Healthy Communities

COVID-19 Guidance for Dentists

Effective May 11

Dental facilities and dental health care providers (DHCP) may resume services that require minimal protective equipment on May 11, 2020. Since dental work often creates aerosols, it carries an added risk of spreading COVID-19, especially to the DHCP, who may then spread it to others. Recommendations are following the CDC and other professional organization guidance to keep patients, DHCPs and the community safe. 
 
Screening Guidelines
  • To address asymptomatic and pre-symptomatic transmission, implement source control (require facemasks or cloth face coverings) for everyone entering the dental setting (DHCP and patients), regardless of whether they have COVID-19 symptoms.
  • Actively screen everyone (DHCP and patients) on the spot for fever (≥100.4°F) and symptoms of COVID-19 (fever, cough, shortness of breath, difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell) before they enter the dental setting.
  • Patient presents with an ASA III (and above) systemic disease;
  • Aged 65 and older that presents with an ASA III (and above) systemic disease.
Patients who meet the following criteria SHOULD NOT BE TREATED at this time:
  • Have returned from overseas travel or from states/metropolitan areas considered hot spots for COVID-19 spread within the last 14 days;
  • Have a fever of 100.4°F+ or greater (DHCPs should use digital thermometer to check each patient prior to treatment);
  • Have symptoms associated with COVID-19 (listed above);
  • Had contact with a person known to be infected with COVID-19 within the previous 14 days;
  • Have compromised immune system;
  • Patient presents with an uncontrolled ASA 2 (and above) systemic disease;
  • Aged 65 and older that presents with an uncontrolled ASA 2 (and above) systemic disease. 
Management of Patients  
 
Patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. It may not be possible to know the cause of any patient’s illness, so it is always important to follow this guidance and standard precautions. 
  • Seek to prevent the transmission of respiratory infections in healthcare settings by adhering to respiratory hygiene/cough etiquette.
  • All patients should be screened in a phone interview prior to the appointment.  Patients with an acute respiratory illness should be identified during a phone screening interview and defer treatment unless it is an emergency case. This emergency patient should be asked to remain in their automobile until summoned directly to the treatment area.
  • Reception rooms should:
    • Follow screening guidelines for all patients as indicated above;
    • Only allow the patient and caregiver, if patient is a minor or elderly that requires assistance, into the office/reception area. If possible, place seating arrangement to allow maximum distance between patients;
    • Provide tissues and no-touch receptacles for used tissue disposal.
    • Remove all magazines, journals, TV remotes, toys or any other objects that may typically be handled by patients.  
Treatment Considerations of Patients 
 
Universal precautions are to be strictly followed in order to minimize the possibility of disease transmission. Because of the frequent production of aerosols during dental treatments, the ADH recommends the following:  
  • Dental team members that are 65 years of age and older may provide dental treatment provided said member passes the daily screening process and does not have an uncontrolled ASA 2 or higher systemic disease condition.
  • The ADA has provided guidelines for mask types for consideration for dental healthcare providers for utilization during patient treatment. Utilization of N95 masks, or comparable type, is the recommended standard for the treatment team (dentist, dental hygienist, dental assistant) which provides the lowest risk of infection to the DHCP during the COVID-19 pandemic. Clerical staff should always wear surgical masks. For additional guidance, refer to the ADA's Return to Work Interim Guidance Toolkit.
  • Patient and dental healthcare workers should perform hand hygiene (e.g., hand washing with antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after possible contact with respiratory secretions and contaminated objects/materials.
  • Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management for COVID-19 (see links below).
  • Patients should use a preprocedural mouth rinse of 1% hydrogen peroxide or 0.2% provodine to reduce the oral microflora;
  • If treatment requires the use of dental instruments which produces aerosols:
    • In addition to the respiratory masks mentioned above, the treatment team members should also consider face shields or goggles, long sleeve jacket or gown and gloves.
    • Using a dental dam is considered the best isolation of the treatment area;
      • Place HVE (high-volume evacuation) as close to the surgical site as possible to capture the generated aerosols.
      • Other HVE devises such as Isolite, Dry Shied, Zirc Mr. Thirsty etc. may be deemed suitable.
      • Avoid the use of ultrasonic or piezo instrumentation during this early return to practice unless aided by a four-handed approach to better capture aerosols.
  • Potentially contaminated aerosols may linger in the treatment room.
    • If possible, isolate the room until proper disinfectant protocols can be performed (see below links).
    • Wipe down all surfaces, replace barriers and display a sign indicating when the room has been cleared. 
Procedure Room Disinfection 
  • Personnel must wear recommended PPE to wipe down all surfaces.
  • Clean and disinfect procedure room surfaces (including faucet handles and all other handles in room).
  • Follow the contact times, as appropriate for the disinfectant product used, assuring the surface being disinfected stays wet for the duration of the recommended time (refer to product label).
  • PPE should be doffed upon leaving the treatment room, immediately followed by performing hand hygiene procedures. 
Information on disinfectants for use against SARS-CoV-2, the virus that causes COVID-19:
Procedure for Disinfection of PPE: 
  • While there is a shortage of vital PPE such as N95 respirators, the CDC has recommended decontamination methods here.
The return to a safe practice of dental services should be considered in phases while keeping a mindful watch on the pandemic and its effect on Arkansans. Guidance of treatment that is considered permissible during each phase can be found in the Arkansas State Board of Dental Examiners May 1 memo. Movement into the subsequent phases will be determined by data gathered and reviewed by the Arkansas Department of Health. Announcements for extending services will be disseminated via the Board of Dental Examiners, the Arkansas State Dental Association, the Arkansas State Dental Hygiene Association and the ADH website. 
 
Phase I
  • Prioritize treatment to focus on addressing dental decay, active periodontitis and preventive services.
  • Reduce patient schedule load to minimize interpersonal contact in reception and business areas of the facility.
  • Allot longer appointment times to allow proper disinfecting protocols to be completed. The goal is to reduce the ‘rapid turnover’ and allow surface disinfectants the proper amount of time to be effective.
  • Limit dental hygiene procedures to hand instrumentation and slow speed hand piece for coronal polishing.
    • Do NOT use ultrasonic/piezo/sonic instrumentation at this time unless a four-handed treatment modality can be achieved.
    • Other HVE as mentioned above should be considered as well.
  • Implement procedures to minimize exposures after procedures:
    • Ask patients to wash their hands for 20 seconds and to wear their mask when they leave the treatment area.
    • When possible, provide all necessary information to patients in the procedure room to avoid congregation at the front desk/waiting area on their way to exit the clinic.
    • Complete paperwork electronically before or after the appointment if possible. 
Phase II
  • Adhere to Phase I, but consider increasing volume, while still allowing enough time for room disinfection. 
Phase III
  • Maintaining an adherence to the proper screening and disinfectant protocols that have been established, the DHCP may utilize their own judgement regarding the patient flow and treatments that are performed.

Resources:

 

Public Health Accrediation Board
Arkansas Department of Health
© 2017 Arkansas Department of Health. All Rights Reserved. www.healthy.arkansas.gov
4815 W. Markham, Little Rock, AR 72205-3867
1-800-462-0599