Considerations for Necessary Oral Mucosal Procedures
From a health care professional exposure perspective oral based
examinations and procedures are of great concern. Per the CDC,
“potential routes of close-range transmission include splashes
and sprays of infectious material onto mucous membranes and inhalation
of infectious virions exhaled by an infected person. The relative
contribution of each of these is not known for
SARS-Co-V-2 ”.13 Furthermore, there is mounting
evidence that SARS-CoV-2 may be transmitted through fomites and
contact.14 An oral health professionals points of
contact during a patient interaction could be both direct and indirect,
including but not limited to the following: 1) contact with human
fluids, 2) contaminated surfaces and instrumentation, and 3) patient
materials.14 While strict hygiene measures are able to
significantly reduce the risk of exposure from indirect routes, due to
the contact with oral mucosal surfaces in the assessment of an OPMD and
need to violate oral mucosal surfaces should an incisional or excisional
biopsy become necessary, one must incorporate added protective measures
to ensure the safety of the entire healthcare team. Below is a summary
of such measures:
- PPE: Conservation of PPEs has been one of the hallmarks of
this pandemic. Our approach has been to use a level 3 surgical mask
with face shield and/or goggles during the in-person evaluation of a
patient who is known to be SARS-CoV-2 negative based on testing within
24 hours. If the patient was unable to be tested or should the patient
present for a surgical procedure then a higher level of PPE is
employed (N95, face shield, disposable medical safety gown, and
disposable working cap).
- SARS-CoV-2 Testing: Globally testing continues to be a major
challenge of this crisis; however, it is becoming more readily
available. It is our recommendation that should a patient require a
biopsy or surgical excision of their OPMD, testing be obtained within
24 hours of the planned procedure with consideration for the
aforementioned PPE options. With regards to testing stewardship this
is where Telehealth evaluation allows for optimization of the
efficiency of the in-person visit. For instance if a patient requires
a biopsy/surgical excision the testing is obtained prior to the visit
with allocation for the necessary PPE. Additionally, during the
Telehealth visit we address any medications or conditions that require
special considerations (i.e., management of antiplatelet
agents/anticoagulants) and obtaining any necessary “clearances” to
avoid any complicating factors and cancelation of procedures and need
for the patient to return to the office.
- Topical Preparation of Oral Mucosal Surfaces With
Povidone-Iodine (PVP-I): Based on mounting evidence of the ability of
PVP-I to inactive SARS coronavirus prior to the biopsy or resection of
an oral mucosal lesion we are currently topicalizing the oral mucosal
surfaces with PVP-I (1 – 7.5%) for 2 minutes prior to delivering
local anesthesia and performing tissue excision.15
- Technical Considerations For Tissue Handling: For incisional
biopsies our recommendation is for use of either a surgical scalpel or
a tissue biopsy technique with avoidance of use of laser technologies
due to concern for viral disease transmission by laser-generated plume
until more robust testing guidelines are established. Furthermore, our
recommendation is for the use of absorbable sutures to avoid risk of
bleeding from an open biopsy wound with return of patient to the
office or having to visit an emergency department secondary to
bleeding. Additional benefit of absorbable sutures is patients do not
have to return for suture removal. Furthermore, should patient require
excision of lesion in the operating room we are minimizing use of
smoking-generating cautery to minimize vaporization of viral
particles.
- Procedure Setting: If the patient is SARS-CoV-2 negative it
is appropriate for the procedure to be performed in the outpatient
clinic setting if the lesion is easily accessible. However, if the
patient’s SARS-CoV-2 status is unknown and a biopsy is warranted, our
preference is to perform the procedure in the clinic setting. However,
if a critical biopsy is necessary and in the absence of testing and if
the lesion is difficult to access (secondary to location or other
factors such as trismus) our preference is to perform the procedure in
the operating room. Should the patient require the procedure in the
operating room preference should be given to excision of lesion in its
entirety with/without use of frozen sections prior to lesion excision
based on the specialists preference.