Special Issue Jul-Sep 2020

Aeeza Malik                           BDS, MDS

Marium Aftab                        MBBS

Malik Saleem Shaukat         BDS, MSc

Basil Khalid                           BDS, M.Phil

Marij Hameed                        BDS, MSc

Razia A. Ahmed                     MBBS, MCPS, MRCOG

OBJECTIVE: To compare the clinical effects of Salvadora persica oral rinse and commercial Phenolic mouth wash on oral health status of socially deprived madrasa girls after six months of a triple blind randomized clinical trial.
METHODOLOGY: Girls aged 18-22 years living permanently in a madrasa of Multan city were recruited. After determining the sample size and trial duration participants were randomized into group A and Group B and were provided with freshly Salvadora persica oral rinse and commercial Phenolic mouth washes respectively. Pre, mid and post-interventional examinations were executed by a single, blind and calibrated examiner using Turesky Quigley Hein Plaque and Loe and Silness Gingival indices. Statistical analysis was carried out by descriptive statistics, two sample independent t-tests and ANOVA. The p-value of <0.05 was considered significant at 95 % confidence level and 80% power.
RESULTS: Sixty subjects were enrolled for the present trial. The mean age of the participants was found out to be 21.5±0.76 years. No statistically significant difference was identified between the mean Plaque and Gingival scores of the two interventional groups at any of the examination phase.
CONCLUSION: Salvadora persica oral rinse is suggested to be equally effective as the commercial Phenolic mouth wash for the control of plaque deposition and prevention of gingival inflammation.
KEYWORDS: Dental plaque, Gingivitis, Miswak, Mouthwash
HOW TO CITE: Malik A, Aftab M, Shaukat MS, Khalid B, Hameed M, Ahmed RA. Comparative clinical effects of salvadora persica oral rinse and a phenolic commercial mouth wash on human oral health; An invivo randomized trial. J Pak Dent Assoc 2021;30(2):87-93.
DOI: https://doi.org/10.25301/JPDA.302.87
Received: 20 April 2020, Accepted: 14 February 2021
Download PDF
Read More

Ayesha Aziz                                     BDS

Syed Zahid Hassan                         BDS

INTRODUCTION

Coronavirus has aroused echoes of SARS-CoV after twenty years. It was first diagnosed in Wuhan, China where a swarm of pneumonia cases were reported of undetermined origin in December 2019. After variety of researches, corona virus was isolated. This virus is less virulent yet similar to SARS-CoV and Middle East Respiratory Syndrome (MERS-CoV). It mostly affects the elderly and the ones with underlying health condition. Novel coronavirus 2019 is zoonotic in origin as this reservoir has previously been the cause of SARS-CoV and MERS-CoV, too. As it emerged from the live animal markets which are famous in Wuhan, the cause can be a widespread animal source present at the market e.g. bats, snakes, dogs, rabbits etc. The series of symptoms included respiratory distress, fever, cough etc. Coronavirus is an airborne microorganism, which is highly contagious.1
The arrival of coronavirus has posed disputes and challenges in medical and dental hospitals. The maintenance of infection and disease control is necessary to carry out emergency care. Dentists have been advised to take several protective and preventive care measures. Minimizing procedures that produce aerosols, spatters or droplets is needed in order to prevent infection. This article is based on our knowledge about the virus, research and experience of infection control in dentistry.

WHAT IS COVID-19?

Coronavirus belongs to the coronavirinaesub virus in the Nidovirus super family which is commonly known for causing lung infections, nasopharyngeal diseases, fever etc. This virus family primarily was of animal origin but now has local human to human spread.1-2 The diagnosis is based on the symptoms and history of the patient. Coronavirus is a single positive strand RNA virus with mutation rate higher than DNA virus. It causes upper respiratory tract infections with severity rate of 5%-15%.3
Coronavirus is transmitted by symptomatic patients, via respiratory droplets from infected patient to others, directly or indirectly on surfaces that come in contact. Primarily, the
transmission is animal to human contact. The possibility of respiratory droplets to infect a person is less if the person is two meters. Members of coronavirus families causes a broad range of diseases in animals and humans. Since, coronavirus is an airborne pathogen, it can stay up to hours in any surface leading to increase human-human spread. Thus, self-isolation is advised in order to control this disease.4 Emerging and remerging diseases are global concern. Given the outbreak of coronavirus, public health sectors have performed a variety of researches in order to learn more about this. Epidemiological studies have shown that as of May 2nd 2020, there have been 3.28 million people affected from the virus from which 1.1 million have died.5
This count is increasing day by day as active cases from all over the world are being reported. Since it is believed that interpersonal spread through respiratory droplets, chances of feco-oral transmission can also be plausible. Chinese researchers have found SARS-CoV traces on the sputum and stool of infected patients. As discussed above, the virus is airborne, vertical transmission i.e. mother to child is yet to be determined.1,3 The characteristics of a dental set up makes dentists the most vulnerable medical professionals, as dental practitioners have high chances of getting exposed. Dental practices should have conscientious infection control protocols for prevention purposes.6

CLINICAL MANIFESTATIONS & MANAGEMENT

Clinically, the novel coronavirus shows classical upper respiratory tract symptoms which includes, flu, fever, cough, malaise, myalgia and difficulty in breathing. Some patients
have reported gastrointestinal problems like diarrhea and vomiting. The incubation period of coronavirus ranges from 1-14 days, patients usually report symptoms on the fifth day of catching the disease. Risk factors include elderly people who are more than 65 years old, immunocompromised patients, a comorbid patient, asthmatic or lung disease patient
etc.7 A proper treatment has not been determined yet, it is symptomatic, only. Patients are advised to take vitamin C diet and immune boosting supplements.

EFFECTS IN DENTISTRY & HOW TO COUNTER THEM

Pondering over the severity of the COVID-19 pandemic, it is crucial to take clear and firm guidelines in order to manage dental patients and to decrease risk of getting exposed.
In a dental set up, infections can occur easily with a needle puncture or via contaminated surfaces when a person with any contagious disease coughs, sneezes or when high suction
devices are used which create aerosols and spatters. Thereafter, any infection can occur directly or indirectly, making dental professional high at risk.8 Since, the characteristics of a
dental setting generates excessive cross contamination, the conventional infection control measures do not work on the critical pandemic COVID-19. Although Centre of Disease Control (CDC) recommends to facilitate dental emergency cases only, it is necessary to know the type of difficulty which needs urgent care. The category of dental treatment that need to be countered urgently include following;

• Fractures of oral maxillofacial region.
• Diffuse soft tissue infection with intraoral or extraoral swelling which can compromise airway.
• Unbearable dental pain due to pulpal inflammation, tooth fracture or trauma.
• Uncontrolled postoperative bleeding.
• Fractured denture or orthodontic device which has caused tissue laceration.9 Owing to the fact that current data suggests that humanhuman spread of nCoV-19 occurs through respiratory droplets, the infected droplets can enter the mouth, eyes, nose or lung inhalation. Therefore, it is necessary for dental professionals to have exceptional personal protective measures. It is also essential that thorough screening of asymptomatic and symptomatic people should be done of anyone entering a dental care setting. Few of these recommendations are needed in order to provide a virus free environment which includes;
• Considering every person as potential COVID-19 carrier.
• Effectively ruling out symptoms of COVID-19 e.g. fever before setting into the healthcare facility.
• Identify the urgent need of patient and focus onto making the treatment as less invasive as possible.
• Determining essential treatment for each patient and its benefit and risks.
• Disinfecting the dental unit after every treatment.
• Use of personal protective equipment (PPE) for every procedure.
• The staff should work at a sufficient distance from the patients, handpieces must have anti reflux devices in order to steer clear of contamination as possible.
• Reduced aerosol generating processes should be done in operating session to improve risk of cross infection.1,9,10 According to a recent study, coronavirus survives on steel or disposable surfaces for as long as 4 to 24 hours.11,12 For this reason, substantial amount of sanitizing and proper hand wash with soap is necessary. On the grounds that the
  virus proliferation is high in specks released when a person coughs or sneezes and every person is considered to be a possible COVID-19 carrier, it is necessary to disinfect all
  the surfaces that the patient comes in contact with. It is important to provide everyone in the facility with a mask to decrease likelihood of infection.12 On the basis of potential transmission of coronavirus in dental practice, it is crucial to maintain three level protective measures particularly primary, secondary and tertiary level protection. Primary
  protection depends upon standard clinical protection i.e. disposable respirators or masks, gloves, gowns etc. Secondary protection consists of advanced care level which includes disposable isolation clothing or surgical clothes, protective eye wear, disposable caps, masks and gloves. Whereas tertiary protection is based on the type of protection where contact patient is COVID-19 positive. However, this type of patient is not generally taken under dental care, but if emergency exists, it is necessary to facilitate this type of patient as well.8,11,12

CONCLUSION

As a part of healthcare fraternity, it is of utmost importance that dental professionals sustain high level of infection control and sanitization. It is also needful to educate patient and dental team about the virus and its severity and decrease the unnecessary amount of panic, in the meanwhile countering emergency dental problems and maintain wellbeing of the patient.

CONFLICT OF INTEREST

None

ACKNOWLEDGEMENTS

We would like to express our profound gratitude to our mentor Dr Ahsan Inayat who has guided and helped us to prepare this short communication.

REFERENCES

1. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19), emerging and future challenges for dental and oral medicine. J Dent Research. 2020;99:481-87. https://doi.org/10.1177/0022034520914246
2. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, Sun C, Sylvia S, Rozelle S, Raat H, Zhou H. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infectious diseases of poverty. 2020;9:1-2. https://doi.org/10.1186/s40249-020-00646-x
3. Raj K, Rohit AG, Singh S. Coronavirus as silent killer: recent advancement to pathogenesis, therapeutic strategy and future perspectives. VirusDisease.2020:1. https://doi.org/10.1007/s13337-020-00580-4
4. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, Xing F, Liu J, Yip CC, Poon RW, Tsoi HW. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to- person transmission: a study of a family cluster. The Lancet. 2020;395 (10223):514-23. https://doi.org/10.1016/S0140-6736(20)30154-9
5. COVID-19 cases worldwide, Google News, May 2nd 2020
6. Coulthard P. Dentistry and coronavirus (COVID-19)-moral decisionmaking. British Dent J. 2020;228:503-05. https://doi.org/10.1038/s41415-020-1482-1
7. Gandhi RT, Lynch JB, del Rio C. Mild or Moderate COVID-19. New England J Medi. 2020 Apr 24. https://doi.org/10.1056/NEJMcp2009249
8. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings2003.
9. Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. The Saudi Dent J. 2020 Apr 7. https://doi.org/10.1016/j.sdentj.2020.04.001
10. Spagnuolo G, De Vito D, Rengo S, Tatullo M. COVID-19 outbreak: An overview on dentistry, Int J Environ Res Public Health. 2020 Mar 22
    https://doi.org/10.3390/ijerph17062094
11. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12:1-6. https://doi.org/10.1038/s41368-020-0075-9
12. Van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO. Aerosol and surface stability of SARSCoV-2 as compared with SARS-CoV-1. New England J Medi. 2020;382:1564-67. https://doi.org/10.1056/NEJMc2004973

1. House Officer at DIEKIOHS, Dow University of Health Sciences, Karachi, Pakistan.
2. House Officer at DIEKIOHS, Dow University of Health Sciences, Karachi, Pakistan.
Corresponding author: “Dr. Ayesha Aziz” < ayesha.aziz13@yahoo.com >

Ayesha Aziz                                     BDS

Syed Zahid Hassan                         BDS

Fariha Irfan                       BDS

Javeria Ali Khan              BDS, FCPS

Batool Ali                            BDS, FCPS

Kashif Aslam                     BDS, MSc

Arshad Hasan                   BDS, FCPS

Anwar Ali                           BDS FDSRCS

Amynah Charania         BDS M.Phil

INTRODUCTION

World Health Organization announced coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as pandemic on 11th March 2020.1
The virus that originated in Wuhan City, in the late December 2019 has now infected more than 3 million individuals in 200 countries worldwide.2 COVID-19 for most individuals causes mild to moderate illness, so patients could potentially present to primary care settings.3
Additionally, the route of spread of this infection are direct contact, droplets and via aerosol. Dental procedures are associated with the production of high volumes of aerosols inside dental operatory. Therefore, dental professionals are amongst the most susceptible group of health care workers.4
A special area of concern is the dental out-patient departments (OPDs) of teaching hospitals across Pakistan. Although, there have been a lot of guidelines for private dental practices, not much has been published about the OPDs. A guideline was prepared by the administration of Dow Dental College before going into lockdown and was disseminated to all departments and shared with Sindh Health Care Commission. However, modifications have been made continuously in the operating guidelines since the start of COVID-19 pandemic. It is therefore a matter of national duty on our part to modify the guideline and present it for dental OPDs of teaching hospitals across the nation.
These OPDs are at a high risk because of the presence of multiple factors. Among them, first is the concentration of dental units in an OPD; according to the accreditation standards of Pakistan Medical and Dental council (PM&DC) there should be at-least 75 dental units in all the dental OPDs of a college for 50 BDS seats.5 Although this number is divided into departments, but still greater risks and precautions are associated as compared to a single dental unit. Second is the skill of the operator. Most operators are dental students who are still in a learning phase, and therefore more prone to occupational injuries incidents.6
Resulting breaches in the infection control protocol may predispose dental professionals and patients to infectious diseases. Third and most important factor is the provision of personal protective equipment (PPE) and related cross infection control measures. With limited cash flow due to lockdown and a resultant slowdown in the national economy, the dental OPDs generated revenue is reduced and the overall budgets of dental universities and colleges are badly affected, in addition to this the students’ ability to pay hefty amount of fee is hampered.7
With the absence or reduction of cash flow, the ability of a dental college to provide necessary equipment and PPE can be compromised. With this preamble, the purpose of this paper is to propose guidelines for dental OPDs of teaching hospitals of Pakistan. The authors have done a literature search and have used available evidence in the preparation of these guidelines. Also, modifications have been made to suit the working conditions and realities of our region. These are the aggregation of the authentic standard guidelines available so far, in future there may be changes according to the best available evidence and should be adopted subsequently.

GENERAL GUIDELINES FOR IMPLICATION OF DENTAL CARE:

Before opening of the dental college preparation:

• Dental and Non-dental staff needs to get educated and trained according to the latest guidelines of Covid-19.8-10
• Dental staff includes all the dentists working in the dental clinic/OPD, dental students, house officers, dental hygienists, dental assistants, lab technicians, technologists, dental nurses, central sterilization (CSSD) staff, and dental radiology staff. Non- dental staff includes administration, reception desk staff, plumbers, electrician, generator staff, lift operator, security guards, janitorial staff, staff working at pharmacy etc.
• Dental staff should be trained by attending webinars and various videos explaining the protocols. In addition to that research articles, reading material should be provided to
  them. The modules are given at https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html.
• A demonstration/drill or standard protocols exercise for the dental and non-dental staff should take place before the dental care opens to the public.
• Purchase of PPE, disinfectants and equipment like scanning thermal guns should be done before opening. For this all the budget, tender documents and related staff meetings
  should be done beforehand.
• Trash cans with trash bags, preferable with foot control should be placed in abundance. Proper waste disposal protocol should be followed.
• COVID 19 pandemic awareness posters including cough etiquettes and hand hygiene instructions should be displayed appropriately in waiting areas.11
  Initial Patient Screening:
• Tele-phonic screening and triaging whereby dental staff members can prioritize treatment need of patients based on emergency level of their dental condition are preferable to restrict unnecessary arrival of patient to dental hospitals.11
• Initial patient screening should be done at two levels:
  1. Related to their health status including assessment of general medical conditions and risk assessment of COVID19 infection. Screening questions for COVID-19 assessment
  can be included in regular medical history form as proposed by American Dental Association (ADA).9 Patients can then be classified as:

Figure 1: Levels of emergency12

Table 1: Dental procedures falling under different emergency levels12

• Patients who are confirmed/suspected cases of COVID-19 infection
• Patients who are at potential risk of infection and may be asymptomatic carriers. (With the help of screening questions those patients which are not confirm cases of
  COVID -19 nor they show any symptoms but have significant history of contact with COVID-19 positive patient or history of travelling can be identified which may be potential asymptomatic carriers/ their status for COVID-19 is doubtful)
• Patients who do not have any significant history, clinically healthy and asymptomatic and are at unknown risk of COVID-19.
  2. Related to their dental condition which includes assessment of treatment need according to the emergency level of their condition. Treatment need for dental emergency conditions can be categorized as:
• Life threatening emergency conditions
• Conditions requiring urgent care/emergent dental conditions
• Elective dental care
• It is recommended that dental hospitals should provide their contact phone numbers, email addresses to the patients through electronic and print media or through other modes of communication so as to make it possible for the patients to make a prior consultation with the aid of telephonic interview or video conferencing.
• An ADA recommended patient screening form9 for COVID-19 can be utilized for the verbal screening of patients for minimizing the risk of unnecessary exposure.
  Treatment Decisions:
  Current recommendations for provision of dental treatment to patient includes:
• All elective procedures should be postponed according to ADA guidelines during COVID-19 pandemic.9,11,13,14
• Patients presenting with odontogenic infections or trauma requiring emergency treatment or for treatment of emergent dental condition with no prior significant history or doubtful symptoms for COVID-19 can be treated with standard dental emergency regimen along with standard and special precautions for COVID-19.
• Patients who are suspected/confirmed case of COVID19 should only be treated for life threatening emergency condition preferably in a negative pressure room with 12 air
  changes per hour minimally or 160 L/s per patient at least with utilizing highest level of personal protective equipment only under specialized care by trained dental team.15
• Patients who are not in any current emergency condition requiring elective care can be explained with the transmission possibilities of COVID-19 disease along with risks and benefits of provision of treatment scheduling appointment when the condition gets better.14

Protocol for entering the Dental College hospital:

For Patients:

For provision of strict infection control following are the guidelines to be observed by the patients presenting to the dental hospital for emergency/ urgent /emergent/ dental care:

1. Physical and verbal screening of the patient at special desks when entering the dental college.20 Body temperature of patients and their attendants should preferably be checked with touch less forehead thermal scanner. In case elevated temperature is noted, patient should be provided with mask and reported to Infectious disease department/isolation ward dealing with COVID-19. The data of such patient should be entered in the dental care data base. All the patients and their escort should wear face mask before entering the dental hospital premises.
2. Patient should be escorted by only one attendant. Attendant should be more than 13 years of age and less than 65 years of age.
3. Patient should be asked not to bring any unnecessary belongings.
4. At least 70% alcohol based hand sanitizer preferably wall mounted should be available for use, with a proper display of how and when to use on charts or panaflex.
5. While using elevator, well-fitting masks should be used, while maintaining a social distance from other occupants and avoiding direct physical contact with lift buttons and
   other objects.
6. Elevators should be disinfected regularly.

Figure 2: Patient protocol for entering dental teaching hospital

For Dental Staff:
Following guidelines and recommendations should be followed by dental staff upon entry:

1. All the dental staff should wear face mask before entering the dental college/ hospital premises. After reaching their respective departments they will remove their mask and wear the PPE again.
2. A health desk may be created at the entry of the hospital where verbal and physical screening of dental staff should be done for symptoms of COVID-19. A touch less forehead thermal scanner may be used at this health desk.
3. Dental Staff must receive a prior training of donning, use and doffing of PPE according to the Occupational Safety and Health Administration PPE standards.16
4. Upon entry dental staff should select appropriate protective equipment according to their OSHA’s risk exposure level as will be discussed later in the article.
5. Donning of PPE and attire change should be done in separate designated areas.16

Preparation for reception desk/ registration counter:
Recommendations for reception desk/registration counter preparation includes:

• Reception and screening desk staff should wear face masks and eye protection, or a transparent glass barrier should be installed in between because they are the first point of contact after patient entry inside dental hospital.9
• Individual phone headsets should be provided to each front desk staffer so as to lessen the spread virus though single phone head piece.9
• Better to have paperless counters. Use of patient management software is recommended.
• Disposable pens should be used or patients instructed to bring their own pen in screening call.9
• Disinfectant wipes or disinfectant spray should be available to clean computer monitors, mouse, printers, or any other touchable surfaces. If surfaces have dirt they should
  be cleaned prior to disinfection.9,11
• To disinfect, use products meeting Environment Protection Agency (EPA) criteria for use against SARS-CoV2 which are appropriate for the surfaces.9,11,17
  Preparation for Patient waiting area:
  Recommendations for waiting area preparation includes9,11,17:
• Waiting area should be displayed with awareness about COVID-19 infection control regarding hand hygiene protocols, cough and sneezing etiquette, instructions for proper disposal of tissue papers, face masks and gloves on charts, panaflex or on digital screens.
• Waiting area should be well ventilated and designed with a seating arrangement that follow appropriate social distancing preferably through placing chairs/sofas/benches approximately 6 feet or 1 meter apart.
• Waiting area should be provided with appropriate number of trash cans with trash bags. Tissue papers and alcoholbased hand rubs should also be placed.
• Toys, reading materials, remote controls or other communal objects that can have patient contact should preferably be removed from the waiting area.
• Floors inside waiting area should be cleaned with soap and water or a disinfectant.
• Other touchable surfaces like tables, chairs, benches, door knobs, switch boards and switches should be routinely cleaned with an EPA approved disinfectant against SARSCOV-2.
  Reassurance of patient regarding infection control:
• Re-assure patients regarding maintenance of infection control procedures in accordance with latest guidelines, ensuring them that their safety is the priority of dental healthcare providers. This can be done through panaflex or screens displayed in waiting area or through letters, emails, mobile short message service (sms).

Patients should be reassured that authentic infection control guidelines will be followed as given by American Dental Association (ADA), Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), World Health Organization (WHO), Government of Pakistan official site for Covid-19 (covid.gov.pk).8-10,18,19

Dental team protection protocol and strategies:
Hand Hygiene:

• WHO has approved hand washing with water and soap as well as use of alcohol based hand rub for hand hygiene.20
• 70-90% Alcohol based hand rubs should only be employed if hands are not visibly soiled.20
• Dental staff should be instructed to perform hand hygiene upon entry into the workplace. WHO recommends employing hand hygiene before and after doing a dental procedure or aseptic/cleaning procedure and after touching inanimate objects.18
  Personal protective measures for Dental Staff:
• Dental team can be categorized according to OSHA’s ‘occupational exposure risk pyramid’ 3 that can help determining the risk levels of a dental team member and provision of personal protection measures accordingly. These include:
• Low Exposure Risk
• Medium Exposure Risk
• High Exposure Risk
• Very High Exposure Risk

Figure 3: OSHA’s ‘Occupational exposure risk pyramid’12

1. Low exposure risk:

• Health Care Personnel and other employees involved in administrative duties inside Dental hospital and not involved in clinical duties or contact with patients come under this
  category.19
• These workers have minimal contact with co-workers and general public.19
• Personal protective measures which can be employed for this exposure risk category involves primary protective measures including face mask, gloves, gowns, and goggles or face shields.19-21

2. Medium exposure risk:

• The Health Care Personnel categorized with this exposure risk provides urgent or emergency dental care to well patients involving non Aerosol generating procedures.19
• These workers have high frequency interaction with the general public.19
• Personal protective measures which can be employed for this exposure risk category involves secondary protective measures with advanced protective care including Respirators (N95 or higher), latex or nitrile gloves, disposable working cap, surgical gowns, isolation clothing and goggles or face shields.19-21

3. High exposure risk:

• The Health Care Personnel categorized with this exposure risk provides Emergency dental care with Non aerosolgenerating procedures, to a known or suspected COVID-19 patient or perform aerosol generating procedures on well patients.19
• These workers have high frequency interaction with the general public.19
• Personal protective measures which can be employed for this exposure risk category involves tertiary protective measures with intensified protective care including Respirators (N95 or higher), latex or nitrile gloves, disposable working cap, surgical gowns, isolation clothing and goggles or face shields, special protective outwear, impermeable shoe cover.19-21

4. Very High exposure risk:

• The Health Care Personnel categorized with Very high exposure risk provides Emergency dental care with aerosolgenerating procedures to a known or suspected COVID-19
  patients.19
• These workers have contact with known or suspected COVID-19 patients.19
• Personal protective measures which can be employed for this exposure risk category involves tertiary protective measures with intensified protective care including Respirators (N95 or higher), latex or nitrile gloves, disposable working cap, surgical gowns, isolation clothing and goggles or face shields, special protective outwear, impermeable shoe cover.1921
• Strict Engineering control measures including equipped isolation rooms need to be employed when working under such exposures.19
  Specifications for Face masks and Respirators:
  Regularly used surgical masks do not provide adequate protection against SARS-CoV2. However, respirators provide better protection and seal. They are available as full and half mask types.22 Following recommendations can be considered regarding face mask and respirators use during COVID-pandemic:
• A triple layered surgical mask should be worn by dental health care providers when within 1-2 meters of patient.9
• For aerosol generating procedures it is advised to use a particulate respirator with protection level equivalent to National Institute for Occupational Safety and Health
  (NIOSH)-certified N95 or European Standard Filtering Face Piece 2 (EU FFP2).11,14
• For performing emergency dental treatment in suspected COVID-19 cases recommendation is to use respiratory protection with higher protection level for example EU FFP3
  respirators conforming to European Standard 149 (EN149).11,14
• Mask fit tests are mandatory before the use of respirators especially. There are mainly two tests; quantitative and qualitative methods for testing a mask fit. Quantitative is
  done by an instrument and gives a numerical reading to check the masks effectiveness however qualitative relies on patients olfactory and taste sense. These methods are
  mentioned in OSHA regulations and in the Hospital Respiratory Protection Program Toolkit at https://www.cdc.gov/coronavirus/2019-ncov/hcp/dentalsettings.html
• The fit test provided by your dental college will only allow you to wear the appropriate model/size/brand mask. Every brand requires separate fit test for example if you qualify a fit test of certain brand it does not mean you are qualified for all.
• The company 3M has enlisted alternatives to N95 at (https://multimedia.3m.com/mws/media/957730O/respiratorsand-surgical-maskscontrast-technical-bulletin.pdf)
  Aerosol generating procedures:
• Aerosols are <50µm diameter particles that are considered to have low settling velocity and once generated can remain suspended in air for upto 6 hours and inanimate objects for upto 9 days.14,23,24
• Aerosols when combined with body fluids like saliva and blood present in oral cavity create ‘bioaerosols’ and thus render the dental team highly susceptible to infection.14,24
• Dental procedures involving the use of high speed handpiece, ultrasonic scaler and air water syringe are considered as high aerosol generation procedures and thus demand extra precautions to be employed.9
• Minimally invasive/ atraumatic techniques should be practiced to avoid aerosol contamination.25
• Avoid the use of aerosols generating equipment which include: high speed hand piece, triple syringe (air/ water syringe) and ultrasonic scalers. Where aerosols generating
  procedures are required use four handed dentistry, high volume suction devices and rubber dam to reduce the aerosols and droplets.25
• Intraoral x-ray examination can stimulate saliva secretion and coughing. Therefore, extra-oral dental radiographies should be consider as appropriate alternatives.9
  Engineering controls:
  It is recommended to ensure a ventilation system at the dental OPDS
• The OPDS should be well ventilated providing air movement from clean to contaminated (patient treatment zone) areas. All the windows should be open to allow sun light and cross-ventilation.25
• Heating,ventilation, air conditioning (HVAC) maintenance individuals should check the filtration efficiency of air conditioners, temperature regulating devices and ensure
  that their filtration capability would be at its maximum limit. Also they should provide safely increase percentage of outdoor fresh air to the operatory.25
• Restrict as much as possible the demand controlled ventilation and continuously use exhaust fans.25
• Use of High efficiency particulate arrestance (HEPA) should be used during aerosols generating procedures and after that. It should be placed close to dental unit but should
  not be obstructed by dental staff. This will reduce the droplets along with HVAC and room ventilation.25
• Upper room ultra-violet germicidal irradiations (UVGI) are also suggested in addition to HEPA and HVAC.25 Patient placement in open floor plan:
• The patients should be seated with 6 feet distance apart on the dental units.
• Easy to clean plastic or glass floor to ceiling physical barriers should be placed between dental units. These partitions can be fixed or movable.25
• It is Suggested to have barriers between dental units if not then the patients should be seated with 6feet distance leaving dental units and only those dental units should be
  used where there is enough space around with good ventilation.25
• Limit the number of patients in the OPDs depending upon the staff, facilities and time to disinfect and ventilate the room.25
• The waiting period should be at least 15 minutes for the dental staff after an aerosol generating procedure and departure of the patient to start disinfecting and cleaning
  protocols.26 Special negative pressure isolation areas in dental colleges/ institutes:
• It is suggested to construct negative pressure isolation dental areas to be used in cases of such pandemics. A negative pressure room maintains an increase pressure within
  the room than outside, the air enters the room through specific devices. The air released into the environment after being treated by various chemicals and UV light devices. The European network of infectious disease (EUNID) states a negative pressure room should have at least 6 times air changes per hour along with an anteroom.27
  Mouth rinse before dental procedures:
  A pre-procedural mouth rinse (PPMR) like 1% hydrogen peroxide or 0.2% povidone iodine would be most useful before starting any dental procedure.14,23,24 However, CDC
  states that the effectiveness of PPMR on COVID-19 has not studied and published specifically but antimicrobials may be responsible for decreasing the COVID-19 load in the environment.
  Patient examination protocols:
• OPDs should be restricted to emergent/urgent and emergency care only.
• Health screening of patients should be done on entry via thermal scanning and interviewing of questions related to COVID-19 susceptibility.
• Hand sanitizers should be provided to the patients after entry inside hospital.
• Dental personnel involved in general and oral examination of patients should be wearing proper PPE.
  Disinfection of the clinical settings:
• The clinic settings should be cleaned and disinfected in accordance with the standard protocol.8
• To disinfect, use products meeting EPA’s criteria for use against SARS-CoV2 which are appropriate for the surfaces.25
• Dental OPDs should be cleaned and disinfect according to OSHA guidelines as these procedures are adequate against SARS-CoV-2.10,26,27
• Dental operatories and high level isolation rooms where AGPs are performed on COVID or Non-COVID patients can also be cleaned and disinfected using OSHA guidelines.26,27
• Standard practices from CDC guidelines are recommended for disinfection and sterilization of dental devices utilized on providing dental care on COVID suspected patient.26,27
• Water and cleaning agents should be used to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant. (OSHA Workers and Employees).
• EPA-registered, hospital-grade disinfectant for appropriate contact times (as indicated on the product’s label) are appropriate for SARS-CoV-2 in settings, including those
  patient-care areas in which aerosol-generating procedures are performed.28
• Disinfectant List N available on the EPA website can be visited for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use
  against SARS-CoV-2.17
  Other disinfectineg methods:
• The effectiveness of ultrasonic waves, high intensity UV radiation, and LED blue light against COVID-19 virus is still unknown according to CDC.29
• The installation of sanitizing chambers is not recommended by CDC in reducing the COVID-19 spread. These chemicals can cause eye, skin and respiratory irritaion and thus cause damage to the body.29
  Management of clinical dental waste:
  Dental clinical waste should be managed according to CDC infection control guidelines along with special precautions for COVID-19 as following8,9:
• The waste (including disposable protective equipment after use) should be transported to the storage area of the institute timely.
• The reusable instruments and items should be pre-treated, cleaned, sterilized, and properly stored in accordance with the guidelines. Better to be done at central sterilization department.
• Clinical dental waste generated by the treatment of patients with suspected or confirmed COVID-19 infection and/or contaminated with body secretions and blood are regarded as ‘infectious medical waste’.
• Double-layer medical waste package bags and “gooseneck” ligation should be used.
• Package bags should be marked and their disposal should be performed according to the requirement for the management of waste.

Pregnant staff members:

1. Pregnant staff members should seek and follow medical guidance from their physician regarding work.
2. Information on COVID-19 in pregnancy is limited;
   offices may want to consider limiting exposure of pregnant
   staff to patients, especially during higher risk procedures
   (e.g., aerosol-generating procedures) if feasible, based on
   dental staff availability.32

Specific Guidelines for Dental Specialties:
Operative Dentistry (including Endodontics)

1. Use rubber-dam when use of a dental high speed handpiece is necessary. This will reduce generation of contaminated aerosols.33
2. Wiping the isolated tooth and rubber dam with iodine scrub may further reduce viral load.
3. Silver diamine fluoride may be used to arrest active dental caries.
4. Chemo-mechanical caries removal or atraumatic restorative technique may be used for management of dental caries.34
5. For treating symptomatic pulpitis:34
   a. After adequate anesthesia, excavators may be used to remove caries and expose pulp.
   b. Alternatively, chemo-mechanical caries removal may be used to remove caries.
   c. The exposed inflamed pulp is then irrigated with full concentration (5.25%) sodium hypochlorite copiously to devitalize it.
   d. A care is taken not to introduce any instrument into pulp.
   e. Once the bleeding stops a temporary restoration is placed.
6. If utilization of handpiece is necessary ‘Anti-retraction dental handpiece’ with specially designed anti-retractive valves or other anti-reflux designs are strongly recommended as an extra preventive measure for cross-infection.

Prosthodontics

1. Removable Prosthodontics
   a. Use well-fitting trays, avoiding sensitive areas of oral cavity to prevent gag or cough.
   b. Use of topical anaesthesia may reduce occurrence of cough reflex during impressions.
   c. Usual disinfection of impressions is highly recommended.
   d. While adjusting a prosthesis which requires repeated insertion/removal from oral cavity, immerse it in a disinfectant before adjusting with a rotary instrument. Do this each time it is removed from mouth.
   e. Same holds true for impressions or others materials requiring multiple insertion/ removal from oral cavity.
2. Fixed Prosthodontics
   a. Same precautions for impressions and prosthesis adjustments as above.
   b. Crown preps may be necessary for crack teeth or teeth with completed Endodontic therapy where delaying may predispose to crown fracture.16
   c. Loose crowns represent loss of function and an emergent condition. Therefore, it may require immediate care.
   d. Consider using a rubber-dam for crown preparations keeping margins supra gingival.
   e. A split dam technique may be used for crown/bridge preparation in certain cases.
   f. Disinfection of the field with Iodine scrub may further reduce the virus load.
   Periodontology:
   1. Ultrasonic scaling is not recommended since it is one of the highest Aerosol Generating Procedure.
   2. Manual scaling with hand instruments is recommended and may be supplemented with careful polishing. Reported efficacy of manual scaling in removing plaque and calculus is acceptable.35
   Oral and Maxillo-Facial Surgery:
   1. Use of resorbable sutures is recommended.
   2. Treat the patient in supine position so that there is an acceptable distance of operator from oral cavity.14
   Orthodontics:
   1. Removable appliances
   a. If no pain & discomfort, than patient does not need to be seen on regular appointment
   b. If mild discomfort = continue wearing along with topical or oral analgesia
   c. If severe discomfort = stop wearing the appliance and store it in proper container
   d. For aligners = switch to the next aligner as recommended by the orthodontist if the patient has the entire set of aligners
   e. Broken or lost aligner = wear the previous aligner to avoid major relapse
   f. Functional appliance = if broken or not fitting, send intraoral pictures to orthodontist and do as suggested by him
   g. Headgears / facemask = wear as per routine and send intraoral picture after a month duration to avoid over correction of malocclusion. Stop wearing the appliance if recommended by your clinician.
   2. Fixed Orthodontics
   a. Sharp wire ends (retainer or braces) = use orthodontic wax or try bending it with tweezers or a pencil with rubber back. If severe discomfort, cut the ends with a sterilized nail cutter after boiling in water at 100°C temperature
   b. Loose bracket = no issue if attached to the wire with ligature tie. If tie removed than remove the bracket with a sterilized tweezer. Use orthodontic wax if discomfort or irritating the lip or cheek
   c. Lost ligature tie or power chain = not an emergency or painful situation. Patient may be seen comfortably after pandemic ends. Cut frayed ends with sterilized scissor if
   need persists.
   d. Abscess around molar bands = contact clinician for medication (analgesic and / or antibiotic). Maintain oral hygiene and perform saline rinses
   i. Trans palatal arch / quad helix/ distal jet/ Nance = leave it in place untouched. If broken or sharp ends use orthodontic wax.

CONCLUSION

This pandemic has changed the way Dentistry is practiced. The future generations of dentists will be trained in literal space suits fearing the arrival of next pandemic. We must be ready for the next one since it may be worse than this time. For this preparation, we need to change a lot of work practices as mentioned but not limited to the guidelines presented above. It is the moral obligation of every practicing dentist to keep him/herself abreast with latest information as this is an actively developing situation.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed. 2020;91:157-60.
2. WHO. Coronavirus (COVID-19): World Health Organisation; 2020 [Available from: https://covid19.who.int/.
3. Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, et al. Clinical Characteristics of COVID-19 Patients With Digestive Symptoms in Hubei, China: A Descriptive, Cross-Sectional, Multicenter Study. Am J Gastroenterol. 2020;115:766-73. https://doi.org/10.14309/ajg.0000000000000620
4. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care. J Endod. 2020;46:584-95. https://doi.org/10.1016/j.joen.2020.03.008
5. PMDC. Evaluation Proformas for BDS, for 50 BDS Admissions 2019 [Available from: http://www.pmdc.org.pk/.
6. Mouth anatomy illustration sciencephoto.com [Available from: https://www.sciencephoto.com/media/1030892/view.
7. Coulthard P. Dentistry and coronavirus (COVID-19) – moral decisionmaking. Br Dent J. 2020;228:503-05. https://doi.org/10.1038/s41415-020-1482-1
8. CDC Guidance for Providing Dental Care During COVID-19 2020 [Available from: https://www.cdc.gov/oralhealth/ infectioncontrol/ statement-COVID.html.
9. ADA Return to work interim guidance toolkit. 2020 [Available from: https://success.ada.org/~/media/CPS/Files/Open%20 Files/ADA_Return_to_Work_Toolkit.pdf.
10. Occupational Safety and Health Administration (OSHA): COVID-19 – Control and Prevention /Dentistry Workers and Employers 2020 [Available from: https://www.osha.gov/SLTC/covid19/dentistry.html.
11. Gopikrishna V. Endodontic and Dental Practice during COVID19 Pandemic: Position Statement from International Federation of Endodontic Associations (IFEA) & Indian Endodontic Society (IES): Faculty of Dentistry, Sri Ramachandra University, Chennai, India.
12. ADA.org: What Constitutes a Dental Emergency? 2020 [Available from: https://success.ada.org/~/media/CPS/Files/ Open%20Files/ ADA_COVID19_Dental_Emergency_DDS.pdf.
13. ADA recommending dentists postpone elective procedures 2020 [Available from: https://www.ada.org/en/publications/ada-news/2020- archive/march/ada-recommending-dentists-postpone-electiveprocedures.
14. Ge Z-y, Yang L-m, Xia J-j, Fu X-h, Zhang Y-z. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci B. 2020:1-8. https://doi.org/10.1631/jzus.B2010010
15. WHO. Clinical management of severe acute respiratory infection when COVID-19 is suspected 2020 [Available from: https://apps.who.int/iris/rest/bitstreams/1272156/retrieve.
16. Sim IG, Lim TS, Krishnaswamy G, Chen NN. Decision Making for Retention of Endodontically Treated Posterior Cracked Teeth: A 5-year Follow-up Study. J Endod. 2016;42:225-29.https://doi.org/10.1016/j.joen.2015.11.011
17. Agency USEP. List N: Disinfectants for Use Against SARS-CoV2 (COVID-19) 2020 [updated 4th June 2020.
18. KNOW ABOUT COVID-19 2020 [Available from: http://covid.gov.pk/.
19. WHO. Novel Coronavirus-China. 2020 2020 [Available from: https://www.who.int/csr/don/12-january-2020-novel-coronaviruschina/en/.
20. CDC Hand Hygiene Guidelines 2020 [Available from: https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html.
21. OSHA. OSHA Fact Sheet. Protecting Workers during a Pandemic 2014 [Available from: https://www.osha.gov/Publications/OSHAFS3747.pdf.
22. Umer F, Haji Z, Zafar K. Role of respirators in controlling the spread of Novel Coronavirus (COVID-19) among dental health care providers: a review. Int Endod.2020;1-6 https://doi: 10.1111/iej.13313
23. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135:429-37. https://doi.org/10.14219/jada.archive.2004.0207
24. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):9-. https://doi.org/10.1038/s41368-020-0075-9
25. Prevention CfDCa. Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html.
26. Baron P. Generation and behavior of airborne particles (aerosols). PowerPoint Presentation. US Department of Health and Human Services, Centers …; 2010.
27. Smith PW, Anderson AO, Christopher GW, Cieslak TJ, Devreede GJ, Fosdick GA, et al. Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement. Biosecur Bioterror. 2006;4:351-65. https://doi.org/10.1089/bsp.2006.4.351
28. How does EPA know that the products on List N work on SARSCoV-2? 2020 [Available from: https://www.epa.gov/coronavirus/howdoes-epa-know-products-list-n-work sars-cov-2.
29. USA CfDC. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 2008 [updated May 2019. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfectionguidelines-H.pdf.
30. Prevention CfDCa. Guidelines for Infection Control in Dental Health-Care Settings – 2003 2003 [Available from: https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf.
31. Administration OSaH. A Guide to Compliance with OSHA Standards 2003 [Available from: https://www.osha.gov/Publications/OSHA3187/osha3187.html.
32. Interim U.S Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.
33. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc. 1989;119:141-44. https://doi.org/10.14219/jada.archive.1989.0131
34. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res. 2020;99:481-87. https://doi.org/10.1177/0022034520914246
35. Krishna R, De Stefano JA. Ultrasonic vs. hand instrumentation in periodontal therapy: clinical outcomes. Periodontol 2000. 2016;71:113-27. https://doi.org/10.1111/prd.12119

1. Demonstrator, Department of Operative Dentistry, Dow Dental College.
2. Assistant Professor, Department of Operative Dentistry, Dow Dental College.
3. Assistant Professor, Department of Orthodontics, Dow Dental College.
4. Associate Professor, Department of Prosthodontics, Dow Dental College.
5. Professor & Principal, Department of Operative Dentistry, Dow Dental College
6. Professor & Principal, Department of Oral and Maxillo-facial Surgery, Dr Ishrat ul Ibad Khan Institute of Oral Health Sciences
7. Professor & Principal, Department of Oral Biology, Dow International Dental College.
Corresponding author: “Prof. Dr. Arshad Hasan” < arshad.hasan@duhs.edu.pk >

Fariha Irfan                       BDS

Javeria Ali Khan              BDS, FCPS

Batool Ali                            BDS, FCPS

Kashif Aslam                     BDS, MSc

Arshad Hasan                   BDS, FCPS

Anwar Ali                           BDS FDSRCS

Amynah Charania         BDS M.Phil

Fazal Ghani                  PhD, FDSRCPSGlasg, MSc, CMP , BDS, BSc

Every postgraduate scholar is required do an individual research project. However, no one could be expected to complete research entirely alone without the
guidance of at least one supervisor.1
An academic and research supervisor is a subject expert in the discipline of the graduate scholar, though not necessarily in the actual research topic of the scholar. However, it is understood that every supervisor does know what it takes to complete an extended postgraduate research project. Also, is the case with most scholars,  none will usually have done the degree course before and also will not have got the kind of experience with which their supervisors have been accredited. Furthermore, without a strong positive supervisor-supervisee relationship, it is unlikely that a scholar could achieve a strong intellectual, emotional and successful career development. Therefore, during the entire period of graduate studies and even after the completion of studies, this mutual relationship can never afford to go wrong.2
A recent publication on the intricacies of supervisee-supervisor relationship can provide a fair and reasonable understanding on the topic.3 This publication, though addressed aspects of mutual relations and expectation in greater depth, it did not touch aspect of remote teaching and supervision of graduate scholars in the unprecedented and testing times like we are currently having due to the COVID-19 outbreak. This pandemic has imposed on us, an unusual working environment whereby both the supervisors and their students are isolating and working from homes. This has caused tremendous uncertainty, fear, desperation to all and interruption of studies and research activities. It has also forced both the supervisors and their students to resort to alternative educational and supervisory activities in order to minimize the adverse impact on the continuity of academics and research. Most supervisors and mentors have already resorted to using remote teaching and supervisory strategies during the current outbreak.4-7 This writing, elaborates upon some consideration and strategies related to remote teaching, supervision and assessment of graduate students. It describes how to create an environment ensuring effective supervision of student from home, information technology online resources to use for remote supervision, monitoring and assessment of graduate students.

ENVIRONMENT FOR REMOTE TEACHING AND SUPERVISION FROM HOME

Face to face (F2F) learning has been managed under the constraint of time, space, high cost, politics and bureaucratic hurdles. In comparison, with the universal availability modern communication tools these days, distant and remote learning and its supervision has become fairly easy. In fact it has helped in creating new educational styles that serve the educational system in an innovative manner.8
The current shutdown of institutions and laboratories has made the task of remote online teaching and supervision of research yet more demanding, with student and researchers confined to their homes to help suppress the spread of COVID-19. Although most supervisors despite having the necessary leadership and management skills, they will now be required to use these skills while mainly in a time not having F2F contact with their students and colleagues. This is because
the whole routine nicely planned and under implementation has suddenly gone unprecedented and lost in the air with no preparation time given. In this time, supervision and guidance must be reorganized, well-focused, relevant and limited to only what is required. For example, if the student is required to get the degree by course-work and thesis or by thesis only as is the case with most universities, then remote supervision must only focus to provide guidance and support for these
activities. However, if a student is to be awarded on the basis of publishing a certain number of research articles, or attendance and presenting in conferences, then help should focus on that. Multiple internet sources and webpages of universities and organization provide guidance and information on effective remote teaching and supervision during this unprecedented time which the supervisors and students may consider and find useful.9-16
The main thing to remember is that in such an unprecedented times, neither the supervisors nor the students can be expected to remain hyper-productive and hence, supervisors need to be realistic about what can be expected and achieved in a lock-down and isolated situation. Every supervisor is to learn staying flexible and leaning into uncertainty. It is also necessary to be hopeful that very soon, the issues faced will be overcome, getting back to normal life and yet remembering not to take things for granted again. Each of us as supervisor must be able to see the emotional toll that the outbreak has on everyone and hence to keep in mind that humanity exists by being all in it together.
Supervisors are also required to mentor and provide a support system for students and encourage them to prioritize their health above their productivity. They must reimagine how to do mentoring in a time of closed institutions, laboratories and where healthcare providers are depleted and stressed and are socially distancing.7
There is much need for unity, compassion, and empathy and a need for to be kind to each other. Everyone, especially the students are having a hardtime. In a situation like this, supervisors must feel privileged to be part of the solution, help and support. A different and changed approach, including a different type of “to do” list and not forgetting to just listening during this period is needed. As there will be many times the need `for live video chat between the supervisors and students as well as colleagues, none should expect to be in formal dress. Similarly, during such live video chats, it should be acceptable  to see each other surrounded by children and pets.7,17 As said, a different type of ‘to do’ list, during the period of social distancing may be suggested to students. While it may be great to involve students in learning and doing quite new things including: mastering a computer language, writing a manuscript from scratch or developing a new way to data analysis, but learning new skills should be a bonus, not an expectation. Rather supervisors should better engage their students in some non-lab activities and to focus on smaller and more easily manageable tasks that would help their overall productivity. These could include: doing a review of literature; writing in detail the outlines and a background section for a manuscript; reading the recommended articles; preparation of research summaries; practicing in live talks and presentations; preparing fellowship and grant applications; and analyses of collected data. The focus should be on keeping students engaged and productive and to reduce the causes of stress and vulnerability of mental health which many students are likely to be experiencing. Suggested approaches may include: acknowledgement of the full range of their emotions by knowing what they are feeling is quite natural and acceptable; reminding them the benefits of hosting virtual entertainment events like, virtual coffee and party hours, and considering discussion of non-scientific topics.
For some, the lockdown situation has made it somewhat impossible to manage being an academic supervisor and researcher as some have to also supervise their own children while working from home. However, a most recent survey of about 3,000 ResearchGate users, also showed that almost half of the researchers believe they had been spending as much, or even more, time collaborating with fellow academics as before the crisis. Furthermore, >40% have found more time to read and write academic articles or peer reviewing of others’ work, and the forging of new partnerships.5

MANAGING REMOTE TEACHING AND SUPERVISION

There is clear and meaningful difference between wellplanned online learning experiences and courses offered online in emergency in response to a crisis or disaster like COVID-19 Outbreak. A recent article provides an in-depth insight to know the differences between the two.18 All involved in this abrupt shift to online teaching and supervision must realize that these crises and disasters also create disruptions to student, staff, and faculty lives, outside their association with the university. So all of this work must be done with the understanding that the move to emergency teaching (ERT) will likely not be the priority of all those involved. Instructors and administrators are urged to consider that students might not be able to attend to courses immediately. As a result, asynchronous, or perhaps hybrid teaching activities might be more reasonable than the realtime live and synchronous ones. Flexibility with deadlines for assignments within courses, course policies, and
institutional policies should be considered. A high level example include; the US Department of Education relaxation on requirements and policies in the face of COVID-19.19 Challenges faced and experiences of emergency remote teaching (ERT) in Afghanistan Bosnia Herzegovina, Cambodia and Liberia have been described by Davies and Bentrovato (2011).20 Remote supervision, also called tele-supervision, or more recently e-supervision, is defined as the use of video conferencing technologies to supervise graduate students.
Todays’ teachers and supervisors, are required to be familiar with the seven domains of digital literacies (Dls). DLs are essentially a set of academic and professional situated practices supported by diverse and changing technologies.21 User is required to be familiar with the use of available online technologies. Furthermore, it is also important to be aware of using several strategies that assist learning, teaching, supervision, guidance and assessment and feedback. Strategies to use include: holding virtual real-time online videoconferences, journal club meeting, web-lectures; providing and / directing students to pre-recorded lectures and tutorials
to access on-demand; putting content onto a digital teaching environment (DTE) or platform for students to access; emailing learning materials or mailing them in print form.
In the vast majority of cases, digital technologies can be used to extend remote teaching, learning and supervisory support via the internet. However, it needs to be ensured that students are informed not to go ahead with the wider uses of the content they receive as this may cause harm to copyright owners. It is better to provide them web-links of the teaching material rather than sending copies of the materials in both soft or hard or print forms to students.22-23 When doing online teaching and supervision of students, the focus should be on the two most important aspects including: how to best support and engage students in an online teaching event or meeting, and what approach, tools, or delivery ideas to use. The material / content to be delivered to student must have: received proper planning in consideration of students’ needs; been designed to be studentcentric; been built on content and media: considered rich resources and activities for teaching and learning; involved active teaching and learning; and have also considered the processes of feedback, review and evaluation. In any group teaching or discussion, irrespective whether it is occurring as F2F or as remote online, a recommended approach to follow is a 5-step sequence.24 This sequence can be summarized as: starting with some recap; introducing things slowly with practice after each part; checking on how students are getting on and picking up on any misconceptions; giving models and scaffolds; reviewing how students are doing.
Aside from all the other strained resources available to the less privileged students, one needs to be also mindful of the common student support challenges including: space and comfort; bandwidth / connectivity; noise and disturbances; time (time zones) and schedules; and safety and pastoral duty.

GADGETS AND ONLINE TEACHING AND MEETINGS MANAGEMENT SOFT-WARE SYSTEMS

Remote supervision and collaboration and even the learning, in the first place requires not only a decent conducive environment but this environment should be supported by an efficient online learning and meeting management software and technology gadgets.25 These certainly include, the very basic infrastructure including a designated space, computer, digital camera, smart TV, XBox, smartphone, internet connectivity, lighting system. These days, both students and
the faculty in higher education sector are required to have digital skills and to be more creative and active learners.26
As we all know that online educational communication activities including virtual classroom and workshops, realtime meetings and video-conferencing has become a big industry operating globally. Many available systems provide very efficient management of online teaching and meeting and conferences and webinars. It will be difficult to elaborate in detail and to compare the so many of them available. Many of us whether academics or students in institutions, universities, or working in offices and organization will have been familiar with one or more of them.27-28 A list of the some of these (in alphabetical order) including their web-links is given in Table 1 for those interested in exploring and learning more regarding their navigation and use.These systems requires payment and subscription with some on
monthly basis. They also vary in their features necessary for managing learning and meeting and conferences and webinars. Therefore, a careful selection can only be made on the basis of how many management features of learning a particular soft-ware or system can offer and which ones are important for a particular learning and meeting event.
Some important learning management features, to keep in mind include: price and subscription; attendee arrangement; board meetings; committee meetings; internal meetings; invitation management; agenda management; action item tracking; legislative meetings; materials management; meeting preparation tools; meeting room booking; minutes management; post-meeting tools; scheduling; travel management; voting management including assessment of outcome and reflection on the learning and meeting. For some soft-wares, a comparative information is given in Table 2.

Table 1: Some popular online learning & meeting management software systems & platforms

Table 2: Comparison of Top Meeting Software (Modified from Reference Number 28).

It is therefore, important that one should not only get familiar with the use and navigation of the chosen learning and meeting software system but also get well-versed with the preparation of teaching, learning and supervisory material. While most of the already prepared and available material (articles, video tutorials) could be shared with students by sending these via email and WhatsApp and providing web-links and sources, virtual live real-time sessions will require one to be well-versed with the software and other requirements for arranging such sessions. Most institutions have already trained its faculty in this regard with many
advising its faculty to conduct such live real-time sessions (Journal club meetings, lectures, practical demonstrations) within the premises of the campus. The benefit of this include the availability of the proper facilities and the support of trained IT personnel. However, those preferring to do the online activities from their home will need to be adequately trained and well-versed in the arrangement, use of learning management software, preparation of appropriate material
(video lecture, tutorial and demonstration). Details of how to do these at home is beyond the scope of this article and will require self-study and / or attendance of necessary theoretical and hands-on training.29-32

REMOTE ONLINE EXAMINATION AND THESIS DEFENSE

Many supervisor are already familiar with the usual degree level course delivery format involving the four main parts: forum discussions; maintaining a personal portfolio; writing assignments; preparing for exams; taking exams. All these activities can he held and managed remotely and online.33 The role of the supervisor and tutor is to guide facilitate students about the content, topics, reading material, the scope and procedures to follow and modes of submission and examinations and their results. Almost all universities including our local, have established and run some online teaching and supervision. They normally provide detail of all aspects related to teaching, supervision and assessment of outcomes of academic and research activities. However, as stated earlier, these have been developed for the already online running courses for times when faculty would be present at their campuses and as well as students coming to campus for learning, when needed. This is not the case now in the COVID-19 pandemic. An important consideration in emergency remote teaching (ERT) as compared to conventional online one is that one has to use a different assessment / monitoring mechanism. This is to consider a simple pass or fail criteria with no marking and grading as is done in the conventional online teaching outcome assessment. This is preferred as comprehensive monitoring and assessment in this unprecedented time is not feasible. Most universities abroad including, USA, UK and Italy have already adopted this approach in their ERT programs / courses in the present COVID-19 emergency. Courses, their delivery and the intended outcome assessment including thesis defense nowhave to be taken as emergency remote teaching (ERT) by trained faculty and supervisors. As there is little opportunity for any face-to-face (F2F) interaction between students, their supervisors and examiners, therefore, all involved including
faculty, students and examiners will need refresher courses for ERT including how to conduct virtual real-time thesis defense sessions.While there are many examples all-over the world, in UK, Oxbridge summer assessments have been shifted to online. Similarly, the Imperial College London, has made history by having successfully examined online, its 280 final year medical students in the 2nd week of March 2020.34 There is a report of a remote virtual thesis defense activity held just before the start of the current pandemic.6 This report provides very useful information and learning, to all including supervisors and students, regarding the preparation, rules, expectations, technology and what problems to expect and how to deal with them and even how to celebrate success. This method of online and remote defense of thesis to use by student is being recommended by many higher education institutions.35 Some universities have prepared useful guidelines and training programs for faculty and students and hence encourage and facilitate them for the remote online defense of PhD thesis.for the remote online defense of PhD thesis.36-38

CONCLUSION S

1. The concept, environment, requirements and management approaches necessary for effective emergency remote online teaching and supervision and educational outcome assessment have been examined in depth.
2. It appears that it is possible to continue with the teaching, supervision and examination of graduate students using emergency online platforms.
3. The current covid-19 outbreak does highlight building on approaches to emergency remote teaching and supervision. Institutions are advised to consider incorporation of courses related to emergency remote teaching and supervision in their faculty development programs and also to include similar courses in the graduate programs they offer to students.
4. Having supported the concept of remote teaching,supervision and assessment, on one side it is reasonable to agree with one of the most famous quotes of Her Majestry, The Queen Elizabeth – II, “I have to be seen to be believed.” I am sure, it’s unlikely she meant to be seen via Zoom. On the other side, we should not forget an old aged and famous saying of Socrates, ‘The secret of change is to focus all of your energy, not on fighting the old, but on building the new’.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Working with your PhD supervisor. https://www.findaphd.com/advice/doing/you-and-your-phd-supervisor.aspx (Accessed 16 April, 2020).
2. Brabazone T. How to upset your supervisor. https://twitter.com/tarabrabazon/status/735910398415626240 . (Accessed April 16, 2020).
3. Ghani F. Editorial. Trainers-trainees relationship in postgraduate education – understanding its intricacy. J Pak Dent Assoc 2020;29:49-51
4. Monash University. Appendix K: Guidelines for remote supervision. Available at: https://www.monash.edu/graduate-research/faqs-andresources/content/chapter-twelve/k (Accessed April 17, 2020).
5. Baker S. ResearchGate chief enthused by lockdown research collaboration.https://www.timeshighereducation.com/news/researchgate-chief-enthused-lockdown-researchcollaboration?utm_source=THE+Website+Users&utm_campaign=d2f777d053-EMAIL_CAMPAIGN_2020_04_16_02_36& utm_medium=email&utm_term=0_daa7e51487-d2f777d053-62229001 (Accessed 17 April, 2020).
6. Frederick A. How to defend a PhD remotely. Career Column. Published online 30 March 2020.Available at: https://www.nature.com/articles/d41586-020-00971-z (Accessed 17 April, 2020). https://doi: 10.1038/d41586-020-00971-z
7. Gotian R. Mentoring during the COVID-19 pandemic. Nature. Career Column, Published online on 03 APRIL 2020. doi: 10.1038/d41586-020-01028-x. Available at: https://www.nature.com/ articles/d41586-020-01028-x (Accessed 16 April, 2020).
   https://doi.org/10.1038/d41586-020-01028-x
8. Elhashash M. Distance learning – Its concept, history, main principles, and techniques. Published online Feb 28, 2019. Available at https://blog.praxilabs.com/2019/02/28/distance-learning-its-concepthistory-main-principles-and-techniques/ (Accessed 17 April 22020).
9. Matthews D. Exchange students across Europe face hefty coronavirus toll. Published online on 17 April, 2020. Available at:
   https://www.timeshighereducation.com/news/exchange-studentsacross-europe-face-hefty-coronavirustoll?utm_source=THE+Website+ Users&utm_campaign=d2f777d053 EMAIL_CAMPAIGN_ 2020_04_16_02_36&utm_medium=email &utm_term=0_daa7e51487-d2f777d053-62229001 (Accessed 17 April, 2020).
10. Gewin V. Five tips for moving teaching online as COVID-19 takes hold. Nature 2020;580:295-296. https://doi.org/10.1038/d41586-020-00896-7
11. University of Rochester, Graduate Education and Postdoctoral Affairs. Preparing for PhD defense. Available at: https://www.rochester. edu/college/gradstudies/phd-defense/index.html (Accessed 17 April, 2020).
12. University of Maryland Graduate School. Advice for Remote Dissertation/Thesis Defenses.https://gradschool.umd.edu/ coronavirus/advice-remote-dissertationthesis-defenses (Accessed 18 April, 2020).
13. Duke University. Pratt School of Engineering. Remote doctoral defenses bring surprising benefits. March 26, 2020. Available at: https://pratt.duke.edu/about/news/remote-doctoral-defenses-bringsurprising-benefits (accessed 17 April, 2020).
14. Kekauoha A. Stanford student presents PhD defense virtually. 19 March, 2020. Available at: https://news.stanford.edu/ 2020/03/19/ stanford-student-presents-phd-defense-virtually/(Acessed 17 April, 2020).
15. Hunter J. Rice’s virtual defenders. Rice University. Graduate and Postgraduate Studies. Tips & Tricks: Virtual thesis defense and submission. Available at: https://graduate.rice.edu/news/tips-tricksvirtual-thesis-defense-and-submission (Accessed 17 April, 2020).
16. Rice University. Graduate and Postgraduate Studies. Defense with Video Conference. Updated March17, 2020. Available at: https://graduate.rice.edu/current-students/candidacy-defense/defensevideo-conference (Accessed !7 April 2020),
17. Dupont SG. How to work from home when your kids are home, too. Published 17 March, 2020. Productivity. Available at: https://www.atlassian.com/blog/productivity/working-from-home-withkids (17 April, 2020).
18. [Hodges C, Moore S, Locker B, Trust T, Bond A. The Difference between Emergency Remote Teaching (ERT) and Online Learning (OL). Published – March 27, 2020. Available at: https://er.educause.edu/articles/ 2020/3/the-difference-between-emergency-remote-teachingand-online-learning (Accessed online 19 April 2020).
19. Guidance for interruptions of study related to Coronavirus (COVID-19). Federal student aid, information for financial aid professionals (IFAP). March 20, 2020).
20. Davies L, Bentrovato D. Understanding education’s role in fragility. Synthesis of four situational analyses of education and fragility: Afghanistan, Bosnia and Herzegovina, Cambodia and Liberia.International Institute for Educational Planning (2011. https://unesdoc.unesco.org/ark:/48223/pf0000191504. (Accessed 19 April 2020).
21. Developing digital literacies. Available at: https://www.jisc.ac.uk/guides/developing-digital-literacies# (Accessed 18 April, 2020).
22. Remote & online learning during the COVID-19 outbreak – Published online 17 March 2020. https://www.smart copying.edu.au/information-sheets/schools/remote-online-learningduring-the-covid-19-outbreak (Accessed 18 April, 2020).
23. Lau J. To zoom or not to zoom? that is the question. Published online 17 April, 2020. Available at: https://www.timeshighereducation.com/news/zoom-or-not-zoom-question?utm_source= THE+Website+Users&utm_ campaign=d2f777d053-EMAIL_CAMPAIGN_2020_04_16_ 02_36&utm_medium=email&utm_term=0_daa7e51487-d2f777d053-62229001 (Accessed 17 April 2020).
24. Enser M. Coronavirus: A five-point model to deliver online learning. Published online on 26 March. Available at: https://www.tes.com/news/coronavirus-5-point-model-deliver-online-learning (Accessed on 18 April 2020).
25. Cochrane Community adapts to their new working situations – see the pictures. Available at: https://community.cochrane.org/news/cochrane-community-adapts-their-new-working-situations-see-pictures. (Accessed 19 April 2020).
26. Turning students from consumers to creators. Published online at: https://www.jisc.ac.uk/news/turning-students-from-consumers-tocreators-28-feb-2019 (Accessed 19 April 2020).
27. Top Video Conferencing Systems for eLearning professionals. Available at: https://elearningindustry.com/top-10-video-conferencingsystems-for-elearning-professionals (Accessed 19 April 2020).
28. Best meeting software in 2020. Available at: https://www.softwareworld.co/top-meeting-software/#GoToMeeting (Accessed 19 April 2020).
29. Education 2.0 & 3.0. all about learning and technology.Available at: https://www.scoop.it/topic/web-2-0-education (Accessed on 19 April 2020).
30. Burns M. EdTech Trend. Turning Students into Content Creators. Published online 26 May 2015. Available at: https://www.channelone.com/ blog_post/edtech-trend-turning-studentsinto-content-creators/ (Accessed 19 April 2020).
31. Frost R. Teaching English. A Task-based approach. British Council. Available at: https://www.teachingenglish.org.uk/article/a-task-basedapproach (Accessed 19 April 2020).
32. Banks R. Producing high quality media whilst working remotely – A guide from FutureLearn Studio. Available at: https://ugc.futurelearn.com/ uploads/files/2a/e3/2ae3cbce-7a73-458c9139-8722f9674def/ FutureLearn_How_to_Teach_ Online__Producing_high_quality_media_whilst_working_remotely.pdf
33. Dana Vioreanu. How do tests, exams and assignments work for online degrees? Published online on 20 Nov 2019. Available at: https://www.distancelearningportal.com/articles/243/how-do-testsexams-and-assignments-work-for-online-degrees.html (accessed 19 April 2020).
34. Study International Staff. These universities have proven that online exams can work. Published online March 24, 2020. Available at: https://www.studyinternational.com/news/online-exams-duringcovid19/ (Accessed 19 April 2020).
35. Flaherty C. Virtual Thesis Defense. https://www.insidehighered.com/news/2020/03/27/rise-remote-phd-defense (Accessed 17 April, 2020).
36. University of Rochester. Graduate Education and Postdoctoral Affairs. Preparing for PhD defense. Available at: https://www.rochester.edu/college/ gradstudies/phd-defense/index.html (Accessed 17 April, 2020).
37. University of Maryland Graduate School. Advice for Remote Dissertation/Thesis Defenses. https://gradschool.umd.edu/coronavirus/advice-remote-dissertationthesis-defenses (Accessed 18 April, 2020).
38. Duke University. Pratt School of Engineering. Remote doctoral defenses bring surprising benefits. March 26, 2020. Available at: https://pratt.duke.edu/about/news/remote-doctoral-defenses-bringsurprising-benefits (accessed 17 April, 2020).

Head of Department of Prosthodontics, Dean Postgraduate Dental Studies, Peshawar Dental College, Peshawar 25160 (Pakistan)
Corresponding author: “Prof. Dr. Fazal Ghani” < fazalg55@hotmail.com >

Fazal Ghani                  PhD, FDSRCPSGlasg, MSc, CMP , BDS, BSc

Hussain Maqbool Ahmed Khuwaja                             MSc

Ali Maqbool                                                                          BDS, MSc

Komal Abdul Rahim                                                         BScN

Sana Gul                                                                                BScN

Sanam Hanif                                                                        BScN

Shabnoor Karim                                                                BScN

INTRODUCTION

Health Sciences Education in Pakistan includes many disciplines ranging from medicine, nursing, pharmacy, physiotherapy, healthcare administration, public health to technicians and biomedical technology. The curriculum of all the higher education programs is over seen by Higher Education Commission (HEC). The Higher Education Commission of Pakistan is a self-sufficient, independent and constitutional establishment for directing, managing, authorizing, funding and monitoring the advanced education endeavors in Pakistan.1
Parallel to HEC, other independent regulatory bodies such as Pakistan Medical and Dental Council (PMDC) and Pakistan Nursing Council (PNC) look after undergraduate and post graduate medical and nursing education programs in Pakistan. However, the current healthcare education curriculums and its delivering methodologies have tragically relapsed and have standardized average quality that requires major revamping in content as well instruction.2,3 HEC, PMDC, PNC and every single administrative authority need to develop and acknowledge the way that instruction and preparing programs in health sciences in Pakistan need
massive change to meet the blossoming healthcare needs and the utilization of modern tools for instance, Artificial Intelligence, Stem Cells Research, Evidence based Medicine, Simulation etc.4
The current pedagogical approaches in most of the medical, nursing and dental colleges include instructor focused, customary subject based curricula, traditional clinical rotations and class room teaching being overseen by educators with minimal proper training in educating and learning. There is minimum availability of simulation based learning or implementation of virtual learning space in most of the schools.5
In the last decade, health sciences education advanced in few private universities which are now offering simulation based and problem based learning. Recently, the World Health Organization (2020), characterized COVID19 as a global pandemic. With the rapid increase in number of cases and no definitive treatment options available for COVID-19, social distancing is considered crucial in reducing the transmission of virus.6 Thus, many affected countries around the world have suspended educational institutions as a physical distancing mechanism in order to reduce transmission of COVID-19.7
This suspension of educational institutions has severe consequences on education and is affecting around millions of student population worldwide.8 Suspending educational institutions, even for the time being can cause hurdles in students learning, performance and skills. It also causes educational inequalities as everybody
do not have access to alternative resources like virtual learning management systems to fill the gap.8 Significantly many educational institutions around the world have switched to digital mode of learning for continuing education, however, in Pakistan because of low literacy rates and small budget being allocated to education sector and generating only 2.1 percent GDP, makes it extremely difficult for investments in resources to uplift from practicing traditional modes of education to digital modes of learning.9
Previous study conducted on exploring challenges of implementing e-learning in a Pakistani university shows that there is less access to digital modes of learning among students in Pakistan.10 Therefore, this research, aims to assess the digital learning practices in health sciences education institutes of Pakistan. Furthermore, we discuss different modes of digital learning strategies available for Higher Education Institutes across Pakistan.

METHODOLGY

This is a descriptive study to collect information from recognized degree awarding health sciences education institutes registered under PMDC and PNC. For the purpose of data collection, lists of recognized health sciences education institutes were used from official websites of PMDC and PNC. Data was collected from the institutes registered with these regulatory bodies until the latest lists were updated and officially available. Data was collected via phone calls on an investigator derived questionnaire (Figure 1) that comprised of questions related to online learning being offered during routine academic year as well as during COVID19 period. This questionnaire was developed on the basis of rapid assessment method as a tool to explore the current online learning practices, hence, it is not a validated questionnaire but a rational approach to conduct rapid needs assessment.

Figure 1: Study Questionnaire

We collected data from 1st April to 15th April, 2020, and entered it in Google Forms. Official websites and social media accounts were also screened for the academic institutes to broaden the data collection strategy where phone numbers were either not available or not being answered due to academic closure. In the absence of any formal list available for contact numbers of all Deans and HODs of all health sciences education institutions, contact numbers of faculty members teaching in various academic institutes were collected via snowball approach because majority of the teaching institutes were closed during COVID19 phase. Snowball approach or network approach was utilized to contact full-time faculty members of respective institutions (11). Descriptive data analysis was done to assess the status
of online learning in medical, dental and nursing education institutes. Ethical Review was obtained from Bhitai Dental and Medical College, Department of Research and Development [ERC No. BDMC/R&D/ERC/2020-05].

RESULTS

The number of medical and dental colleges recognized by PMDC are 114 and 55 respectively. However, 3 medical colleges and 3 dental colleges have been asked to stop admission by PMDC, resulting in 111 medical colleges and 52 dental colleges. There are 62 recognized degree awarding nursing schools mentioned in the latest list available on PNC website. Table 1 clearly shows the disparity in health sciences education institutes in Pakistan where majority of the recognized institutes are located in Punjab and Sindh.

Table 1: Distribution of Recognized Health Science Education Institutes across Pakistan

Table 2 shows the number of higher education institutes which are practicing online learning during routine academic year as compared to online learning being offered during COVID19 pandemic. Out of 111 medical colleges, merely 24 colleges (19.5%) offer online learning during academic year and 25 (22.5%) are offering during COVID19. Among 52 dental colleges, only 9 colleges (17.3%) offer online learning during routine academic year, whereas, 14 colleges (26.9%) are offering online learning during COVID19. Out of 62 recognized degree awarding nursing institutes, only 3 institutes (4.8%) offer online learning during routine academic year, whereas, 19 institutes (30.6%) are offering it during COVID19. It is evident that the percentage of higher education institutes that offer online learning during routine academic year is extremely low

Table 2: Online Learning (OL) in Recognized Health Science Education Institutes across Pakistan

DISCUSSION

Due to rapid the spread of COVID 19, academic halt foisted many health sciences universities to digitalize the learning environment; so students will get an opportunity to be fairly interactive with substantive online resources in the absence of traditional classroom setup. The accessibility, affordability and availability of accessories for distance learning have always been challenging for developing countries. Nonetheless, out of eight countries in South Asian Association for Regional Cooperation (SAARC) i.e. Bangladesh, India, Pakistan, Sri Lanka and Afghanistan somehow manage to create e-learning platforms for their students.12 Various studies have shown India is growing up in providing e-learning in medical education. Online Google groups are being used extensively by Medical Council of
India to train medical faculty, user friendly app on smartphones allow medical students to participate in videoconferencing.13 Currently, synchronous learning has
almost been ubiquitous all around the world; where educator, trainer, consultant and medical staff are connecting with student, trainee, consultee and patient respectively in their real time. A study described that video conferencing is considered a remarkable synchronous approach for medical and nursing students of Sub Saharan Africa.14 Blended learning approach via a Learning Management System (LMS) is also being implemented in few nursing, medical and dental universities in Pakistan15-17 for instance in DOW University of Health Sciences15,18 and the Aga Khan University.19 Synchronous and asynchronous video/audio, Virtual Learning Environment (VLE), videoconferences, online discussion forums, Virtual Classroom, Repository and Hypertext are some of the common digital modalities used in Pakistan’s medical universities.9
Although 1 in 4 health sciences education institutions in Pakistan are offering online learning according to our data, many universities are still deprived with accessibility of technical and spacious setup, availability of internet facilities/ electronic gadgets at home and adequate funds; which are creating barriers in implementation of e-learning.20 As the need for e-learning is increasing in health sector for continuous medical and nursing education, it is also important for non-health sciences institutions to engage themselves in digital learning. According to the HEC Universities ranking21, National University of Sciences and Technology (NUST) being the top most in engineering field is using blended learning in their curricula. National College of Arts (NCA) being top amongst the Arts universities is
also using online classes as a mode of delivering classes during COVID-19 outbreak. In addition to these, Institute of Business Administration (IBA), and SZABIST are also playing their part to promote blended learning in their academic years and during COVID-19 pandemic.
According to HEC’s recent guidelines, Higher Education Institutions (HEIs) in Pakistan can use different technology solutions especially during this pandemic outbreak, so that the education of students does not suffer. These guidelines have detailed instructions for HEIs to prepare faculty members for online readiness and faculty’s capacity in conducting online classes.22 Some of these software’s are Modular ObjectOriented Dynamic Learning Environment (MOODLE), Google Classrooms, Microsoft Teams, and Virtual University Learning Management System (LMS). There are also forums for video conferencing such as Zoom, Adobe Connect, WebEx, and BigBlueButton.23 Diversified approaches of digital learning during the corona pandemic crisis may significantly deliver tremendous
benefits to higher education system. On the contrary, biomedical community i.e. students, educators and institutions are left in uncharted water to cross over the barriers in initiating the distance education platforms.
Digital learning in health sciences has incredibly impressed technology user-friendly students. It has also given an opportunity to students to easily access in their flexible time, place and as frequently reuse the e-resources as well. Synchronous online forums are also beneficial to promote networking among peer to peer or student to faculty communication via instant messages, live videos, interactive white boards and sharing resources in real time.24 However, few students criticized synchronous mode as a missing opportunity to build teacher student relationship.25 A study suggested that Massive Open Online Courses (MOOC) like “Discover Dentistry”26 could motivate students to enthusiastically participate in the flipped classroom.27 On the contrary, unavailability of digital gadgets i.e. laptops,
smartphones, computers etc. affect the computer literacy among few medical and dental students of developing countries15,28 which demotivates the students towards digital environment. Hence, adequate equipment and vocational facilitation is needed before a successful implementation of digital learning is expected.
Globally, health sciences faculty members highly appreciate the e-learning environment in terms of time effectiveness in upgrading the resources and it allows them
to learn and reflect upon various concepts according to evidence based practices in medical education.27,29 Similarly, few educators shared their positive reviews regarding Virtual Classroom; it provides platform to students for easily accessing PowerPoint presentation, recoded lectures, and step by step instructions to attempt quizzes and get feedback on it .25 On the other hand, lack of technical skills i.e. inability to operate software to create online discussion forum, selection
of software to interact with students through videoconference, recording lectures and typing skills elevate resilience for faculty to adopt digital learning environment.28 HEC’s online learning guidelines for HEIs suggest that they need to be very clear in terms of effective utilization of material, human and financial resources within their constraints for the integration of e-resources in offering online classes.22,30 It gives economical advantage to the institution by giving coverage to large volume of users in long run. One study from Pakistan suggested that webinars or online lectures are the simplest and user friendly modalities
to initiate routine academic activities such as those sessions which do not require a practical training such as small classroom discussions or large classroom lectures.17 While, to ensure the faculty and student have adequate internet connectivity, accessories of digital gadgets at home, maintaining quality of e-learning are the most crucial and serious concerns for all the universities in Pakistan; if these concerns are not addressed, they may lead to cancellation of the semester by the universities.30 At the same time, professional training and strengthening the confidence in faculty, students and IT professionals at the institutional level must be a major challenge in implementation of e-learning.28
To the best of our knowledge, this is the first attempt to map the status of online learning in medical, dental and nursing schools of Pakistan. No previous study has conducted such assessment. We acknowledge the fact that there may be some data which we would have missed due to unavailability of information. However, there is clear evidence in itself that all academic institutions in this digital era must have their websites updated and official social media pages available for current as well as prospective students to approach them virtually.31

CONCLUSION

This study draws attention to a dire need of investment in capacity building of educators as well as development of necessary infrastructure in health sciences education institutions in Pakistan. Due to COVID19 Pandemic, many things will leave an everlasting impact on the lives of people.Thus, PMDC and PNC must realize the need for digital learning, especially online classes to support health sciences education as an effective strategy as per HEC’s evidence based guidelines. Furthermore, research on the efficacy of online teaching, readiness of educators, satisfaction of students and feasibility of scaling up digital learning in post-graduate health sciences education programs need to be conducted.

ACKNOWLEDGEMENT

None

FUNDING DISCLOSURE

None

DISCLOSURE STATEMENT

All authors declare that they have no conflicts of interest in regard to this work.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Khan TA, Jabeen N. Higher Education Reforms and Tenure Track in Pakistan: Perspectives of Leadership of Regulatory Agencies. Bull Educ Res. 2019;41:181-205.
2. Nasim M. Medical education needs to change in Pakistan. JPMAJ Pak Med Assoc. 2011;61:808.
3. Khan AW, Sethi A, Wajid G, Yasmeen R. Challenges towards quality assurance of Basic Medical Education in Pakistan. Pak J Med Sci.
   2020;36:4-9. https://doi.org/10.12669/pjms.36.2.1319
4. Memon AR, Rathore FA. Moodle and Online Learning in Pakistani Medical Universities: An opportunity worth exploring in higher education and research. J Pak Med Assoc. 2018;68:1076-78.
5. Latif MZ, Wajid G. Reforming Medical Education in Pakistan through strengthening Departments of Medical Education. Pak J Med
   Sci. 2018;34:1439. https://doi.org/10.12669/pjms.346.15942
6. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020;395(10228):931-34. https://doi.org/10.1016/S0140-6736(20)30567-5
7. Rose S. Medical Student Education in the Time of COVID-19. J Am Med Assoc.2020. https://doi.org/10.1001/jama.2020.5227
8. UNESCO. COVID-19 Educational Disruption and Response: United Nations Educational, Scientific and Cultural Organization; 2020 [Available from: https://en.unesco.org/covid19/educationresponse.
9. Adnan M, Yousaf Z, Gilani AH. E-Learning with Digital Media and Human Development: The Way Forward for Pakistan. J Educ Res. (1027-9776). 2019;22(2).
10. Qureshi IA, Ilyas K, Yasmin R, Whitty M. Challenges of implementing e-learning in a Pakistani university. Knowledge Management & E-Learning: An Int J. 2012;4:310-24. https://doi.org/10.34105/j.kmel.2012.04.025
11. Sadler GR, Lee HC, Lim RSH, Fullerton J. Recruitment of hardto-reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12:369-74. https://doi.org/10.1111/j.1442-2018.2010.00541.x
12. Hazra UK, Das R, Mu kherjee S. e-Learning Platform in SAARC Countries. Library Philosophy and Practice. 2019:1-9.
13. Dhir SK, Verma D, Batta M, Mishra D. E-learning in medicaleducation in India. Indian Pediatrics. 2017;54:871-77. https://doi.org/10.1007/s13312-017-1152-
14. Mars M. Building the capacity to build capacity in e-health in sub-Saharan Africa: the KwaZulu-Natal experience. Telemed e-Health.
    2012;18:32-7. https://doi.org/10.1089/tmj.2011.0146
15. Baig QA, Zaidi SJA, Alam BF. Perceptions of dental faculty and students of E-learning and its application in a public sector Dental College in Karachi, Pakistan. J Pak Med Assoc. 2019;69, No.9:1319- 324
16. Cassum S, Hussein S, Allana S, Dias JM. Experiences of adopting blended pedagogies in health assessment course in post RN baccalaureate program of nursing in Karachi, Pakistan. J Educ Training Studies. 2016;4:221. https://doi.org/10.11114/jets.v4i1.1168
17. Jawaid M, Aly SM. ‘E-learning’modalities in the current era of Medical Education in Pakistan. Pakistan J Medi Sci. 2014;30:1156.
    https://doi.org/10.12669/pjms.305.4351
18. Jawaid M, Ashraf J. Initial experience of eLearning research module in undergraduate medical curriculum of Dow University of Health Sciences: Development and students perceptions. Pakistan J Medi Sci. 2012;28.
19. Dias JM, Kurji Z. Evaluation of teaching and learning course in the nursing baccalaureate curriculum in one University Teaching Hospital in Karachi, Pakistan. Procedia-Soc Behavior Sci. 2011;15:2963-6. https://doi.org/10.1016/j.sbspro.2011.04.223
20. Ali S, Uppal MA, Gulliver SR. A conceptual framework highlighting e-learning implementation barriers. Information Technology & People. 2018. https://doi.org/10.1108/ITP-10-2016-0246
21. HEC. 5th Ranking of Pakistani Higher Education Institutions (HEIs). Higher Education Commission; 2016.
22. HEC. HEC COVID-19 GUIDANCE 2020 [Available from:https://www.hec.gov.pk/english/Pages/Covid-19-Guidance.aspx.
23. Khan AS, Ghani ST, Naeem, Qayyum Z, Rashid R. How can Universities prepare for the transition to virtual instruction? : Higher Education Commission; 2020.
24. King S, Greidanus E, Carbonaro M, Drummond J, Boechler P, Kahlke R. Synchronous Problem-Based e-Learning (ePBL) in Interprofessional Health Science Education. J Interactive Online Learn. 2010;9:133-50.
25. Masic I. E-learning as new method of medical education. Acta informatica medica. 2008;16:102. https://doi.org/10.5455/aim.2008.16.102-117
26. Stokes C, Towers A, Jinks P, Symington A. Discover Dentistry: encouraging wider participation in dentistry using a massive open online course (MOOC). Bri Dent J. 2015;219:81-5. https://doi.org/10.1038/sj.bdj.2015.559
27. O’Doherty D, Dromey M, Lougheed J, Hannigan A, Last J, McGrath D. Barriers and solutions to online learning in medical education-an integrative review. BMC Med Educ. 2018;18:130. https://doi.org/10.1186/s12909-018-1240-0
28. Ranasinghe P, Wickramasinghe SA, Pieris WR, Karunathilake I, Constantine GR. Computer literacy among first year medical students in a developing country: A cross sectional study. BMC Res Notes. 2012;5:504. https://doi.org/10.1186/1756-0500-5-504
29. Huynh R. The role of E-learning in medical education. Academic Medicine. 2017;92:430. https://doi.org/10.1097/ACM.0000000000001596
30. HEC. Government Directive of 26 March 2020. In: Commission HE, editor. 2020.
31. Bélanger CH, Bali S, Longden B. How Canadian universities use social media to brand themselves. Tertiary Educ Manage. 2014;20:14- 29. https://doi.org/10.1080/13583883.2013.852237

1. Senior Instructor, School of Nursing and Midwifery at Aga Khan University.
2. Assistant Professor and Vice Principal, Department of Oral Biology and Health Professional Education, , Bhittai Dental and Medical College.
3. Registered Nurse, Aga Khan University Hospital.
4. Registered Nurse, Aga Khan University Hospital.
5. Registered Nurse, Aga Khan University Hospital.
6. Registered Nurse, Aga Khan University Hospital.
Corresponding author: “Dr. Ali Maqbool” < khuwajas@gmail.com >

Hussain Maqbool Ahmed Khuwaja                             MSc

Ali Maqbool                                                                          BDS, MSc

Komal Abdul Rahim                                                         BScN

Sana Gul                                                                                BScN

Sanam Hanif                                                                        BScN

Shabnoor Karim                                                                BScN

Samir Riaz Qazi                               BDS, FFDRCSI, M.Phil

Nurain Rehman                               BDS

Sameer Nasir                                    BDS

INTRODUCTION

This report establishes infection control recommendations for essential dental care among different categories of dental practices in Pakistan, during the COVID-19 pandemic. These recommendations supplement the government of Pakistan guidelines1 for practicing dentistry during the pandemic, by providing details
on environmental infection control, patient management, and safety of patients and dental health personnel; and specifically aim to address the concerns of Pakistani dentists that have not been discussed in other documents published for practice of dentistry during the COVID-19 pandemic.1-8 Based on local determinants and cultural dimensions, methods have been introduced to implementinfection control measures, which are pragmatic and easyto adopt by Pakistani dentists.
Needs assessment was performed by a field survey of 25 dental practices in Lahore, and an online survey of 35 dental practitioners in Pakistan, published as part 1 of this study. The main needs identified were: infection control training of dental health care workers (DHCWs), financial aid and loans, patient awareness and compliance, management of walk-in patients, correct use of PPE and disinfectants, use of high volume suction and rubber dam, economical means of aerosol control and improvement in clinic ventilation and sterilization facilities, and access to genuine and reasonably priced infection control supplies.
The objective of this study was to develop interim workflow guidelines based on specific needs of dental settings in Pakistan to help navigate through the COVID-19 pandemic.

METHODOLOGY

Results of the needs assessment (part 1 of this study) were used to define and describe three clinic categories, based on infrastructure, facilities, and availability of resources. The Government of Pakistan guidelines1 for dental practice during the COVID-19 pandemic were reviewed and areas identified that required further details for adequate implementation, and for addressing the needs identified. Recommendations and protocols were developed for each of the previously defined clinic categories, after reviewing documents by international and local professional organizations from the fields of dental health care, public health, and hospital epidemiology and infection control1-12, and by reviewing well designed scientific studies and previous work by the authors.13
In the absence of scientific evidence for preventive measures against SARS-CoV-2 spread, certain recommendations are based on strong theoretical rationale,
suggestive evidence derived from scientific studies on the spread and control of respiratory viruses having properties similar to SARS-CoV-2, or opinions of respected authorities based on clinical experience.

RECOMMENDATIONS

These recommendations are not comprehensive, and supplement the Government of Pakistan guidelines for practice of dentistry during the COVID-19 pandemic.
The following categories of dental clinics in Pakistan were defined, and have been used for the recommendations below.
Category A: Clinics confined to one room or hall. The dental surgery/surgeries are not adequately partitioned from the waiting and reception area. Total staff number may be as low as 2, with one dentist and an assistant. Lavatory facilities may not be present or may be shared with other building inhabitants. Minimal infection control facilities are available.
Category B: Clinics with more than one room, where the surgery/surgeries and reception/waiting area have ceiling high partitions with interconnecting doors which may be closed. Lavatory facilities may be shared among patients and staff. Two assistants may be available for each surgery. Basic PPE and infection control supplies are available.
Category C: Clinics with good infrastructure and purpose built facility, able to meet international guidelines.

1 Clinic reorganization & infrastructure changes
1.1 Clinic Zones
1.2 Ventilation of the Dental Clinic & Surgery
1.3 Patient Management and Flow
1.3.1 Walk-in Patient Management
1.3.2 Scheduled Patient Management
1.3.3 Post Procedure Management

2 Personal Protective Equipment
2.1 PPE Guidelines
2.1.1 Entry to Clinic
2.1.2 Exit from Clinic
2.2 PPE for Patient Evaluation & Non-aerosol Procedures
2.3 PPE for Aerosol Generating Procedures
2.3.1 Minimum PPE requirements for Aerosol Generating Procedures
2.4 PPE Donning and Doffing
2.5 Seal Check for Respirators

3 Procedure Infection Control Protocol
3.1 Protocol for Aerosol Generating Procedures
3.1.1 Guidelines for Aerosol Procedures when Clinic Ventilation is Inadequate
3.2 Protocol for Non Aerosol Generating Procedures

4 Disinfection
4.1 Technique for Using Disinfectants
4.2 Selection of Disinfectant
4.3 Protocol for Disinfection after an Aerosol Procedure
4.4 Disinfection of Clinic Environment
4.5 Disinfection of Reusable PPE
4.6 Waste Disposal
4.7 Disinfection of Miscellaneous Items

1- Clinic Reorganization & Infrastructure Changes
1.1 Clinic Zones
Most clinics require improvement in ventilation, and need to reassign areas in the clinic to facilitate patient flow and procedures during the pandemic (Fig. 1). Infrastructure changes may be necessary to improve ventilation (section 1.2 Ventilation of the Dental Clinic and Surgery), and to add facilities for handwashing, laundry, and showering. For reassignment of clinic areas (Fig. 1), zones may be marked on the floor using a material compatible with frequent disinfection.

1. Triaging Zone
2. Seating Area
3. Donning & Doffing Zones
4. Surgery
5. Storage Area
6. Dining Area
7. Changing Area

Triaging Zone

This area is for screening of both walk-in and scheduled patients.

• For Category A clinics, this area may be outside the door of the clinic, in shade, ideally with a pedestal fan in the summers (Fig. 1).
• For Category B & C clinics, this area may be inside, close to the entrance of the clinic.
• Patient information leaflets and posters should be posted in this zone displaying in-office conduct guidelines. Leaflets and SOPs should be laminated for easy disinfection. The following should be included in the leaflets:
• Patients must not be escorted by any attendants,

with the exception of children, and those needing assistance.

• Patients should leave all extra bags/ belongings in their transport vehicle, if possible.
• Patients should be wearing face masks before entrance into the dental office.
• All patients (walk-in & scheduled) will be screened for COVID-19 symptoms.
• COVID-19 screening questionnaire, a thermometer and disinfection wipes should be present at the triaging station. A non-contact infrared thermometer is recommended.
• DHCW in this zone should wear a surgical mask and face shield/eye protection.8 This PPE is preferable to erecting plastic or plexiglass screens.
• Provide a hand sanitation station at the entrance, with a notice to use it before entry into the rest of the office.
• See section 1.3.1 Walk-in Patient Management, for further information.

Seating Area

• Category A clinics should instruct the patients to wait in their transport vehicles or in a waiting zone established outside the clinic (Fig. 1). These practices should not have any seating area inside the clinic.
• Category B & C clinics may follow the same policy but if necessary can place chairs at least 6 foot apart in this area.
• Carpets should be removed from this area; sofas should be replaced with chairs without armrests. Toys, reading material or other communal objects in
  the clinic should be removed.
• Hand sanitizer should be available. Surgery
• The surgery needs to be cleared of all cabinets, stools, furniture and other non-essential removable items.
• All materials, instrument packs, and movable equipment, paper records, electronics, and other items in the dental surgery should be stored/ placed outside
  the surgery. The surgery door should have a self-closing device attached to it.
• For category A clinics all items should be stored in airtight containers, drawers, cabinets or packs.
• All items and surfaces of the entire category A practices, including electronics, will need to be disinfected, and there should be nothing out in the open.
• Paperwork must be limited as much as possible.
• If using paper charting, cover it with a clear barrier so you may read what is needed for appointment and use disposable pens.
• Place chart notes away from the patient contactarea when possible.
• Computers & laptops should be removed from the surgery. If the use of these is absolutely necessary during procedures, barriers may be used. However,
  surfaces underneath the barriers commonly get contaminated while removing barriers and aerosols may penetrate barriers that are not airtight. Both
  situations require disinfection of barrier covered surfaces afterwards. Hence, it is best to remove all unnecessary items from the surgery.
• All air-entry or leakage points, other than the desired air entry points, need to be sealed. See section 1.2 Ventilation of the Clinic and Dental Surgery.
• One or two small openings may need to be created into the dental surgery, for air inflow, and to pass materials into the surgery during aerosol procedures.
• This may be a gap between the door and the floor (for air), or via a slit in the lower part of the door (for air and passing items), or through a wall, or through a window in the surgery. The size of the opening for air should be governed by the airflow (air changes an hour). See section 1.2 Ventilation of the Clinic and Dental Surgery.
• The opening for passage of items, if separate from the air entry point, should be closable with a tight seal.

• Category A clinics should install multiple through the wall exhaust fans in surgery. See section 1.2 Ventilation of the Clinic and Dental Surgery.
• Category B & C clinics should consider in-line exhausts with ducts collecting, and safely exhausting air outside, which are preferred over through-the-
  wall exhausts. See section 1.2 Ventilation of the Clinic and Dental Surgery.

Donning Zone & Doffing Zone
Donning zone: clean area for putting on PPE. Doffing zone: dirty area for removing PPE. Both zones require hand hygiene facilities. The doffing zone requires large yellow contaminated waste receptacles.

• For Category A clinics
• The donning zone may be established on the clean side of the clinic where fresh/ new PPE may be stored in sealed cabinets.
• The doffing zone may be established close to the dental unit.
• For Category B & C clinics
• The donning zone
• may be established in a clean area, outside the dental surgery, either in a dedicated room, or in a corridor on the “clean” side of the surgery door.
• Donning zone may include the clean storage area.
• The doffing zone
• may be established
  a. just inside the door of the surgery, or
  b. in the corridor outside, on the “dirty” side of the door,
  c. or in a separate room.
• The doffing zone should have adequate ventilation and may be located next to the waste disposal area, laundry collection and disinfection area, and showering facility.
• Both the zones may be in the same ante-room to the surgery, with a clean and a dirty side.

Storage Area

• For category A clinics all sterilised instrument packs, new PPE, and dental materials, and clean items should be stored in airtight cabinets/containers. Instrument packs may be left inside the autoclave to prevent contamination from aerosols.
• Category B & C clinics are likely to already have a separate area for sterilization and storage of clean and sterilized instruments.

Dining Area

• Consumption of food and drinks should take place in a well-ventilated room of the clinic, not in any of the above areas.
• Social distancing (6 foot distance) must be observed, as masks cannot be worn.
• Break times may be staggered to ensure that social distancing can be maintained in this area.
• Disposable cutlery and crockery may be used, and the waste collected in yellow contaminated waste receptacles.
• Each DHCW should disinfect the surfaces used and touched, before leaving the area.
• The use, and disinfection, of any communal items in this area e.g. tea or coffee making facility, should follow a set protocol based on sound judgement and recommendations for infection control. See section 4 Disinfection.
• Food may be consumed in individual vehicles, or outside the clinic.

Changing Area

• A changing area may be established where clinic staff can remove street clothing to change into clinic attire i.e. scrubs on entry into the clinic, and vice versa on exit from the clinic. Showering facility may be part of the changing area.

1.2 Ventilation of the Clinic and Dental Surgery
Adequate Ventilation: when the dental surgery is in a separate room, which is partitioned from the rest of the dental practice, and there is adequate airflow out of the surgery, so that with the door closed, no aerosol can escape from the dental surgery into the rest of the clinic. Category B & C clinics, after implementation of recommendations.
Inadequate Ventilation: when there is no complete partition between the dental surgery and the rest of the practice. Aerosol may diffuse to all parts of the dental practice. Category A clinics. Note: Aerosol procedures should be avoided.
After an aerosol procedure, the door of the dental surgery should remain closed until the aerosol has been eliminated, so that no aerosol escapes to the rest of the clinic. SARS CoV-2 aerosols persist for at least 3 hours if the room is not ventilated.14 During these 3 hours the virus will settle on surfaces and survive for 2-3 days.14

• Adequate ventilation of the dental practice can minimize the risk of infection, and reduce aerosol clearance times.12
• Once the aerosol has been eliminated from the room, patients and DHCWs may exit, and cleaning and disinfection may be performed using routine PPE.12

For establishing adequate ventilation, air entry and exit points into the dental practice need to be identified, and air flow established in the practice and the dental surgery according to existing infrastructure, needs, preferences, and resources (Fig. 2).

Ventilation for Category A Clinics:

• For general ventilation of the clinic, these practices should at minimum install exhaust fans (Fig. 2). Windows may be opened if present, and pedestal and wall bracket fans may be used to direct airflow towards the outside.
• Aerosol procedures should be avoided. See section 3.1.1 Guidelines for Aerosol Procedures when Ventilation is Inadequate.
• Practices should consider installing partitions sealing the surgery from the rest of the clinic. Plastic sheets may be used, though it may be best for practices to
  invest in solid partitions, with doors that have closable openings for air-entry, and item passage.

Ventilation for Category B & C Clinics
i. Ventilation of the Entire Clinic

• Use principles for dental surgery ventilation (below) to ensure adequate ventilation and air flow through the entire practice, especially the doffing zone and dining area.

ii. Options for Ventilation of the Dental Surgery
a. Through-the-wall exhausts

• The exhaust should be installed so that it is located opposite to the point of air-entry, which is usually through a gap between the door and the floor, or may be established elsewhere e.g. window.9
• The door should be kept closed during aerosol procedures, and no air should leak into the rest of the dental practice.
• Install a self-closing device on the door.9
• Depending on the air flow rate of the exhaust fan, more than one exhaust fan may be installed in the dental surgery, to ensure more air changes per hour.
• Test by closing the surgery door and:
• Release smoke near the air inlet. The smoke should all get sucked into the surgery.
• Or place a thin strip of tissue paper near the air inlet. The strip should get sucked into the surgery.15
• On the outside of the building, the exhaust fan should ideally be located 25 foot away from human traffic and from other air inlets to the building.16
  b. In-Line Exhausts with Ducts
• In-line exhausts with ducts are preferred to through-the-wall exhausts.
• The inlet of the duct may be installed 6 inches from the floor, near the foot end or the head end of the chair. Air entry should be from the opposite side of the room.16
• On the outside of the building, the exhaust duct outlet should be 25 feet from human traffic and air inlets16, and ideally on the roof pointing up. If requirements cannot be met, or if there are health care and environmental concerns, exhaust air may be filtered.
• Seal all other air entry points in the surgery to try and create better airflow and possible negative pressure. E.g. seal electrical sockets, air conditioner grills, leaks from around the windows and other doors.
• Use guidelines above for the door, and for testing.

c. Other Methods
Methods that follow may be considered by Category C clinics, but are NOT recommended for immediate implementation during the pandemic, due to lack of evidence or their use in the control of SARS-CoV-2 transmission. Some of these methods are expensive and impractical to implement, and may have value mostly as marketing tools.
I. HVAC systems with HEPA filters, and Negative Pressure Dental Surgery.

• Medical and dental engineers should be consulted. Requires major infrastructure changes.
• HVAC systems with HEPA filters may be used for disinfection and cooling of all air re circulating in the dental practice, and for all air-entry to the
  dental surgery.9 Note: HEPA filters are not designed for filtration of wet aerosols9, and their efficacy for SARS-CoV-2 aerosol filtration is not known.
• Follow guidelines above for exhausting air.
• The dental surgery may be converted to a negative pressure room, with >12 air changes an hour.9
• Ante-room (at half negative pressure) may be established:

a) For donning and doffing of PPE – with assigned clean and dirty areas.
b) For passage of instruments and equipment during the procedure.

• Aerosol clearance time at 12 air changes per hour is 35 minutes, and at 50 air changes per hour is 8 minutes.12
• Use of portable or plug-in air purifiers with HEPA filters may help improve clinic air quality, and may reduce aerosol clearance time after procedures. They may be used when clinic ventilation is not adequate. Note: these devices do not replace the need for adequate ventilation and airflow, and the use of PPE.
  II. Aerosol reduction devices
• The use of rubber dam and one or two large bore (at least 8mm dia.) high volume suctions should be the primary measures for aerosol reduction. There is
  no evidence yet to support the use of any other device for COVID-19 aerosol control.
• Aerosol collectors do not reduce the microbial contamination reaching the dentist. Despite their use, contamination is found on the head and attire of the
  operator and assistant, and the aerosol persists in the room for the usual time, based on ventilation and airflow.17
• UV Light: The use of a UVC light may help improve air quality and partially disinfect surfaces after a procedure, or at the end of the day. Use during the aerosol clearance time is not possible due to the presence of personnel in the room. Use afterwards will increase between-patient time, as disinfection will still need to be performed .18
• Fogging, commonly with hypochlorous acid, is used in some practices, after all other disinfection procedures, as an additional measure for improving air quality. There is no evidence to support the use of fogging (a room or a person) for control of COVID-19 transmission.
  1.3 Patient Management & Flow
  1.3.1 Walk-in Patient Management
• Screen all patients in the triage zone. For organizing the Triage Zone, see section 1.1 Clinic Zones.
• Ask questions about COVID-19 symptoms and contact with COVID-19 patients (questionnaire), and about the presenting complaint.
• Record temperature.
• Record contact information (for calling patient, follow up, and contact tracing).
• Verbally explain clinic policy for treatment during the pandemic
• If the case is non-urgent, the patient should not be seen immediately, and instead contacted by the dentist for a remote consultation using appropriate communication technology, see section 1.3.2 Scheduled Patient Management.
• If a patient is positive for symptoms of COVID-19, Government of Pakistan dental practice guidelines must be followed (do not treat).1
• Ask patients to call and report any illness or systemic symptoms they develop after their visit to the clinic.
• According to clinic policy, hand over:
• Patient information form, consent form, COVID-19 questionnaire, a disinfected or disposable pen, information leaflets on COVID-19 clinic protocols, and a surgical mask if the patient is not wearing one. See Triage Zone, section 1.1 Clinic Zones.
• Ask the patient to wait in their transport or in the waiting area, outside or inside the clinic. See Waiting Area, section 1.1 Clinic Zones.
• While waiting, the patient should be contacted by the dentist over phone for screening and pre- treatment counselling. See section 1.3.2 Scheduled Patient Management.
• Call the patient when ready.
• Open the door for the patient Receive forms, pen, leaflets (and payment, if applicable) in a tray/basket (to be considered as dirty/infected).
• Offer hand disinfectant.
  1.3.2 Scheduled Patient Management
• All patients who call the clinic for a consultation must initially be scheduled for a remote dentistry consultation.
• This remote dentistry session includes:
• Screening patients for COVID-19 by asking relevant questions.
• Patient evaluation using audio-visual means, and categorizing urgency of treatment.
• For non-emergency cases, advice may be given on the phone.
• If the patient requires urgent treatment:
• Schedule appointment.
• Brief the patient about information relevant to their treatment including cost, pre & post-procedure instructions and follow up (inform if they develop COVID-19 symptoms), clinic entry and exit protocol, and take verbal informed consent.
• Document all communication in the patient record.
• Appointments for patients must be spaced out such as to avoid patients waiting in the seating area, keeping in mind the time required for disinfection of the surgery.
• If clinic ventilation is not adequate, schedule one aerosol generating procedure at the end of the day. See section 3.1.1 Guidelines for Aerosol Procedures
  when Clinic Ventilation is Inadequate.
• Patients should be encouraged to make payment electronically when possible.
  1.3.3 Post Procedure Patient Management 
• All post-op instructions should be given to the patients prior to the start of the procedure, i.e. during their remote consultation or after triaging, to
  minimise contact with the dentist and dental staff post-procedure.
• After an aerosol generating procedure (AGP)
• Patients may exit the dental surgery after the minimum aerosol clearance time, when ventilation is adequate.12 In category A clinics, exit should be as soon as possible. See section 3.1.1 Aerosol Procedures when Ventilation is not Adequate; for aerosol clearance times, see 1.2 Ventilation of the Clinic and Dental Surgery.
• Patients should remove any PPE they are wearing during the procedure before exiting the surgery, or in the doffing zone. See Doffing Zone, section
  1.1 Clinic Zones.
• Patients should perform hand hygiene before exiting the clinic.
• Door should be held open for patients on exit.

2- Personal Protective Equipment

The most efficacius PPE items against COVID-19 are masks and eyewear, as these items protect the nose, mouth and eyes, which are the routes of entry for the virus. N95 or better respirators, and airtight eye protection, e.g. goggles, are recommended for all patient contact.
2.1 PPE Protocol
2.1.1 Entry to the Clinic

• Patients should be asked to
• Wear a surgical mask, or follow strict respiratory etiquette i.e. cough or sneeze into elbow or sleeve.
• Optionally, according to availability and clinic protocols, patients may be asked to wear gowns and shoe covers/shoes, head caps.
• For aerosol generating procedures (AGPs), patients should be asked to wear a gown and protective eyewear, which should be removed just before leaving the dental surgery, or in the doffing zone. See Doffing Zone, section 1.1 Clinic Zones.
• Staff members should
• Change into work clothes e.g. scrubs, or wear a gown on top of regular clothing.
• Change shoes to closed work shoes, made of material which may be sprayed with liquid disinfectant when necessary. If not changing shoes, disinfect street
  shoes including soles.
• Wash hands.
• Wear a surgical mask, which should be worn all day.
• When staff members are in close proximity to patients (e.g. triaging zone), eye protection should be used.
• Gloves do not need to be worn routinely in the clinic. Instead, frequent hand hygiene is critical, along with disinfection of shared items (computers, phones) and commonly touched surfaces. See section 4.4

2.1.2 Exit from the Clinic
Work clothes and shoes should be considered infected, and need to be disinfected before routine washing.

• Staff Members should change into street clothes.
• Work clothes should be
• placed in a designated bucket/receptacle for disinfection,
• or sealed in a plastic bag to take home for disinfection (this is not recommended, and every clinic should provide laundry service for work clothes)
• The outside of this bag should be disinfected, and hands washed.
• Another option is to go straight home and remove the contaminated clothes for disinfection, and take a shower, but the transport used may get contaminated and will need to be disinfected.
• Wearing work clothes when using public transport is not recommended.

2.2 PPE for Patient Evaluation and Non Aerosol Procedures
Generation of aerosols is not only limited to dental AGPs but may occur any time the patient coughs or gags.

• History Taking:
• The dentist and patient should wear surgical masks and, if possible, protective eyewear.
• The dentist should stand at the 7 or 8 o’clock position during history taking, ideally 6 feet away.
• Dental Examination and Non-Aerosol Procedures:
• Wear N95 respirator. If disinfecting and reusing respirators, a disinfected respirator may be used.8 See section 4.5 Disinfection of reusable PPE.
• When N95 respirators are not available, a surgical mask may be used in an emergency, with a face shield and eyewear.19
• Protective Eyewear is recommended for both the patient and dentist.
• Gowns and head caps or other outer attire may be used according to clinic policy.
• If outer attire/gown is not being changed between patients, attire should be considered infected, and all effort should be made to prevent the attire contacting the next patient, or other surfaces in the clinic.
• If the mask and eyewear are not being changed between patients, at minimum, wash hands after a procedure, adjust the mask and eyewear, wash hands again, and then wear new gloves for the next patient.

2.3 PPE for Aerosol Generating Procedures (AGPS)
AGPs include:

• Ultrasonic scaling and polishing
• Air Polishing and abrasion, prophy jets, rubber cups
• Any procedures involving use of air-water (triple) syringe
• Use of slow and high speed rotary instruments
• Tooth preparation (Crowns, Bridges, Fillings, and Veneers etc.)
• Root canal opening
• Sectioning of teeth for extraction using burs Dental implant placement
• Denture adjustments, when contaminated with saliva
• Sharp edge reduction
• Air abrasion
• Procedures involving lasers
  The principle for risk reduction remains the same: protect the mouth, nose and eyes, which are portals of entry for the virus. Everything else (skin, hair, attire, shoes) may be carefully disinfected after the procedure.

2.3.1 Minimum PPE Requirements for AGPS:
i. Mask: N95 or better respirator.

• Over masking with a surgical mask may be done to protect the N95 respirator from droplets.
• Check fit and perform user seal check. See section 2.5 Seal check for Respirators.

ii. Eyewear:

• Protective eyewear with side protectors, and face shield.
• If possible use eyewear with airtight seal (e.g. goggles), in which case face shield is not essential, but is still useful as it will protect the mask and face from droplets.

iii. Other PPE:

• Wear a gown and head cap, or coveralls, and/or other PPE according to clinic policy.
• Wear shoe covers, or disinfect shoes before exit from surgery.
• Gowns protect the inner attire from large droplets and some aerosol. After removal of outer PPE, inner attire, skin and hair should still be considered contaminated.

2.4 PPE Donning and Doffing
PPE Donning (wearing) Sequence20:
1. Perform hand hygiene.
2. If double gloving, put on gloves.
3. Put on shoe covers (if applicable).
4. Put on a gown.
5. Put on a mask/respirator.
6. Put on eye protection.
7. Put on a head cap (if applicable).
8. Perform hand hygiene.
9. Put on gloves.

PPE Doffing (removing) Sequence20:
1. If double gloving, remove outer gloves.
2. Remove shoe covers (if applicable).

• Or disinfect shoes including soles, on exiting the dental surgery.

3. Remove head cap (if applicable).
4. Remove gown and gloves together.

• Break the ties at the neck by pulling on the front portion of the gown with the hands still gloved, balling or rolling in the contaminated surfaces, and pulling the gloves off inside-out as the hands are withdrawn from the gown sleeve.
• The gown and gloves can then be placed in a disposal receptacle together.

5. Perform hand hygiene.
6. Remove eye wear.
7. Remove mask/respirator.
8. Perform hand hygiene.

2.5 Seal Check for Respirators
a. Positive Pressure Seal Check21
Conducted on respirators without exhalation valves.

• Once the respirator is properly donned,
  1. Place your hands over the face piece, covering as much surface area as possible.
  2. Exhale gently into the face piece.
• A slight positive pressure should build up inside the face piece without any evidence of outward leakage of air at the seal.
• Signs of leakage:
• Feeling of air movement on your face along the seal of the face piece.
• Fogging of your glasses.
• Lack of pressure being built up inside the face piece.

b. Negative pressure Seal Check21
Conducted on respirators with exhalation valves. May be used for respirators without exhalation valves.

• Once the respirator is properly donned

1. Cover the filter surface with your hands as much as possible and then inhale.
2. The face piece should collapse on your face and you should not feel air passing between your face and the face piece. In case of unsatisfactory positive or negative seal check21

• Use both hands to readjust the nosepiece by placing your fingertips at the top of the metal nose clip.
• Slide your fingertips down both sides of the metal strip to more efficiently mould the nose area to the shape of your nose.
• Readjust the straps along the sides of your head until a proper seal is achieved.

3- Procedure Infection Control
Note: protocols always need modification according to local circumstances, resources, and feasibility.

3.1 Infection Control Protocol for Aerosol Generating Procedures (AGPS)

• Absolute requirements for AGPs:
  i. Adequate ventilation of the dental surgery. See section 1.2 Ventilation of the Dental Clinic and Surgery.
  ii. N95 or better respirators and eye protection. See section 2 Personal Protective Equipment.
  iii. Rubber dam, if applicable.22
  iv. High volume suction. 23
• Before patient entry, aseptically set up the instrument tray, load LA syringe, dispense any materials needed during the procedure (e.g. on a glass slab, dappen
  dish). Apply barriers, according to clinic policy.
• If there is adequate ventilation (section 1.2 Ventilation of the Dental Clinic and Surgery), any other items that are needed during the procedure may be placed on a trolley outside the operatory door (or in the corridor, or in an ante-room) along with bins for disposal of waste and reusable attire (e.g. gowns).

Dentists and assistants should don PPE in the donning zone i.e. designated clean area of the clinic. See sections 1.1 Clinic Zones & 2.3 PPE for Aerosol Generating Procedures & 2.4 PPE Donning and Doffing.

• Patients should be given a gown and eye protection to wear .23
• Patients should be asked to perform
  preprocedural mouth rinse using a. 1% hydrogen peroxide for 60 seconds or b. 0.2% povidone-iodine for 30 seconds.24
• High volume suction should be held 6 to 15mm from an aerosol generating device25, using an appropriate suction tip with at least an 8mm wide opening.25
• After the procedure has started,
• Bottles and tubes of materials should not be opened inside the aerosol room.
• Any further materials and items needed should be handed or dispensed by a second assistant outside the room via the air entry point, or by briefly, partly opening the door.
• When aerosol generation ends, time should be noted.
• Patients may exit the surgery, after waiting for aerosol clearance time (section 1.2 Ventilation of the Dental Clinic and Surgery), removing PPE in the doffing
  zone. See Doffing Zone, section 1.1 Clinic Zones.
• DHCWs should dispose of contaminated waste and sharps before leaving the room, and remove shoe covers or disinfect shoes at exit.
• All PPE, except mask and eye protection, should be removed before leaving the surgery, or removed in a designated doffing (dirty) area of the clinic. See PPE Doffing Sequence, section 2.4 PPE Donning and Doffing.
• For disinfection of the dental surgery after an aerosol procedure, see section 4.3 Protocol for Disinfection after an Aerosol Procedure

3.1.1 Guidelines for Aerosol Procedures when Clinic Ventilation is Inadequate
If clinic ventilation is inadequate (section 1.2 Ventilation of the Dental Clinic and Surgery), aerosol procedures should not be performed.1 In case an aerosol procedure needs to be done in emergency:

• Procedure should be scheduled/performed at the end of the working day.
• Only the patient, dentist and assistant/s (all using appropriate PPE, see section 2.3 PPE for Aerosol Generating Procedures) should be present in the entire dental practice during the procedure. All other persons must vacate the clinic.
• Planning is necessary to dispense all materials and items needed for the procedure before the generation of aerosol.
• All material bottles and other loose items should then be stored in airtight containers, so they do not need disinfection later.
• Any leftover dispensed materials at the end of the procedure must be discarded.
• If any bottle/tube/container is opened during the procedure, the entire material/item should be considered contaminated.
• The patient and all staff should leave the clinic as soon as possible after an aerosol procedure, removing mask and eyewear immediately before exit.
• Clinic exhausts should be left turned on.
• DHCWs attire, shoes, hair and skin at exit should be considered contaminated. Disinfect hands and wear a clean mask if possible. Avoid touching the mouth, nose and eyes.
• The clinic should not be entered for at least 3 hours after the procedure.
• Upon entry (the next day) or after at least 3 hours, the entire dental practice environment must be disinfected thoroughly, because during the first few hours aerosol will settle on all clinic surfaces and the virus may survive on these surfaces for 3 days.

 3.2 Infection Control Guidelines for Non-Aerosol Generating Procedures

• Non-aerosol procedures, even routine examinations, may generate aerosols if the patient coughs or gags.26
• Protocols generally similar to aerosol generating procedures should be used.
• The patient is not required to wear any PPE during non-aerosol procedures.
• For PPE and attire recommendations, see section 2.2 PPE for Patient Evaluation & Non-aerosol Procedures.
• Disinfection of the dental surgery after the procedure may be limited to the dental unit, and other commonly touched surfaces.

4- Disinfection
For disinfection to be effective, the surface must be exposed to the disinfectant for the required time. This usually means that the surface needs to stay wet with the liquid disinfectant.
4.1 Technique for Using Disinfectants

• Wear gloves. If using sprays, wear a mask and eye protection.
• Clean visible contamination on the surface using a disposable wipe, damp with soap solution or disinfectant.
• Apply the disinfectant using a disposable cloth or wipe soaking in disinfectant.
• The surface may be sprayed and a gloved hand (or wipe wet with disinfectant) used to spread the disinfectant.
• Ensure that the entire surface stays wet with the disinfectant for the recommended time.
• For the floor, a mop soaked in disinfectant solution may be used to spread the disinfectant for the required time. Sprays are not as effective as a mop for floor disinfection.27

4.2 Selection of a Disinfectant

• From the disinfectants available, each practice may select 2 or 3 disinfectants for daily use, according to their needs.
• In addition to the disinfectants discussed underneath28, any intermediate level disinfectant, with tuberculocidal claim, may be used for surfaces, instruments, and equipment disinfection, following manufacturer instructions.
  a. Soap solution
• Soap or detergent solutions can destroy coronaviruses, but the surface requires rubbing with the solution,which is impractical for routine use.
• Use for:
• Hand washing.
• Cleaning surfaces before disinfection.
• Routine instrument cleaning after disinfection.
• Laundry of attire.
  b. Sodium Hypochlorite  
• Available commonly as 5.25% household bleach. 12-15% concentrations are available.
• Wear mask, gloves, and eye protection while preparing, and during use.
• Is corrosive to metals; do not immerse instruments for more than 10 minutes, and do not use routinely on metal surfaces.
• Use as:
• 0.1% solution to disinfect instruments and other items by immersion for up to 3 to 5 minutes.29 Rinse instruments prior to immersion in sodium hypochlorite
  solution and immediately after removal from the solution.
• 0.1% solution for disinfection of surfaces and floors. Surfaces should stay wet for1 minute.29
• 0.05% solution for disinfection of attire by immersion. Soak thoroughly and leave immersed overnight or at least 30 minutes.30
• 0.5% solution for waste disinfection.30
  c. Hydrogen Peroxide
• Available commonly in 1-6% concentration.
• After application on surfaces, it is non-toxic to skin, and is compatible with many impression materials and common surfaces of the dental surgery.
• Use as
• 1% solution for surface disinfection. Exposure time: 1 min.
• 1% solution for mouth rinse, for one minute.
• 3% solution for disinfection of items by immersion, for at least one minute.24
  d. Alcohol
• Generally used in combination with other disinfectants for surface disinfection. Available as wipes, sprays, gels, hand disinfectants, and as isopropyl alcohol. Non-toxic to skin, and compatible with most surfaces.
• 70% solution is effective for surface disinfection when applied for 1 minute.31
• It is useful for disinfection of hands and gloves, surfaces of the dental unit, and for items like curing lights, bottles, tubes, shoes.
• Alcohol fixes bio burden and dust onto surfaces and is not ideal for routine use as a surface disinfectant.
• In hot environments, alcohol may evaporate while being sprayed, and from the surface being disinfected, before the recommended contact time is over. Especially when concentrations higher than 70% are used.
• If using alcohol, clean surface thoroughly first, followed by liberal application and spreading.

4.3 Protocol for Disinfection after an Aerosol Procedure

• Start disinfection of the dental surgery after aerosol clearance time is over, which is 3 hours when ventilation is not adequate. See section 1.2 Ventilation of the Clinic and Dental Surgery.
• An intermediate level disinfectant nontoxic to human skin, non-corrosive to metals, and compatible with the dental unit upholstery, is needed for all commonly touched surfaces, and for the dental unit.
• For floors and other uncommonly touched surfaces, sodium hypochlorite or other intermediate level disinfectants, may be used, following manufacturer recommendations.
• Protocol:
• Wear a surgical mask, gloves and protective eyewear.
• Clean all commonly touched areas and all visible contamination using soap solution and disposable wipes. Paying attention to the spittoon and surrounding area. Paying attention to the spittoon and surrounding area.
• Remove all handpiece tubing and the triple syringe from their holders, hold everything over the spittoon and run water through all the tubes for 30 seconds.11
• Before replacing the tubes and syringe, disinfect the holders first, and then wipe one tube at a time with a disposable wipe wet with the disinfectant, followed by spraying all tubes, connectors, and syringe thoroughly with the disinfectant.
• Disinfection of the dental unit tray, arms, light, entire seat, assistant side suction holders and tubing, and the dental unit tubing may follow in a set routine, using disposable wipes wet with the disinfectant and/or spray.
• Surfaces must stay wet with the disinfectant for the recommended time.
• All other surfaces of the dental surgery, within reach, need similar disinfection. For e.g. counters, cabinets, doors, handles, stools, sharp boxes, waste baskets, trolleys, bottles, x-ray units, computers, screens and all other surfaces and items in the room, including walls and windows. It is preferable to remove all unnecessary items from the surgery to make this task easier.
• If surfaces or items not in routine use have been covered by an airtight barrier, the barrier may be cleaned and disinfected without having to change it between patients.
• Disinfect the floor at the end, starting from a corner away from the door and ending by cleaning the area inside and outside the door.
• Soles of DHCW shoes should be wet with the disinfectant, or use a disinfectant spray on the shoes.
• Remove PPE on exit from surgery and wash hands. Dental Unit water cleaning Ensuring quality of dental unit water reduces bioburden in aerosols. Dental unit waterlines promote bacterial growth and development of biofilm due to the presence of long narrow-bore tubing, inconsistent flow rates, and the potential for retraction of oral fluids from hand pieces into the unit tubing.32
• Ensure quality by intermittent or continuous treatment (disinfection), always according to the dental unit manufacturer’s recommendation. Examples:
  a. Continuous Treatment
• Use 0.02% hydrogen peroxide solution33, or 0.12% chlorhexidine32 as dental unit water.
  b. Intermittent Treatment
• Weekly 0.5% Sodium Hypochlorite Shock Treatment34:
  1. Detach the unit’s water bottle, add bleach solution to it and then re attach the bottle to the unit.
  2. Run the bleach solution into each line
  3. Run each scaler, handpiece, and air- water syringe line for 10 seconds or until you smell the bleach flow out the spout or you notice the “slippery” feel of the bleach.
  4. After 10 minutes, detach the water bottle, dump the remaining solution into the sink, and refill with warm water.
  5. Flush the lines for 1-3 minutes or until the remaining bleach odour disappears.
• After procedures, discharge water from the water- lines of handpieces, scalers and air-water syringes by operating the devices for 30 seconds.32 See
  section 4.3 Protocol for Disinfection after Aerosol Generating Procedures.
• For sterile procedures (e.g. oral surgery), sterile irrigants (e.g. saline) should be used. Delivery systems should have sterile water lines/tubes, either disposable or autoclavable.32

4.4 Disinfection of Clinic Environment

• Identify all commonly touched surfaces in the clinic, and list in a logical sequence for disinfection. Surfaces include door handles, areas touched on door frames, furniture, counters, light switches, water dispenser, sinks, fixtures, soap dispensers, thermometer.
• Prepare a trolley with supplies, or have available:
• One or two disinfectants in spray bottles. See section 4.2 Selection of Disinfectant.
• Disposable wipes
• Gloves
• Waste basket
• Floor wiper
• Train all DHCWs in the clinic on disinfection protocols, and assign one DHCW to disinfect all listed surfaces multiple times a day (at least twice daily), using a disinfectant non-toxic to human skin.
• Relevant surfaces must be disinfected after entry and exit of every patient and staff member.
• If present, the toilet must be disinfected after every use. DHCWs may be trained to disinfect the toilet themselves after use.
• Wear a mask, gloves and eye protection during disinfection.
• All visible contamination should be washed or cleaned, and all surfaces of the toilet, including floor, liberally sprayed with a disinfectant.
• If using sodium hypochlorite, or other disinfectant toxic to skin, after the required disinfection time, wash and/or wipe-clean the toilet seat, tap fixtures and other commonly touched surfaces using disposable wipes.
• The floor should be rinsed and wiped at the end. At the end of the day, all dental practice floors need disinfection, along with all furniture and surfaces identified previously.
• In poorly ventilated clinics, the day should start with complete dental practice disinfection. See section 3.1.1 Guidelines for Aerosol Procedures when Clinic Ventilation is Inadequate.

4.5 Disinfection of Reusable PPE
i. Masks and Respirators
All surgical masks and single use respirators (e.g. N95) should ideally be used once and disposed of. There is no clear recommendation on the reuse of surgical masks. The use of liquid disinfectants reduces filtering efficiency of these masks, as does autoclaving, and these methods should not be used. Disinfection with time (stored in a paper bag for one week) may be attempted in case of non-availability. All surgical masks that get wet during use should be discarded.8
In the situation of shortage of N95 masks during the pandemic, and need to provide urgent care, CDC recommends different 7 methods of disinfection of respirators.8
Two are discussed below.
Precautions when Using “Disinfected” respirators8

• The outside of the mask should be considered contaminated. Wear gloves when putting on, and/or perform hand hygiene after touching or adjusting the mask.
• Avoid touching the inside of the mask.
• Visually inspect the respirator to determine if its integrity has been compromised.
• Check that respirator components such as the straps, nose bridge, and nose foam material did not degrade, which can affect the quality of the fit, and seal.
• Perform a user seal check after putting on. See section 2.5 Seal Check for Respirators.
• If the integrity of any part of the respirator is compromised, or if a successful user seal check cannot be performed, discard the mask and try another.

For aerosol procedures, it is recommended that a new N95, or better respirator, be used. Disinfected N95 respirators
should be reserved for non-aerosol procedures.8

Methods of N95 and Respirator Disinfection

Do not use autoclave, dry heat, alcohol, soap, bleach and dry microwave radiation.19 .

• For reusable respirators (e.g. P100), manufacturer instructions should be followed for disinfection.
• Disinfection Methods for Single Use Respirators include:
  a. Time
• Corona virus lasts on masks for 5-7 days.35
• Procedure:
  1. Label a paper bag with user name and date.
  2. After use, place the respirator in the paper bag, held open by an assistant.
  3. Wash hands.
  4. Store in a well-ventilated area for at least one week.
  5. Reuse after one week.
• Should be re-used only by the labelled user, following precautions above.
• Do not re-use more than 5 times.
  b. Hydrogen Peroxide (H202)
  Some respirators may be suitable for disinfection by immersion in liquid (3-6%) hydrogen peroxide for at least one minute.
  CDC has listed the respirators that may be disinfected safely with hydrogen peroxide.8

ii. Washable Gowns and Attire
Washable gowns and attire may be reused after disinfection and laundry. Disinfect by immersion in 0.05% sodium hypochlorite solution for at least 30 minutes, followed by rinsing and routine laundry.30
iii. Reuse of Eyewear and Face Shields

• If not changing eye protection between patients, consider the eyewear and face shield infected, and whenever touched, perform hand hygiene, or change gloves.
• After use, eyewear should be washed with soap and water. If not using a disinfectant, wash thoroughly with soap and water, rubbing or brushing all surfaces for 1-2 minutes to create foam/bubbles.
• If using a disinfectant; wash, rinse, dry with a disposable tissue, and apply the disinfectant using spray, wipes, or immersion. The disinfectant may be rinsed off after the required time, especially if using sodium hypochlorite or another disinfectant toxic to skin. After cleaning and disinfection, anti- mist sprays or other coatings may be used.
  iv. Loupes
  Standard loupes may be difficult to wear with current PPE recommendation, and if used, manufacturer guidelines should be followed for disinfection between patients.
  v. Head cap/protection
  Reusable plastic head-caps may be washed and disinfected like the eyewear. However, single use disposable head coverings are preferred.
  4.6 Waste Disposal
• Waste collection in the dental clinic should be in:
• Plastic bag lined containers:
• Waste receptacle for non-contaminated waste.
• Yellow baskets for contaminated waste.
• Sharp containers: sealable puncture-resistant containers (thick plastic) with a biohazard label, located at the point of use, for collection of needles, scalpel blades, syringes etc.
• Collected contaminated waste should be sealed in leak-resistant biohazard bags and sent for incineration; along with all 2/3rd full sharp containers.11
• All clinic waste being disposed of as garbage should be disinfected first.
  1. Wear gloves, mask and protective eyewear.
  2. Do not overfill the garbage disposal bag.
  3. Liberally spray the garbage, inside the disposal bag, with an appropriate disinfectant, e.g. 0.5% sodium hypochlorite .36
  4. Seal the bag; spray the outside with the disinfectant to wet all surfaces.
  5. Remove gloves (and other PPE according to clinic policy).
  6. Wash hands.
  7. Ideally wait 24 hours before disposal.
  4.7 Disinfection of Miscellaneous Items
  The following methods of disinfection may be considered. (See section 4.1 Technique for using Disinfectant and section 4.2 Selection of a Disinfectant)
  i. Paper:
  Time: leave for 3 days in a well-ventilated place; dry heat: maintain at 100 C for 15 minutes in an oven; moist heat – autoclave, ink may run; spray or immerse in liquid disinfectant – may destroy the paper, ink may run; UV/sunlight: expose paper to direct sunlight for 2-3 hours each side.14
  ii. Money:
  Time: store for 9 days in a clean place. Dry and moist heat may be used as for paper. Money generally tolerates these methods well. Disinfectants may be tried e.g. 70% alcohol spray/immersion, and immersion in dilute (up to 0.05%) sodium hypochlorite solutions.14
  iii. Pens:
  Time: leave for 9 days. Disinfectants: Plastic pens may be washed with soap, and a disinfectant applied e.g. alcohol, hydrogen peroxide (not sodium hypochlorite).
  iv. Cardboard boxes:
  Time: Store in a clean well-ventilated area for 2-3 days before opening. Spraying with a disinfectant may be attempted in case urgent opening is required. Discard the box after opening and perform hand hygiene.14
  v. Mobile phones:
  Use a hand disinfectant or a disposable wipe soaked in disinfectant.14
  vi. Keys:
  Carry only essential keys. Disinfect using a hand disinfectant, or a disinfectant wipe/spray. May be periodically washed with soap and water.

CONCLUSION

Based on the needs of Pakistani dentists during the COVID-19 pandemic, guidelines established in this article include recommendations for clinic reorganization, improved ventilation, management of walk-in patients, correct use of PPE, environmental infection control, and protocols for aerosol procedures and disinfection. These recommendations supplement the Government of Pakistan guidelines for dental practice during the pandemic. Implementation of these guidelines requires effort at the national level for DHCW training, monitoring of practices, and ensuring availability of infection control supplies, as discussed in part 1 of this study.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the help of Dr. Saqib Riaz Qazi and Dr. Maryam Ejaz in reviewing the article.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Ministry of Health Services, Government of Pakistan. Guidelines for providing dental care services during COVID-19. 2020 May 3.
2. American Dental Association. Return to work interim guidance toolkit. 2020 Mar 24 [cited 2020 May 20]. Available from: https://www.ada.org/en/publications/ada-news/2020-archive/april/adatask-force-assembles-interim-guidance-toolkit-for-dentists-returningto-work
3. National Health Service. COVID-19 guidance and standard operating procedure. 2020 Apr 15 [cited 2020 May 20]. Available from: https://www.england.nhs.uk/coronavirus/wp-content/ uploads/sites/52/2020/04/C0282-covid-19-urgent-dental-care-sop.pdf
4. Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. The Saudi Dent J. 2020 Apr 7. https://doi.org/10.1016/j.sdentj.2020.04.001
5. California Department of Public Health. COVID-19 guidance for dentistry. 2020 Apr 7 [cited 2020 May 20]. Available from: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/ GuidanceforDentistry.aspx
6. Missouri COVID-19 Dental Task Force. Guidance for your practice. 2020 Apr 29 [cited 2020 May 20]. Available from: https://sitefinity.ada.org/docs/librariesprovider30/publications/covid/ task-force-guidelines-for-mo-dental-practices_042920.pdf?sfvrsn=2
7. Indian Dental Association. Indian Dental Association’s preventive guidelines for dental professionals on the coronavirus threat. 2020 [cited 2020 May 20]. Available from: https://www.ida.org.in/ pdf/IDA_Recommendations_for_Dental_Professionals_on_the_Cor onavirus_Threat.pdf
8. Center for Disease Control and Prevention. Interim infection prevention and control guidance for dental settings during the COVID19 response. 2020 May 3 [cited 2020 May 20]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
9. Lynne Sehulster, Raymond Y.W. Chinn. Guidelines for environmental infection control in health-care facilities, recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003 / 52(RR10);1-42
10. World Health Organization. COVID-19: Operational guidance for maintaining essential health services during an outbreak. 2020 March 25 [cited 2020 May 20]. Available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/technicalguidance/infection-prevention-and-control
11. William G. Kohn, Amy S. Collins, Jennifer L, Jennifer A. Harte, Kathy J, Dolores M. Malvitz. Guidelines for infection control in dental health-care settings. Morbidity and Mortality Weekly Report Recommendations and Reports Vol 52. 2003; No. RR-17
12. Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-Care facilities. 2003 [cited 2020 May 20]. Available from: https://www.cdc.gov/infectioncontrol/ guidelines/environmental/appendix/air.html
13. Qazi SR, Qureshi A, Nasir S, Khan A. Cross infection control in dental practice – guiding manual for dental health care workers, World Health Organization (WHO)/ Ministry of Health, Government of
    Pakistan, Publication, Islamabad. 2005.
14. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England Journal of Medicine. 2020;382:1564-67. https://doi.org/10.1056/NEJMc2004973
15. Gore B, Smith K. Tuberculosis infection control: a practical manual for preventing TB, 2011. San Francisco (CA). 2011.
16. Anderson J, Geeslin A, Streifel A. Minnesota Department of Health Office of Emergency Preparedness. Airborne infectious disease management: methods for temporary negative pressure isolation. St. Paul, MN.
17. Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NK et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature. 2020 Apr 27:1-6 https://doi.org/10.1038/s41586-020-2271-3
18. Andersen BM, Bånrud H, Bøe E, Bjordal O, Drangsholt F. Comparison of UV C light and chemicals for disinfection of surfaces in hospital isolation units. Infection Control & Hospital Epidemiology. 2006;27:729-34.
    https://doi.org/10.1086/503643
19. American Dental Hygienists’ Association. ADHA interim guidance on returning to work. 2020 May 28 [cited 2020 May 28]. Available from: https://www.adha.org/resources-docs/ADHA_Task ForceReport.pdf
20. World Health Organisation. How to put on and take off personal protective equipment (PPE). 2020 April 22 [cited 2020 May 20]. Available from: https://www.who.int/csr/resources/publications/ putontakeoffPPE/en/
21. U.S. Department of Health and Human Services, Center for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH). How to properly put on and take off a disposable respirator. 2010-133
22. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dental Association. 1989;119:141-44. https://doi.org/10.14219/jada.archive.1989.0131
23. Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures. J Am Dental Association (1939). 1994;125:579-84. https://doi.org/10.14219/jada.archive.1994.0093
24. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. International Journal of Oral Science. 2020;12:1-6. https://doi.org/10.1038/s41368-020-0075-9
25. Avasth A. High volume evacuator HVE in reducing aerosol an exploration worth by clinicians. Journal of Dental Health, Oral Disorders & Therapy. 2018;9(9). https://doi.org/10.15406/jdhodt.2018.09.00371
26. Atkins J, Chartier Y, Pessoa-Silva CL, Jensen P, Li Y, Seto WH. Natural ventilation for infection control in health-care settings. Geneva: World Health Organization; 2009. Available from: https://www.who.int/water_sanitation_health/publications/natural_v entilation/en/
27. Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Environmental cleaning for the prevention of healthcare-associated infections.
28. United States Environmental Protection Agency. List N: products with emerging viral pathogens and human Coronavirus claims for use against SARS-CoV-2. 2020 [cited 2020 May 20] Available from: https://www.epa.gov/pesticide-registration/list-n-disinfectants-useagainst-sars-cov-2
29. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. J Hospital Infection. 2020 Feb 6. https://doi.org/10.1016/j.jhin.2020.01.022
30. Ipswich Massachusetts Government. Guidelines on the use of disinfectants. 2011 Oct 31 [cited 2020 May 20]. Available from: https://www.ipswichma.gov/DocumentCenter/View/10072/50ppmGuidelines-on-the-Use-of-Disinfectants
31. Ribeiro MM, Neumann VA, Padoveze MC, Graziano KU. Efficacy and effectiveness of alcohol in the disinfection of semi-critical materials: a systematic review. Revista latino-americana de enfermagem. 2015;23:741-52. https://doi.org/10.1590/0104-1169.0266.2611
32. Singh V, Nagaraja C, Hungund SA. A study of different modes of disinfection and their effect on bacterial load in dental unit waterlines. European J General Dentistry. 2013;2:246-51. https://doi.org/10.4103/2278-9626.115999
33. Dallolio L, Scuderi A, Rini MS, Valente S, Farruggia P, Sabattini M et al. Effect of different disinfection protocols on microbial and biofilm contamination of dental unit waterlines in community dental practices. International journal of environmental research and public health. 2014;11:2064-76. https://doi.org/10.3390/ijerph110202064
34. Fritz C. How to shock your dental waterlines. ProEdge Dental Water Labs, 2019 Mar 14 [cited 2020 May 20]. Available from: https://blog.proedgedental.com/blog/how-to-shock-your-dentalwaterlines
35. Chin A, Chu J, Perera M, Hui K, Yen HL, Chan M, Peiris M, Poon L. Stability of SARS-CoV-2 in different environmental conditions. medRxiv. 2020 Jan 1. https://doi.org/10.1101/2020.03.15.20036673
36. Environmental Health and Safety, University of Toronto. Laboratory hazardous waste management and disposal manual. [Cited 2020 May 20]. Available from: https://ehs.utoronto.ca/laboratory-hazardouswaste-management-and-disposal-manual/biological-wastedisposal/using-bleach-as-a-disinfectant/

1. Consultant Oral Surgeon, Dr. Qazi & Associates.
2. Advanced Clinical Training Preceptor, UCLA School of Dentistry.
3. Chief Consultant, DentiMed.
Corresponding author: “Dr. Samir Riaz Qazi” < samirqazi@gmail.com >