Laura Kryzostaniak

During the first weeks of the coronavirus disease 2019 pandemic, most dental practices closed their doors to patients, although many remained open for emergencies. Since reopening in May and June, practices are running under a new standard operating procedure.

Practice owners may have feared patients wouldn’t return, but most are seeing the opposite. Patients are so eager to return to their dentist’s office that many practices are booked well into October.

“I was shut down between March 18 and May 18,” says John Flucke, DDS, who practices in Kansas City, Missouri and is Chief Dental Editor for 

. “Since we’ve reopened on May 18, I can barely sit down. It’s a good thing, but it just doesn’t make any sense to me. Everyone was saying that nobody was going to go out or spend money for fear of the economy, but life has been crazy busy.”

Centers for Disease Control and Prevention: Interim Guidance for Businesses and Employers Responding to Coronavirus Disease 2019 (COVID-19)

Centers for Disease Control and Prevention: Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19

Centers for Disease Control and Prevention: Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance)

Centers for Disease Control and Prevention: If You Are Sick or Caring for Someone

Centers for Disease Control and Prevention: How COVID-19 Spreads

Despite the nation getting back to normal, the number of COVID-19 cases is still rising. Since reopening more public spaces, every day in July saw record numbers. Several states set record highs for daily new coronavirus cases as of mid-July, including Alaska, California, Florida, Texas, and North Carolina.

Despite the ever-present danger of the pandemic, dental professionals believe it is their duty to continue to provide care to patients.

“In March, we all thought this was just a virus, so we treated it as such,” says Katrina Sanders, RDH, a member of the 

editorial advisory board. “But we’re now learning that not only does this virus replicate in the host, which is done through inflammatory pathways, it also has systemic complications.”

Sanders says individuals with high levels of inflammation are experiencing the worst symptoms of the virus. Because periodontal disease is the second-most frequent modifiable inflammatory condition in the U.S., she believes dental professionals play a critical role in mitigating the effects of this illness on the most vulnerable population. For that reason, it’s unlikely that her practice in central Arizona will see another closure.

“We opened fully on May 1, but we’ve recently seen an incredible spike in COVID-19 cases in Arizona, so we take it day by day,” Sanders says. “However, I don’t suspect we’ll go back to just treating emergency cases.”

Many practices reopened to help keep their dental patients out of emergency departments. “We felt strongly about our obligation to see patients when they had dental issues so we could keep them out of the ER,” says Jeffrey Rohde, DDS, who practices in Santa Barbara, California. “The ER isn’t as equipped to handle dental issues. Plus, they’re using up time and resources on dental patients, and dental patients are potentially being exposed to illnesses.”

While there are some exceptions, most dental professionals feel safe returning to work. There have been changes in infection control protocol in every practice in the U.S., but many of them are subtle, because they were already doing what they could to limit the transmission of airborne infections before the pandemic.

“I [am in] surgeries in the operatory with our periodontists,” Sanders says. “When I would go into a surgical operatory, I would wear a hair bonnet, a gown, and a level-3 ASTM mask. Our patients were using pre-procedural mouth rinses, and my assistant was using a high-volume evacuation system.”

For Sanders, the only differences now are that she never removes her mask and she wears a face shield over it. The difference for patients is that they wear a mask when they come into the practice. These aren’t major changes.

“Our office had been doing a lot of these things before coronavirus came to the U.S.,” she says. “Our practice might look a little different, but it’s not dramatically different, and our patients appreciate that. They recognize that we were doing the things that were necessary before this pandemic.”

One area where practices are seeing significant changes is the patient experience. Waiting rooms have become obsolete. Patients wait in their cars in the practice’s parking lot, only entering the practice after they’ve received a text from the front desk telling them it’s their turn to check-in.

They are screened as they walk in, which includes taking their temperature and asking them questions about any symptoms and their potential risk. Paperwork has been completed online in advance, or patients fill out forms with a sanitized pen, which they then keep or throw into a container for disinfection. Patients wear masks before entering the facility and only take them off once they are in the dental chair. After the procedure, the mask goes back on and the patient leaves the facility, likely without encountering another patient on the way.

The risk of contracting COVID-19 increases whenever someone leaves their home, and the dental practice is no exception. However, seeing the new procedures in place in dental practices alleviates the fear many patients have. “All you have to do is walk into a dental office to know that we are doing things differently,” says Kim Miller, RDH, BSDH, a consultant and coach for Inspired Hygiene, and a member of the 

editorial advisory board. “We are dressed differently, taking temperatures, asking different questions, and asking patients to sanitize their hands. And because we’re doing things differently, patients are feeling safe.”

While some practices already had most of the recommended personal protection equipment (PPE) on hand during this pandemic, many delayed reopening because of a delay in getting PPE. Some previously donated the PPE they had to hospitals, which were more in need in those first few weeks.

“We were concerned hospitals weren’t going to have enough gear to handle the number of patients,” Rohde says. “We were seeing nurses in New York wearing trash bags, so we donated our own stuff. And then in early May when it looked like we were going to be able to open up again, we tried to reorder stuff and we couldn’t get it. PPE was either being requisitioned by the state of California to be used for health care workers, or people were hoarding what they had.”

To work around the PPE shortage, Rohde’s staff found old lab coats in their closets, which they would use once before placing in bags until they were deemed safe to wash and use again. For masks, they were wearing 3M N95 masks from the hardware store under level-2 and level-3 masks, which served as barrier protection. 

"Thankfully, we were on a limited schedule, so we didn’t need a lot of equipment,” Rohde says. “But that’s how we saw people for a week or two until our orders came in.”

Other practices near him were using daily racks for their medical supplies, cycling the supplies weekly so that any contamination would dissipate before the next use.

Donning proper PPE for aerosol-generating procedures (AGP) is not new in dentistry, but that doesn’t mean the newest recommendations have been easy to meet. The industry is seeing a shortage of dental hygienists and assistants, some of whom fear returning to work because their practice isn’t following the CDC’s recommendations.

“The CDC has guidelines, but ultimately, they leave most of these guidelines to the interpretation of the employer who is providing the equipment,” Sanders says. “There are a lot of dental professionals in a situation in which they don’t have the recommended equipment. Many of them are trapped in an ethical dilemma in which they must consider how to effectively treat their patients with a level-2 or level-1 mask or without proper high-volume evacuation or are expected to return to work even though the equipment they need is on back order.”

She adds that because the guidelines are left open to interpretation, some practices require their staff to work even if they test positive for the virus. While this is a highly questionable decision, practices will start seeing more staff members test positive in the next few weeks and months, and they’ll need to have a protocol in place.

“This is going to happen in every dental practice in the country at some point,” Rohde says. “One of their staff members will test positive, not because they got it at work, but because they’re living their lives. People are still going to restaurants and birthday parties.”

One of Rohde’s staff members has already tested positive for the virus. The staff member didn’t have any symptoms and was tested as a precaution before seeing an elderly family member. When Rohde told his staff the next day, he says there was a collective panic.

“The whole worry was that doctors’ offices were going to suffer economic ruin from having to shut down for two weeks every time someone tests positive, but the CDC is saying not to panic and shut down,” he says. “They say that if a health care provider works with someone who has tested positive, but they’ve been wearing their mask around them, they don’t have to run out and get tested. If they weren’t wearing a mask around the person and were closer than six feet for more than 15 minutes, that’s considered high-risk exposure—in which case that person should quarantine and get tested.”

Rohde then came up with a clear set of guidelines, which he calls a decision tree.

“This isn’t going away any time soon, so you need to have those protocols,” he says. “Even if you think the steps on your plan are over the top, just have a plan. And know that the second you hear something new, you can update it.”

He advises answering questions such as, what do you do when a staff member or a patient tests positive? What do you do when a patient says they feel OK, but they have a sore throat? It takes some pressure off the staff to know how the practice will deal with these situations before they arise.

Flucke seconds that opinion. “One of my mentors told me that if I prepare for an emergency, then it ceases to be one,” he says. “So, when things like this happen, I plan for the worst-case scenario. I feel like I can plan around most of this and we’ll be just fine.”

Overall, the patient response has been positive. Some practices are seeing patients get defensive after being told they have to wear masks in the practice, but those are rare cases.

“I’ve had about five patients refuse to wear masks in the office and have instead elected to wait until masks aren’t required,” Flucke says. “I don’t think the sky is falling, but you do have to analyze what is safest, and cutting infections by wearing masks and washing your hands is the safest. I don’t know how it went from ‘masks prevent infection’ to ‘don’t oppress me.’”

For practices that weren’t very cautious about AGP before, these recommendations will bring lasting changes. After all, infection control standards and policies have been built on previous epidemics, Sanders says.

“Nobody was wearing gloves and masks in dentistry until the HIV/AIDS epidemic,” she says. “The industry was very cavalier when it came to bloodborne pathogens prior to that. Here we are on the other side of the spectrum with airborne pathogens, recognizing that perhaps we haven’t been cognizant of what the research was recommending, and that’s a problem.”

Sanders adds that it has been normal to show up to work sick and to treat patients who are sick in order to keep a productive schedule. Sick days for many are rare, and we may save them for vacation or childcare leave. But calling in with a fever and body ache now is taken much more seriously.

“These are things that we have needed to change in the culture of dentistry for a long time,” she adds. “The dental practices that are going to take this opportunity to pivot and do the right thing are going to rise to the top. We saw this with the HIV/AIDS epidemic: the offices that did not align with what was required of them in that moment, who had doctors reusing needles or improperly sterilizing equipment, had to send letters to their entire dental populations explaining that they were likely exposed to HIV and Hepatitis C. We’re going to see the same thing for the practices that force positive-testing employees to come in or who go back to doing things the way they were before.

“This is a big wakeup call for the dental community,” Sanders continues. “This is an opportunity for us to define ourselves as essential workers, given the work we do with inflammation to mitigate the risk of infections. This is our chance to pull up a seat at the table with all of the other medical providers who are truly doing integrative work for comprehensive patient care. Now is the time to elevate our standards and permit patients to expect better of us.”

Articles

As COVID-19 cases rise, dental professionals still feel a responsibility to their patients.

Safety fears changing practices after COVID-19

While the coronavirus disease 2019 pandemic rages unfettered, health care professionals must continue to treat patients. The Centers for Disease Control and Prevention (CDC) has recommended limiting elective procedures to decrease the risk of spreading COVID-19, they also advise implementing certain protocols to protect health care professionals and patients.

In a news release from the American Dental Association (ADA) published May 29, ADA President Chad Gehani, DDS, said, “Oral health is an important part of overall health. Resuming regular dental visits are important because treatment, as well as prevention of dental disease, helps keep people healthy. [Guidelines] from the ADA and the CDC give dental professionals the information they need to practice as safely as possible.”

Scientists believe it’s possible for a person to contract COVID-19 by touching an infected surface and then touching their face. However, the virus is thought to spread mainly from person to person, particularly when people are within 6 feet of each other and an infected person coughs, sneezes, or talks, producing droplets that can be inhaled by others nearby. Not everyone who is infected shows symptoms of COVID-19, so a person who is infected could unknowingly spread the virus.

The dental chair is an excellent location for the virus to spread if proper precautions aren’t taken. The CDC has published recommendations for dental health care personnel (DHCP) who expand care to non-emergency patients.

To help prevent the spread of COVID-19, the CDC earlier had recommended reducing facility risk by canceling elective procedures and offering telemedicine when possible. Other key recommendations include limiting points of entry, implementing source control for everyone who enters the facility, and screening for symptoms. However, because infected patients could be asymptomatic, it is necessary to act as if all patients and providers potentially are carriers.

To protect health care personnel, the CDC recommends emphasizing hand hygiene and limiting the number of staff providing care.

As dental practices see patients during the ongoing pandemic, staff will need to rely on 

American Dental Association COVID-19 Practice Resources: bit.ly/ADAPracticeResources. The ADA offers a slew of COVID-19 related resources for practices that are updated regularly, including:

Steps to follow when a patient tests positive for COVID-19

ADA State Mandates and Regulations: bit.ly/ADAStateRegs

An interactive map provides the latest information from state-to-state, including the current number of cases, mandates from the state government, and recommendations from state dental boards

ADA Mental Health Resources: bit.ly/ADAMentalHealth

Features online, on-demand courses covering stress, anxiety, and staying health
during the pandemic

Mental health resources from the National Alliance on Mental Health and the American Foundation for Suicide Prevention, among others

Centers for Disease Control and Prevention Guidance for Dental Settings: bit.ly/CDCDentalSettings. The CDC’s COVID protocol, last updated June 17, offers practices guidance covering:

Administrative controls and work practices

Sterilization and disinfection of patient-care items

CDC Infection Prevention and Control Recommendations for Healthcare Personnel: bit.ly/CDCIC

Screening for signs and symptoms of COVID-19

Implementing universal source control measures

Performing targeted SARS-CoV-2 testing of patients without symptoms

Creating a rapid response to SARS-CoV-2 exposure

personal protective equipment (PPE). However, the CDC states that PPE is the least effective control, as it depends on proper fit and correct, consistent use. Also note ongoing and intermittent shortages of PPE in the U.S., including N95 respirators, facemasks, eye protection, gowns, and gloves. Each facility is responsible for finding alternatives to protect their providers when recommended PPE is unavailable.

Alternatives to N95 masks include a respirator that offers a higher level of protection, such as other disposable filtering facepiece respirators, powered air-purifying respirators, or elastomeric respirators.

 N95 masks can be used for extended use (keeping the mask on for encounters with several patients) and limited reuse (using the same respirator for multiple patient encounters, but removing it between encounters), but the CDC advises the respirators be discarded following aerosol-generating procedures (AGP). The advised practice in the dental office is to don a new N95 respirator for each patient who is assumed to be non-contagious, as well as to use eye protection (goggles or full-face shield), gloves, and gowns.

The number of staff present during AGPs should be limited, and room surfaces should be cleaned and disinfected promptly. The Environmental Protection Agency’s “List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19),” lists disinfectants currently available as well as instructions for using them.

For more information about cleaning rooms and PPE, refer to the CDC’s “Clinical Questions about COVID-19: Questions and Answers.”

The CDC offers several recommendations for health care facilities to limit the risk of exposure and transmission of COVID-19. It’s important to remember these practices are recommended for all patients, not just those who are or may be infected.

CDC recommended infection prevention and control practices for routine activities during the pandemic include:

Implement telehealth and triage protocols, and postpone any non-urgent visits. Patients should reschedule non-emergency appointments if they have symptoms of COVID-19 on the day of the appointment.

Screen everyone who enters the facility for signs and symptoms of COVID-19. Make sure patients are wearing face coverings or face masks and take their temperatures. If a patient’s temperature is below 100.4° F and they are asymptomatic, dental care may be provided. Limit points of entry and post visual aids about wearing face masks and performing hand hygiene. The practice should also provide hand sanitizer, tissues, and no-touch trash cans.

Implement universal source control measures, such as wearing cloth face coverings or face masks that cover a person’s nose and mouth. The only people who should not wear masks are children under 2 and anyone who has trouble breathing or is unable to remove the mask without assistance. Patients should have their mouths and noses covered whenever they are not in the dental chair.

Implement universal use of PPE. This includes a face shield or goggles, a face mask, gloves, and an isolation gown.

Optimize engineering controls and indoor air quality. Use physical barriers and vacuum shrouds for aerosol-generating surgical procedures, as well as optimizing air-handling systems or adding a portable HEPA filtration unit where permanent air-handling systems are not an option.

Create a process to respond to exposures. Request that patients inform the practice if they develop symptoms or are diagnosed with COVID-19 within 2 days following their dental appointment. The practice should have a process for notifying the local health department of any suspected or confirmed cases of infection and performing contact tracing.

Staff should perform hand hygiene before and after all patient contact, after contact with potentially infectious material, and before donning and after removing PPE.

Hands should be washed with soap and water for at least 20 seconds and sanitized with alcohol-based hand sanitizer containing 60% to 95% alcohol.

All PPE should be in accordance with OSHA PPE standards

, and all staff should be trained on when to use PPE, what PPE is necessary, how to put on and take off PPE to prevent self-contamination, how to dispose of or disinfect and maintain PPE, and the limitations of PPE.

The CDC advises that chairs in the waiting room be placed at least 6 feet apart.

 Toys, magazines, and other frequently touched objects that can’t be regularly cleaned or disinfected should be removed from the waiting area. The number of patients in the waiting room should be kept to a minimum; avoid overlapping dental appointments.

Because practices are reopening after a period of closure, manufacturers’ instructions for use should be reviewed for the following: Dental unit waterlines, autoclaves and instrument cleaning equipment, air compressors, vacuum and suction lines, radiography equipment, high-tech equipment, amalgam separators, and other dental equipment. The CDC has published an article titled “Guidance for Reopening Buildings After Prolonged Shutdown or Reduced Operation” for further reference.

Health care personnel should limit clinical care to 1 patient at a time. Operatories should be set up so that only clean and sterile supplies needed for the procedure are readily accessible. Everything else should be in covered storage. Aerosol-generating procedures should be avoided in favor of minimally invasive and atraumatic restorative techniques that use hand instruments instead of ultrasonic scalers.

If AGPs can’t be avoided, the CDC recommends the use of 4-handed dentistry, high volume evacuation suction, and dental dams. They also recommend preprocedural mouth rinses such as chlorhexidine gluconate.

Because scientists are continuing to learn more about this virus, recommendations are constantly changing. It is strongly advised that you regularly consult the CDC, OSHA, and your state dental boards directly for any new information on providing treatment during this pandemic.

To ensure that everyone in the practice is on the same page, consult the ADA and Organization for Safety, Asepsis and Prevention (OSAP) webinar, “COVID-19 Response—CDC Guidance for Dental Settings,”

 which was recorded May 28 and is available on the ADA website for on-demand viewing, along with other webinars. Attendees can earn 1 continuing education credit from this course.

OSAP and DentaQuest have put together a comprehensive guide outlining the best practices for infection control during the pandemic,

which includes checklists about preparing the clinic for patient appointments and delivering safe patient care.

Because all of the resources pertaining to providing care during the COVID-19 pandemic are constantly being updated, consult the organizations on a daily basis, particularly the CDC’s Guidance for Dental Settings page, which includes key points and summaries of recent changes at the top of the page.

1. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Centers for Disease Control and Prevention.Updated July 15, 2020. Accessed June 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

2. List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19). United States Environmental Protection Agency. Updated July 9, 2020. Accessed June 2020. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19

3. Clinical Questions about COVID-19: Questions and Answers. Centers for Disease Control and Prevention. Updated July 7, 2020. Accessed June 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html

4. Regulations (Standards - 29 CFR). Occupational Safety and Health Administration. Accessed June 2020. https://www.osha.gov/laws-regs/regulations/standardnumber/1910

5. Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response.” Centers for Disease Control and Prevention. Updated June 17, 2020. Accessed June 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

6. Guidance for Reopening Buildings After Prolonged Shutdown or Reduced Operation. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/php/building-water-system.html

7. COVID-19 Response — CDC Guidance for Dental Settings (Recorded Webinar). American Dental Association. Accessed June 2020. https://ebusiness.ada.org/Education/viewcourse.aspx?ID=436

8. OSAP/DQP Best Practices for Infection Control in Dental Clinics During the COVID-19 Pandemic. OSAP and DentaQuest. Updated June 19, 2020. Accessed June 2020. https://cdn.ymaws.com/www.osap.org/resource/resmgr/dentaquest/INC-1353_Best_Practices_for_.pdf

During the pandemic, practices have had to navigate an ever-changing list of infection control guidelines and protocols.