working environment to facilitate dentistry and oral procedures. Oral procedures requiring the use of powered instrumentation (drills, burrs, scalers) that will aerosolize the room with bacterial contaminants should be confined to a designated, well‐ventilated space, and isolated from sterile surgery suites. Laminar air flow (LAF) ventilation systems accompanied with high‐efficiency particulate air (HEPA) filters are recommended for use in surgical settings, especially a dental operatory. The combination of LAF and HEPA filters is designed to significantly reduce personnel exposure to aerosols and improve the overall air quality. Filters should be replaced roughly every 6–12 months.
Personal Protective Equipment
The impact of aerosolized exposure can significantly impact the systemic health of clinical staff. As a result, due diligence must be exercised to ensure that proper personal protective attire is worn when necessary. Standard operating room attire consists of a clean pair of scrubs, bouffant cap, dedicated surgery footwear (closed toed) or shoe covers, and a surgical mask that will provide the appropriate level of protection the procedure requires. Full radiation safety protection must be worn at all times when obtaining dental radiographs while limiting exposure to radiation as much as possible. Exam gloves must be worn at all times when contact with mucous membranes, excretions, secretions, blood, and bodily fluids is likely to occur. Gloves should be discarded when heavily soiled and immediately following each use. Gloves should also be disposed of during the intraoperative phase when transitioning from dirty to clean areas/procedures on the same patient. Hand hygiene should be practiced before and after donning gloves. Protective eyewear (goggles/full face shield) should be worn during oral procedures involving irrigation. Disposable gowns should be worn when handling patients with infectious diseases. It may be necessary to wear a level‐4 gown to prevent strike‐through from occurring in certain procedures containing infectious fluids. Surgical masks vary in terms of level of protection and filtration. The purpose of N95 masks is to aid in protection against airborne zoonotic infectious diseases. Although the surgical caseload in veterinary medicine in which N95 masks would be required for use is relatively low, it is suggested that individuals involved in dentistry and oral surgery procedures are fit‐tested to secure an appropriately sized N95 mask to wear when needed. The reader is referred to the American Society of Testing Materials guidelines regarding performance criteria for grading masks.
Standard Oral Surgical Preparation Protocol
The oral cavity should be irrigated with 0.12% chlorhexidine gluconate antiseptic rinse to reduce the number of microbial bacteria inside the patient's mouth, which also effectively reduces the aerosol contamination in room air. The reader should follow the facility's specific guidelines for standard aseptic skin preparation for oral procedures that require a skin incision.
Patient Positioning
Patients are placed in lateral or dorsal recumbency for oral emergency procedures. It is the nurse's responsibility to ensure that the patient is kept warm and dry throughout surgery. Use of veterinary warming devices is encouraged to reduce the patient's risk of developing hypothermia, which could lead to a prolonged anesthetic recovery. Warming devices to consider include circulating water blanket, forced‐air warming blanket, IV fluid warmer, reservoir warmer for dental water, and ample blankets/towels. It is advisable to intubate the patient using a cuffed endotracheal tube. In addition, the pharynx should be packed with gauze (pharyngeal packing) prior to the start of the procedure to decrease the risk of fluid aspiration.
Surgical Supplies
Oral surgery sets can be created based on grouping instrumentation required to perform specific types of procedures. Examples include small and large dental surgical instrument sets, periodontal extraction cassettes, orthodontic supplies including glass ionomer cement and light cure composites, and pulpectomy sets (Boxes 2.34–2.37, Figures 2.36–2.39).
Instrument Sterilization
Most dental instruments can undergo the same cleaning/disinfection routine as standard surgical instruments, with the exception of motorized instruments, such as handpieces, which cannot tolerate any means of immersion. Thus, only the external surfaces of motorized instrumentation can be cleaned manually, using a lint‐free cloth, and well‐soaked with a suitable cleanser/disinfectant spray, as defined in the manufacturer's instructions. Materials that contain hardening properties (i.e., cement) should be debrided from instruments promptly after use to avoid material from bonding to the instrument. Otherwise, debris congestion could inhibit sterilization by obstructing heat or chemical vapor from penetrating the soiled area. All other dental instrumentation should be pretreated with a foaming, enzymatic disinfectant spray, followed by a thorough rinse. Instruments should be processed in an ultrasonic cleaner for a full clean and rinse cycle. If the clinic does not own an ultrasonic cleaner, it is imperative that the instruments are meticulously scrubbed and rinsed thoroughly. Instruments should be dried, inspected for surface damage, and assessed for sharpness, prior to placing them inside a wrapped perforated instrument cassette or a paper/plastic sealed pouch. Finally, instruments should be stored neatly in a clean environment to avoid risk of contamination. Veterinary practices equipped with a washer sterilizer on site may use this method to aid in the complete decontamination of reusable instruments. Washer sterilizers facilitate an automated cleaning process consisting of water and detergent, followed by a rinse and dry cycle, and conclude with an immediate‐use steam sterilization cycle, known as “flash” sterilization. Flashed instruments are typically not intended to be stored for future use. However, the respective technique is satisfactory for instrumentation designated for use in non‐sterile procedures only. All hinged instruments should be unlocked prior to processing and lubrication. Refer to the instrument manufacturer's instructions for reprocessing guidelines. Sterilization and disinfection methods of dental surgery instruments are categorically classified as critical, semi‐critical and non‐critical. Critical refers to instruments that penetrate bone and mucosa and semi‐critical refers to instruments that contact the oral mucosal. Both of these categories require heat sterilization. Non‐critical refers to skin contact; these instruments should be immersed in disinfectant.
Box 2.34 Large Dental Surgery Set
Mosquito hemostats (10)
Kelly hemostats (3 curved)
Minnesota retractors (2)
Blade handles (no. 3, No. 4)a
Backhaus towel clamps (5 small)
Backhaus towel clamps (2 large)
Allis tissue forceps (2)
Metzenbaum scissors (long, short)a
Mayo scissor
Needle drivers (2)a
Rat tooth forceps (2)a
Ligature
