key: cord-0917167-b05xk1hw authors: Shen, Yi; Zhao, Ji-Hong; Cai, Yu; Wu, Yang title: Low-risk Clinic Model in Oral Surgery Clinic during COVID-19 Pandemic date: 2021-04-09 journal: J Stomatol Oral Maxillofac Surg DOI: 10.1016/j.jormas.2021.04.001 sha: 80175a6cdd1c0e8beccd5fe8f334305e77ec1810 doc_id: 917167 cord_uid: b05xk1hw nan The pandemic of coronavirus disease 2019 , caused by the SARS-CoV-2 virus 1 have become a major challenging public health problem for not only China but also countries around the world 2 . It brings enormous pressure to people, both in physical conditions and psychological health 3 . Due to the characteristics of dental practice, it's high risk of nosocomial infection between dental practitioners and patients. Close contact, the spatter of oral secretions, saliva, blood, and aerosols generated by high-speed turbines or ultrasonic instruments create a presumed risk of nosocomial infection in dental practice 4 . If infected individual was in the incubation period without any symptoms, the attending doctors may be infected during treatment 5, 6 , even more frightening is that he/she deliberately concealed the fact of infection. Routine dental treatment can easily lead to the explosive spread of the epidemic. On January 23 rd , 2020 the city of Wuhan was lockdown, and subsequently the dental clinics were almost completely terminated except emergency care 7 . On April 8 th , with the reopen of Wuhan, the Hospital of Stomatology, Wuhan University (WHUSS) has resumed its clinical practice gradually. The using of high-speed turbines and piezosurgery were still prohibited. Routine oral surgery including the extraction of impacted wisdom teeth and other dental-alveolar surgery had to be delayed. With the effective quarantine and treatment of patients suffered from in Wuhan city, as well as the continuous improvement of epidemic prevention measures 8 , crowds of patients, who were delayed treatment due to the pandemic, poured into dental clinics. The number of patients increased sharply, therefore, there was an urgent need to recover regular oral surgical treatment, and this also pose a high challenge to both dental practitioners and hospital: 1) Due to the characteristics of dental settings, the risk of cross infection between dental health care providers and patients can be very high 9 . Dental practitioners and patients are worried about being infected in hospital. 2) The free tests for all residents in Wuhan only conducted nucleic acid tests, these may be not enough to free from infection and ensure the safety for. and there were probably false negative results, which may be not enough to ensure the safety. A low-risk clinic model was set up to ensure the safety and psychological relief for medical staffs and patients. All dental care providers were allowed to work after obtaining negative results of COVID-19 virus nucleic acid and serological antibody test. Meanwhile the patients should provide nucleic acid test, serological antibody test and/or chest computed tomography (CT) test within 3 days before treatments. After passing the COVID-19 screening, patient was permitted to receive surgical treatment in a separate clinic room equipped with air disinfection and purification. A total of 410 patients were involved undergoing impacted wisdom teeth extracting or other dental-alveolar surgery in 6 weeks. All the patients were satisfied with the treatment during follow-up visits. No virus spreading was observed among patients and medical staffs. The questionnaire showed that most medical staffs acknowledged the benifits of low-risk clinic model. This study was approved by the review board of the Ethics Committee of the Hospital of Stomatology, Wuhan University. Informed consent was signed by all patients after detailed explanation. 1. Requirements for dental care providers: All employees of WHUSS received COVID-19 nucleic acid and serological antibody test every month, and those with negative results were qualified their clinical work. Both oral surgeons and nurses used tight personal protective equipment (PPE) 10 (Table 1) . Besides, they are required to wear a mask (YY 0969-2013) when in the hospital, except when they do clinical examination and treatments. After the preliminary assessment, two kinds of patients were recommended to be treated in low-risk clinic. 1) Patients who must use high-speed turbines and piezosurgery for complex surgical operations, or patients with severe oral and maxillofacial trauma and bleeding. 2) Patients who were afraid of being infected COVID-19 during oral procedure. Furthermore, the patients were required to provide results of COVID-19 tests including virus nucleic test and serological antibody test 3 days before operation. Preoperative blood analysis and coagulation function test were also performed. We told the patient that invasive oral surgery may cause transient bacteremia, and then there will be a temporary temperature rise. If the patient has a persistent fever, nucleic acid testing should be performed immediately at the nearest fever clinic. Personnel are not allowed to enter the clinic room during sterilization 11 . The specific operation process is shown in Figure 2 . Throughout usage of the clinic, desktop air disinfection machine was placed at the entrance of the low-risk room. The machine keeps running and disinfect operating room during working. 4 . Postoperative follow-up of patients: At 7 days and 30 days after operation, patients were followed up by telephone to see if they have any symptoms of COVID-19, such as fever, cough, difficulty breathing, diarrhea, nausea, body ache, loss of smell or loss of taste. We told them if any of these symptoms were present, a nucleic acid test should be performed immediately. Besides, patients were asked to evaluate the low-risk clinical mode (Table 2) . 5 . Dental care providers survey scale: Psychological questionnaire for medical staffs was used to evaluate whether the low-risk clinic model can comfort them during this special period. There were 426 patients (203 males and 223 females), aged from 7 to 74 years old, were treated in the low-risk clinic room from May 4 th , 2020 to June 14 th , 2020. Two patients had a history of COVID-19, while all the other patients had no experience to contact with COVID-19, whose results of nucleic acid test, serological IgG and IgM antibody test were all negative. Those two recovered cases who have been recovered more than one month (check-out from COVID-19 quarantine ward more than one month) had the results of COVID-19 nucleic acid (-), IgM (-) and IgG (+) preoperatively. Furthermore, their additional chest CT scan showed air bronchogram decreases during the recovery phase 12 , which allowed these two patients to proceed their dental treatments. The results of questionnaire on medical staffs showed that the low-risk clinic has significantly alleviated the anxiety to perform dental treatments just after COVID-19 pandemic. All the medical staffs believed that the transmission of COVID-19 virus in the hospital could be effectively prevented by triple protection, including strict personal protection, air suction and disinfection room during operation, and strict virus examination for both dental care providers and patients. Low-risk clinic model strengthened the confidence of dental care providers at work. The outbreak of COVID-19 has caused an extremely negative impact on people's lives and work. Patients fear suffering from COVID-19 because of their increased exposure in assembly occupancies and contagious treatments. Hence, they are unwilling to accept dental treatments or only deal with necessary emergencies. Meanwhile, dental practitioners gain a higher occupational risk due to dental activities 13 . To a certain extent, dentists aggravate the worry and depression for infection. In March 2020, psychological survey showed that 90.2% hospital staffs were worried about being infected in daily procedure. As a result, preventive and control measures are urgently needed for dental practices during COVID-19 pandemic 14 . Low-risk clinics are suitable for low-risk patients. It is mandatory for patients to perform the nucleic acid and serum antibody tests of COVID-19 within 3 days before operation. The reported incubation period of SARS-COV-2 was 3~10 days. Choosing the shortest time can maximize patient safety. Therefore, we believe that preoperative detection within 3 days can effectively reduce the possibility of transmission. Specific test indicators include nucleic acid tests for viral RNA testing, from nasal swabs or throat swabs, and serological antibody test result. Viral nucleic test indicates whether patients suffer from COVID-19 and have infectivity or not, which is the current gold standard for the diagnosis of COVID-19 15 . And they currently offer the most sensitive and early detection of COVID-19 16 . However, there are many limitations of the RT-PCR tests that make them unsuitable for use in the field for simple and rapid screening of patients such as complex protocols, number of false negatives, and long turned turnaround times 17 . Serological antibody test, comprising of IgG antibody and IgM antibody, can precisely identify asymptomatic infectors and those who had already recovered from COVID-19 18 . High IgG antibody titers indicate the acquisition of resistance to re-infection 19 immediately. It should be noted that if a patient has a serological IgG antibody (+) test，as well as nucleic acid (-), IgM (-) results, which means this patient had a history of suffering with COVID-19. This patient may be in the recovery period or has clinically recovered. The IgG antibody can exist in the body for a long time with no or extremely low infectivity. In this situation, the chest CT should be supplementary 20, 21 . Physicians evaluate the chest CT results to determine whether the patient was cured. The recovery patient showed a reduction in size and/or density of lesions 22 . In order to block the spreading of COVID-19 virus thoroughly, certain specific measures must be taken to obtain virus-free operative circumstance in the low-risk clinic. As a topical antimicrobial agent, CPC inactivates the virus through its lysosomotropic action and by destroying the capsid 23 . A recent review preconized its use in reducing the risk of spreading SARS-CoV-2 through aerosols, although its action against this virus remains controversial 24 . China has a strict management system for COVID-19. Every day, the Chinese Center for Disease Control and Prevention (CDC) will give timely and accurate notice to the newly diagnosed patients, suspected patients, suspected fever patients, close contacts and asymptomatic infected people in each city. All confirmed patients and suspected patients strive to achieve early detection, early isolation and early treatment. From May 2020 to July 2020, there were 7 new cases reported in Wuhan. According to the information released by the CDC, these infected patients had never been to our hospital. None of our patients had close contact with these infected people. We believe that strict control of infectious diseases can significantly limit the spreading of COVID-19. Postoperative investigation showed that 97.2% of patients believed that low risk clinics could alleviate the psychological anxiety and improve their trust in hospitals. The setting of the clinic is conducive to reduce the occurrence of cross infection. Due to the dual protection of clinical medical staff and patients, patients are more willing to make appointments for low-risk clinic service than ordinary clinic service. According to the previous investigation, most of the staffs in our hospital were anxious and worried about being infected with COVID-19 during dental practices. Before using the low-risk clinic mode, only 35.3% of the medical staffs in our department believed that this working mode benefit preventing the spread of virus. With increased application, medical staffs gradually accepted and recognized this working mode. The working enthusiasm was significantly improved. Sharply 6. Would you choose to be treated in the low-risk clinic rooms? 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