Novel Coronavirus: What Your DSO or Dental Group Needs to Know *Updated 3/18/2020* ADA Calls Upon Dentists to Postpone Elective Procedures

Updated 3/18/2020

The Association of Dental Support Organizations held a teleconference board meeting discussing the COVID-19 pandemic. One of the many things discussed was the definition of essential vs. non-essential dental care. Please click HERE to read the guide.

Updated 3/16/2020

ADA Calls Upon Dentists to Postpone Elective Procedures (March 16, 2020)

The American Dental Association (ADA) recognizes the unprecedented and extraordinary circumstances dentists and all health care professionals face related to growing concern about COVID-19. The ADA is deeply concerned for the health and well-being of the public and the dental team.

In order for dentistry to do its part to mitigate the spread of COVID-19, the ADA recommends dentists nationwide postpone elective procedures for the next three weeks. Concentrating on emergency dental care will allow us to care for our emergency patients and alleviate the burden that dental emergencies would place on hospital emergency departments.

As health care professionals, it is up to dentists to make well-informed decisions about their patients and practices. The ADA is committed to providing the latest information to the profession in a useful and timely manner.

The ADA is continually evaluating and will update its recommendation on an ongoing basis as new information becomes available.

If you have questions that are not answered by the FAQ, please email [email protected].


Dentists are urged to view the Centers for Disease Control and Prevention COVID-19 situation webpage for current insight. Standard precautions should be taken with all patients, at all times.


Availability of Personal Protective Equipment

The CDC has not changed its guidance on single-use disposable facemasks, which are regulated by FDA to be single use and should be worn once and discarded.

Page 41 of the CDC Guidelines for Infection Control in Dental Health-Care Settings has the following guidance:

  1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering of blood or other body fluids;
  2. Change masks between patients, or during patient treatment if the mask becomes wet.

CDC urges Dental Health Care Personnel (DHCP) concerned about healthcare supply for PPE to monitor Healthcare Supply of Personal Protective Equipment for updated guidance, and to be familiar with the Interim Infection Prevention and Control Recommendations.

The CDC guidelines notes that, in cases when a patient presents with symptoms of a respiratory infection, DHCP may consider postponing non-emergency or elective dental procedures until a patient is no longer contagious with diseases that may be transmitted through airborne, droplet, or contact transmission (e.g., sneezing, coughing, and contact with skin).

If urgent dental treatment is necessary, DHCP and medical providers should work together to determine the appropriate precautions on a case-by-case basis to avoid the potential spread of diseases among patients, visitors, and staff. Because dental settings are not typically designed to carry out all of the Transmission-Based Precautions that are recommended for hospital and other ambulatory care settings, DHCP and medical providers will need to determine whether the facility is an appropriate setting for the necessary services for a potentially infectious patient.

Prevention of Suspected Respiratory Disease Transmission in the Dental Healthcare Setting

Patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. The primary infection control goal is to prevent transmission of disease. CDC recommends a multi-step approach that begins before the patient arrives at the practice and includes guidance regarding their arrival and for the complete duration of the affected patient’s presence in the practice.

It may not be possible to know the cause of any patient’s illness so it is important to follow this guidance and standard precautions at all times.

Infection control issues during patient assessment:

Acute respiratory icon
  • Patients with an acute respiratory illness should be identified at check-in and placed in a single-patient room with the door kept closed.
Cough etiquette icon
Disposable mask icon
  • Offer a disposable surgical mask to persons who are coughing; and provide tissues and no-touch receptacles for used tissue disposal.
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  • Ill persons should wear a surgical mask when outside the patient room.
Patient assessments icon
  • Dental healthcare personnel assessing a patient with influenza-like or other respiratory illness should wear disposable surgical facemask*, non-sterile gloves, gown, and eye protection (e.g., goggles) to prevent exposure. Since recommendations may change as additional information becomes available it’s a good idea to check the CDC website for COVID-19 updates.
Hand hygiene icon
  • Patient and dental healthcare workers should perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after possible contact with respiratory secretions and contaminated objects/materials.
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*Until additional specific information is available regarding the behavior of COVID-19, the guidance provided in the “Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission” is recommended at this time. Also recommended is a review of Prevention Strategies for Seasonal Influenza in Healthcare Settings.

Summary

Respiratory hygiene/cough etiquette infection control measures along with contact precautions are currently recommended for preventing transmission of COVID-19 and all flu-like illnesses in a dental healthcare setting. CDC continues to monitor activity relating to COVID-19 and is coordinating efforts with health departments in Arizona, California, Illinois, Massachusetts, Washington, and Wisconsin and communicating with the World Health Organization. This is an evolving situation and CDC is updating its guidance and information as it becomes available.


Updated 3.15.20 – The following information is sourced directly from OSHA, OSAP,  ADA, and  US Department of Labor.

Dentists should advise patients (and staff) who are experiencing acute respiratory illness, including symptoms of fever, cough or shortness of breath, to remain home and reschedule appointments.

Dental health care personnel should be alert and identify patients with an acute respiratory illness when they arrive for their appointment.

Dentists are advised to continue to screen all patients for recent travel to any locations confirmed by the Centers for Disease Control and Prevention to have confirmed cases of COVID-19, also known as the new coronavirus. Any travel completed between December and now is considered recent travel. As part of the screening, dentists should also verify when the patient returned to the United States. Dentists can check the list daily until health officials report that screening is no longer necessary.

Appropriate questions to screen patients for coronavirus could include asking if the patient has traveled internationally in the last 14 days or has been in close contact with another person who has been diagnosed with or under investigation for COVID-19, and whether the patient has a cough, fever or shortness of breath.

If the patient reports that at least two weeks have passed since their return from one of the CDC-reported countries and no symptoms have presented, the dental office can proceed with the appointment.

To help prevent the transmission of all respiratory infections, dental practices should adhere to respiratory hygiene/cough etiquette infection control measures, such as performing hand hygiene, providing tissues and no-touch receptacles to throw away used tissues and offering face masks to patients who are coughing. Offices also should follow routine cleaning and disinfection strategies used during flu season.

Some commonsense recommendations include:

  • Screen patients for international travel, signs or symptoms of infection when you update their medical histories.
  • Include temperature readings as part of your routine assessment of the patient prior to performing dental procedures.
  • Make sure the personal protective equipment you are using is appropriate for the procedures performed.
  • Use a rubber dam whenever possible to decrease possible exposure to infectious agents.
  • Use high speed evacuation for all dental procedures producing an aerosol.
  • Autoclave your hand pieces after each patient.
  • Have your patient rinse with 1% hydrogen peroxide before each appointment. Coronavirus is vulnerable to oxidation; this will reduce the salivary load of oral microbes.
  • Clean and disinfect public areas frequently, including door handles, chairs, and bathrooms.

Every procedure and every patient is unique. Appropriate personal protective equipment should be available when instruments that produce an aerosol are used and it’s a good idea to consider using high speed evacuation in those cases since aerosol spread is one way that coronavirus can be transmitted. Of course, since no single answer can apply to every possible situation, dentists and hygienists should use their best professional judgment to determine what instrumentation should be needed for a particular procedure.

The CDC recommends using “social distancing” whenever possible as an effective way of decreasing the likelihood of transmitting coronavirus. On March 7, 2020, the agency updated its definition of social distancing to mean “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.”

With that advice in mind, consider implementing these steps in your practice:

  • ask patients to arrive on time for their appointments, rather than too early, since that will minimize the amount of time they spend in your waiting room or reception area
  • remove magazines, reading materials, toys and other objects that may be touched by others and which are not easily disinfected
  • schedule appointments to minimize possible contact with other patients in the waiting room
  • while physical barriers may reduce or eliminate exposure to coronavirus, installing glass partitions may not be feasible in all practices.

Employers should consult with legal counsel before requiring an employee who recently traveled to China or through any region where there has been an outbreak of the virus to stay home from work to ensure the employer is not violating the Americans with Disabilities Act or any local, state or federal anti discrimination laws.

The CDC’s interim guidance also covers the importance of ensuring that “sick leave policies are flexible and consistent with public health guidance” and provides recommendations on practicing good hand hygiene in the workplace.

Dentists should review their office policies and discuss with their employees any current or needed efforts to prevent the spread of the virus.

If you suspect a patient or employee has COVID-19, contact your local health department immediately if you suspect a patient has COVID-19. You can also contact your state health department.

HIPAA’s Privacy Rule allows covered entities to disclose needed protected health information to public health authority responding to a public health emergency.

If a patient with a confirmed case of COVID-19 requires urgent dental treatment, the dentist and the patient’s medical providers should work together to determine the appropriate precautions on a case-by-case basis: this coordinated approach is critical in order to ensure that the risk of potential spread of disease among patients, visitors, and staff is kept as low as possible.

Because dental settings are not typically designed to carry out all of the Transmission-Based Precautions that are recommended for hospital and other ambulatory care settings, dentists and medical providers will need to determine whether the facility is an appropriate setting for the necessary services for a potentially infectious patient. It may be necessary for treatment to be performed in a healthcare setting that offers the additional protections that should be maintained in these cases.

Personal Protective Equipment – PPE

The type of personal protective equipment (PPE) that should be worn will depend upon the procedures being performed. Under OSHA, PPE is considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

CDC’s guidance for single-use disposable facemasks has not changed. These masks are tested, and regulated by FDA to be single use. CDC’s position is that a new facemask should be for each patient. CDC’s specific guidance for facemasks is on page 41 of the Guidelines:

  1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering of blood or other body fluids;
  2. Change masks between patients, or during patient treatment if the mask becomes wet.

LEVEL 1 MASKS
Masks that have been rated Level 1 have the least fluid resistance, bacterial filtration efficiency, particulate filtration efficiency, and breathing resistance. These can be worn for procedures where low amounts of fluid, spray or aerosols are produced, for example, patient evaluations, orthodontic visits, or operatory cleaning.

LEVEL 2 MASKS
Level 2 masks provide a moderate barrier for fluid resistance, bacterial and particulate filtration efficiencies and breathing resistance. These can be used for procedures producing moderate to light amounts of fluid, spray or aerosols. Some examples of procedures are sealant placement, simple restorative or composite procedures or endodontics.

LEVEL 3 MASKS
Level 3 masks provide the maximum level of fluid resistance recognized by ASTM and are designed for procedures with moderate or heavy amounts of blood, fluid spray or aerosol exposure. Some examples of these procedures are crown or bridge preparations, complex oral surgery, implant placement, or use of ultrasonic scalers.

CDC has more information on the differences between N-95 respirators and surgical masks. If the decision is made to use respirators in your facility, OSHA does maintain requirements for medical evaluation and fit-testing in their toolkit for health care use of respirators.

Practices experiencing difficulty obtaining personal protective equipment (PPE) may have to triage patients as a way to ensure that adequate PPE is available for patients whose appointments are most urgent.

If your office is concerned about a potential or imminent shortage of PPE, CDC recommends you alert your state/local health department and local healthcare coalition, as they are best positioned to help facilities troubleshoot through temporary shortages. You can also report the shortage to the FDA at [email protected].

CDC recommends that Dental Health Care Personnel (DHCP) concerned about healthcare supply for PPE regularly monitor Healthcare Supply of Personal Protective Equipment for updated guidance. They should also be familiar with the Interim Infection Prevention and Control Recommendations.

OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) requires that workers be protected from exposures to blood and body fluids that may contain bloodborne infectious agents. OSHA’s Personal Protective Equipment standard (29 CFR 1910.132) and Respiratory Protection standard (29 CFR 1910.134) require protection for workers when exposed to contact, droplet and airborne transmissible infectious agents.

Interim CDC guidance for businesses and employers recommends that employers now encourage employees who report symptoms of acute respiratory illness to stay home and not return to work until they are free of symptoms for at least 24 hours.

The Department of Labor’s has ongoing efforts to educate the workers and employers about the COVID-19 outbreak:

  • In addition to the guidance, OSHA recently launched a COVID-19 webpage that provides infection prevention information specifically for workers and employers, and is actively reviewing and responding to any complaints regarding workplace protection from novel coronavirus, as well as conducting outreach activities.
  • The Wage and Hour Division is providing information on common issues employers and employees face when responding to COVID-19, including effects on wages and hours worked under the Fair Labor Standards Act and job-protected leave under the Family and Medical Leave Act.
  • The Office of Workers’ Compensation Programs has also published guidance for federal employees and outlines Federal Employees’ Compensation Act coverage as it relates to the novel coronavirus.

OSHA just released (3.15.20) Guidance on Preparing Workplaces for COVID-19. Read HERE.

Sources: ADSOOSHA, OSAP,  ADA, and  US Department of Labor


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