When COVID-19 ravaged the country in March, dental practices were largely shut down, except for emergency procedures. Now, as the country steadily reopens, dental offices are starting to get back to business; however, under firmer health and safety guidelines
“We are dutifully following guidelines with the American Dental Association (ADA) and CDC,” confirms one Dr. Meenal Patel, a dentist in Cary and a professor at the University of North Carolina at Chapel Hill.
Face to face
While many doctors are now seeing patients online, dentists must see patients in-person to perform procedures effectively, says Natalie Raper, administrative director at MAHEC Dental Health.
According to the CDC, the risk of transmitting COVID-19 is higher for dental professionals than for those in other careers. Dental professionals use rotary instruments such as air-water syringes, ultrasonic scalers, and drills that create aerosols.
“Pretty much everything in a dental office, except for the stainless-steel instruments, produces an aerosol. Even an electric toothbrush produces an aerosol,” Janessa Bock, president-elect of the Texas Dental Hygienists’ Association was quoted in May highlighting how risky their job has become.
And while masks shield the mucous membranes of the nose and mouth from droplet spatter and aerosol, they do not provide total protection against inhaling airborne infectious pathogens.
All this has made dentists reconsider how they will be conducting dental procedures, henceforth.
Staggering appointments and increased screening
Many dental practices are now adjusting schedules to space out appointments. This helps control the number of people in the dental premises and allow additional time for cleaning between patients.
“The first thing is staggered scheduling. There are limits on how many people can come into the office at a time,” says Dr. Jill Shelton Wagers, a dentist with Boise Bench Dentistry and president of the Idaho State Dental Association.
Dental offices are also eliminating shared spaces. No more waiting lounges and rooms. All courtesy items such as toys for kids, magazines, or snack bars have been temporarily removed.
Besides that, every office is now screening patients for COVID-19 symptoms. For example, during an interview with NBC 10 News, Dr. Stevens Brown, an oral surgeon and a member of the Rhode Island Dental Association, said his patients are first screened via phone to ascertain if they have any signs of COVID-19. He adds that, before accessing their offices, patients are again screened in the parking area and have their temperatures checked.
In some instances, Brown said he even orders a Coronavirus test a few days before performing some procedure to ensure the patient is healthy.
As per the current situation, high levels of hygiene must be observed everywhere. Therefore, dentists have been left with no choice but to increase sanitation in all areas of their offices. More so, they are now required to have sanitized tools ready before a patient arrives for an appointment. In some procedures, or where possible, they are even required to employ single-use tools.
Rules have also been put in place to ensure that dental chairs and non-disposables are carefully disinfected before every patient turns up for treatment.
Draping the operatory
Most dental settings have several cabinets and flat surfaces. In addition, numerous pieces of equipment are stored in treatment rooms. Dental assistants should drape these tools routinely to prevent them from being contaminated or exposed to aerosols unnecessarily.
The flat surfaces (such as Mayo stands and tray tables), fronts of cabinets, and equipment (such as scanning devices and radiography units) should be draped. In most cases, dental offices are using plastic drapes since they can be easily wiped down with sanitizers and disinfectants; hence, they do not warrant to be replaced after each patient’s visit.
Draping the treatment rooms is a significant departure from the existing infection control practices, but until dentists can be allowed to test patients for COVID-19, this safety measure shouldn’t be overlooked.
Changing dental procedures to prevent aerosols
As mentioned earlier, some dental procedures and equipment (water/air syringes, for example) may generate more aerosols than others. As such, CDC and other relevant dental authorities have advised dentists to adjust these kinds of procedures, if at all possible.
But where aerosols are unavoidable, dentists are advised to use safer tools such as rubber dams, anti-retraction hand pieces, and high-volume evacuators (HVE) as opposed to saliva ejectors.
For instance, a dentist using rubber dams can considerably reduce the production of blood- and saliva-contaminated spatter or aerosol, especially in cases where dental ultrasonic devices and high-speed handpieces are used. Equally, the use of anti-retraction high-speed handpieces comes in handy during aerosol-producing procedures. They effectively cut the backflow of HBV and oral bacteria, compared to those hand pieces with no anti-retraction function.
Again, in procedures where aerosols are unavoidable, dentists and their teams are wearing CDC-recommended face masks and other PPE, to protect themselves from contracting the virus. Here we are talking about face shields, air-purifying elastomeric (e.g., full-face or half-face) respirators, gloves, hairnets, and full-body suits and gowns.
“We are wearing N95 and KN95 masks. We are also wearing goggles with a full face shield in front of us. We are also wearing surgical scrub caps,” said Dr. Maggie Davis, a pediatric dentist in Palm Harbor, when talking about the new strict safety procedures being implemented in dental offices. She’s also having every employee in her office wear disposable gowns over their scrubs that they change with every patient visit.
To ensure high-levels of hygiene and minimize the salivary load of oral microbes in the patients' mouth during dental procedures, dentists now administer preprocedural mouth rinse, which contains oxidative agents like 0.2% povidone or 1% hydrogen peroxide.
It’s crucial to understand, though, while preprocedural rinses may reduce the amount of virus or bacteria in a patient’s mouth, salivary glands have shown to be reservoirs of COVID-19 virus. Therefore, the reduction of viral load as a result of using pre-procedural rinses might be transitory. If possible, it may be better to have the patient rinse several times even during a single procedure. This would be most relevant during nonsurgical periodontal procedures.
Reconfiguring offices and operation rooms
Since it is practically impossible to avoid spatter during dental procedures, more care is being taken by dentists to address airflow in the dental premises. The CDC recommended that dental offices should update their HVAC systems with modern filters and proper maintenance.
Also, some dental offices have been investing in Ultraviolet germicidal irradiation (UVGI) technology. According to an article on Today’s RDH, UVGI is mostly utilized as a lamp in the treatment room for air purification. It can be a great addition to standard sterilization efforts in a dental clinic to help better attain proper infection control, besides the surface disinfection and the conventional heat sterilization.
Lastly, many dental offices have installed physical barriers (like plastic dividers, Plexiglass) in shared areas to help minimize contact between employees and patients as well.
“Patients are kept six feet apart, and the plexiglass separates them from receptionists,” said Dr. Steven Kupferman, while outlining the changes that have been implemented in his Century City office.
Going above and beyond safety guidelines during dental procedures
The dental industry's current situation puts special attention on hygiene and preventive measures during procedures. Most prophylaxis and restorative procedures cannot be carried out without using tools that generate potentially infectious droplets, aerosols, and spatter.
Today, the short term goals for every dentist should be to maintain hygiene and perform dental procedures safely in a way that won't risk the health of the patients.
On the other hand, the longer-term solution to this whole situation will be inventing an appropriate COVID-19 vaccine akin to what we have for influenza. With a vaccine, the probability of handling an infected patient will be significantly reduced, and the immunity of dental professionals will be considerably improved.
Until this happens, dental professionals need to take infection control steps and precautions far beyond what the industry routinely was used to, before this pandemic.