We decided to close our dental offices nationwide in mid-March, before guidelines from government and organized dentistry were clear. We did this to protect our patients and our teams, prevent the spread of the COVID-19 virus, and make PPE available to hospitals.
In advance of reopening, we have created new protocols to enhance our already-proactive approach to protect the health and safety of our patients, teams and communities. The following protocols meet or exceed Federal, State, and Local guidelines.Click the links below for more information.
PRIOR TO REOPENING
- Deep clean entire dental office to include:
- De-cluttering of all work areas -- All signs, models, and equipment that are not being used on the specific patient coming in are to be stored either inside a cabinet or at least 6 feet from the patient. All counters must be cleared and emptied except for equipment that will be used specifically on the next patient.
- Wipe all surfaces with EPA-approved disinfectantusing wipe/wipe technique.
- Install and run medical-grade air filtration system that filters air particulates down to 0.01 microns in each operatory.
- Install easy-to-read social distancing signage in prominent places as well as signage asking patients to contact the office should they develop COVID-19 symptoms within two days of their visit.
- Install plexiglass guards at the front desk, if a pedestal desk, then mark point 6 ft. away for patient to stand on and staff may be asked to wear a face shield.
- Use scripts/FAQ's to help staff consistently and accurately answer patient questions related to COVID-19.
- Run, purge, shock, and disinfect water lines prior to reopening and periodically per CDC and ADA guidelines.
- Check for the proper functioning of all equipment and re-sterilize prior to reopening and periodically per CDC and ADA guidelines.
- Check inventory of all supplies including disinfectants, cleaners and PPE prior to reopening and on a weekly basis thereafter. We should have at least two weeks worth of PPE in stock.
- Team members will complete a temperature, oximetry and symptom check daily and will send logs in weekly.
- Team members experiencing influenza-like-illness (ILI) at any time such as fever at or temperature above 100 degrees and/or with either cough or sore throat, muscle aches, loss of taste/smell, chills, sore throat or those who have had close, prolonged contact with a COVID-19 positive individual (15 min or more with no face covering or mask) will alert their supervisor and the Chief Dental Officer and not report to work. Employees may be asked for medical clearance or COVID-19 testing prior to approval of their return to work.
- All front line team members will be required to receive the flu vaccine within thirty (30) days of it becoming available unless medically advised against it, in which case a medical clearance will be required and employee will be asked to wear a mask at all times while at work. This is mandatory, however, exceptions may be made as allowed by the State.
- If one of our team members is at a higher risk of contracting COVID-19 due to CDC recognized factors such as age above 65, a pre-existing condition causing immunosuppression such as cancer, diabetes, pregnancy, history of chemotherapy, severe obesity (BMI above 40), moderate to severe asthma, serious liver, kidney or lung conditions, or are otherwise immunocompromised, and that individual is concerned about returning to work, that individual should consider contacting his/her primary physician for further guidance in addition to Human Resources at 949-305-2464 to discuss options. (see [Ref. B] HIGH RISK CONDITIONS AND RISK FACTORS PER THE CDC)
- Team members will be screened with touchless temporal infrared thermometer and pulse oximeter on a daily basis prior to their shift upon arrival while still maintaining social distancing measures, and a log will be sent to the Chief Dental Officer on a weekly basis. If any team member has a temperature over 100 degrees or an oximeter reading of 92% or under, the Chief Dental Officer and HR shall be immediately notified and employee is to be sent home and medical clearance will be requested prior to return.
- As of 6/17, the CDC is no longer requiring a 15 minute wait on cleaning a room after a patient has been seen. Please refer to the Respiratory Protocol to see recommended wait times for aerosol producing procedures.
- Stagger patient appointment times to avoid the congregation of people.
- Send screening questions to patient prior to arrival at the office (see [Ref. C] COVID-19 SCREENING QUESTIONS ). Screening questions shall be answered prior to arrival. If patient answers yes to any of the questions, a teledentistry appointment is to be offered instead of an in-person visit, and patient will be referred to their medical provider and asked to self-quarantine for 14 days based on current public health guidelines. The patient’s chart should be documented in progress notes and a flash alert created.
- Add "buffer" time in between each patient to allow for deeper disinfection and to further improve the ability to avoid the congregation of people.
- Wait a minimum of 15 minutes after a patient leaves to start cleaning the room if there were aerosols, significant splash or splatter.
- Build schedules based on emergent priorities (patients who are in pain, emergencies, crown seats; patients referred out to specialty requiring follow-up; patients who are mid-treatment or have conditions that could worsen should care be delayed etc.). . For a period of time that will be determined based on government and dental industry guidelines, we will prioritize ADA-defined emergency and urgent patients(see [Ref. A] WHAT CONSTITUTES A DENTAL EMERGENCY?) that are not considered high risk per CDC guidelines(see [Ref. B] HIGH RISK CONDITIONS AND RISK FACTORS PER THE CDC)
- Patients with COVID-19 who have symptoms and were directed to care for themselves at home in order to be eligible for dental care may discontinue home isolation and be eligible for dental care under the following conditions:
- Option 1: At least 3 days (72 hours) have passed since recovery, [which is defined as a resolution of fever without the use of fever-reducing medications, and improvement in respiratory symptoms (e.g., cough, shortness of breath)] and, at least 10 days have passed since symptoms first appeared
- Option 2: Resolution of fever without the use of fever-reducing medications and, improvement in respiratory symptoms (e.g., cough, shortness of breath) and, with negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected? 24 hours apart (total of two negative specimens). (per ADA Interim Guidance)
- All patient communications and all patient information will be HIPAA-protected by Onsite Dental.
- Send screening questions to patient prior to arrival at the office(see [Ref. C] COVID-19 SCREENING QUESTIONS ). Screening questions shall be answered prior to arrival. If the patient answers yes to any of the questions, a teledentistry appointment is to be offered instead of an in-person visit, and the patient will be referred to their medical provider and asked to self-quarantine for 14 days. The patient's chart should be documented in progress notes and a flash alert created.
- Patients should also be screened upon arrival to make sure answers have not changed. Their pre-screening temperature and blood oxygenation (to be taken chairside) must be noted in their charts. Pulse oximeters are to be disinfected before and after each use.
- Inform patients that due to space restrictions, they cannot bring anyone with them to their appointment.
- Inform patients not to bring excess materials/baggage with them (coats, backpacks, etc.); however, they can bring their phones to take pictures of post-op instructions as we will not be providing printed copies of any paperwork. Our goal is to be as touchless (and therefore paperless) as possible.
- Signage must be posted at all public entrances requesting that all individuals:
- 1.experiencing any symptoms described in the screening questions (which should also be listed) do not enter the facility
- 2.maintain six feet of social distancing between one another
- 3.avoid physical contact such as shaking hands
- 4.use a face covering as much as possible
- The protocols shall be posted.
PATIENT ARRIVAL PROTOCOL
- All personnel including front desk staff will wear masks at all times and social distance during breaks and lunch times. Common areas such as break rooms and restrooms shall be disinfected before and after each use and hands thoroughly washed for at least 30 seconds.
- If patients wish to, or if the waiting room does not allow for appropriate social distancing (at least six feet apart), they may wait in their personal vehicle or outside the facility where they can be contacted by a mobile phone when it is their turn to be seen. This can be communicated to patients during appointment scheduling, based on established office procedures.
- Each reception area will have markers indicating where patients should sit or stand to maintain social distancing. For offices without sufficient reception area space for six feet of separation between patients, no more than one patient and one team member will be at the front desk at the same time.
- Practice Manager/Front Desk will squeeze hand sanitizer (with a minimum of 60% alcohol) on patients hands upon pre-screening.
- Patient will receive a temperature check conducted by Practice manager/Front Desk performed by a touchless infrared temporal thermometer and answers to pre-screening questions verified; Should a patient’s temperature be above 100.4, allow for patient to cool down and check for a second time if patient has been sitting in a hot car or standing outside in the sun. Provide the patient a mask and refer patient to their medical provider should their temperature remain above 100.4. Should a patient’s oximetry reading (taken chairside) present at 92 or below, check for dark nail polish, review medical history to rule out COPD, asthma, hand circulation issues. Retake for a second time while patient is still to confirm reading. If reading is still 92 or below, dentist to review medical history and if necessary in their clinical judgement, refer to their medical provider.
- Practice Manager/Front Desk will re-confirm that the screening questions previously sent to patients are still a no (see[Ref. C] COVID-19 SCREENING QUESTIONS). If the patient answers yes to any of the questions, patient will be asked to leave the office, call their doctor, and self-quarantine based on current public health guidelines.Alternatively, patient may call back to reschedule if symptom free for a minimum of 14 days.
- Patient will receive a temperature check conducted by Practice manager/Front Desk performed by a touchless infrared temporal thermometer and will be screened with a pulse oximeter. Should a patient’s temperature be above 100, allow patient to cool down and check for a second time, if patient has been sitting in a hot car or standing outside in the sun. Provide the patient a mask and refer patient to their medical provider should their temperature remain above 100. Should a patient’s oximetry reading present at 92 or below, check for dark nail polish, review medical history to rule out COPD, asthma, hand circulation issues. Retake for a second time while patient is still to confirm reading. If reading is still 92 or below, refer to their medical provider.
- Once cleared, the patient will proceed to operatory. Providers will wait for the patient in the operatory and not walk over to the front desk until the patient has been cleared by the practice manager. Clinical staff should remain at least six feet away from the reception area.
- Once seated and prior to procedure, patients will rinse and gargle with commercially available rinse that contains 1.5% hydrogen peroxide or Providine just prior to beginning treatment.
- Wipe down additional surfaces (door handles, desks, walls,etc.), above and beyond normal disinfection protocol, in between each patient and every time a patient enters and leaves the office.
- Wipe down signature pads, IPADS, signature pens and attached pens before and after each patient use, or use barrier tape alternatively for each patient.
- iPads and signature pens and pads must be wiped down after before and after each use.
- Remain fully paperless to minimize patient physical contact with objects.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
- All OSD team members will wear face masks at all times, including front office(see [Ref. D] MASK USE).Team members that are required to use an N95 or KN95 due to their role, will undergo an initial mask fit test.
- Provide PPE to patients who request it, and instruct them how to use it.
- Train teams, and re-train them weekly, on proper donning and doffing of PPE https://youtu.be/syh5UnC6G2k
- Hold a minimum of 14 days of PPE in inventory, including N95 or KN masks, face shields and disposable gowns.
- All team members will thoroughly wash their hands or sanitize before and after each patient visit and at the end of the day and change out of their work clothes and shoes before going home. . Team members may opt to soak shoes in 10% bleach solution, however, please note that soles may wear out faster. Disposable booties will not be offered due to the fact that they are very slippery and could cause accidents. Team members will change from scrubs to personal clothing before returning home. Upon arriving home, if they have not done so, team members should take off shoes, remove and wash clothing (separately from other household residents and at a high temperature), and immediately shower before greeting family members.
- Each team can decide which head covers to use. Practice Managers/Front Desks do not require head covers unless they are assisting clinically.
- Dentist and team will use Optradam rubber dam or latex alternative such as nitrile and/or Xuction HVE, Isolite or Mr. Thirsty for all aerosol-producing procedures.
- Hygienists will perform all procedures with Xuction HVE, Mr. Thirsty, or Isolite and Sweep Prophy splatter-reducing brush.
1. [Ref. A] WHAT CONSTITUTES A DENTAL EMERGENCY?
Use this for prioritizing patient scheduling after an office reopens.
Dental emergencies are potentially life-threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:
- Uncontrolled bleeding
- Cellulitis or a diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromises the patient's airway
- Trauma involving facial bones, potentially compromising the patient's airway
Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These, which should be treated as minimally invasively as possible, include:
- Severe dental pain from pulpal inflammation
- Pericoronitis or third-molar pain
- Surgical post-operative osteitis, dry socket dressing changes
- Abscess, or localized bacterial infection resulting in localized pain and swelling
- Tooth fracture resulting in pain or causing soft tissue trauma
- Dental trauma with avulsion/luxation
- Dental treatment required prior to critical medical procedures
- Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
- Biopsy of abnormal tissue
Other urgent dental care includes:
- Extensive dental caries or defective restorations causing pain -- Manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)
- Suture removal
- Denture adjustment on radiation/ oncology patients
- Denture adjustments or repairs when function impeded
- Replacing temporary filling on endo access openings in patients experiencing pain
- Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa
Routine or non-urgent dental procedures include but are not limited to:
- Initial or periodic oral examinations and recall visits, including routine radiographs
- Routine dental cleaning and preventive therapies
- Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma) or other issues critically necessary to prevent harm to the patient
- Extraction of asymptomatic teeth
- Restorative dentistry including treatment of asymptomatic carious lesions
- Aesthetic dental procedures
2.[Ref. B] HIGH RISK CONDITIONS AND RISK FACTORS PER THE CDC
Use this for screening and protecting higher risk patients during initial reopening period. Higher risk patients will be scheduled at a later date based on public health and dental industry guidelines.
- Moderate to severe asthma
- Chronic lung disease
- Serious heart conditions
- Chronic kidney disease being treated with dialysis
- Severe obesity
- People aged 65 years and older
- People living in nursing homes or long-term care facilities
- Immunocompromised- Transplant patients, cancer patients, any patient with a history of chemotherapy, for example
- Liver disease
3. [Ref. C] COVID-19 SCREENING QUESTIONS
Use these to screen patients over the phone before the patient presents to the office, and reconfirm upon arrival.
Please advise if in the last fourteen (14) days you have experienced the following:
- Dry cough? Yes / No
- Shortness of breath or difficulty breathing? Yes / No
- Fever or feeling feverish? Yes / No
- New loss of sense of taste or smell? Yes / No
- Close contact with a COVID-19 positive individual? Yes / No
- Chills with or without repeated shaking? Yes / No
- Fatigue/muscle pain? Yes / No
- Headache? Yes / No
- Sore throat? Yes / No
- Congested or runny nose? Yes / No
4. [Ref. D] MASK USE
Masks are a required part of routine safe patient care, and the selection depends on several factors including the ASTM level for the type of procedure being performed, comfort, and cost. Below are the mask level recommendations for different dental procedures per the American Society for Testing and Materials Standards (ASTM) and OSAP, however, due to the current COVID-19 pandemic, the CDC recommends use of N95 respirators particularly when performing an aerosol producing procedure:
- Level 1 masks (low protection at ≥ 95% BFE and PFE) are suitable for brief examinations, exposing radiographs, and cleaning tasks.
- Level 2 masks (moderate protection at ≥ 98% BFE and PFE) are preferable for procedures that involve a moderate level of aerosols such as hand instrumentation and sealants.
- Level 3 masks(high level of protection at ≥ 98% BFE and PFE) are used for procedures involving high levels of aerosols such as ultrasonic scaling, surgical procedures, and crown preparation.
Please note: Although a level 2 mask would be sufficient for exposing radiographs and routine dental hygiene procedures such as hand scaling, a level 3 mask is preferred when performing tasks such as ultrasonic instrumentation. Depending on the frequency of powered instrumentation use, it might be wise to continue to use level 3 masks.
The 2003 CDC guidelines recommend masks be changed between patients when they become wet from breath or splash, and during patient care with highly aerosolized procedures. Wet masks can lead to microbial penetration, making the mask ineffective. Masks should create a seal covering the nose and mouth and be comfortable without any gaps, which may allow microorganisms to penetrate. https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
- Occupational Safety and Health Administration. Bloodborne Pathogens Standard Regulations (Standard 29 CFR. 1910.1030). Available at: osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051. Accessed May 8, 2018.
- Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):1–61.
- Food and Drug Administration (FDA). Guidance for Industry and FDA Staff: Surgical Masks. Available at: fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm072549.htm. Accessed May 8, 2018.
- Molinari J, Nelson P. Face masks what to wear and when. The Dental Advisor. October 18, 2014.
- Molinari J, Nelson P. Face mask performance: Are you protected? Available at: medicom.com/uploads/files/Medicom%20Face%20Mask%20Performance
- %20Article_v3(1).pdf. Accessed May 8, 2018.
- American Society for Testing and Materials Standards (ASTM). ASTM F2100–11. Standard Specification for Performance of Materials Used in Medical Face Masks. Available at: astm.org/Standards/F2100.htm. Accessed May 8, 2018.
July 7, 2020