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Patient Safety Tip
of the Week
May
5, 2020 COVID-19 and the Dental Office
We’ve done several columns on patient safety in
dental practice. But COVID-19 certainly raises a new concern. Most dental
practices had closed (except for emergencies) during the current COVID-19
pandemic. But many are now preparing to re-open as some of the state-imposed
restrictions are being relaxed. You should be concerned not only if you are a
dentist or work in a dental office, but also if you are a patient needing
dental care or services.
The basic concern is
that the nature of dental instruments, particularly high
speed drills, makes aerosolization unavoidable. So
it is incumbent upon all dental practices to ensure that their staffs and their
patients are protected against exposure to coronavirus.
A lot of planning
needs to take place prior to re-opening a dental practice. Considerations include: patient and staff screening procedures, infection
control procedures, maintaining social distancing, scheduling, staff education
and training, patient education, alternate workflows, inventory of PPE,
contingency planning, and others.
We’d start with an inventory of PPE (personal
protective equipment). Your inventory of PPE should also take
into account your likely “burn” rate (i.e. how fast you will go through
your PPE supplies). If hospitals are any indicator of “burn” rates, make sure
your estimates of PPE needs are adequate. Important: If your dental office
is unable to secure the appropriate PPE to safely operate, your practice should
not reopen until it is obtained.
Of course, PPE (personal protective equipment)
is of greatest concern. CDC guidelines (CDC
2020a) recommend, during aerosol-generating
procedures (e.g. use of dental handpieces, air/water syringe, ultrasonic
scalers), put on one of the following:
an N95 respirator or a respirator that offers
a higher level of protection such as other disposable filtering facepiece
respirators, powered air-purifying respirators (PAPR’s), or elastomeric
respirators. CDC has a good section on PPE (personal protective equipment),
including sections on “How to Put On (Don) PPE Gear” and “How to Take Off
(Doff) PPE Gear” that include posters and a video (CDC
2020c).
PPE also includes
appropriate eye protection. CDC states “Before entering the patient room
or care area, put on eye protection (i.e., goggles or a full
face shield that covers the front and sides of the face).” It notes
that personal eyeglasses and contact lenses are NOT considered adequate eye
protection. If respirators are not available and surgical masks are used, wear
a full-face shield.
Clean gloves
and gowns are also needed before entering the room.
The CDC guideline (CDC 2020a) also has recommendations on removal, disposal or disinfection
of all PPE on leaving the room.
Dental healthcare facilities should ensure
that hand hygiene supplies are readily available to all dental healthcare
personnel in every care location.
But even before PPE,
office practice management needs to change to meet the new COVID-19
world. The Indiana Dental Association (Indiana is one of the first states
re-opening dental practices) has several practical recommendations (IDA 2020):
- Ask patients to wait in their cars and call the
office to “check in” once they have arrived and have a staff member call
or text the patient when a treatment room is available.
- Escort the patient directly to the treatment
room where he or she may fill out any required paperwork and answer any
medical health questions while sequestered.
- Wipe down the clipboard and writing utensil
after each patient has completed check-in paperwork.
- Discourage patients from bringing companions to
their appointment, except pediatric patients, people with special needs,
elderly patients, etc. In those cases, limit companions to just one.
- Remove magazines, reading materials, toys and
other objects that may be touched by others and which are not easily
disinfected.
- Print and place signage in the dental
office for instructing patients on standard recommendations for
respiratory hygiene/cough etiquette and social distancing.
- Schedule appointments far enough apart to
minimize possible contact with other patients in the waiting room.
- Allow time to disinfect and set up the room for
the next patient.
- Surfaces such as door handles, chairs,
desks, elevators, and bathrooms should be cleaned and disinfected
frequently.
CDC has guidelines
and recommendations that are updated as needed (CDC 2020a). First, it is important to make sure your own staff does not
expose patients or other staff to COVID-19. CDC says “Implement sick leave
policies for DHCP that are flexible, non-punitive, and consistent with
public health guidance, allowing employees to stay home if they have symptoms
of respiratory infection. Ask staff to stay home if they are sick and send
staff home if they develop symptoms while at work.”
Next, you need to
assess patients for the likelihood that they might be harboring coronavirus. CDC
recommends you telephone triage all patients in need of emergency dental
care. You should assess the patient’s dental condition and determine whether
the patient need to be seen in the dental clinic. Use teleconferencing or teledentistry options as alternatives to in office care. If
dental treatment can be delayed, provide patients with detailed home care
instructions and any appropriate pharmaceuticals.
If emergency dental
care is medically necessary for a patient who has, or is suspected of having
COVID-19, airborne precautions (an isolation room with negative pressure
relative to the surrounding area and use of an N95 filtering disposable
respirator for persons entering the room) should be followed. Dental treatment
should be provided in a hospital or other facility that can treat the patient
using the appropriate precautions.
Practices should pre-screen
patients (with a phone call the day prior to a visit) for symptoms of COVID-19.
In addition to the classic symptoms of fever, cough and shortness of breath,
CDC has recently updated its list of COVID-19 symptoms and signs to include
chills, repeated shaking with chills, muscle pain, headache, sore throat, and new
loss of taste or smell (CDC 2020b). If the patient has symptoms suggestive of COVID-19 they should
be referred to their medical provider and perhaps referred to a hospital that
has dental capabilities and takes care of COVID-19 patients.
If a patient must be
seen in the dental clinic for emergency care, CDC recommends you systematically
assess the patient at the time of check-in. The patient should be asked about
the presence of symptoms of a respiratory infection and history of travel to
areas experiencing transmission of COVID-19 or contact with possible patients
with COVID-19. If the patient is afebrile (temperature < 100.4˚F) and
otherwise without symptoms consistent with COVID-19, then emergency dental care
may be provided using appropriate engineering controls, work practices, and
infection control practices.
Some practices will
undoubtedly use touchless thermometers to screen patients. But we see problems
with that. First, some dental patients, such as those with a dental abscess,
may have a fever and not have COVID-19. Second, many patients may be in an
asymptomatic phase of COVID-19 yet be capable of shedding virus. So, as below,
you need to assume that every patient might be harboring coronavirus and take
appropriate safety precautions.
In Japan, dentists
will be allowed to take nose and throat swab samples to test patients for the
novel coronavirus (Neuman 2020). Allowing onsite testing for COVID-19 in dental practices may
be a consideration. However, given that false negative tests may occur, one
cannot rely on a single negative test to conclude the patient does not harbor
the coronavirus responsible for COVID-19. Just as we adopted universal
precautions back when HIV first appeared, we need to assume that every
patient might harbor COVID-19 and use the same precautions for all patients.
Social distancing
should be practiced in the dental office. You should ensure that patients are
able to sit at least 6 feet apart in the waiting area and that also requires
that scheduling of patients is such that there will never be more than a set
number of patients in the waiting room at one time.
CDC made several revisiions on April 27, 2020 to its guidelines for dental
settings (CDC 2020a), including:
- To address asymptomatic and pre-symptomatic
transmission, implement source control (require facemasks or
cloth face coverings) for everyone entering the dental setting
(dental healthcare personnel and patients), regardless of whether they
have COVID-19 symptoms
- Actively screen everyone
on the spot for fever and symptoms of COVID-19 before they enter the
dental setting
- Actively screen dental healthcare
personnel on the spot for fever and symptoms before every shift.
All patients should wear facial masks in the waiting
area. The dental practice should have masks available for those patients who
did not wear their own mask. You also need to have alcohol-based hand
sanitizer available in the entrance, waiting area, and any other site where
patients or staff should be disinfecting their hands. (Keep in mind that
washing hands with soap and water is actually preferable to use of
alcohol-based hand sanitizers but soap and water is not practical in the
waiting area.) You should also make available tissues and no-touch receptacles
for disposal at facility entrances, waiting rooms, bathrooms, and patient
check-ins.
If dental care is
indicated, CDC recommends certain work practices and certain ones to avoid. For
example, you should avoid aerosol generating procedures whenever possible.
Avoid the use of dental handpieces and the air-water syringe. Use of ultrasonic
scalers is not recommended during this time. Prioritize minimally
invasive/atraumatic restorative techniques (hand instruments only). If aerosol
generating procedures are necessary, use four-handed dentistry, high evacuation
suction and dental dams to minimize droplet spatter and aerosols. The
number of dental healthcare personnel present during the procedure should be
limited to only those essential for patient care and procedure support.
Visitors should not be present for the procedure.
Dental healthcare
personnel should wear a facemask at all times
while they are in the dental setting. When available, surgical masks are
generally preferred over cloth face coverings for dental healthcare personnel because
surgical masks offer both source control and protection for the wearer against
exposure to splashes and sprays of infectious material from others. Cloth face
coverings should NOT be worn instead of a respirator or facemask if more
than source control is required.
CDC notes that some dental
healthcare personnel whose job duties do not require PPE (such as clerical
personnel) should continue to wear their cloth face covering for source control
while in the dental setting. Other dental healthcare personnel (such as
dentists, dental hygienists, dental assistants) may wear their cloth face
covering when they are not engaged in direct patient care activities and then
switch to a respirator or a surgical mask when PPE is required. Dental
healthcare personnel should remove their respirator or surgical mask and put on
their cloth face covering when leaving the facility at the end of their shift.
Education of all
staff about PPE is important. Dental facilities should provide dental
healthcare personnel with training about when, how, and where cloth face
coverings can be used including frequency of laundering, guidance on when
to replace, circumstances when they can be worn in the facility, and the
importance of hand hygiene to prevent contamination. Dental facilities should
provide all staff with job-specific training on PPE and have them
demonstrate competency with selection and proper use (putting on and removing
without self-contamination). Because cloth face coverings can become saturated
with respiratory secretions, dental healthcare personnel should take steps to
prevent self-contamination, including:
- change the coverings if they become soiled,
damp, or hard to breathe through
- coverings should be laundered daily and when
soiled
- perform hand hygiene immediately before
and after any contact with the cloth face covering
The CDC guideline (CDC 2020a) also has recommendation on cleaning and disinfecting rooms and
equipment. Also included are sections on post-exposure guidance and contingency
and crisis planning.
The American Dental
Association’s Interim Guidance for Minimizing Risk of COVID-19 Transmission (ADA 2020) has sections on:
- Dentist and Dental Team Preparation
- Screening for COVID-19Status and Triaging for
Dental Treatment
- Instructions for Patient Arrival
- Standard and Transmission Precautions and
Personal Protective Equipment (PPE)
- Clinical Technique (Handpieces, Equipment,
etc.)
- Steps After Suspected, Unintentional Exposure
- In Between Patients
- Post-Operative Instructions for Patients
- When Going Home After a Workday
In addition to state
and local health departments, OSHA, CDC and the American Dental Association
oversee workplace safety. Remember: before you re-open you need to protect
your patients, your staff, and yourselves.
Also note that many
of the recommendations above, especially those related to practice management,
scheduling, staff training, etc., are also useful for any type of medical
practice.
Some of our
previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
July 2019 “Dental Prescribing Called Into Question”
September 2019 “New Guidelines for Pediatric Dental Sedation”
References:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
CDC (Centers for Disease Control and
Prevention). Coronavirus Disease 2019 (COVID-19). Using Personal Protective
Equipment (PPE). CDC 2020; April 27, 2020
https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
IDA (Indiana Dental Association). Indiana
Dental Association COVID-19 Task Force: Interim Guidance and Recommendations.
https://i6nif33omr43m6n4h1w9uvq8-wpengine.netdna-ssl.com/wp-content/uploads/task-force-guidance.pdf
CDC (Centers for Disease Control and
Prevention). Coronavirus Disease 2019 (COVID-19). Symptoms of Coronavirus. CDC
2020; April 27, 2020
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Neuman S. Japan To
Allow Dentists To Conduct Coronavirus Tests. NPR 2020;
April 28, 2020
ADA (American Dental
Association). ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission.
Last Updated: April 1, 2020
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