On June 3, 2020, the Centers for Disease Control and Prevention (CDC) hosted a Clinician Outreach and Communication Webinar, which provided further clarification to the CDC’s Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response, as well as commentary on recent updates to the guidance.
Based on the guidance to date, we have prepared a list below of 10 key considerations as you reopen your dental office.1
Patient and Facility Management Strategies
Prior to Patients Entering the Office.2 Dental offices should contact all patients prior to dental treatment to assess need for in-office dental care, or whether at least initially, whether care can be provided via telehealth. If the provider determines that dental care should be provided in-office, the dental office should:
- When scheduling an appointment, request that patients limit visitors to the appointment to only those who are necessary (such as a parent or other caretaker) for public health reasons. If there is currently no waiting room for visitors – let the patient know that the visitor will need to remain in the parking lot/car.
- Advise patients that they and their visitors will be required to wear face covering and will undergo screening for fever and symptoms consistent with COVID-19. If supplies are adequate, dental offices should have extra surgical masks for patients who do not arrive with face coverings – which can be provided with or without charge. If the dentist decides to charge patients for provided surgical masks, the dentist should notify patients during the screening call to ensure compliance with surprise billing requirements.
- Call patients 24 hours prior to their appointment to remind them of their appointment and to determine if they have symptoms consistent with COVID-19 – do not text message with patients regarding whether they have COVID-19 symptoms;
- If the patient reports COVID-19 symptoms, explain that it is best to reschedule their appointment from a public health perspective.3
- If you cannot reach a patient prior to their appointment, ask patients when they call from the parking lot (or otherwise when they show up for their appointment) whether they are experiencing COVID-19 symptoms. If they are, reschedule the appointment.
Upon Patient Arrival at the Office. Dental offices should systematically assess all patients and visitors upon arrival to:
- Ensure patients and visitors are wearing a mask or cloth face covering, or provide a surgical mask (see guidance above). If they are not, gently remind them that it is legally required in order to be seen for the appointment. For instance, if they are calling from the parking lot – remind them that they need a mask. It also helps to put a sign on the door that no one should enter without a mask.
- Ask about the presence of fever or other symptoms consistent with COVID-19.
- Actively check the patient’s temperature. If the patient is afebrile (has a temperature below 100.4˚F), is without symptoms consistent with COVID-19, and the patient confirms that neither they nor a family member has had close contact with a person with COVID-19, then dental care may be provided.
- If, however, a patient arrives with suspected or confirmed COVID-19 or has a temperature of over 100.4 ˚F, the dental office should reschedule the appointment and either (i) send the patient home with a recommendation to contact their primary care provider; or (ii) if the patient is acutely sick, refer the patient to a medical facility (or offer to call someone who can), or call 911 as needed.
If emergency medical care is necessary for a patient with suspected or confirmed COVID-19, and the person is not able to safely leave the dental office (and is therefore waiting for an ambulance or family member), the patient should be escorted to and from an individual room set up for COVID-19 patients with a closed door and private bathroom, if possible.
Dental offices should consider alerting other patients and employees who were in the office on the same day (as the infected patient) about the suspected COVID-19 infection (without disclosing patient name or identifiers).4
The dental office should follow the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, including the use of respirators for staff and cleaning and disinfecting procedures implemented at the office.
Patient Placement. Individual patient rooms are preferred for the provision of dental treatment. If individual rooms are not possible because the dental office has an open floor plan, the dental office should, prior to opening (or if already open, as soon as possible):
- Ensure at least six (6) feet of space between patient chairs.
- Place physical barriers between patient chairs and explore the possibility of easy-to-clean floor-to-ceiling barriers that do not interfere with fire sprinkler systems. If applicable, dental offices should discuss with their landlords whether costs associated with physical barriers can be shared or otherwise require permission from the landlord for installation.
- If possible, operatories should be aligned with the direction of airflow into the space to help with dispersing airborne particles.
- If feasible, the patient should be directed with their head away from pedestrian corridors, near the return air vents (in the manner noted above),5 and towards the rear wall when there are vestibule-type office layouts. If not sure if this requirement is being met by the office, we recommend consulting with an HVAC professional to ensure the chairs are appropriately positioned.
- Cleaning Procedures Between Patients.6 Dental offices should wait at least 15 minutes after completion of treatment and exit of each patient to clean and disinfect the dental operatory.7 For emergency medical care for patients with COVID-19, dental health care personnel (DHCP) should delay entry into the operatory until sufficient time has elapsed for enough air changes to remove potentially infectious particles. Calculations for sufficient time to elapse for the removal of 99% of airborne particles are provided by the CDC – likely at least one hour to be safe.8
- Post-Treatment. Dental offices should ask patients to put their face covering back on upon completion of treatment and request that patients inform the dental clinic if they develop symptoms or are diagnosed with COVID-19 within 14 days after the dental appointment. Dental offices will need to develop a tracking mechanism for its patients, including maintaining a log and contact information of visitors that accompany each patient so that if an individual reports having had COVID when visiting the office, the office is able to track when such person was at the office and notify others appropriately.9
Hygiene and Precautions. Dental offices should practice strict adherence to hand hygiene. Proper hand hygiene practices should include:
- Providing supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rubs with 60–95% alcohol, tissues, and no-touch receptacles for disposal, at facility entrances, waiting rooms and patient check-ins.
- Ensuring that hand hygiene supplies are readily available to all DHCP in every care location.
- DHCP performing hand hygiene immediately before and after any contact with their own or the patient’s facemask or cloth face covering. Patients should also be instructed to perform hand hygiene immediately before and after any contact with their own facemask or cloth face covering.
- Performing hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves.
- Using alcohol-based hand rubs with 60–95% alcohol, or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled with blood or other bodily fluids, wash your hands with soap and water before returning to using alcohol-based hand rubs.
Dental offices should also ensure that all patients, visitors, and staff adhere to respiratory hygiene and cough etiquette, and post visual alerts at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) to patients and staff about hand hygiene, including how and when to perform hand hygiene, the requirement to wear a cloth face covering or facemask, respiratory hygiene and cough etiquette and the screening requirements.
Waiting Room. Dental offices should take steps to minimize the number of persons waiting in the waiting room. Such steps may include:
- Requesting that only necessary visitors (e.g., caretaker or guardian) accompany the patient to the dental visit.
- Allowing patients to wait in their cars or outside the facility, where they can be contacted by mobile phone when it is their turn for dental care.
- Minimizing overlapping dental appointments.
Also, we are seeing dental offices require that no individuals sit in the waiting room except for necessary visitors (e.g., caretaker or guardian) accompanying patients to the dental visit. Patients may call the front desk when they arrive and be escorted immediately and directly to the dental office room when it is their time to receive treatment. We recommend advising patients that visitors should remain in their car in the parking lot, if possible.
If the dental offices are comfortable having patients in the waiting room, the dental office should install physical barriers (e.g., glass or plastic windows) at the reception area to limit contact between triage personnel and potentially infectious patients, and place chairs in waiting rooms at least six (6) feet apart. Prior to making such changes, dental offices should consult with their landlord as applicable—including whether costs can be shared or permission is required before making any changes to the space. Toys, magazine, and other frequently touched objects that cannot be regularly cleaned or disinfected, should be removed.
- Ventilation System. The dental office’s HVAC and ventilation system is key in mitigating the spread of COVID-19 though airborne particles—along with patient placement during treatment and other facility considerations detailed in this summary. Dental offices should discuss with their landlord and an HVAC professional whether any of the recommendations detailed in the Engineering Controls section of the CDC guidance can be implemented at their office. Such requirements may be more easily implemented in new constructions or offices currently under renovation. We do not believe that the CDC is suggesting that offices expend significant capital or cause further delays to reopening to implement these guidelines; however, the CDC guidelines should be considered given the risks associated with individual offices, patient population, community spread and other factors.
Dental Treatment and Dental Settings. Dental offices should ensure that DHCPs stay with one patient until dental care is complete.10 Dental offices should also, when possible, avoid aerosol-generating procedures (such as the use of dental hand pieces, air/water syringe and ultrasonic scalers). If aerosol-generating procedures are necessary for dental care, the dental office should:
- Use four-handed dentistry, high evacuation suction, and dental dams to minimize droplet splatter and aerosols.
- Only personnel essential for patient care and procedure support should be present during the procedure.
DHCPs must wear facemasks or cloth face covering at all times while they are in the treatment setting and should wear such coverings while not actively providing treatment to a patient. DHCPs should also take steps to prevent self-contamination, and follow CDC’s Healthcare Personnel with Potential Exposure Guidance for potential work exposure.
Monitor and Manage DHCPs. Dental offices should both ensure that DHCPs regularly monitor themselves for fever and symptoms consistent with COVID-19, screen all DHCP at the beginning of their shift for fever and symptoms consistent with COVID-19, and implement flexible, non-punitive sick leave that is consistent with public health guidance.11
Dental offices should ensure that DHCPs are properly educated and trained about when, how, and where cloth face coverings can be used, and provide job- or task-specific education and training on preventing transmission of infectious agents. DHCPs should also be trained on the appropriate use of PPE prior to caring for a patient, and be trained on health care respiratory protection.12
Additionally, only dental supplies and instruments needed for a dental procedure are readily accessible. All other supplies and instruments should be in covered storage to avoid potential contamination. Any supplies and equipment that are exposed but not used during treatment, should be considered contaminated and be disposed of or reprocessed properly.
We are happy to discuss any of the above guidance or recommendations.
Sample Additional State Guidance
The below is a summary of state-specific guidance in addition to the CDC guidance highlighted above. Please let us know if you have questions about the below or other state specific requirements.
California – On May 7, 2020, the California Department of Public Health (CDPH) released Guidance for Resuming Deferred and Preventive Dental Care. The guidance references the approaches detailed in resources from the CDC, ADA, OSHA, and the California Dental Association, and includes some additional requirements that should be reviewed by dental professionals. Additional requirements include:
- Patients with active COVID-19 infections should not receive dental treatment in the dental office. Dental offices and medical providers should work together to determine an appropriate facility for treatment.
- For patients with suspected or confirmed COVID-19 infections, dental offices should wait to provide treatment until at least 72 hours since the last fever without anti-fever medications and improved respiratory symptoms, and at least 10 days since symptom onset.
- Procedures on patients with COVID-19 should be carried out in accordance with Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard.
- Dental offices must be aware of county or local orders that may be more stringent than the public health orders.
- It is strongly recommended that dental offices have a minimum two-week supply of PPE.
- Dental offices should have written procedures for screening patients for COVID-19 based on CDC guidance.
Florida – As of May 4, 2020, pursuant to Governor Ron DeSantis’ Executive Order 20-112, elective procedures are allowed to resume in dental offices. The executive order is not specific to dental offices; however, relevant requirements include:
- A facility must have adequate supplies of PPE to complete all medical procedures and respond to COVID-19 treatment needs, so that the facility does not need to seek assistance from the federal or state government for shortages.
- A facility must not have sought any federal, state, or local assistance for PPE since reopening to perform elective procedures.
- A facility must not have refused to provide support to or proactively engage with skilled nursing facilities, assisted living facilities, and other long-term care residential providers.
In addition, the Florida government’s COVID-19 website for health care providers references other CDC guidance and includes a Clinical Screening Tool for Identifying Persons Under Investigation with COVID-19 and Priorities for Testing Patients with Suspected COV-19 Infection.
Illinois – As of May 11, 2020, the Illinois Department of Public Health (IDPH) revised its Interim Guidance to recommend the resumption of routine oral and dental care. The revised guidance references the approaches detailed in resources from the CDC, ADA, and OSHA. Additional details in the revised guidance include:
- The potential to incorporate COVID-19 testing into the provision of care.
- The risk of aerosol production for different oral and dental procedures.
Massachusetts – As of June 6, 2020, Massachusetts Health and Human Services released its Reopening Approach for Phase 2 of the Commonwealth’s four-phase reopening plan. Effective June 8, 2020, Phase 2 allows health care providers to cautiously and incrementally resume in-person, elective, non-urgent procedures and services, such as routine dental visits. The guidance is not specific to dental offices; however, it includes:
- Attestation requirements for specific capacity criteria, public health standards, compliance standards, and Phase 2 considerations.
- Routine preventative dental care, including cleanings, as an example of new services to begin in Phase 2.
New York – As of May 31, 2020, the New York State Department of Health released Interim Guidance for Dentistry During the COVID-19 Public Health Emergency, which details the minimum requirements for a dental office to reopen in the state as of June 1, 2020. The guidance is substantially similar to CDC guidance, although it includes some additional requirements that should be reviewed by dental professionals. Additional requirements include:
- Dental offices must maintain logs that include the date, time, and scope of cleaning and disinfection.
- Requirements to maintain screening questionnaires and contact logs.
- Requirements to appoint a central point of contact responsible for receiving and attesting to the questionnaires, and a site safety monitor responsible for continued compliance with the office’s safety plan.
- If emergency dental care is necessary for a patient with COVID-19, the dental office should conform to the CDC’s Interim Infection Prevention and Control Recommendations or refer to a facility that is able to conform to the recommendations.
Texas – Beginning May 1, 2020, pursuant to Governor Greg Abbot’s Executive Order (GA-19), all licensed dental professionals must comply with emergency rules promulgated by the Texas State Board of Dental Examiners. Guidance provided by the Board references the CDC guidance, and is substantially similar, although it includes some additional requirements that should be reviewed by dental professionals. Additional requirements include:
- Dental offices should create COVID-19 procedures and provide training to DHCP on these procedures.
- Dental offices should encourage DHCP to receive their seasonal flu vaccine.
- Dental offices should consider their staff’s susceptibility to COVID-19 in determining tasks for particular staff to perform.
- DHCP should check their temperature twice a day, regardless of symptoms.
- We recommend reviewing the CDC’s presentation and guidance as you prepare to reopen your dental offices, as well as the CDC’s Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic. Every dental office should also stay informed by regularly consulting with the Occupational Safety and Health Administration (OSHA), as well as state and local health departments for updates regarding reopening of dental offices and healthcare facilities. Finally, the CDC made it clear that its Guidelines for Environmental Infection Control in Health-Care Facilities from 2003 and updated in 2019 (the 2003 Guidance) was still in effect.
- CDC guidance includes a tiering of precautions based on community transmission rates, with stricter precautions for communities experiencing minimal to moderate or substantial community transmission. Most of our clients should strive for the stricter requirements in anticipation of a potential second wave of COVID-19 infections.
- The CDC released a telephone script with accompanying decision algorithm and messages. Screening procedures should incorporate this guidance, as well as information provided by state and local authorities.
- The CDC’s benchmark for potential exposure is that the patient must have had prolonged close contact (within six (6) feet for at least 15 minutes). Even if there is no potential exposure in such circumstances, dental offices should have a process for notifying local health departments about known or suspected cases of COVID-19, and should develop a plan, in consultation with local health departments, for how potential exposures will be investigated and contact tracing will be performed. The alerts to the other patients in the office must not identify the patient with the COVID-19 infection.
- See drawing on Slide #26 of the Clinician Outreach and Communication Webinar.
- List N on the EPA website includes EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.
- 15 minutes is an interim recommendation developed for dental settings. The CDC indicated during the presentation that it will continue to review this information and update its recommendations accordingly.
- During the June 3 webinar, the CDC provided an example of this calculation that resulted in a recommended wait time of 42 minutes to clean and disinfect after completion of treatment on a patient with COVID-19. The CDC referred providers to the chart on Page 223 of the 2003 Guidance for more information. The highest wait period was 138 minutes for rooms in which the air changes per hour equal two (2).
- The CDC recommends contact tracing for anyone with prolonged close contact (within six (6) feet for at least 15 minutes) with the person with COVID-19. Dental offices should perform a risk assessment for DHCP who had prolonged close contact with the patient, and perform contact tracing for patients and visitors who had prolonged close contact to the patient. Dental offices should follow the process for investigating potential exposure and contact tracing discussed with local health departments, and notify local health departments about known or suspected cases of COVID-19.
- If DHCPs provide care to multiple patients at once, DHCPs should follow the Using Personal Protective Equipment (PPE) section of the CDC guidance with respect to discarding certain PPE after each use, and properly cleaning, decontaminating, and maintaining reusable PPE after and between uses.
- Please see U.S. Employer Return-to-Work FAQs for additional guidance on the challenges employers face as they re-open including as related to employee screening. See also Top 9 Operational Challenges for Offices with Phase 3 Guidance from Illinois and the City of Chicago for an example of state requirements regarding employee screening procedures.
- The CDC has released guidance on Strategies to Optimize the Supply of PPE and Equipment, which includes strategies for optimizing the supply of gloves, gowns, eye protection, face masks, N95 respirators, and higher-level respirators in response to PPE shortages. The CDC has also released guidance on Factors to Consider When Planning to Purchase Respirators from Another Country. This guidance should help you acquire respirators that have been properly tested and approved.
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