Service protocol in Oral and Maxillofacial Surgery in times of COVID-19

This article brings a complete protocol to be followed by all dental professionals who practice the specialty of Oral and maxillofacial surgery.


GENERAL
The pandemic situation caused by the new virus 2019-nCOV in which our country is immersed, will take the Emergency Committee of the Faculty of Dentistry of the University of the Republic, to facilitate all Odontologists of Uruguay and Personal Auxiliary maximum scientific information, with the objective of providing useful tools for the prevention and control of cross contamination in the dental clinic. This work would be complementing the different reports for Dentistry in our country.

Public Health Ministry Recommendations
Service coordinator.  1 -Postponing consultations, procedures and dental surgery, not urgent, reprogramming the mismas.
 2 -During the duration of the health emergency period, limit attention only to urgent and emergency consultations and procedures. The urgency and need for a procedure based on clinical judgment and must be taken on a case-by-case basis.
 3 -Schedule urgent appointments, maintaining distance between patients, avoiding their coincidence in the waiting room. In any circumstance, a proper medical history must be carried out. Assess the state of health of the patient and the presence of pre-existing pathologies, which complicate the treatment to carry out the pathognomonic treatment of the Corona Virus disease: headache, fever, tinnitus, odynophagia, ageusia, dysgeusia, dysnea, decay, conjunctivitis, dysosmia or anosmia, abdominal pain, vomiting, diarrhea, thrombosis, etc. 1 ) Hay who knows if he has kept in touch with people who are carriers of Covid-19. If the patient has these symptoms, he must be referred to his health provider, in order to implement with his doctor an immediate isolation as indicated by the Ministry of Public Health's regulations.

COVID-19 and maxillofacial surgery
The COVID-19 pandemic is a global problem with a major impact on Oral and Maxillofacial Surgery. 2 -4 The idea of this work is to bring colleagues who develop Oral Surgery, the specialty in Oral Surgery and Traumatology and maxillofacial patients who need to be surgically In some situations by the characteristics of the urgency the emergency is not possible to consider the realization of this protocol of 2 tests alternated for 24 hours. and it is essential to approach the patient immediately. 1 Consideration should be given to limiting contact with these patients by the 60-year-old major surgical person, with background pathology, as immuno-suppressed, with respiratory upheavals and other comorbidities. Limit surgical personnel to personal experience with surgical experience and residents will be compromised gradually in accordance with their training. All procedures must be considered of high risk and must have the aerolization of particles in each surgical procedure. It is also necessary to count on the appropriate infrastructure to carry out this procedure. Mask N95, 99 or 100, conventional cap, with shield overprotector on the cap, lenses, on impermeable tunic, 2 pairs of non-porous guantes, cap and zapatones. Other protocols propose different types of masks, FFP3,FFP2 o PAPR, que dan una mejor protección 4 ,, 6. If you want to check the quality of the materials according to the international quality standards and do not use the copies. For the request for complementary imaging examinations, it is important to consider the use of extraoral examinations to reduce the contagion of the acting person. Chest radiography is mandatory in all surgeries with general anesthesia. It is necessary to individualize this request that in many opportunities and pathologies the retro apical image is required. Computed tomography must be considered and justified by a cost theme that it disadvantages.

Surgical considerations
 I) Airway management  The intubation must be performed by the anesthesiologist but trained by the surgical team in surgery with general anesthesia.  It is not necessary to leave during extubation, due to the fact that at the moment the patient discharges, the extubargo is placed on an oxygen mask, which protects the aerosol generated in that instant. 2 -3 , 5  The tracheotomy in patients with the Corona Virus or the disease developed must be carried out just as when the patient does not have it.  C5 -Self-tapping screws.
 C6 -If osteotomy is required, use powerful saws.
 III) Oncology  If the surgery and radiation treatment is equivalent to the surgical treatment, the surgical treatment is recommended.
 Considerations for all we must consider a surgical case.  Cellular spino carcinoma, with fast skin growth and regional disease.

Service protocol in Oral and Maxillofacial Surgery in times of COVID-19
 Salvage surgery, for persistent or recurrent illness.
 High degree of sino-nasal malignancy, without effectiveness in conservative treatment.
 All cancer patients undergoing surgery must be tested to detect the Corona Virus without being asymptomatic. Asymptomatic patients who have to be operated on for tumors have a post-operative condition but are more complicated than those who have not.
 We work with a strict relationship with other surgical disciplines, Otorhinolaryngology, Plastic Surgery, in order not to coincide with three patients, one of each specialty in the CTI, with pathologies that involve mucous membranes.  In those cases in which there have been conservative treatments, extraction should be carried out more quickly and thus avoiding the installation of infectious processes.
 Surgical dental emergencies: a) dental emergencies: hemorrhage: bleeding profusely difficult to control, b) infection and increase in the extra-intraoral diffuse volume,  Other dental emergencies: pulpitis, pericoronaritis, periodontitis, absenteeism, acute alveolar abscess, GUNA, pathological fabric impostergable by its clinical aspect.
 Preferably, schedule through the Patient Admission Registration Service and approve the instance to conduct the minimum interrogation to assess the clinical condition of the patient. In the event that the patient competes before calling, as usually happens in a clinical trial, he must be received by the assistant who will deliver a form with the evaluation questions of the surgical risk.
 -Dental emergency concept. It is very important to have in mind what must be considered an unavoidable dental emergency. Having established gravity concepts and acting accordingly, the following must be considered as urgent: the pain, the infection, the trauma, the hemorrhage, the joint block, the dislocation of the (Temporulatory Articulation. (ATM)  -Instructions to the patient before entering the surgical block.
 The patient must compete only at the clinic without accompaniment, unless he requires it due to some disability or justified cause.
 It must enter without reloj, pulseras, caravans, rings Etc.
 The virus stays on time on metal surfaces. It should be punctual at the time mentioned.
 To challenge the proposed interrogation.
 Fleet the hands with alcohol in gel for 20 seconds.
 In the hypothetical case of crossing with another patient, you must keep a distance of 2 meters.
 In case of paying the consultation in treasury it is ideal to do it with the card and not the money.
 -Protocol for reception of patients. It will be necessary to mark a suitable distance in the place of reception for the patient, ideal 1.8 meters and separated from the patient by an acrylic mat. The person who receives it must wear a mask and lenses. At that time, alcohol and gel will be given to the patient to fleet the brothers.  The sillas deberán will be separated at least with 2 meters of distance between them.
 -Espacios Generales  Remove automatic towels and dryers from the toilets and towels using disposable paper. Pack and clean them and provide liquid soap and gel alcohol.
 It is necessary to perform the protection of the points and the vacuum with sterile barrels.
 The vacuum cleaner must be of high fluidity.
 The patient must sign the surgical consent. 4 -5 , 8 , 10  Conception of interventions of high risk:  Extraction of retained teeth. After the care  Among patients:  Protocol for cleaning and disinfecting the cabinet  All clothing used will be removed, eliminating the first two. Guantes y la sobre tunic, hacia afuera.
 They will turn waste into a bag that will be placed in another bag and will turn into a container adapted to that purpose.
 All surfaces must be cleaned with the indicated material and wait a few minutes before another patient enters.  All members of the health team must handle the information as they do at home, while on a working day for the family members. 7 -8 , 11  These are recommendations and not mandates, for decisions that must be adjusted to each individual case, in daily practice. Treatments should be the most effective possible .

CONCLUSIONS
We are facing a pandemic that is causing the unity of all, on the ground due to the exponential increase of cases among the population, due to suffering the contagion among health agents and the levels of infrastructure and adequate protection material.
As dentists, we must commit and strive to treat the patient in the safest way and with the most up-to-date recommendations available.
Because of the success of the analyzed international literature, we should have a clear picture of the health status of the patient, perform the pre-surgical screening of SARS-COV2 in all patients who are going to operate on oral and maxillofacial pathologies and do not use infected masks. FFP3 in negative patients and consider the international protocol in infected patients. Obvious of these measures supposes a risk that would attack the ground against the integrity of the patient, the bell of all the surgical team that participates in his attention.