Department (OPD), minor surgical procedures in the clinics, and for managing patients in the triage and operation theatres. Particular emphasis should be given to disinfection and infection control measures to minimize the risk of COVID-19. Infection control in the clinical, hospital, and operation theatre setup is the most essential factor in the prevention of spread of COVID-19 disease in the workplace. The use of Personal Protective Equipment (PPE), barrier techniques, proper hand wash practices, surface disinfection, and proper sterilization of instruments help in infection control. Providing effective treatment to patients with conditions that cannot be deferred or controlled by pharmacological management and taking care to minimize the risk of COVID-19 to the hospital personnel is the primary concern in the present scenario.

Keywords: COVID-19, Guidelines, Infection Control


How to cite this article:
Nayak SS. Managing the oral and maxillofacial surgical patient during the SARS-CoV-2 pandemic: A review of guidelines. J Int Oral Health 2020;12, Suppl S2:93-7

How to cite this URL:
Nayak SS. Managing the oral and maxillofacial surgical patient during the SARS-CoV-2 pandemic: A review of guidelines. J Int Oral Health [serial online] 2020 [cited 2021 Apr 16];12, Suppl S2:93-7. Available from: https://www.jioh.org/text.asp?2020/12/8/93/301868


  Introduction Top


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a strain of coronavirus that causes COVID-19, an infective respiratory illness.[1] After an incubation period of 2–14 days, the infected individual may experience symptoms of the disease.[1] Flu-like symptoms, which include fever, difficulty in breathing, and tenderness and pain in the muscles, are usually exhibited. Acute respiratory distress syndrome, pneumonia, septic shock, and death could occur in severe untreated cases.

Since December 2019, the SARS-CoV-2 has been causing havoc across the world. This sudden outburst and spread of the virus left the entire medical field in a dubious situation. During this pandemic, health care workers are at a very high risk of contracting the disease. The SARS-CoV-2 is known to spread through aerosol, mucosal, or respiratory droplets and also by contact with an affected person.[2] The virus can remain infectious on inanimate surfaces for 2 hours and more, depending on the temperature, humidity, type of surface, and viral load.[3] It is also possible to become infected by touching surfaces or objects that are contaminated by the virus and then touching one’s nose, mouth, or eyes with the same hand.[1] Door handles, mobile phones, and light/ lift buttons are some of the surfaces that can be commonly exposed to viral contamination.[1]

The dental fraternity has been afflicted in unimaginable ways. Due to the type of work and instrumentation used, oral and maxillofacial surgeons are particularly at risk.[4] As patients with trauma and oncology who are treated with maxillofacial surgery require urgent attention, the treatment protocol has been modified to adapt to this pandemic outbreak.[4] A lot of emergency cases requiring the intervention of Oral and Maxillofacial surgeons include procedures that are invasive, and involve the usage of aerosol-generating drills. The objective of this article is to shed light on how oral and maxillofacial patients can be managed effectively by following formulated guidelines in the wake of COVID-19.


  Materials and Methods Top


Functioning during the national lockdown

During the four phases of the unprecedented nationwide lockdown (25 March 2020 to 3 May 2020), the Department of Oral and Maxillofacial Surgery in Manipal College of Dental Science, Manipal was functioning round the clock to manage all cases of maxillofacial emergency; it joined hands with the Department of Emergency Medicine while dealing with trauma management. Right from the management of tooth pain to managing a neoplastic growth in the oral cavity, every case scenario was initially treated in the emergency triage with maximum precautions, as COVID-19 testing kits were not available during the initial phase of the lockdown. All patients were treated as suspected COVID-19 cases, and universal precautions were strictly followed. With the release of lockdown restrictions, the number of cases started increasing even further, along with road transport accidents and emergency trauma cases.

OPD Protocol

The normal OPD started functioning during the “unlock phase” 1.0 and 2.0. To minimize the risks to a health-care professional, after the initial examination, patients were treated on an appointment basis during the first five working hours of the day. The last part of the day was purely dedicated to infection control measures, which included disinfection of the operating dental chairs/ surfaces and fumigation of the working area on a daily basis. The number of extraction cases increased as time went by, as patients preferred extraction over aerosol-related therapeutic procedures.

Body temperature testing (thermal testing) was mandatory for all patients entering the OPD. Brief travel history and complaint history were made a note of. Social distancing was maintained in the waiting area, with a minimum distance of 6 feet between two adjacent waiting chairs. All patients were made to compulsorily sanitize their hands with a foot-controlled hand sanitizer system in the reception area. Only the patients were allowed inside the clinical working area, and their attendees remained seated outside. The use of a face mask was made mandatory to all, except in the case of a patient who was undergoing active treatment.

Guidelines followed in the oral and maxillofacial surgery clinics

The oral and maxillofacial team was split into three groups, with each consisting of a senior faculty, two junior faculty and two postgraduates. The first group managed the OPD; the second team managed the emergency cases in the hospital triage and attended to the ward patients; and the third team exclusively managed the operation theater cases. The duties were carried out on a weekly rotation basis. The primary purpose of working in three different groups was to avoid all the doctors being in the same place at the same time, thereby lessening the chances of acquired infection.

Active treatment intervention is done in:

  • Patients having excessive pain that cannot be managed by medication


  • Patients having conditions such as abscess/ space infections, which, if left untreated, could aggravate and lead to a poor prognosis


  • Patients with emergency conditions that could lead to any systemic ailment


  • Surgical/ nonsurgical management of displaced fracture, head and neck oncological cases that require immediate intervention


  • All procedures are to be performed while wearing Special Personal Protective Equipment (SPPE) [Figure 1], including N95/FFP2/FFP3/PAPR (Powered, Air-Purifying Respirator) mask [Figure 2], protective eyewear, face shield, surgical gloves, nonporous gown, and disposable head cap. Scrubs worn during the procedure are to be changed immediately after the procedure. Dental chairs are to be sanitized regularly after each patient uses them, and the usage of disposable patient gowns makes it easier to work in a minimal risk environment. Each patient is made to rinse with a solution of povidone–iodine before any treatment procedure is initiated.
    Figure 1: Surgeon in a PPE kit

    Click here to view
    Figure 2: Surgeon wearing a PAPR

    Click here to view


    All minor surgical procedures are done meticulously, ensuring proper care to both the operator and the patient. To avoid unnecessary workload, not more than three minor surgery cases are done per day on an appointment basis. Instruments used are to be discarded in the washing area, with the utmost care taken by the nursing staff and by following all necessary precautions. The staff nurse handling the instruments and sharp needles should also wear a Personal Protective Equipment (PPE) kit for protection.

    Guidelines followed in the management of maxillofacial surgical patients in triage and operation theaters

    Patients brought into the triage are checked for symptoms of fever or respiratory illness (dry cough, sputum production, shortness of breath) and other symptoms such as soreness of throat, fatigue, and myalgia. Newer symptoms such as loss of smell (anosmia), congestion or runny nose, nausea or vomiting, and diarrhea are also assessed among these patients. [Annexure 1]

    Other considerations

  • The most experienced member in the team of anesthesia experts carries out airway management.


  • Short-term paralytic agents are given for reducing coughing.


  • After intubation, the operating personnel team waits outside for 20minutes, after which they enter while wearing the full PPE kit.


  • Closed reduction with self-drilling screws is preferred over open reduction if internal fixation is not required.


  • A transcutaneous approach is adopted rather than an extended intraoral approach.


  • Drilling with minimal irrigation during plating procedures is carried out.


  • Oncological considerations

    Surgery for benign slow growing tumors can be deferred till the pandemic settles down. Malignant conditions may need early surgical intervention with adequate protective measures.

    Cases indicated for surgery include:

  • Cases that can have a poor prognosis on delaying the treatment (squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx)


  • Cancers with impending airway compromise


  • High-grade or progressive salivary tumors requiring prompt treatment


  • Salvage surgery for recurrent/ persistent disease


  • High-grade sino-nasal malignancy requiring immediate surgical intervention



  •   Results Top


    By following proper guidelines and protocol in the management of both outpatients and inpatients, an infection-free environment in the working and operating area is ensured. This significantly minimizes the risk for the surgeons, clinicians, nursing staff, health care staff, and patients.


      Discussion Top


    A lack of timely and proper guidelines in dealing with patients in the COVID 19 era has resulted in an increased number of COVID-19 cases and this is reaching dangerous propositions in the affected countries.[5] Infection control in the clinical, hospital, and operation theater setup is the most essential factor in the prevention of the spread of COVID- 19 disease in the workplace. The use of PPE, barrier techniques, proper handwashing practices, surface disinfection, and proper sterilization of instruments help in infection control.[2] A proper understanding about the behavior of the virus when it comes into contact with surfaces and with different disinfectants can help in the proper sanitization of the medical setup. A study by Ong et al. evaluated the presence of the coronavirus among COVID-19 patients in a hospital room, and the study found that samples from toilet bowls and sinks were positive for SARS-CoV-2.[6] Samples taken from air vents tested positive, indicating the hazards of working in an air-conditioned environment. Sodium dichloroisocyanurate was used for disinfecting surfaces, and the samples collected after disinfection tested negative.[6] Among the other disinfectants used, 0.1% sodium hypochlorite for 1min is found to be effective against the coronavirus.[3] It has been demonstrated that at room temperature, the human coronavirus can remain on surfaces for a period of up to 9 days and that 0.1% sodium hypochlorite or 62%–71% ethanol for 1min is effective for disinfecting these surfaces.[3] The advantages of using povidone–iodine have been emphasized by many authors. Eggers et al. carried out an in vitro study to prove the bactericidal and virucidal efficacy of povidone–iodine gargle/ mouthwash against respiratory and oral pathogens.[7] Kirk-Bayley et al. advocated coating of the oral cavity and nasal passages of both the patient and the operating personnel before any treatment procedure.[8] Following these guidelines, the utilization of sodium hypochlorite as a surface disinfectant and povidone–iodine as a gargle/ mouthwash before any procedure was made mandatory in our unit.

    While dealing with emergency cases, every patient should be treated as a potential positive case for the virus and adequate precautions should be taken.[9],[10] Zou et al. doubted the effectiveness of FFP2 masks and reported that only PAPR, which was used during the major outbreak in China, helped in the reduction in viral transmission to the medical staff.[11] The PAPR should be used as the primary form of protection for treating patients with emergency conditions who cannot be tested.[9],[11] Limited physical interactions between patients and health-care personnel and a restriction on relatives’ visits to the patient are to be followed to limit the spread of infection.[12]

    As the pandemic in the current scenario is showing no signs of a slowdown, to prevent viral transmission, the use of telemedicine and smartphone applications is advised for quick diagnosis and management at the dental and medical offices.[13] The rapidly spreading COVID-19 disease has necessitated the need for the supply of many types of PPE equipment and other official health supplies at a rapid pace. The advent of three-dimensional (3-D) printing technologies using stereolithography helps in creating medical equipment, spare parts, compatible tubes, and different types of PPE equipment parts at a faster rate to meet the ever-rising demand.[14] Moreover, to deal with the present pandemic, international scientific societies have started developing guidelines for their respective specialties.[15],[16] The guidelines and protocols presented in this article, when implemented, can ensure the safety and care of dental professionals in general and oral and maxillofacial surgeons in particular.


      Conclusion Top


    In the present situation, the main concern is to provide effective treatment to patients with conditions that cannot be deferred or controlled by pharmacological management, while simultaneously taking care to minimize the risk of COVID-19 to the practitioner, the patient, and the hospital staff by strictly following the formulated guidelines. A telephone triage, including telemedicine and smartphone applications, is to be advocated for quick and early diagnosis of this disease. Newer modalities such as 3-D printing of medical and PPE equipment to meet the ever-rising demand should be implemented in all centers dealing with COVID-19 patients.

    Acknowledgement

    Not applicable.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Author contribution

    The article has been read and approved by the author.

    Ethical policy and institutional review board statement

    Not applicable.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form/ forms, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Data availability statement

    Not applicable.





     
      References Top

    1.
    Fiorillo L, Cervino G, Matarese M, D’Amico C, Surace G, Paduano V, et al. COVID-19 surface persistence: A recent data summary and its importance for medical and dental settings. Int J Environ Res Public Health 2020;17:3132.  Back to cited text no. 1
        
    2.
    Guo ZD, Wang ZY, Zhang SF, Li X, Li L, Li C, et al. Aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards, Wuhan, China, 2020. Emerg Infect Dis 2020;26:1583-91.  Back to cited text no. 2
        
    3.
    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.  Back to cited text no. 3
        
    4.
    Bali RK, Chaudhry K Maxillofacial surgery and COVID-19, The pandemic!! J Maxillofac Oral Surg 2020;19:159-61.  Back to cited text no. 4
        
    5.
    Maffia F, Fontanari M, Vellone V, Cascone P, Mercuri LG Impact of COVID-19 on maxillofacial surgery practice: A worldwide survey. Int J Oral Maxillofac Surg2020;49:827-35.  Back to cited text no. 5
        
    6.
    Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT, Wong MSY, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-cov-2) from a symptomatic patient. JAMA 2020;323:1610-2.  Back to cited text no. 6
        
    7.
    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.  Back to cited text no. 7
        
    8.
    Frank S, Capriotti J, Brown SM, Tessema B Povidone-iodine use in sinonasal and oral cavities: A review of safety in the COVID-19 era. Ear Nose Throat J 2020;99:586-93.  Back to cited text no. 8
        
    9.
    Givi B, Schiff BA, Chinn SB, Clayburgh D, Iyer NG, Jalisi S, et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic. JAMA Otolaryngol Head Neck Surg 2020;146:579-84.  Back to cited text no. 9
        
    10.
    Zimmermann M, Nkenke E Approaches to the management of patients in oral and maxillofacial surgery during COVID-19 pandemic. J Craniomaxillofac Surg 2020;48:521-6.  Back to cited text no. 10
        
    11.
    Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-cov-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-9.  Back to cited text no. 11
        
    12.
    Allevi F, Dionisio A, Baciliero U, Balercia P, Beltramini GA, Bertossi D, et al. Impact of COVID-19 epidemic on maxillofacial surgery in Italy. Br J Oral Maxillofac Surg 2020;58: 692-7.  Back to cited text no. 12
        
    13.
    Cervino G, Oteri G COVID-19 pandemic and telephone triage before attending medical office: Problem or opportunity? Medicina 2020;56:250.  Back to cited text no. 13
        
    14.
    Fiorillo L, Leanza T Worldwide 3D printers against the new coronavirus. Prosthesis 2020;2:87-90.  Back to cited text no. 14
        
    15.
    French Association of Rhinology (AFR) and French Society of Otorhinolaryngology (SFORL). Consultations and medical treatment inrhinology in the context of the COVID-19 epidemic. March 23, 2020. Available from: https://www.sforl.org/wp-content uploads/2020/03/AFR-SFORLCOVID-19-V2 [Last accessed on 2020 Apr 24].  Back to cited text no. 15
        
    16.
    Meng L, Hua F, Bian Z Coronavirus disease2019 (COVID-19): Emerging and futurechallenges for dental and oral medicine. J Dent Res 2020;99:481-7.  Back to cited text no. 16
        


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      [Figure 1], [Figure 2]



     

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