Recommendations from the Institute for Hygiene and Infection prevention at Robert-Koch-Institute (Germany RKI, www.rki.de)

During the treatment of the orofacial region there exists a transfer risk through skin- and mucomembranous contact or through transfer by instruments of the following pathogenic agents:

• Herpes-simplex-virus type 1
• Staphylococcus
• Bacteria and viruses, which can infect the respiratory tract: e.g. Influenza or streptococcus

1. Hand hygiene:

Hygienic hand disinfection: Suitable are all pharmaceuticals which observe the following criteria:
-> HBV- HIV- HBC efficacy - Certified from the group of applied hygiene (VAH (Germany))
Application: Before and after every treatment:

• Wash and dry hands, followed by applying 3ml of disinfection fluid for 30 seconds. Do not wipe off. If the fluid evaporates before 30 seconds, reapply.
• In case of a higher risk of infection, keep the fluid on for 3-5 minutes (see application recommendations of the pharmaceutical).
• In every oral examination or treatment medical gloves should be worn (DIN EN 455).

2. Instrumental hygiene:

Non-critical: Instruments used exclusively extra-orally will be classified as uncritical, these are:

• Ruler
• Caliper rule  
• Tuning fork
• Reflex hammer
  -> In this case you should use a disinfection wipe or bath and apply additional manual cleaning as necessary. The specific information of the producer should be paid attention to. The wiping disinfection should be authorized by the VAH (in Germany)
• Treatment couch
  -> Should the treatment couch come in contact with diseased parts of the skin or saliva, it should be cleaned with a surface disinfectant.

Semi critical: Instruments, which come in contact with mucomembranous or infected skin, these are:

• Lip expander
  It requires a thermal disinfection.
  -> If you do not own a thermal disinfector we recommend a collaboration with a physician or dentist to avoid this expensive purchase.
• -> Alternatively, we recommend disposable lip expanders.
  -> Generally: Disinfected instruments must be stored in a hygienic, dry and dust-protected area.

Critical:  Instruments which penetrate the skin or mucosa and come in contact with blood are not used in CRAFTA® treatment.

Instruments that penetrate the skin or mucosa and come into contact with blood are not used in CRAFTA® treatment during mobilization and exercise therapy.

In some countries, the myofascial trigger point therapy is additionally performed by means of acupuncture needles (dry needling). There are special hygiene guidelines, since a contact with blood is possible. The acupuncture needles used for this purpose are disposable material.

Report on (Covid-19) infection prevention in (physio) therapeutic treatment of the orofacial region.

(based on: S1 guideline (long version) Dealing with dental patients when exposed to aerosol-borne pathogens)

(AWMF registration number: 083-046)

According to current knowledge, general infection prevention (e.g. questions about status of infection beforehand, disinfection, distance, face mask, possible eye protection and protective clothing) already used in physiotherapy expanded to patients with orofacial complaints who require intraoral inspection and treatment.

As an additional measure, to reduce potential virus contamination from droplets and aerosols, mouth rinsing or gargling with mucosal antiseptic shortly before intraoral physiotherapeutic treatment can reduce a potential virus concentration in the oral cavity for about 30 minutes [13].

There is limited evidence of the virucidal effect against enveloped viruses for the following over-the-counter antiseptic mouthwashes available for physiotherapy practices:

--> Recommended procedure: rinse / gargle for 30-60 seconds. [12]

Note: The additional measure relates to the evidence mentioned above, should always take place for the patient on a voluntary basis and does not contain any legal information or liability.

In the eventual implementation of these measures in practice, each therapist must act in accordance with the applicable legal provisions of the respective country and profession rules.

Literature:

1. Herrera, D., et al., Is the oral cavity relevant in SARS-CoV-2 pandemic? Clinical oral investigations, 2020. 24(8): p. 2925-2930.
2. Peng, X., et al., Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci, 2020. 12(1): p. 9.
3. Meng, L., F. Hua, and Z. Bian, Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. Journal of Dental Research, 2020: p. 0022034520914246.
4. Eggers, M., et al., In Vitro Bactericidal and Virucidal Efficacy of Povidone-Iodine Gargle/Mouthwash Against Respiratory and Oral Tract Pathogens. Infectious Diseases and Therapy, 2018. 7(2): p. 249-259.
5. Kariwa, H., N. Fujii, and I. Takashima, Inactivation of SARS Coronavirus by Means of Povidone- Iodine, Physical Conditions and Chemical Reagents. Dermatology, 2006. 212(suppl 1)(Suppl. 1): p. 119-123.
6. Meister, T.L., et al., Virucidal Efficacy of Different Oral Rinses Against Severe Acute Respiratory Syndrome Coronavirus 2. The Journal of Infectious Diseases, 2020
7. Bernstein, D., et al., In vitro virucidal effectiveness of a 0.12%-chlorhexidine gluconate mouthrinse. J Dent Res, 1990. 69(3): p. 874-6.
8. Park, J.B. and N.-H. Park, Effect of chlorhexidine on the in vitro and in vivo herpes simplex virus infection. Oral Surgery, Oral Medicine, Oral Pathology, 1989. 67(2): p. 149-153.
9. Marui, V.C., et al., Efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: A systematic review. J Am Dent Assoc, 2019. 150(12): p. 1015-1026.e1.
10. Galván, M., et al., Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. A pilot study. J Periodontal Res, 2014. 49(6): p. 696-702.
11. DAHZ (Deutscher Arbeitskreis für Hygiene in der Zahnmedizin). Hygieneleitfaden, 14. Ausgabe 2021.
12. S1-Leitlinie (Langfassung) Umgang mit zahnmedizinischen Patienten bei Belastung mit Aerosolübertragbaren Erregern AWMF-Registernummer: 083-046 Stand: März 2021 Gültig bis: März 2022
13. Casale et al. Could nasal irrigation and oral rinse reduce the risk for COVID-19 infection? International Journal of Immunopathology and Pharmacology Volume 34: 1–3 June 2020
14. 14 Bizzoka et al, Covid-19 Pandemic: What Changes for Dentists and Oral Medicine Experts? A Narrative Review and Novel Approaches to Infection Containment , International Journal of Environmental Research and Public Health May 2020
15. Kirk-Baley et al The use of Povidone Iodine nasal spray and mouthwash during the current COVID-19 pandemic may protect healthcare workers and reduce cross infection. Pre print. 2020
16. 16. Seneviratne J et al., Efficacy of commercial mouth‐rinses on SARS‐CoV‐2 viral load in saliva: randomized control trial in Singapore , Original, https://doi.org/10.1007/s15010-020-01563-9 Nov 2020