key: cord-0860001-kdu4yoi8
authors: Nadershah, Mohammed; Al-Sebaei, Maisa; AlJabbab, Abdulsalam; AlMajid, Emtenan; AlShadwi, Ahmad
title: Consensus Statement of the Saudi Society of Oral and Maxillofacial Surgery on practice during the COVID-19 pandemic in Saudi Arabia
date: 2020-12-03
journal: Ann Saudi Med
DOI: 10.5144/0256-4947.2020.491
sha: 6b9b1ba025f2604131913b0cbe08bc1a54406023
doc_id: 860001
cord_uid: kdu4yoi8

The coronavirus pandemic (COVID-19) has impacted essentially every country's healthcare system in extraordinary ways, fundamentally changing the way we deliver care. The practice of oral and maxillofacial surgery is no exception. In response to this global health crisis, the Saudi Society of Oral and Maxillofacial Surgery has prepared this consensus statement to inform our clinical and other medical colleagues and the public at large on proper procedures during this time. The statement is based on the best scientific evidence available and follows the guidelines put forth by the Saudi Ministry of Health on the COVID-19 response. It explains how to manage and triage oral and maxillofacial patients based on the level of care needed at the time of clinical presentation.

in December of 2019. This novel virus was first reported to affect patients in the province of Wuhan in China prior to rapidly spreading throughout the globe. 2 Unlike the first two outbreaks, which were regional epidemics, the World Health Organization declared it as a pandemic in March 2020. It has spread to over 7 million people in 216 countries in about 6 months with a reproduction rate of 1.4 -5.5. 3 The possible routes of infection are direct contact and droplet transmission. Aerosol production is also considered a high-risk route for viral transmission. 4 Global measures to contain the spread of the virus are focused on physical distancing and interruption of human-to-human contacts. This has led to enormous economic, social, and health impacts throughout the world. The influx of patients requiring intensive care for respiratory support has overwhelmed the healthcare system in many countries, which has made medical care for many non-COVID-19 related patients inaccessible. Additionally, patients are at risk for acquiring the COVID-19 during medical treatment.

A multicenter international cohort study in 24 countries examined complications in patients with confirmed COVID-19 infection undergoing surgery. 5 The study included 835 patients who underwent emergency The coronavirus pandemic (COVID-19) has impacted essentially every country's healthcare system in extraordinary ways, fundamentally changing the way we deliver care. The practice of oral and maxillofacial surgery is no exception. In response to this global health crisis, the Saudi Society of Oral and Maxillofacial Surgery has prepared this consensus statement to inform our clinical and other medical colleagues and the public at large on proper procedures during this time. The statement is based on the best scientific evidence available and follows the guidelines put forth by the Saudi Ministry of Health on the COVID-19 response. It explains how to manage and triage oral and maxillofacial patients based on the level of care needed at the time of clinical presentation. surgery and 280 patients who had an elective surgery. The 30-day mortality was 23.8% and the pulmonary complications were 51.2%. They found a significant risk with age >70 years (P<.0001), emergency procedures (P=.026), and major surgery (P=.047). This consensus paper aims to guide the oral and maxillofacial surgeon and hospitals in the management of patients during the COVID-19 pandemic and during the transitional period of re-opening dental offices.

The Saudi Society of Oral and Maxillofacial Surgery (SSOMS) is the scientific umbrella under which all professionals practicing or interested in the field of oral and maxillofacial surgery register to be updated with the latest news, research or innovation in the discipline. Since its foundation in 2008 under the governance of the Saudi Commission for Health Specialties, the SSOMS quickly establish itself as one of the fastest growing scientific societies in Saudi Arabia and the GCC countries and more recently has solidified an global presence with various memorandums of collaboration with multiple world renown academic bodies and professional associations concerned with advancement of oral and maxillofacial surgery in addition to regular participation in international conferences and events.

The SSOMS COVID task force members are the five authors of this report. The consensus was made using the best published scientific date, practices available when the paper was written in addition to recommendations made by the MOH that are relevant to the practice in Saudi Arabia.

Triage of patients in need of oral and maxillofacial surgery is an important component of the new practice norm during the COVID-19 pandemic. The surgeon should assess the urgency, complexity, available facilities (e.g. availability of intensive care beds and operating time), the patient's COVID-19 status and the current local guidelines to prioritize care during a pandemic. Surgical intervention should be simplified and aimed at minimizing hospital stay. Previous experiences with respiratory viral pandemics have shown a potential risk of resource shortage. Moreover, healthcare facilities might have to focus on critically ill COVID-19 patients limiting access to other patients. In a situation where the medical center lacks the facilities and/or equipment to handle high-risk or COVID-19 patients, then the patient should be transferred to a tertiary care center able to manage these cases.

It is recommended that all patients be tested for COVID-19 prior to any surgical procedure in the operating room if surgical intervention cannot be delayed.

All emergency procedures with a pending result should be performed in the designated COVID-19 operating room, while taking the precautions recommended such as using proper personal protective equipment and performing surgery in a negative-pressure operating room. It is important to have a clear and well-communicated concept for prioritizing procedures in oral and maxillofacial surgery. Globally, these guidelines may differ between institutions, depending on the healthcare system, the surge of cases and the current nature of the pandemic in each country. 6 The Saudi Society of Oral and Maxillofacial Surgery proposes a priority system for use by surgeons using their best clinical judgment. The system categorizes the clinical oral and maxillofacial surgery cases according to severity, giving a priority score of 1, 2, 3, or 4 ( Table  1 ). Priority 1, which includes cases that must be operated within 24 hours, are severe facial infections (with airway involvement), emergency facial trauma (e.g. airway compromise, retrobulbar hematoma, inferior rectus entrapment), bleeding, and condylar dislocation. Cases categorized as priority 2 should be managed within 7 days; these include: localized dental Infections, severe acute pain with locked jaw and limited mouth opening and other facial bone fractures that necessitate urgent repair to prevent unacceptable sequelae (e.g. infection, permanent functional deformity, and severe cosmetic deformity). Priority 3 is given to cases that should be managed within one week to one month. These include benign and malignant tumors (non-critical cancer patients), cysts, and extraction of painful non-restorable teeth. Priority 4 includes all elective cases that can be postponed for a month or more. These cases include cosmetic surgery, orthognathic surgery, cleft lip and palate surgery, temporomandibular joint reconstruction, and elective dentoalveolar surgery.

The lifting of the COVID-19 restrictions on healthcare facilities has provided room to accommodate elective procedures and guidelines for those cases, as has been published by the Saudi Center for Disease Prevention and Control (SCDC). A preoperative COVID-19 checklist for elective surgery can be used as a guide for this category, where a score of less that 10 indicates low risk, while score of 10 or more indicates high risk. The scoring system has two parts: part A addresses exposure risk and part B addresses clinical signs and symptoms. An algorithm developed by the SCDC provides directions for patients that require elective procedures (Figure 1) . 7

The continuity of care for maxillofacial surgery patients is crucial for successful management in the pandemic era. Mandatory safety measures enforced to prevent the disease spread, such as social distancing and curfews, can compromise the delivery of needed care and lead to unwanted outcomes, especially for patients with maxillofacial oncology, trauma, and fascial space infections, where the delay or interruption of the treatment plan may result in morbidity or mortality. Due to the specific nature and close contact of the patient in the dental setting, the United States Center for Disease Control (CDC) and the National Center for Immunization and Respiratory Disease have released updates on guidance for dental practices during the COVID-19 pandemic. In the latest release on June 17, 2020, the CDC provided guidelines for clinical care during COVID-19 pandemic in a dental setting. 8

It is recommended to contact patients by phone prior to the appointment to screen for COVID-19 symptoms or exposure and obtain their risk score. The patient must limit those who accompany him/her to one person. The patient and accompanying person are assessed upon arrival in a designated visual triage location where temperature is checked. A face covering (mask or cloth covering) must be donned. It is recommended that outpatient clinics have facemasks and hand sanitizer readily available for those patients prior to entering the clinic.

Only urgent procedures (refer to previous section) are performed in suspected or confirmed COVID-19 patients. According to recent Saudi Arabian Ministry of Health (MOH) guidelines, those patients have to be treated in air-controlled rooms, such as dental clinics with a negative pressure HVAC system or portable HEPA filter with airborne precautions or in a portable dental clinic inside an airborne infection isolation room (AIIR) in a hospital setting.8 Clinics or medical centers that do not have these facilities should instruct patients prior to coming to the clinic to seek treatment in centers/hospitals where these equipment/facilities are available. Emergency room consultations are managed in a similar fashion.

Alternatives are needed to the usual on-site visits for follow-up after procedures where outcomes are assessed and patient concerns or inquiries are addressed. Those alternatives might include telemedicine/teledentistry made possible by recent advances in health information technology. The advantages of virtual clinics during the COVID-19 pandemic include reducing the chances of cross-contamination for patients and providers while overcoming any disruption in patient care.

For procedures that are likely to generate splashing or spattering of blood or other bodily fluids such as extraction of teeth or minor intra-oral surgical procedures, the CDC recommends that the dental healthcare professional wear a surgical mask, eye protection and gown. Additionally, the Saudi MOH mandates a surgical gown for non-aerosol procedures. For procedures likely to generate aerosol secondary to use of an airdriven handpiece in the dental unit such as surgical tooth extraction or minor oral surgical procedures requiring bone removal, a surgical gown, N95 respirator, hair cap, face shield/goggles and gloves are necessary, according to the Saudi MOH guidelines. 9 The N-95 respirator must be fitted to the practitioner. The dental healthcare professional must be trained for proper donning and doffing of personal protective equipment. Since aerosols can be contaminated with bacteria, fungi and viruses that are potentially hazardous, procedures that require the use of aerosol generating equipment should be limited. COVID-19 has the potential to spread through droplets and aerosols from infected individuals in dental settings. Anti-retraction handpieces have been recommended to reduce crosscontamination. 10 In summary, the Saudi Society of Oral and Maxillofacial Surgery consensus statement provides guidance for surgeons and healthcare institutes for prioritizing the management of oral and maxillofacial surgery patients during the COVID-19 pandemic. These guidelines do not replace sound clinical judgement, institutional policies and procedures, and government mandates.

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