North Texas Dentistry Special Issue 2020 NTD SP ISSUE 2020 DE | Page 19

The dental team falls in the highest 10% risk bracket for exposure to
COVID-19 based upon the close proximity of the clinical team (being
within one foot ) to the patient’s mouth. Further, we generate aerosols
during common elective procedures and most procedures last about
30-40 minutes. Due to the airborne nature of transmission, lack of
availability of at least N-95 respirators, and lack of engineering controls
such as high-air evacuation or exchanges in treatment areas, the
dental team has been handicapped in providing care for most patients
during the past two months. Now that we have guidance, improved
availability of respirators and engineering controls, screening
and diagnostic tests, and growing interest in dental infection control,
we are preparing to start seeing patients for procedures that are not
urgent or emergent.
The dental team must follow physical distancing measures socially as
well in their personal lives, as now you are going to be seeing patients.
Communication
Proactively call, text, or email scheduled patients and tell them not
to come if not feeling well on the day of their appointment. Post the
same message on your clinic’s website, entry door, and at the front
desk. The same applies if you or your staff are not feeling well, are at
high-risk, or if there is a family member at high-risk for COVID-19.
Triaging patients over the phone, or using other digital resources such
as having them fill out a screening form with presenting symptoms
will help. In my 30 years of experience as a clinical faculty, clinical
screening and diagnosis is not set up for teledentistry, and this will
end up leading to face-to-face screenings and contact with the patient.
When patient is being discharged, instruct them to let the clinic
know if they become positive for COVID-19 within 8-9 days of dental
treatment (by then they could show serious health issues if already
infected before dental treatment). If the patient calls post facto and
reports that they have tested positive, it will begin a cascade of
actions for the dental team members who were exposed, from getting
tested to self-quarantine and possibly seeking care if testing positive
for COVID-19.
Patient flow and tracking
Use fewer operatories (reduce by a third) and allow fewer patients
based on the severity of their reported issue. Move slowly for the first
week, only treating emergencies and later taking patients for elective
care as well. Learn and experience opening up with a higher level of
awareness and step up your infection control (better overkill before
than concern after).
Only allow the patient into the clinic, unless the patient is a minor or
they need an assistant (elderly, incapacitated, wheelchair-bound). If
the patient or their attendant is positive for any symptoms, defer care
and ask them to see a physician. Ask that they return only after they
do not have symptoms or have tested negative for COVID-19 and
have recovered. If the patient/attendant is negative for symptoms,
then let them in. Provide the patient (and the attendant if present) a
level-1 mask if they do not have one and take their body temperature
on check-in. Rate of flow per team is one patient per hour for nonaerosol
generating procedures. Use atraumatic restorative treatment,
At check-in, provide
patients with a mask if
they do not have one and
take their temperature.
hand instruments, and slow speed instruments for disease control as
this applies to both the dentist and hygienist (for only a few days). Stay
problem-focused and concentrate only on the main treatment issue.
After discharge, instruct both the patient and attendant to inform you
immediately if they have been exposed to or have been infected with
COVID-19 within 8 days after discharge so that you may quarantine
all personnel exposed to the patient and seek care.
Engineering controls
Increase air evacuation by
running the HVAC continuously.
There are devices to
increase air evacuation from
within the operatory to outside.
There are air recirculation
devices with a HEPA
filter (99.97 level) with a capacity
to filter and recirculate
air, with some that
include the addition of UVC
to the system (more expensive).
Use of Rubberdam +
HVE, Isolite, or DryShield is
also beneficial in both the
hygiene and other restorative operatories. Please use one of these
recirculation devices in the front office/check-in area.
Work practice controls
An air purifier with HEPA filtration
helps control aerosols
Follow strict personal hygiene and cough etiquette. Avoid or reduce
procedures that generate aerosols. Routine use of pre-procedural
mouth rinse for patient is a good practice. Handwashing with 2-4%
CHG is better than alcohol sprays and gels alone. Wash your hands
before gloving and after taking off the gloves. Don’t touch your face,
eyes, or contact lenses without handwashing. Wash your face after
the morning session and before going home. Use an intermediatelevel
disinfectant with both a hydrophilic and lipophilic virus kill claim
as a surface disinfectant.
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