ADA and CDC for dentists and staff to safely and effectively treat patients, along with ideas from other practices.
It is important to note that these precautions will also greatly decrease our exposure to other serious contagious diseases like HIV, hepatitis, tuberculosis and the regular flu.
Before Dental Care
Preparing the Staff
and the Office
Make sure all dental office team members have received their seasonal flu vaccine.
1. All dental office team members should self-monitor for any fever or COVID-19 like respiratory symptoms.
2. If they come down with any symptoms, they should NOT come to work and self-report via phone.
Practice owners/HR managers should follow the ADA’s guidelines for “What to do if one of my staff members is diagnosed with COVID-19” if positive.
3. At the office, doctor(s) and all dental office team members should take their temperatures and answer screening questions once or twice per day. These need to be logged and recorded.
4. Make sure there is sufficient personal protective equipment (PPE) supplies and prepare for supplies being unavailable in the near future. All dental staff should wear their masks as much as possible while in the office.
5. If scrubs are to be worn, staff should change between street clothes and scrubs upon entry and exit. Extra foot wear or foot coverings can be used by team members and doctors.
6. Provide sufficient supplies for infection control (e.g., alcohol-based hand rub with 60-95% alcohol, tissues, and no-touch receptacles for disposal at entrances, waiting rooms, and patient check-ins.)
7. Routine cleaning and disinfection procedures should be followed using a detergent or soap and water to preclean surfaces prior to applying a disinfectant.
8. Remove magazines, reading materials, toys and other objects.
9. Place signage to remind patients of standard recommendations for respiratory hygiene/cough etiquette and social distancing.
10. Ideally, a virtual waiting room should be established where patients wait in their vehicles or outside until they can be escorted directly to the operatory. If this is not possible, arrange reception areas to provide for social distancing.
11. If possible, eliminate paperwork and send forms to patients electronically, which can then be entered into the patient’s record.
12. Some offices have installed plexiglass shields at their front desks to shield any transmission.
13. Cover treatment chairs and light handles, etc. to the extent possible with protective wraps, and then wipe them down with a high-level disinfectant.
14. Communication among dentists, including at study clubs, can help mitigate the anxiety which dentists and their teams feel right now. Supporting each other and using local, state and national resources can help make the restart process smoother and more directed.
Screening Patients
For COVID-19 and
Triaging Dental Treatment
1. Dentists should try to communicate with their patients to discuss their needs. A “touch” by their dentist, or an appropriate staff member, to say that they are concerned about their oral health during this crisis would be a great way to maintain patient loyalty and comfort.
2. When scheduling or confirming appointments, screen all patients for symptoms of respiratory illness and contact with possible patients with COVID-19.
3. Schedule appointments far enough apart to minimize possible contact with other patients in the waiting room. Schedule higher risk patients (the elderly and those with pre-existing conditions) first thing in the morning to limit possible exposure.
4. If appropriate, use teleconferencing or teledentistry options as alternatives to in-office consultation.
5. Discourage patients from bringing companions to their appointment unless absolutely necessary.
6. Patients with dental emergencies which cannot be delayed, and with symptoms of respiratory illness or a known COVID-19 positive test, should be referred for emergency care to a site where high level transmissionbased precautions are available.
During Dental Care
Standard and
Transmission-Based
Precautions
And Personal Protection
1. Prescreen all patients by phone prior to arrival at your office. Documentation of screening in the patient’s record is recommended. During this call, review COVID-19 practice entry and seating procedures with the patient so they know what to expect upon arrival.
2. Require all patients wear masks, or provide them with one upon arrival at their appointment.
3. Systematically assess the patient at the time of check-in. Take the patient’s temperature to make sure it is normal (100.4o F or less.) A suggested patient screening form is available from the ADA in its complimentary Returnto-Work-Toolkit and the companion guide, the COVID-19 Hazard Assessment Guide and Checklist. The screening should be documented in the patient’s chart for each visit.
4. When available, some offices are planning to use the Abbott ID
NOW COVID-19 molecular point-of-care test for patients, which delivers positive results in as little as five minutes, and negative results in 13 minutes.
5. When available, some offices are planning to screen patients in the office with a COVID-19 antigen test, or a COVID-19 virus polymerase chain reaction (PCR) test, both of which detect if the patient actively has the virus. Other offices are using currently available Oral DNA tests to screen their patients and staff for COVID-19.
6. Consider using a face shield in addition to mask and goggles to cut down on splatter reaching mucous membranes.
7. At the time of publication, N95 or KN95 masks should be changed at least once a day. An overmask of level 1, 2 or 3 mask can be worn over the higher level mask to protect it from splatter and aerosol.
Clinical Techniques
1. Use a 1.5 percent hydrogen peroxide, or a 1 percent Betadine as a preprocedural mouth rinse.
2. If possible, use extraoral dental radiographs, such as panoramic radiographs or cone beam CT scanning as appropriate alternatives to intraoral dental radiographs.
3. If an aerosol-producing procedure is being performed, use a high-volume evacuation suction, along with rubber dams where possible, to help minimize aerosols and droplet splatter. The use of an HVE will collect 90-95% of the aerosol generated. (JADA 2009 Harrell and Molinari).
4. Consider using negative-pressure, external oral suction devices, which reduce aerosols. Some units incorporate a medical grade UV light disinfectant system which kills all viruses and germs in the filter.
5. Consider scheduling aerosolgenerating procedures as the later appointments of the day to allow the room to rest and aerosols to dissipate before the room is re- used. Hand scaling should be used when possible.
6. Some doctors are putting individual, medical-grade air purifiers in every treatment room. Some of these stand-alone units, such as IQAir, filter to .003 microns. (The COVID19 virus is 0.125 microns.) These units have been shown to reduce viral, bacterial, and fungal particulates by up to 99.97 percent.
7. Consider using resorbable sutures whenever possible to eliminate the need for a follow up appointment.
8. Some offices are installing ultraviolet germicidal irradiation (UVGI) systems in each treatment room in order to kill or inactivate microorganisms. They can be mounted on the ceiling or wall and are also available in portable and free-standing forms. They are turned on between patients for a designated time period to provide surface disinfection.
9. Some offices are installing systems designed to generate electrolyzed hypochlorous acid (HOCL) — a strong, oxidant, antiseptic solution used to sanitize all contact surfaces throughout the office.
More importantly, it may be possible that HOCL can be used in a fogger to sanitize entire rooms, surfaces, and PPE.
10. Some practices are using Ozone generators in the evening when the office is closed to further treat the air in the office.
In Between Patients
11. Disinfect non-dedicated and nondisposable equipment (e.g., handpieces, dental x-ray equipment, dental chair and light) according to manufacturer’s instructions.
12. High-touch surfaces such as clipboards, counters, phones, keyboards, light switches, door handles, chairs, desks, elevators, and bathrooms, and, if possible, floor surfaces, should be cleaned and disinfected frequently,
13. Consider providing pens (with office brand for marketing) for each patient and then giving it to them, rather than reusing. Some offices are sanitizing pens after each use.
After Dental Care
14. If a patient reports signs or symptoms of COVID-19, refer the patient to their medical provider for assessment.
15. Dental personnel should change from scrubs to personal clothing before returning home. Upon arriving home, dental auxiliary staff should take off shoes, remove and wash clothing separately from other household residents, and immediately shower.
Conclusion
As we transition back into practice, we must remain vigilant and continue proper procedures as most authorities believe the risk of this virus, while waning, will remain.
Unfortunately, all forms of dental treatment, except for emergencies, have been put on hold for the past two to three months. Without treatment, dental disease continues to progress.
In the COVID-19 era, intervention in the dental disease process becomes more critical. Oral health is critical to overall health, as well as a healthy and robust immune system necessary to fight diseases like COVID-19. Dental disease can progress to periodontal disease, which is a major risk factor for heart disease, high blood pressure, diabetes and, in particular, pneumonia. All of these comorbidities are major risk factors for COVID-19 mortality.
As health care professionals we have the duty to protect the public and maintain the highest standards of health care and infection control. We are here to assist you and your patients with their periodontal needs.
It is important to make informed clinical decisions, educate the public to prevent panic, while promoting the health and well-being of our patients during these challenging times.
We hope this article has helped to expand or reinforce your knowledge on the recommended practices for COVID-19 at the time of publication.
We wish you health and prosperity as we continue to manage this situation in our society.
Working together we will all get through this.