Dental care workers are at the front lines of exposure in any pandemic where oral droplets are a primary means of transmission. Still, dental care is vital, necessary to the overall health and well-being of patients, and it cannot be put off forever. Regular dental care is important to maintain progress in fighting caries disease and fighting serious infections in the mouth. It also keeps such infections from developing in the first place. So, it’s understandable that many offices across the country are facing hard decisions about when to reopen.
Balancing patient health needs and the safety of office staff is incredibly tricky, particularly when facing a pathogen that is still being researched and about which the information and understanding is constantly evolving. Worse still, the financial pressures involved in keeping your practice closed are real and need to be weighed as you consider the public good. As you wrestle with the difficult decision about how and when to open your practice (or how to continue operating your practice), there is some guidance available from the CDC. Additionally, the American Dental Hygienists Association (ADHA) has released interim guidance on returning to work during this difficult time, when regulation and recommendations vary widely by state. So, as you make your plans, you’ll want to keep the following in mind:
1. Are you are following regulations specific to your area?
As of right now, each state has its own recommendations for dental practices and mandates for dental practices. The American Dental Association has an interactive map and tracking tool, keeping information on the evolving situation nationwide with updates to the site Monday through Friday. Your local regulations should, first and foremost, inform your decision to keep your practice open or closed. The CDC still recommends postponing elective procedures and prioritizing urgent care. Further, since states are updating regulations and recommendations as the situation changes, you will need to actively monitor your state and national guidance to be sure you remain compliant.
2. Do you have enough supplies to open safely?
With national difficulty in obtaining adequate personal protective equipment (PPE), it’s vital for you to take stock of what supplies you have, what supplies you can still reliably obtain, and how long those supplies will allow you to care for patients. Your team will need full sets of protective equipment—gloves, single use gowns, properly fitted N95 or better respirators or, in the event respirators are unavailable, surgical masks with full face shields—for each patient treated in your office. Because your staff will need to change out PPE between each patient, you’ll also need to have adequate disposal supplies to safely handle soiled equipment. Even your front desk should consider supply needs. If you give a patient a pen to sign a document, the patient should be instructed to keep the pen as their own.
3. Can you adequately screen staff and patients to minimize the possible spread of infection?
When your practice re-opens, chances are good your day to day practice habits and procedures will look quite a bit different than they did before March. Part of re-opening safely will require daily contact-free temperature checks and daily health screening questionnaires for your staff. Staff who have symptoms should be instructed to stay home and follow up with their primary care doctor for additional guidance. Patients should be screened via phone calls the day before their appointment, have a contact-free temperature check and health screen at the time of the appointment, and follow-up screening calls 48 hours after their appointments. Any patient who has symptoms should be directed to their primary care doctor or appropriate local health services. If a patient has symptoms after having been seen in the office, it’s important to follow local guidelines about reporting possible contact to the local health department.
4. Is your area experiencing a re-surge in infection?
You will need to keep tabs on your local conditions. If there is a flare-up of active infections, you may need to cut back to emergency procedures or consider closing. Because of the nature of dental care, there is simply no way to completely eliminate the risk of transmission of an oral pathogen, so in a time of high infection, safety may require you to reschedule non-emergent patients.
5. Are you ready to space out patients and fully disinfect between every patient?
According to the best guidance available, you will need to space out patients to allow for social distancing. That means empty waiting rooms and not double booking patients. In fact, you should reduce possible sources of contagion by removing toys, magazines, and other objects from the waiting room and advising patients to keep personal items in their cars and out of the office. In an ideal world, each hygienist would have 2 chairs so that they can see patients in one chair while the other is being disinfected. Every surface needs to be completely wiped and disinfected between patients. That may mean bringing in additional cleaning staff (who would also need protective gear while cleaning) or giving hygienists additional time to prep rooms between patients. Speaking of disinfecting and controlling the spread, shoes worn in patient rooms need to stay at the office and disinfected daily.
6. Is your practice ready for preventing aerosols as much as possible?
You need to consider your procedures when reopening. From starting each cleaning with an antimicrobial rinse to training yourself not to use air and water on the syringe at the same time, you will need to carefully consider what procedures are appropriate to control infection while maintaining your patients’ oral health. ADHA guidelines include not using air polishing, using hand instruments instead of ultrasonic instruments for scaling, and using full-mouth rubber dams when placing sealants. Here is a recent presentation by Dr. V Kim Kutsch that offers suggestions regarding aerosol control and pre-rinse.
This is a challenging time for everyone, so if you are feeling overwhelmed, remember you are not alone and reach out to your professional organizations and your personal network for help and support. The ADHA, the ADA, and OSHA all have guidance specifically for dental offices and employees. Delta Dental also is offering assistance and loan assistance for their independent provider network. Also, the National Network for Oral Health Access (NNOHA) has a COVID-19 specific resource page with recordings of webinars for dental healthcare providers, including information on burnout, stress management, and self-care.