The First Line of Defense Against Infection in the Dental Practice

The National Institute for Occupational Safety & Health’s (NIOSH) hierarchy of controls offers a series of methods in which dental practices can protect team members from harm. At the very bottom of the hierarchy, the last line of defense is personal protective equipment (PPE), but even before that, there are a series of recommended mechanisms that can head off potential dangers. The first and best way to mitigate is eliminating the hazard altogether, and this is where front desk staff plays a critical role. They can serve as gatekeepers, even preventing at-risk patients from entering the practice.

Play it Safe

“Administrative controls are an interesting part of that diagram, because it tells us by modifying the way we work, we can do things to mitigate a hazard,” infection prevention consultant Katherine Schrubbe, RDH, BS, MEd, PhD says. “Thanks to the pandemic, we’ve become more aware of that. At the very top, we have elimination. Elimination means things like vaccination and not taking care of people that come to the front desk that are obviously ill, or those patients who call and say, ‘I really don’t feel well today. I’m sick.’ That’s elimination. You’re eliminating that hazard.

“That’s a huge deal, because the front desk teams are the first line of defense,” she continues. “The people who sit at the front desk many times ask, ‘Should we sit through OSHA training too? Isn’t that just for the clinical people?’ And I always say, ‘No. The entire team should participate. And you–the reception area team–you’re the first people that get coughed on.”

Given the past 3 years, it might be easy to forget that diseases beyond SARS-CoV-2 exist. But there are other concerns that front desk staff can help detect.

“We not only screen for COVID-19, but now we’re hitting flu season,” Dr Schrubbe says. “There’s going to be other respiratory infections out there with patients. We don’t really want to bring any respiratory infections into the practice. So that kind of messaging is important.

Patients are still faced with screening questions that enter the dental setting. The pandemic has spurred that protocol. We probably should have been asking these questions all along because respiratory issues are a problem, no matter what. If we’re going to generate aerosols and we have a patient that presents with any type of respiratory infection, we don’t really want that patient in the office, period.”

Guidance

The Centers for Disease Control and Prevention (CDC) guidance is somewhat of a moving target. Most recently, CDC revised its guidance as it relates to the interim infection prevention and control recommendations for healthcare personnel in September 2022.

“Even though we are this far into the pandemic, it is still recommended to establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2,” Olivia Wann, JD, the founder of Modern Practice Solutions, says. “So, we should still post visual alerts at the entrance, and they even recommend dating the alert so they don’t think it’s outdated information, and it’s key to have a process to make everyone entering the facility aware of recommended actions to prevent transmission. Most dental offices are sending out screening questions via text to ward off anybody coming in with symptoms or having been exposed to COVID, as well as repeating this screening process when they’re in the office.”

The most recent guidance eases requirements for patients coming to the practice, but that doesn’t mean front desk staff should be any less vigilant.

“People are getting more relaxed,” Wann says. “CDC’s latest recommendations indicate that healthcare personnel could choose not to require universal source control when community transmission levels are not high. Granted, if it’s the office policy to continue wearing source control, that’s up to the practice owner.

“We had a support question which was, ‘Can we reinstate our coffee bar?’” she continues. “Well, there’s nothing in the guidance that says you cannot have a coffee bar, but what the owner or the management should consider is, ‘What’s the risk of infection and cross-contamination with the coffee bar?’ ‘Are the straws single wrapped?’ And, just like my law office, if somebody wants a cup of coffee, we’ll make it for them rather than touching all the cups and straws and whatnot. This decision would be a policy directive of the dental practice itself, rather than what is currently being addressed in the CDC guidance.

“And that’s true, too, of magazines,” she continues. “When the pandemic initially hit, they did not recommend having reading material in the lobby area where multiple people are touching it. Currently, we’re going into flu season. Would that not be a good practice to continue minimizing the touch surfaces?”

Messaging

It isn’t just when patients come to the practice that problems can be detected. When they are called or texted for appointment reminders, that is an ideal time to keep them informed or even prevent an infectious patient from coming in.

“There is a lot of messaging that could be conveyed during an appointment confirmation,” Dr Schrubbe observes. “A lot of our electronic patient record systems now will send a text message for a confirmation, and they can modify and specify that messaging to say that if you have any COVID symptoms, if you’ve had a positive test, if you’ve been exposed, please let us know. We’ll reschedule, but even beyond COVID-19, it could be as simple as if you’re sick, please call us and we’ll reschedule.”

“They should certainly inquire if they have symptoms of COVID, and they may want to be specific in stating symptoms such as cough, fever, runny nose,” Wann adds. “And really, even if it’s not COVID–they have a fever and a runny nose or they are coughing–it may indicate flu or even the cold that’s contagious. So perhaps the COVID 19 pandemic gave us better control on not permitting patients to access care that’s not an emergency.”

Reception

The reception area is the first place where patients are exposed to the practice, and it is an important location to begin the practice’s infection prevention efforts. Something as simple as hygiene stations or signage can help in those efforts.

“Long before the pandemic, CDC recommended having hand sanitizer, a waste receptacle, a box of tissue, and even displaying the ‘Cover Your Cough’ poster,” Wann says. “That’s certainly not mandatory, but just reminding individuals to practice respiratory etiquette.”

“You should have a box of tissues available for everybody in the reception area,” Dr. Schrubbe adds. “And you should have a hand-free receptacle, like a small waste basket so that people who use that tissue have a place to put it, otherwise, they’ll leave it on your coffee table or on your front desk.”

Some simple signs posted in the reception area both remind patients of respiratory safety steps along with conveying an overall message of wellbeing.

“If we take a step back, the CDC guidance says that part of our standard precautions is to include respiratory hygiene and cough etiquette into our protocols,” Dr Schrubbe adds. “Pandemic or not, when I provide OSHA/CDC trainings or give a CE program, we talk about making sure that protocol is implemented, and that is a simple thing. It means you have hand sanitizer available in the reception area. That means you have signage somewhere in the practice that says, ‘Cover your cough’, or ‘Tell us if you’re sick’, or things related to respiratory issues.”

CDC’s recommendations are dynamic. That is, they aren’t etched in stone. While taking temperatures was commonplace last year, that requirement has been eased.

“We do not need to take temperatures,” Dr Schrubbe observes. “The CDC removed the practice of taking temperatures quite some time ago, because fevers were not always indicative of a COVID-19 infection. A patient may present with a fever, but maybe it is be related to a dental infection or even something more systemic, such as an ear infection. The current CDC guidelines say we should still be screening our patients, and depending on the level of community transmission, that’s going to drive whether to mask or not to mask.”

The reception area is its own environment, somewhat subtly, as infection control is concerned. These days, the front desk staff’s efforts are more apparent. But, there are small things that can be done to subliminally convey a feeling of safety.

“A lot of practices have put their reception areas back together, but if you watch closely, it’s very interesting,” Dr Schrubbe says. “Patients come in and they naturally separate from each other. The human behavior that we have now, unless it’s a mom and a child or maybe a married couple, people don’t sit in the next chair. They don’t sit next to a stranger. They actually seem to naturally separate themselves now.

“According to current guidance, any type of public high-touch areas, should be routinely cleaned and disinfected,” she continues. “Those common high-touch areas like the doorknobs, door handles , reception desks, consult room tables, should be cleaned at least once a day. Wipe them down. You can buy an over-the-counter disinfectant wipe from Home Depot, Target, or wherever. Do not use your clinical, EPA-registered, intermediate-level disinfectants in your reception area. Those are specified for blood and body fluids. You can buy your basic Clorox wipes or household cleaning wipes to use in the common non-clinical areas. I also think that coming into a practice that looks noticeably pristine and clean at check-in and checkout, in restrooms and consult rooms is important and sets the tone for a safe clean patient environment. Even just a very mild scent of a cleaning product can have a positive impact.”

The reception area may seem like just a couple of staff members behind the desk checking in patients, verifying insurance coverage, or setting up a 6-month prophy visit. Beyond those administrative duties, those team members serve as the practice’s front line of defense in the war on infection.