What is standard operating procedure SOP in dentistry?

February 23, 2021

Standard Operating Procedures (SOP) are a part and parcel of any professional field. These are approaches that are strategically and tactically executed for better efficiency of the respective profession. Dentistry too has had its SOP in each country across the globe. These SOP change with time and development in the field of medical and dental science. In dentistry, the most recent changes in SOP have been made following the outbreak of the COVID-19 pandemic. These changes shall be discussed in this section along with the importance of practicing evidence-based dentistry and the way the dental office and staff should execute their given roles.

Social distancing norms has directly affected the way the patients are scheduled for their treatment. The time between two treatments is utilized in disinfecting the operative area (fallow time). Patients are assessed based on the amount of risk they carry for the spread of any infection. They are triaged, meaning, categorically placed as low, medium or high risk patients. In case the patient's complain is a routine checkup or simply a decayed teeth without pain, they are kept under low priority. Emergency treatments and the ones that need resolution of any pain related symptoms are prioritized first.

In the process of scheduling appointments for a patient, it should be checked if the patient can be treated over the phone and medications can be prescribed accordingly. If the patient is scheduled or recalled, they are advised to wear a mask for protection. Moreover, they can be advised to come alone or in case of kids, only a single parent should be allowed to reduce the crowd in the waiting room and respect social distancing.

In the waiting room, a person from the dental team is assigned a role of checking patient's temperature with a thermal gun. The same person should advise the patients to rub their hands with alcohol-based sanitizers. The patients are made to sit 3 feet apart from each other. Patients should not be allowed to wear footwear once they enter the waiting room. If needed, foot covers can be provided. In case it is feasible, the dental team can also install a display that showcases the importance of oral hygiene during the pandemic.

Before the patient enters the dental surgery, it should be ensured that there is appropriate ventilation in that area. Water lines should be disinfected, air conditioners must be avoided and each member of the dental team involved in the treatment should wear the necessary personal protective equipment (PPE).

Once the patient enters the dental office, he or she is asked to rinse his or her mouth with an antimicrobial mouthwash. After the dentist makes the diagnosis and formulates a treatment plan, he or she needs to see whether there is a need for aerosol generating procedures (AGP) or not. AGP procedures involves the use of dental drill or ultrasonic scaling machines which release aerosols that can effectively transmit infection. If an AGP procedure is not needed, the patient is discharged. If it is needed, high volume suction and rubber dam application is mandatory. The suction sucks all the fluid from the patient's mouth while the dentist is performing the procedure whereas rubber dam helps in isolating the tooth or teeth that require treatment, thereby blocking the other parts of the oral cavity to the external environment.

The chosen treatment for the patient must be based on evidences available in the literature. What, why, when and how are the four questions that a dentist must explain to the patient regarding his chosen plan of treatment. This is crucial as any mistake or flaw can result in a medicolegal case.

Once the treatment ends, patient is rescheduled if needed. In the waiting room, the patient is asked to make the necessary payment; preferably cashless. Both the patient and dentist should wash their hands after the treatment ends. The patient is advised to put-on his or her mask during the discharge.

The dental clinic is now disinfected. Various methods have been employed for this. These methods consume at least 15 minutes. Air filtration through special filters can take about 20 minutes to disinfect the area. Ultraviolet Germicidal Irradiation takes only 15 minutes but is an expensive alternative. A disinfecting defogger which is hydrogen peroxide based can take up to 30 minutes. If any of these methods are not possible, then simple ventilation of the dental operatory should be done for one hour.

The clinical area disinfection also involves changing the instruments used by the dentist and sending the used ones for sterilization. The spittoon should be cleaned using sodium hypochlorite and suction tips should be discarded. If needed, the clinical area around the chair (3 feet radius) should be mopped.

At the end of the day, the dentist and his or her team should remove the PPE kit in a designated room for the same. All the biomedical waste must be removed on the same day. The SOP for a dental operatory thus concludes. However, certain key points must be mentioned which are sub-classified in this protocol.

Firstly, a Covid-19 based questionnaire must be filled before starting the treatment. This includes patient's own health status, travel history and if they have been in contact with an already infected person. Seconly, emergency care must be categorized as emergency, urgent or elective care. Appointments should be made based on this. Thirdly, air ventilation should be such that it flows from the less contaminated zone (dentist) to the more contaminated zone (patient) and later filtered to the external environment. Fourthly, dentists should follow a proper protocol called as "donning and doffing" which emphasizes on the sequence in which the PPE kit must be wore and removed. Finally, the housekeeping must be taught how to clean and disinfect the areas outside of the operatory which includes walls, windows, blinds, platforms, reception area, waiting area etc. They too must perform all the cleaning after donning the PPE kit.

SOP in dentistry are now needed more than ever due to the Covid-19 pandemic. Despite the administration of vaccines, patients carry a risk of infection as the full success rate of the vaccination is yet to be established over a longer course of time. Moreover, not only Covid-19, but any other microbial infection can be blocked if the SOP is religiously followed.

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