The anticipation seemed to be over when the Centers for Disease Control and Prevention (CDC) released its long-awaited guidelines for dental settings in response to the COVID-19 pandemic. Although the CDC has set up a framework for dental healthcare providers, it is encouraged to consult state dental boards and state health departments to stay current on local requirements. These will vary due to the different rates of infection throughout the country.
The risk associated with treating patients during the pandemic is directly associated with aerosols produced during procedures. The CDC states that surgical masks protect mucous membranes from droplet spatter, but they do not provide protection from the inhalation of infectious agents. Currently, there are no studies that assess the risk of contracting SARS-CoV-2 from dental procedures.
It is imperative to monitor trends in your area for any changes in the number of cases, which would lead to needing to alter practice protocol. The CDC provides a source that is updated daily with trends that should be followed. Listed in the data are confirmed and probable cases. Confirmed cases are cases that meet confirmatory laboratory evidence, while probable cases are less definitive and use multiple factors for determination. The factors used for determining a probable case include a combination of meeting clinical criteria, epidemiological evidence, meeting presumptive laboratory evidence, or meeting vital records criteria.The accuracy of the provided data is largely dependent on state and local public health departments. The exact numbers are difficult to report because not everyone that is infected gets tested as well as delays in reporting and testing. Therefore, data reported by the individual state should be assumed as the most accurate.1,2,3
Crisis Standards of Care
Before offering elective services, dental healthcare providers must ensure they are operating without the “crisis standards of care” in place. Crisis standards of care are defined as “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.
This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations.”4
Crisis standard of care is implemented when there is a need to conserve limited resources, such as PPE, as well as to allow all individuals access to care by reducing the number of patients in the hospital for elective procedures.6
By staying abreast of that status of crisis standard of care conditions, practice owners can determine when to resume elective procedures.1
Screening and Patient Management
The CDC is recommending actively screening for fever and symptoms of COVID-19, regardless of the level of community spread currently in your area. If your community is experiencing minimal transmission and the patient does not present with symptoms, strictly adhering to standard precautions is acceptable. However, due to the nature of the virus and the documented spread by asymptomatic and pre-symptomatic carriers, it is strongly advised to adhere to following more stringent protocol described below.
Contact patients via telephone prior to appointments. Telephone triage will help determine if the patient has any symptoms that would require the appointment to be rescheduled. This also gives the facility the opportunity to encourage patients to limit the number of visitors accompanying them, as well as advising the patient that they and anyone accompanying them will be requested to wear a face covering upon entering the facility.
This telephone call also gives the facility the opportunity to prepare the patient for the changes they will see at their appointment, including routine temperature checks. This may help avoid confusion and upsetting the patient.
Upon arrival, all patients should be screened with a questionnaire and temperature check. Patients who pass the screening questionnaire and are afebrile (defined by the CDC as temperature <100.4o F) may be provided with dental care using appropriate engineering, administrative, and infection control considerations that will be discussed later.
Upon departure, it is recommended that patients put on their face covering as they leave the treatment area and make their way out of the facility. Even with extensive screening practices, there is a possibility that a patient may develop symptoms after dental treatment. Advise patients to contact the facility if they develop symptoms within 14 days of their appointment.1
Taking extra steps to ensure patient and staff safety is simple and, in some cases, provide helpful reminders to reduce the spread of COVID-19. The CDC recommends providing posters on proper hand hygiene, respiratory hygiene, and cough etiquette in strategic locations. Additionally, it is recommended to provide hand hygiene and respiratory hygiene stations with alcohol-based hand rub (60% to 95% alcohol), tissues, and no-touch trash receptacles at entrances, patient check-in areas, and waiting rooms.
Installation of physical barriers at reception areas to reduce contact with potentially infectious patients is recommended. If patients will be utilizing the waiting room, chairs should be a minimum of six feet apart. All objects that cannot be regularly disinfected should be removed from the waiting area, such as magazines, toys, video game controllers, or any other object that may be frequently touched.
Minimize the number of patients waiting in the waiting room. This can be accomplished by having patients wait in their vehicles or by staggering appointment times.1
Equipment may require maintenance after prolonged office closures and non-use. Two such pieces of equipment that should be evaluated are dental unit waterlines and autoclaves. Test water quality to ensure safety prior to performing dental procedures. Water quality should meet the standards of the EPA for safe drinking water. Contact the manufacturer of the dental unit to determine if there is a need to shock the water lines prior to use. As always, continue standard maintenance and monitoring of dental unit waterlines.
Confirm all routine cleaning and maintenance has been done according to the manufacturer’s recommendations on all equipment used for cleaning and sterilizing instruments. Test sterilizers using a biologic indicator per the manufacturer’s instructions for use prior to reopening.1
Administrative Controls and Work Practices
Recommendations for work practice and administrative controls in an effort to reduce the spread of COVID-19 include limiting the number of patients in the facility, avoiding aerosol-generating procedures, and taking specific precautions when they are necessary, limiting the supplies and instruments accessibility, as well as using pre-procedural mouth rinses.
The CDC recommends limiting clinical treatment to one patient at a time when possible. When treating and setting up operatories for treatment, all supplies not necessary for the procedure should be covered or put away in drawers and cabinets.
Any supplies or instruments exposed during the procedure are to be considered contaminated and must be disposed of or reprocessed properly. This means clear all counter space of any items. For example, place gloves in a drawer, and mouth rinses and cups for rinsing should be in a cabinet. Note pads and pens should be stored in a drawer until needed. Only items needed for the procedure should be readily accessible.
Reducing aerosols is particularly important. The CDC recommends avoiding aerosol-producing procedures whenever possible. This includes avoiding the use of handpieces, air/water syringes, and ultrasonic scalers. Prioritize treatment to minimally invasive procedures that are done using hand instruments only.
If an aerosol-producing procedure is necessary, use four-handed dentistry, high volume evacuation, and dental dams to reduce the number of aerosols produced. Additionally, only the dental healthcare providers necessary for the procedure should be present in the operatory.
Pre-procedural mouth rinses with an antimicrobial product are also recommended, with the caveat that there is no published evidence regarding the effectiveness of a pre-procedural mouth rinse in reducing viral load of SARS-CoV-2.1
Recommended engineering controls include ventilation systems, strategic patient placement, and controlled patient volume. Considerations regarding patient volume should include determining the maximum number of patients who can safely receive care. When making this determination, it is important to factor in the layout of the facility, the number of rooms, and the amount of time needed to properly disinfect operatories.
Ideally, patient placement is best in individual rooms; however, open floor plans are quite popular in dental settings, which will require other considerations when placing patients for treatment. Facilities with open floor plans should strategically place patients at least six feet apart, orient operatories parallel to the direction of airflow when possible, and provide physical barriers.
Physical barriers are important when using portable HEPA air filtration systems. Physical barriers should be easy to clean and be floor to ceiling length. Additionally, if possible, patients’ heads should be placed near the return air vents and away from people passing by in the halls. In vestibule type operatories, placing the patients head towards the wall is recommended, if feasible.
Finally, properly maintaining ventilation systems is an important part of engineering controls. Check the direction of airflow of the facility’s ventilation system. Ideally, the airflow should move from a clean area to a contaminated area. If it does not, it is encouraged to adjust or install and maintain this direction of air movement. Consult with a heating, ventilation, and air conditioning professional to discuss increasing filtration efficacy, as well as the possibility to increase outdoor air supplied via the HVAC system.
A few other considerations listed were portable HEPA air filtration systems and upper-room ultraviolet germicidal irradiation (UVGI). Portable HEPA filtration systems reduce particle count and will reduce turnover time of operatories. The HEPA units should be placed close to the patient chair, but not behind the clinician, this is to ensure the airflow is not pulled into or past the breathing zone of the clinician.
The germicidal effect of UV light was first discovered in the late 19th century. Since its discovery, it has been found effective in improving air quality by reducing airborne pathogens. It has been recommended by the CDC for use in preventing the spread of tuberculosis in isolation rooms for several years. UVGI makes it possible to disinfect a large volume of air without overexposing people to UVC. It has a low initial and running cost, which is a huge benefit as well.1,6
Hand Hygiene and Universal Source Control
Hand hygiene has always been important in a dental setting, now more than ever. It is crucial to brush up on proper hand hygiene to keep clinicians and patients safe. You can view detailed instructions for hand hygiene here. Hand hygiene should be practiced before and after contact with patients, after contact with any possible infectious materials, as well as before and after donning PPE.
Facilities should ensure hand hygiene supplies are readily available at every care location in the facility.
As a part of source control efforts, the CDC recommends all dental healthcare providers wear a mask in the dental setting. Cloth masks are acceptable for employees that do not require PPE. Employees that do require PPE may wear cloth masks when not engaged with patient care and when leaving the facility at the end of the day.
If a dental healthcare provider touches their mask, they must perform hand hygiene immediately before and after. Face masks should be changed if they become soiled, damp, or hard to breathe through. Cloth face coverings should be laundered daily.1
Personal Protective Equipment (PPE)
First and foremost, the CDC states regarding PPE, “Ensure that you have the appropriate amount of personal protective equipment (PPE) and supplies to support your patient volume. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.” Employers can refer to the OSHA PPE standards to determine appropriate PPE for employees.
In summary, the OSHA PPE standards include the following guidelines also found on the CDC website. Dental facilities are required to make certain that all reusable PPE is thoroughly cleaned, decontaminated, and stored between uses.
During procedures likely to produce splashing or spattering, dental healthcare providers should wear “a surgical mask, eye protection (goggles, protective eyewear with solid side shields, or a full-face shield), and a gown or protective clothing.” During procedures that produce aerosols, dental healthcare providers should consider using a N95 respirator (this includes aerosol-producing procedures on patients assumed to be noncontagious). Other options include disposable filtering facepiece respirators, PAPRs, or elastomeric respirators.
If none of these are available, use of a surgical mask and a full-face shield is recommended. The CDC states, “If a surgical mask and a full-face shield are not available, do not perform any aerosol-generating procedures.”
Employers should review and document proper donning and doffing techniques with staff. Each facility should have written policies and procedures for safely donning and doffing PPE. There are multiple sources that can be used; detailed steps can be found here.1
PPE Optimization Strategies
During the COVID-19 pandemic, suppliers have reported shortages of PPE, particularly masks and respirators. With this in mind, the CDC has developed a series of strategies or options to optimize supplies of PPE as well as a burn calculator to help facilities determine the rate at which they use PPE items. This can help with strategies to optimize the use of PPE during the shortage associated with COVID-19.
It is important to note, these strategies are only intended to remain in place during shortages of PPE. These strategies are tiered and sequential; therefore, reviewing and understanding the sequence is imperative.
An example used by the CDC regarding extended use of masks and respirators states the only time this should be done is if all applicable administrative and engineering controls have been implemented. This would include selectively canceling elective and nonurgent procedures, the guidelines for extended use of PPE is not meant to encourage facilities to practice at normal capacity during a PPE shortage.1,7,8
Environmental Infection Control
The procedures for environmental cleaning and disinfecting of surfaces has not changed drastically in the face of the pandemic. The guideline for infection control in a dental setting (2003) provided by the CDC should still be followed.
The difference is in the time elapsed between when the patient exits the operatory to when the dental healthcare provider should proceed to clean and disinfect the area. For patients NOT suspected of being infected with COVID-19, the dental healthcare provider should wait 15 minutes after dismissing the patient and before re-entering the operatory to clean and disinfect the area.
If a patient is seen that is suspected of being infected with COVID-19, the time elapses may vary depending on the rate of air changes per hour of the facilities HVAC system. For example, if the facility’s rate change per hour is 8, the time required for 99% efficacy for removal is 35 minutes; for 99.9% efficacy for removal, the time elapse would be 52 minutes.
The EPA only recommends the use of disinfectants on List N for use against SARS-CoV-2. No other alternative disinfecting methods have been shown effective against SARS-CoV-2. This includes ultrasonic waves and LED blue light. Additionally, the EPA does not routinely review these methods; therefore, they cannot confirm the safety or efficacy of these types of methods.
The management of laundry and medical waste should continue to follow policies previously implemented.1,9,10
Additional Precautions for Patients with Suspected or Confirmed Infection of COVID-19
Patients who arrive at your facility with suspected infection should be rescheduled. If the patient does not present with severe symptoms, advise the patient to return home and contact their primary physician. If the patient presents with severe symptoms such as shortness of breath, send the patient to a medical facility or call EMS.
If emergency care is necessary for a patient with a confirmed infection with COVID-19, special precautions are required. Treatment should be performed in an enclosed room with no other patients scheduled at that time, preferably at the end of the day. Avoid aerosol-producing procedures if possible. If aerosol-producing procedures are necessary treatment should be performed in an airborne infection isolation room.
For the complete list of recommendations refer to the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.1,11
Test-Based Strategies and Monitoring Dental Healthcare Providers
Facilities may want to implement pre-procedure testing for COVID-19. This can help better determine what level of PPE is necessary, helping to conserve PPE and preventing further shortages. However, this is not a foolproof method to determine risk. Some tests can produce false negatives. Another consideration is the time it takes to administer tests and get results, As testing improves, more rapid and accurate tests may become available, making this a more important step in reducing the spread of COVID-19.
Facilities will need to implement strategies to monitor dental healthcare providers. This should include monitoring for fever and other symptoms. A policy should be put in place that encourages dental healthcare providers to stay home when feeling sick. These employees should be assured there will be no penalty when they need to stay home due to symptoms or fever.
If a dental healthcare provider becomes feverish or develops symptoms while at work, they should don a face covering, advise their supervisor, and leave work immediately. The CDC defines a fever in dental healthcare workers as >100.0o F.
Although these changes will certainly take time to get used to, it is especially important that we follow these guidelines. We all want what is best for our patients. We all vowed to “do no harm.” Ignoring or irresponsibly proceeding with care while not adhering to the CDC’s guidelines may lead to dental practices becoming a vector for this disease. If that were to happen, the public may see dentistry as a risk and avoid much-needed treatment.
Dentistry has fought tooth and nail to be considered an important part of overall health. Let’s continue to show our patients the importance as well as the lengths we will go to keep them safe. As more research emerges, including effective treatments and vaccines, these guidelines may change. As frustrating as it can be to try to keep up with an evolving situation, it is necessary.
Annual infection control CE classes should be required for all license renewals in the future, not only for the safety of our patients but for the safety of dental healthcare providers. If you are not required to take an annual infection control CE course, please consider doing it electively to stay informed on any changes that may follow this update.
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