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Infection Control, Patient Screening and PPE

Official Guidance

From the CDPH

Released May 7, updated guidance for resuming deferred and preventive dental care.

View CDPH Guidance

Official Guidance

From the CDC

Updated May 19, interim infection prevention and control guidance for dental settings during the COVID-19 response.

View CDC Guidance

COVID-19: Patient Screening, Infection Control, PPE FAQ

Back-to-Practice Interim guidance

On April 27, as part of the governor’s framework for modifying his shelter-in-place order, he announced plans to permit hospitals to begin to provide some additional essential surgical care, such as tumor removal and heart value replacement. That guidance stated that the California Department of Public Health would be updating its April 7 dental guidance separately. On May 7, CDPH released updated interim guidance for dental care.

This movement to begin to open up the economy and allow more business activity is influenced by California’s success in managing the pandemic early on, which has resulted in low community transmission rates and surge preparation in our health care system. These are excellent signs and bode well for California’s continued successful pandemic response. Additionally, for health care in general and dentistry in particular, plentiful access to PPE and expanded testing are also essential to moving forward with more care.

The CDPH guidance states that, “It is important to continue to monitor COVID-19, including case counts and hospitalizations and their impact on the health care delivery system” and encourages dental offices to track trends in their communities via a new state data portal at update.covid19.ca.gov/. The guidance also notes that, “Many local health departments are also publishing community-level data that may be helpful to your practice for assessing pandemic conditions in your community.”

As dentists assess their individual access to required resources and readiness to resume providing more dental care, it is important that they review the May 7th CDPH interim guidance. That guidance remains fundamentally the same, recommending protocols that reduce close contact between individuals and practices that reduce the opportunity for aerosol disease transmission during the dental visit.

The following FAQ is designed to answer some of your questions:

Are there regulatory requirements that I should be aware of?

You must comply with Cal/OSHA’s requirements for the airborne transmissible disease (ATD) standard, which include:

Must I do anything different when screening my patients during this interim period of care?

As patients may still unknowingly carry and transmit SARS-Cov 2, the coronavirus that causes COVID-19, each patient seeking care at your dental office or clinic must be screened to limit the risk of virus transmission.

This screening is essential to determine the appropriate options for managing the patient’s dental care and the appropriate location for that care. Dentists are reminded that patients with active symptoms of an ATD should not receive treatment in a dental office, and if in-person consultation occurs, the patient must be wearing a mask prior to entering the dental office. Dentists should work with the patient’s medical provider to determine the appropriate setting for further care for persons with confirmed or suspected COVID-19.

How should I screen for COVID-19?

CDA has a resource that provides guidance on screening patients for COVID-19.

It is best to begin the screening process at the time the appointment is requested. Ask the patient over the telephone or telehealth platform if they:

Have tested positive for COVID-19 and, if yes:

  • The date when symptoms began to abate. See below for information to help you determine when to schedule the appointment.
  • If they are symptomatic or currently under mandatory isolation.
  • Have had close contact with an individual diagnosed with COVID-19 or with symptoms.
  • Have any of the following symptoms: Cough, shortness of breath, unexplained fever (≥100.4º F), chills, repeated shaking with chills, muscle pain, headache, sore throat and/or new loss of taste or smell within the prior two weeks.

Furthermore, as California moves farther into the next stage of pandemic management and regions within California begin to loosen stay-at-home orders, people will also begin to move between communities, states and countries that have varying levels of COVID-19 activity. If your community has low transmission levels and businesses are operating, you may want to consider adding a screening question that asks whether the patient or members of the patient’s immediate household have traveled outside of the community within the last three weeks. Patients with potential exposure to the SARS-Cov 2 virus from areas with active transmission rates should postpone care for three weeks, or if emergency care is required, it should be provided under COVID-19 suspected status.

If a patient passes these screening questions and will be seen in the office but plans to bring a driver, remind the patient that the driver should remain outside the office. Obtain the driver’s phone number to notify them that the patient is ready to leave. If a parent, guardian or caretaker must accompany a patient to the appointment, provide a face mask if they are not wearing one and be certain they comply with social distancing rules in the waiting area.

What steps do we take when the patient presents for treatment?

When the patient presents:

  • Provide a face mask if the patient is not wearing one.
  • Take a temperature reading to verify the absence of a fever (any temperature above 100.4°F).
  • Reconfirm the screening questions by observation and verbally with the patient. We recommend using CDA’s patient-screening form, which is regularly updated with the most recent CDC symptoms.
  • Complete necessary documentation and discussion, such as health history and treatment informed consent form. Have the patient sign a statement agreeing to notify the dental practice if within two weeks of treatment they test positive for COVID-19.
  • A dental practice has a legal and ethical obligation to inform patients if a staff member they have been in contact with has tested positive for COVID.
What personal protective equipment (PPE) should we wear? Do we have to have an N95 mask?
  • Dental professionals should use the level of PPE appropriate to the disease transmission risk, with higher-level PPE reserved for procedures that may pose a higher risk.
    • Consider designating a “work-only” pair of shoes that you leave at the office.
  • A Level 3 mask and face shield are considered appropriate respiratory protection and should be worn by all treatment staff for non-aerosol-producing procedures, as these masks protect the nose and mouth from spatter, but not from inhalation of small potentially infectious aerosols.
  • Aerosol-producing procedures warrant additional focus on respiratory protection for all treatment staff. N95 filtering facepiece respirators or other types of N95 masks and face shields are recommended. Use a Level 3 surgical mask with a face shield only if an N95 mask is not available.
    • N95 masks are only effective if properly fitted. Dental professionals should follow all N95 use all requirements, including obtaining a medical clearance and initial fit test if an N95 mask is employed.
  • PPE functions as just one layer of disease transmission protection. The judicious use of intraoral engineering controls, such as rubber dams and high-speed suction, reduce aerosol spread beyond the immediate extraoral space to treatment staff and beyond. For aerosol-generating procedures, these additional procedural precautions should be considered during this interim time in the COVID-19 pandemic:
  • Consider a preoperative viricidal rinse or mouth swab (e.g., hydrogen peroxide or povidone-iodine).
  • Choose dental treatment options that minimize aerosols; use rubber dams or continuous suction dental isolation systems as much as possible.
  • Rinse the oral cavity slowly, avoiding unnecessary splatter.
  • Use chairside high-speed evacuation and/or other engineering or equipment controls for aerosol management.
  • Minimize intraoral X-rays for patients prone to coughing or gagging.
What must I do when treatment is complete?
  • Dispose of single-use or soiled PPE immediately in trash cans placed near the exits of each treatment room; disinfect reusable PPE in a manner that prevents cross-contamination.
  • Use a disinfectant that meets the requirements of the state dental board's infection control regulations and follow the product’s directions to thoroughly clean and disinfect procedure room surfaces. Reference this listof EPA- and state-approved disinfectants.
  • If foot coverings were not used, be sure to change and disinfect footwear before leaving the office. Upon returning home, immediately remove clothes and shower and then wash clothes.

Treating a patient who had COVID-19: How long should I wait?

  • Without testing, it is currently recommended that symptomatic individuals who had the disease may leave home isolation 10 days after symptoms first appeared and at least three days after recovery (including fever reduction without the use of fever-reducing medication).
  • An individual who tested positive for COVID-19 but was asymptomatic can be scheduled for an appointment at least seven days after the date of the positive test.
  • Until clearer evidence on infectivity timelines is determined, dentists and staff should take the additional respiratory protection precautions described above.
  • If testing is available, it is recommended that a person be considered recovered if fever is resolved without fever-reducing medication, respiratory symptoms have improved and at least two consecutive FDA emergency-use authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA tests, using respiratory specimens collected > 24 hours apart, produce negative results. This testing requirement will change over time as tests and test accuracy improves.
What do I do if I run out of face masks, gloves or other PPE?

Adequate PPE is a prerequisite to opening your dental office for nonemergency care. If you do not have adequate supplies to protect you and your staff, you must readjust your care schedule to this reality. You may want to reach out to your local dental society, colleagues and other health care professionals or facilities to learn if supplies are available. Emergency supplies can also be requested through your local Medical and Health Operational Area Coordinator (MHOAC). Please know that there may be a long waiting period.

MHOAC Contact List

Can I wash or reuse face masks?

Single-use masks, or disposable masks, should not be washed for the purpose of reusing with patients. The CDC provides guidance on extended use and reuse of N95 respirators. OSHA provides guidance on decontamination of respirators.

What do I do if I suspect exposure to COVID-19 in the practice? Do my staff and I need to self-quarantine?

That is a decision that can only be made at the time of the event and certain factors would have to be considered and assessed. For example, an employee or a patient whose partner has a co-worker exhibiting symptoms is a low-risk situation compared to a situation where an employee or patient has a partner who has symptoms consistent with COVID-19. Individuals who have reported possible exposures to their medical care providers should follow the provider’s instructions. Consult with your local public health department if exposure risk is high, for example, when a patient was seen in the office and then reports within a couple weeks that they have tested positive for COVID-19. CDC has FAQs on suspected or confirmed cases of COVID-19 in the workplace.

Be sure to keep up with news on the virus and on guidelines or orders from your local public health department.

What policies and practices should my employees follow to minimize exposure?

Interim CDC guidance for businesses and employers recommends that:

  • Employers place posters that encourage coughing and sneezing etiquetteand proper hand hygiene at the entrance to their workplace and in other areas where the posters are likely to be seen.
  • Clean and disinfect public areas frequently, including door handles, chairs and bathrooms.
  • Employees who report symptoms of acute respiratory illness should stay home and not return to work until they are free of symptoms for at least 24 hours without the use of fever-relieving or symptom-altering medications.
  • If an employee appears to be sick upon arrival to work, they should be separated from other employees and sent home immediately.
  • Employees cover a cough or sneeze with a tissue and disinfect frequently touched objects and surfaces using an appropriate disinfectant product.
  • Employees wash hands often with soap and water for at least 20 seconds. If soap and water are not readily available, an alcohol-based hand sanitizer with at least 60% alcohol can be used.

For in-depth interim guidance and resources on preparing your practice, patient care and practice management, visit https://www.cda.org/Home/Practice/Back-to-Practice


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