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A detailed report on the measures taken in the Department of Conservative Dentistry and Periodontology in Munich at the beginning of the COVID-19 outbreak

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Objectives The corona disease (COVID-19) is developing into one of the greatest challenges for healthcare professionals around the world. In this article, we report the detailed actions taken in the Department of Conservative Dentistry and Periodontology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany, during the early phase of the COVID-19 pandemic.Material and methodsAfter a joint on-site inspection of the dental clinic with the Department of Clinical Microbiology and Hospital Hygiene, existing clinical and hygiene protocols were adapted for COVID-19 patients.ResultsA comprehensive summary of the preparation of the facilities as well as pre- treatment, treatment and posttreatment protocols are described and arising problems are being discussed.Conclusions The importance of rigorous hygiene and treatment protocols as well as a sufficient supply of PPE for dental offices and hospitals is highlighted. The measures reported may be subject to change due to the dynamics of the pandemic.Clinical relevanceThe modes of transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (e.g., droplets, aerosols, and fomites) can pose a risk for dental healthcare professionals and patients alike. The presented measures may guide dental faculties and dental practices during the early stage of the COVID-19 crisis.
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DISCUSSION PAPER
A detailed report on the measures taken in the Department
of Conservative Dentistry and Periodontology in Munich
at the beginning of the COVID-19 outbreak
Christian Diegritz
1
&Jürgen Manhart
1
&Katharina Bücher
1
&Béatrice Grabein
2
&Günther Schuierer
2
&Jan Kühnisch
1
&
Karl-Heinz Kunzelmann
1
&Reinhard Hickel
1
&Christina Fotiadou
1
Received: 21 April 2020 /Accepted: 26 June 2020
#Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract
Objectives The corona disease (COVID-19) is developing into one of the greatest challenges for healthcare professionals around
the world. In this article, we report the detailed actions taken in the Department of Conservative Dentistry and Periodontology,
University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany, during the early phase of the COVID-19
pandemic.
Material and methods After a joint on-site inspection of the dental clinic with the Department of Clinical Microbiology and
Hospital Hygiene, existing clinical and hygiene protocols were adapted for COVID-19 patients.
Results A comprehensive summary of the preparation of the facilities as well as pre- treatment, treatment and posttreatment
protocols are described and arising problems are being discussed.
Conclusions The importance of rigorous hygiene and treatment protocols as well as a sufficient supply of PPE for dental offices
and hospitals is highlighted. The measures reported may be subject to change due to the dynamics of the pandemic.
Clinical relevance The modes of transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (e.g.,
droplets, aerosols, and fomites) can pose a risk for dental healthcare professionals and patients alike. The presented measures
may guide dental faculties and dental practices during the early stage of the COVID-19 crisis.
Keywords COVID-19 .SARS-CoV-2 .Dentistry .Dental hygiene protocol .Dental treatment protocol
Chronic of the COVID-19 outbreak
In December 2019, the first cases of patients with pneumonia of
unknown origin were described in Wuhan city, Hubei Province,
China [1]. In January 7, 2020, a novel β-coronavirus was isolated
and declared as the causative pathogen [2]. The virus was officially
named severe acute respiratory syndrome coronavirus 2(SARS-
CoV-2) and has since then spread rapidly around the globe [3]. On
January 30, the World Health Organization declared the COVID-19
outbreak a public health emergency of international concern [4]. As
of April 12, 1,695,096 cases, in 213 countries, and 105.865 fatalities
have been reported worldwide, with daily increasing numbers.
The first confirmed case of the coronavirus disease
(COVID-19) in Germany was diagnosed on January 27 in
Munich, Bavaria [5]. Although initially the spreading could
be contained due to immediate contact tracing and strict iso-
lation measures, new cases appeared all over Germany as of
February 26 [6]. This development lead to a cascade of events
that include the activation of the crisistask force (February 27)
and the initiation of the Robert Koch Institute (RKI) pandemic
plan followed by the gradual lock down of daycare centers,
schools, and universities (March 14) and the declaration of a
curfew and a contact ban (March 22) [6].
SARS-CoV-2
The SARS-CoV-2 is a novel β-coronavirus of the
Coronaviridae family [2]. Coronaviruses are most
*Christian Diegritz
diegritz@dent.med.uni-muenchen.de
1
Department of Conservative Dentistry and Periodontology,
University Hospital, LMU, Munich, Germany
2
Department of Clinical Microbiology and Hospital Hygiene,
University Hospital, LMU, Munich, Germany
https://doi.org/10.1007/s00784-020-03440-z
/ Published online: 1 July 2020
Clinical Oral Investigations (2020) 24:2931–2941
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... In patients of group C) and for those patients of group B) who refuse to be tested or have a positive RAT, the treatments are limited to dental emergencies only. This follows the strategy of minimizing the contact time as well as the duration of aerosol producing treatments [16]. The patients receiving treatment would be cases under severe pain, having a bacterial infection or suffering from consequences of an accident. ...
... In addition to the above precautions, it is advised to use additional PPE (FFP2/ mask, single use gowns and bonnets etc.) with patient groups B and C [16]. Dental care providers belonging to any risk group should critically calculate the risk and balance reasons whether to treat or not to treat SARS-CoV-2 positive or suspect patients. ...
... The time interval between two treatments in a room should be chosen sufficiently to allow disinfection measures to be carried out and to adequately ventilate. Appointments and updates should be made using digital communication [16]. ...
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Introduction The COVID-19 pandemic poses a continued challenge for all parties involved especially for the dentist as routine operation must be resumed. Rapid Antigen Tests (RATs) are actually recommended to identify and minimize infectious risks. However, there is still no guideline on the implementation of RATs in a dental or medical setting. Methods Based on data and an extensive literature research regarding rapid antigen testing and reflecting the recommendations given by the various professional societies a task force was formed to determine a specific testing and treatment strategy. Results A comprehensive test and treatment strategy and risk analysis was developed with practical suggestions for a wide range of typical activities in dental and medical offices. The transmission of SARS-CoV-2 and its variants via aerosols and droplets as well as the difficulties to maintain the minimum distance form special challenges to the dental routine. RATs might in addition to optimal and necessary hygienic standards in combination with the use of adequate personal protection equipment be an important instrument in managing the challenges. Conclusions The present work gives recommendations for dental routine operation (dental practices, outpatient clinics) to provide the necessary dental care for the population while protecting the doctor, practice team and patient at the same time.
... Therefore, in addition to ensuring adequate periodic air exchange, all surfaces, chairs, magazines, and doors that could come into contact with medical staff and patients were to be treated as "potentially contaminated". 2 The complete removal of leaflets and magazines from the dental office was also to be considered. 24 In order to reduce the number of people in the office, people accompanying the patient were asked to wait outside or in a car, the exception being when the patients were unable to arrive to the appointment by themselves due to their health condition. 2 In the waiting room, the chairs were taped and marked with social distance signs. ...
... 2 In the waiting room, the chairs were taped and marked with social distance signs. 24 The whole air conditioning system required strict and frequent decontamination. 2 ...
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This article describes what changes have had to be made to the functioning of dental practices due to the COVID-19 pandemic and how the pandemic has affected dental staff. Dentists are at high risk of infection and this is associated with fear, including the fear of being infected by their co-workers and patients, or that they will infect their families. The introduced changes include increased protective measures, and the introduction of additional questionnaires and procedures. In dental practices, the use of personal protective equipment (PPE) has been increased and changes have been introduced in the functioning of surgeries in accordance with the recommendations of dental associations and governments. The aforementioned changes have significantly reduced the comfort of dental work, increased the costs of treatment and reduced the availability of dental treatment. A novel solution to this situation has been the implementation of teledentistry, which helps to reduce the number of non-emergency visits. This process involves the remote facilitation of dental treatment by means of technology (i.e., phone or the Internet) without direct contact with the patient. Due to the restrictions implemented during the pandemic, many universities have introduced remote or hybrid teaching for both didactic and practical classes.
... Dentists are known to have a high risk of infection due to possible transmission via aerosols and droplets [5,6], which are unavoidable for many dental procedures as well as close proximity to many patients. As a result, increased hygienic demands and requirements for social distancing were implemented within the already high hygiene standards in dentistry [7]. Dental students face the same potential risks as dental health care staff within the patients' treatment and chairside education. ...
... In terms of using the Likert scale, we considered the answer choices of fully agree, rather agree, partially agree, disagree, and fully disagree. A detailed explanation of the increased hygienic measures for clinical as well as educational settings at our department can be found in Diegritz et al. [7]. Furthermore, separate entrances for students were installed, two groups were formed to diminish the number of students simultaneously present in the building, and one-way walking markings were set up in the course rooms as well as distance lines in waiting areas (e.g., in front of the students' stock issue). ...
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Modern teaching formats have not been considered necessary during the COVID-19 pandemic with uncertain acceptance by students. The study’s aim was to describe and evaluate all measures undertaken for theoretical and practical knowledge/skill transfer, which included objective structured practical examinations (OSPEs) covering a communication skills training. The students’ performance in the OSPE as well as the theoretical knowledge level were assessed, of which the latter was compared with previous terms. In conservative dentistry and periodontology (4th and 5th year courses), theoretical teaching formats were provided online and completed by a multiple-choice test. Practical education continued without patients in small groups using the phantom-head, 3D printed teeth, and objective structured practical examinations (OSPEs) including communication skills training. Formats were evaluated by a questionnaire. The organization was rated as very good/good (88.6%), besides poor Internet connection (22.8%) and Zoom® (14.2%) causing problems. Lectures with audio were best approved (1.48), followed by practical videos (1.54), live stream lectures (1.81), treatment checklists (1.81), and virtual problem-based learning (2.1). Lectures such as .pdf files without audio, articles, or scripts were rated worse (2.15–2.30). Phantom-heads were considered the best substitute for patient treatment (59.5%), while additional methodical efforts for more realistic settings led to increased appraisal. However, students performed significantly worse in the multiple-choice test compared to the previous terms (p < 0.0001) and the OSPEs revealed deficits in the students’ communication skills. In the future, permanent available lectures with audio and efforts toward realistic treatment settings in the case of suspended patient treatment will be pursued.
... In this study, 59.5% (n = 47 of 79 questionnaires included) considered phantom heads the best substitute for live patient care and 88.6% (n = 70 of 79) rated the course organization as very good/good. A decisive disadvantage from the authors´ point of view, however, is that the practical part of the course, as mentioned above, had to take place in the clinic rooms and thus under particularly elaborate protective measures [28]. ...
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Abstract Background Due to the SARS-CoV-2 pandemic and the accompanying contact restrictions, a new challenge arose for dental education. Despite the limited overall situation, it must be ensured that, in addition to theoretical content, practical skills in particular continue to be taught. Therefore, the aim of this study was to develop and implement an online hands-on course for dental students that ensures practical training, even during the pandemic. Methods The newly developed course was held from April 2020 to March 2021. A total of six groups (each consisting of approximately 40–50 students) took part in the course. The participating students were in their 3rd, 4th or 5th year of study. The course taught theoretical basics (via an online platform) and promoted the learning of practical/surgical techniques on models such as bananas, pork bellies, or chicken thighs with live demonstrations (via ZOOM) and interactive post-preparation by students at home (and in a rotating small group of 3–7 students on site). Student self-evaluation (at the beginning and end of the course) and course evaluation were performed using questionnaires. The learning success was analyzed (through self-evaluations) using Wilcoxon signed-rank tests (significance level alpha = 0.05). Results Concerning students´ self-evaluations, the theoretical knowledge, general surgical skills (such as surgical instrument handling), and specific surgical skills (such as performing a kite flap) improved during the course, with significant results (p
... Vasan et al dentistry and Periodontology in a dental hospital in Munich. 43 To the best of the author's knowledge, this is the first study conducted to evaluate the prevalence of SARS-CoV-2 infection among healthcare workers in a dental hospital in India. It is suggested that these precautionary measures must be undertaken by dental practitioners even after vaccination due to the rapidly mutating nature of the virus giving rise to the appearance of newer strains. ...
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Introduction: The COVID-19 pandemic has led to major challenges for the healthcare sector across the globe including dental healthcare workers (DHCWs) due to the increased risk of transmission of virus during aerosol-generating procedures. We conducted the present retrospective analysis determining the risk of contraction of COVID-19 infection among DHCWs since the outbreak of the pandemic for a year (March 2020 through March 2021) in Mumbai. Methods: In total, 18,058 patients visited the Nair Hospital Dental College for dental treatment related to the Department of Conservative Dentistry and Endodontics during the assessed year. All the patients were subjected to intensive triage, which included recording their body temperature, oxygen saturation level, travel, and COVID-19 exposure history. Results: A total of 26 DHCWs were responsible for attending and treating the patients with all the standard infection control measures. Seventy-four (0.40%) patients out of 18058 were referred for a nasal rapid antigen test (RAT) on giving a positive affirmation about COVID-19 like symptoms when screened at the triage. Of those 74 patients referred, 20 reported a positive nasal rapid antigen test and the infection was confirmed by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Among 26, 9 (34,7%) DCHWs were found to have contracted the infection during the assessed year. Conclusion: The analysis found that the risk of COVID-19 infection contraction amongst the DHCWs is considerably less. This could be attributed to the intensive triage and the preventive measures taken while rendering treatment.
... By adapting to the new conditions of the pandemic and implementing the recommendations of the WHO and national organizations, dental offices were able to function safely [14][15][16][17][18][19][20]. ...
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Proper oral health care has an impact on the health of the entire body. The COVID-19 pandemic has affected the functioning of the healthcare sector, including dental services. The aim of this study was to analyse the behaviour of patients with regard to their use of dental services during the pandemic. The data were obtained from paper registration forms taken from five dental offices in the city of Cracow between March 2019 and February 2021. During the analysed periods, interest among first-time patients in dental services decreased to 37% (during the month when interest in dental services was at its lowest) compared to the year preceding the COVID-19 pandemic. The number of cancelled visits increased by between 15% and 50% compared to the pre-pandemic period. During the pandemic, appointments made by existing patients increased by up to 84% compared to 2019. The decision by patients to postpone dental treatment not only has adverse effects on their oral and body health, but in turn results in higher health care costs. Given the potential for another pandemic, further long-term research is required to develop and implement special protocols to make the public aware of the safety of health care.
Chapter
The novel coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus presents with nonspecific symptoms such as fever, dry cough, shortness of breath, weakness, headache, and diarrhea. The primary mode of transmission of SARS-CoV-2 is through direct or indirect inoculation of the mucous membranes (eyes, nose, or mouth) with infectious respiratory droplets or fomites. Periodontal tissue can serve as a barrier to the SARS-CoV-2 virus in infected individuals. There are similarities between COVID-19 and periodontal disease, based on pro-inflammatory cytokines released by the body. A periodontal emergency arises when an acute condition involving the periodontium causes pain, forcing the patient to seek urgent care; therefore, most periodontal treatment can be considered as dangerous work compared to other dental procedures regarding the aspect of bioaerosol generation procedure. Transmission can occur through direct doctor-patient contact, as well as contamination from instruments or surfaces in the dentist’s practice room, and it is recommended to use PPE, to avoid aerosol splashes that occur during the work procedure, where aerosol granules and droplets can last 30 minutes after the treatment procedure is performed. The use of teledentistry is very important in periodontal care, in communication with patients regarding chief compliant, risk factor control, and oral hygiene instruction.
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Respiratory and fecal aerosols play confirmed and suspected roles, respectively, in transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). An extensive environmental sampling campaign of both toilet and non-toilet environments was performed in a dedicated hospital building for patients with coronavirus disease 2019 (COVID-19), and the associated environmental factors were analyzed. In total, 107 surface samples, 46 air samples, two exhaled condensate samples, and two expired air samples were collected within and beyond four three-bed isolation rooms. The data of the COVID-19 patients were collected. The building environmental design and the cleaning routines were reviewed. Field measurements of airflow and CO2 concentrations were conducted. The 107 surface samples comprised 37 from toilets, 34 from other surfaces in isolation rooms, and 36 from other surfaces outside the isolation rooms in the hospital. Four of these samples were positive, namely two ward door handles, one bathroom toilet seat cover, and one bathroom door handle. Three were weakly positive, namely one bathroom toilet seat, one bathroom washbasin tap lever, and one bathroom ceiling exhaust louver. Of the 46 air samples, one collected from a corridor was weakly positive. The two exhaled condensate samples and the two expired air samples were negative. The fecal-derived aerosols in patients' toilets contained most of the detected SARS-CoV-2 in the hospital, highlighting the importance of surface and hand hygiene for intervention.
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A few details in our Review require clarification or amendment. We described 0.5% hydrogen peroxide in various parts of the manuscript to be effective against human coronaviruses in 1 min based on the study by Omidbaksh et al. [34]. In this study however, the test product was described as hydrogen peroxide-based but in an accelerated form (ACCEL TB from Virox Technologies Inc.). The formulation contains “very low levels of food-grade anionic and nonionic surfactants” in addition to 0.5% hydrogen peroxide. These are expected to “act in synergy with hydrogen peroxide to produce the desired microbiocidal activity”. Based on the US patent 6,346,279 referenced by Omidbaksh et al. “the solution also contains from 0.1 to 5.0% of at least one acid compound, e.g. phosphoric and/or a phosphonate with from 1 to 5 phosphonic acid groups, and from 0.02 to 5% of at least one anionic surfactant”. The exact composition of the formulation remains unknown. The product safety data sheet provided by the manufacturer of the product, however, declares only one active ingredient which is 0.5% hydrogen peroxide. Neither the article by Omidbakhsh et al., nor the above-mentioned patent, describe any comparative data for 0.5% hydrogen peroxide with and without acceleration. We are not able to evaluate if the acceleration significantly contributes to the virucidal activity of 0.5% hydrogen peroxide although it is plausible. Thus the results on 0.5% hydrogen peroxide described in our review can only be attributed to 0.5% hydrogen peroxide in an accelerated form. In addition, we want to clarify the description of the concentrations of alcohols more specifically. For ethanol it is always w/w except for 80% [v/v: reference 14] and 70% [unknown if v/v or w/w; reference 30]. For 2-propanol it is always w/w except 75% [v/v; reference 14] and 70% and 50% [unknown if v/v or w/w; references 28 and 30]. The mixture of 1-propanol and 2-propanol is w/w [references 28 and 29]. Finally, in the Discussion, the sentence “In an observational study, it was described that students touch their face with their own hands on average 23 times per h, with contact mostly to the skin (56%), followed by mouth (36%), nose (31%) and eyes (31%)” should have read “In an observational study, it was described that students touch their face with their own hands on average 23 times per h, with contact mostly to the skin (56%), followed by mouth (16%), nose (14%) and eyes (12%).”
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Background: Respiratory and faecal aerosols play a suspected role in transmitting the SARS-CoV-2 virus. We performed extensive environmental sampling in a dedicated hospital building for Covid-19 patients in both toilet and non-toilet environments, and analysed the associated environmental factors. Methods: We collected data of the Covid-19 patients. 107 surface samples, 46 air samples, two exhaled condensate samples, and two expired air samples were collected were collected within and beyond the four three-bed isolation rooms. We reviewed the environmental design of the building and the cleaning routines. We conducted field measurement of airflow and CO2 concentrations. Findings: The 107 surface samples comprised 37 from toilets, 34 from other surfaces in isolation rooms (ventilated at 30-60 L/s), and 36 from other surfaces outside isolation rooms in the hospital. Four of these samples were positive, namely two ward door-handles, one bathroom toilet-seat cover and one bathroom door-handle; and three were weakly positive, namely one bathroom toilet seat, one bathroom washbasin tap lever and one bathroom ceiling-exhaust louvre. One of the 46 air samples was weakly positive, and this was a corridor air sample. The two exhaled condensate samples and the two expired air samples were negative. Interpretation: The faecal-derived aerosols in patients' toilets contained most of the detected SARS-CoV-2 virus in the hospital, highlighting the importance of surface and hand hygiene for intervention.