What is COVID-19

COVID-19 is the infectious disease caused by the most recently discovered coronavirus. This new disease was unknown before the outbreak began in Wuhan, China, in December 2019.

The risk of catching COVID-19 from someone with no symptoms is low. However, many people with COVID-19 experience only mild symptoms. It has been reported that some COVID-19 patients displayed no symptoms for the first 1-3 days, yet were contagious.

While the virus seems to have emerged from an animal source, it is now being spread from person-to-person. Presently, there is no reason to believe that animals, including pets, might be a source of the infection. To date, CDC has not received any reports of pets or other animals becoming sick with the virus. However, since animals may spread other types of disease (zoonoses) to people, it is always important to wash your hands immediately after handling animals.

The CDC has taken early and aggressive actions to prevent the spread of SARS-CoV-2, the virus that causes the disease named COVID-19, in the United States, through a combination of proven public health actions. At the same time, the CDC is preparing for the possibility that the COVID-19 situation in the U.S. could become more serious, with sustained community transmission, and is taking steps to make sure there are enough supplies and appropriate guidance to prevent spread of disease, especially among healthcare personnel caring for patients with COVID-19.

What are the symptoms of COVID-19?

The most common symptoms include fever, dry cough and fatigue. In many cases, individuals may experience nasal congestions, runny nose, sore throat, diarrhea and muscle ache.  Some individuals become infected but do not develop any symptoms. About 80% of cases recover without needing any special treatment.

Those that develop severe illness have difficulty breathing/shortness of breath, persistent pain or pressure in the chest, confusion and bluish lips/face. In severe cases, COVID-19 could result in pneumonia and death.

Patients should seek medical attention if they experience fever, cough or difficulty breathing.

Who is at highest risk?

Individuals ages 60 and up and those with pre-existing medical conditions such as diabetes, high blood pressure, heart disease, lung disease and cancer are at highest risk.

A recent CDC study shows that a patient who has COVID-19 may be infectious from 1-3 days before they display any symptoms of the disease.

Is COVID-19 a Bloodborne Pathogen?

COVID-19 is not considered a Bloodborne Pathogen, as the disease transmission occurs through respiratory secretions and not blood. The Bloodborne Pathogen Standard, however, offers a framework that may help control the virus and thus should be followed as part of the General Duty Clause and PPE Standard. The Bloodborne Pathogen Standard emphasizes the need for using Standard Precautions, which are crucial in minimizing the spread of COVID-19.

Dental facilities have high potential for the spread of this disease due to procedures that involve the oral cavity and generate aerosols 

Below are recommendations to prevent transmission:

Communication and Screening of Patients

• Update patient medical history at each visit
• Screening interviews of the patient should be done by telephone, text or video conference before the visit.
• Ask the following questions:
  •  Have you been in the presence of someone with a confirmed case of COVID-19?
  • Have you been in the presence of someone who has been or is being quarantined for COVID-19?
  • Have you exhibited any symptoms of respiratory infection or fever?
• Patients that answered YES to screening questions must contact their primary physician or public health department and reschedule their appointment.
• If you suspect a patient has COVID-19, contact your local or state health department.
  • HIPAA’s Privacy Rule allows covered entities to disclose needed protected health information to public health authorities responding to a public health emergency.
• Ask patients to arrive on time for their appointments (not early) to minimize the amount of time and exposure in the waiting room
• Schedule appointments in a manner to minimize possible contact with other patients
• Remove magazines, reading material, toys and any other objects patients frequently touch and are difficult to disinfect
• Ask patients not bring relatives or friends with them to their dental visit—if they do, ask that they wait in the car.
• Should a patient require that someone accompany them into your office, that individual must be screened for COVID-19 as well.
• Place posters that encourage correct cough/sneeze etiquette as well as proper hand hygiene at the entrance to your workplace.
• Provide alcohol-based hand rub, tissues and no-touch disposal receptacles for use by employees and patients.

Employee Training

Provide annual required OSHA and infection control training to all new and existing employees. In addition, supplement this training with specific training on COVID-19.

Emphasize Standard Precautions 

Review the proper use and disposal of personal protective equipment (PPE) for all employees.

Advise the dental team to stay home if they are experiencing acute respiratory illness, including symptoms of fever, cough or shortness of breath.

Review proper hand hygiene and respiratory hygiene/cough etiquette.

• Instruct employees to disinfect their hands between patients with an alcohol-based hand sanitizer that contains at least 60-95% alcohol. Soap and water should be utilized preferentially if hands are visibly contaminated and must always be used before eating and after toileting
• Properly don and doff personal protective equipment (a diagram showing proper technique may be found on the CTP homepage (compliancetrainingpartners.com) by clicking the “COVID-19” button.
• Clean PPE such as protective eyewear (safety glasses with side shields or face shields) with soap and water between patients, or if visibly soiled, disinfect them
• Provide soap and water as well as alcohol-based hand rubs in multiple locations throughout the workplace.
• Advise employees to avoid touching their eyes, nose and mouth.
• Do not rely solely on PPE-Healthcare personnel can protect themselves when caring for patients by following infection prevention and control practices, which includes the appropriate use of engineering controls, administrative controls, and personal protective equipment.
• Perform proper environmental surface cleaning and disinfection:
• It appears that COVID-19 may live on hard surfaces, at room temperature, for up to several days.
• Provide disposable disinfectant wipes so that commonly used surfaces (e.g. doorknobs, keyboards, armrests, remote controls, countertops, desks, etc.) may be decontaminated.
• Make sure that the disinfecting product you are using is approved by the EPA for use against Sars-Cov-2. The list may be found at  https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

Beyond Standard Precautions

• Include temperature readings as part of routine assessment prior to performing any dental procedure.
• Take the temperature of staff members twice daily and have them self-monitor for symptoms of respiratory disease.
• Advise all staff members to have the seasonal flu vaccine.
• Staff members should leave all protective clothing (e.g., long-sleeved scrubs, scrub pants, lab coat) at the office for laundering or pick-up by a laundry service or consider using disposable.
• Place all contaminated clothing in a fluid resistant laundry bag labeled with the biohazard symbol.
• Take extra-oral radiographs (e.g., panoramic or cone beam CT) as intra-oral sensors or films can stimulate saliva production and coughing.
• Turn the fan on the heating and cooling system to “ON” rather than “AUTO,” which will increase air circulation.
• If possible, open a window.
• Consider purchasing a HEPA air filtration device for your office.
• Use high speed evacuation for all dental procedures that may produce an aerosol.
• Minimize the use of the saliva ejector, as retraction of oral fluids and cross contamination is always a concern.
• Minimize the use of the air water syringe, as aerosols may be created.
• Use a rubber dam where possible, as they provide a barrier between the operator and the oral pharynx.
• Use resorbable sutures so that a second visit is not needed.
• Instruct patients to rinse with a 1% hydrogen peroxide before beginning dental treatment
  • Most over the counter hydrogen peroxide rinses are 3%. Combine one-part hydrogen peroxide with two parts water. Your final mix will have a concentration of 1% hydrogen peroxide. Note that the effectiveness of hydrogen peroxide against COVID-19 is still unclear
  • Clean and disinfect public areas frequently: door handles, chairs and bathrooms
  • Full coverage of the dental chair with a barrier cover
  • Air purifying devices that utilize HEPA filtration
  • Placing a disposable gown, surgical cap, gloves and shoe covers on the patient
  • Staff members should glove in their car before entering the office. Upon entering, they should perform hand hygiene
  • The dental team should wear surgical caps and shoe covers once they enter the dental office or consider leaving shoes at the office
  • Staff members should wash their hands and then glove before leaving the workplace. Once they get in their car, they should remove the gloves and place them in a bag
  • Disinfect areas they touch in their car on a daily basis
  • Staff members should remove their clothes immediately upon entering their home and take a shower

COVID-19 Emergency Patients

If a patient with a confirmed or suspected case of COVID-19 is in pain or needs emergency treatment, the dentist and the patient’s medical providers should work together to identify a facility that can safely treat the patient, as most dental offices are not often designed to carry out Transmission-Based Precautions.

If a patient who presents in your facility is suspected or confirmed to have COVID-19, take the following actions:

• Place a mask on the patient immediately
• Send the patient home, if not acutely sick
• If acutely sick, refer them to a medical facility (e.g., difficulty breathing)
• If dental treatment is urgently needed, refer to an appropriate facility

The CDC states that patients with COVID-19 who have completed home isolation clearance can receive emergency dental care.

Accumulating evidence supports ending isolation and precautions for persons with COVID-19 using a symptom-based strategy. Specifically, researchers have reported that people with mild to moderate COVID-19 remain infectious no longer than 10 days after their symptoms began, and those with more severe illness or those who are severely immunocompromised remain infectious no longer than 20 days after their symptoms began. Therefore, CDC has updated the recommendations for discontinuing home isolation as follows:

Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue isolation under the following conditions:

• At least 10 days* have passed since symptom onset and
• At least 24 hours have passed since resolution of fever without the use of fever-reducing medications and
• Other symptoms have improved.

*A limited number of persons with severe illness may produce replication-competent virus beyond 10 days, that may warrant extending duration of isolation for up to 20 days after symptom onset. Consider consultation with infection control experts. See Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance

What disinfectant is effective at killing COVID-19?

Coronaviruses are considered enveloped viruses and are one of the easiest types to kill. Routine cleaning and disinfecting procedures that include an EPA-registered hospital grade disinfectant that has a  tuberculocidal claim are very effective. The disinfectants used should show the claim: “[Product name] has demonstrated effectiveness against viruses similar to SARS-CoV-2 on hard non-porous surfaces. Therefore, this product can be used against coronaviruses when used in accordance with the directions for use against [name of supporting virus] on hard, non-porous surfaces.” The CDC has published a list of acceptable disinfectants which may be found at. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

Aerosol Producing Procedures

If the dental team is using equipment that produces aerosol (i.e. ultrasonic scalers, high/low speed  handpiece and air/water syringe) extra caution should be taken, as aerosol spread is one method COVID-19 can be transmitted. It is the professional judgement of the doctor to determine if these devices are needed on a patient to patient basis. An N95 mask or respirator must be used during any aerosol generating procedure. Remember that procedures can only be done on a patient NOT suspected to have COVID-19, based upon your screening procedures. If the patient is known or suspected to have COVID-19, they cannot be treated in a standard dental facility.

Mask and Mask Shortage

Practices are struggling to obtain PPE. If such a shortage could close down your practice, you may have to triage patients to ensure that adequate PPE is available for patients whose appointments are most urgent. If your facility is concerned about a potential or imminent shortage of PPE, the CDC recommends you alert your state/local health department and local healthcare coalition, as they are best positioned to help facilities troubleshoot through temporary shortages. You can also report the shortage to the FDA at deviceshortages@fda.hhs.gov.

CDC urges Dental Health Care Personnel (DHCP) concerned about healthcare supply for PPE to monitor Healthcare Supply of Personal Protective Equipment for updated guidance, and to be familiar with the Interim Infection Prevention and Control Recommendations.

• CDC’s guidance for single-use disposable facemasks has not changed. These masks are tested and regulated by the FDA as single use items.
• Change masks between patients, or during patient treatment if the mask becomes wet.

What do the different levels in masks mean?

The type of mask needed while treating a patient may depend on the procedure. ASTM International is an international standards organization that develops and publishes voluntary consensus technical standards. It established performance levels for masks depending on fluid resistance, bacterial filtration efficiency, particulate filtration efficiency, breathing resistance and flame spread.

Level 1 have the least fluid resistance, bacterial filtration efficiency, particulate filtration efficiency, and breathing resistance. These can be worn for procedures where low amounts of fluid, spray or aerosols are produced, for example, patient evaluations, orthodontic visits, or operatory cleaning.

Level 2 provide a moderate barrier for fluid resistance, bacterial and particulate filtration efficiencies and breathing resistance. These can be used for procedures producing moderate to light amounts of fluid, spray or aerosols. Some examples of procedures are sealant placement, simple restorative or composite procedures or endodontics.

Level 3 provide the maximum level of fluid resistance and are designed for procedures with moderate or heavy amounts of blood, fluid spray or aerosol exposure. Some examples of these procedures are crown or bridge preparations, complex oral surgery, implant placement or use of ultrasonic scalers.

What is an N95 mask and should it be used in my facility?

N95 masks are considered respirators and have strict requirements to achieve compliance. For example, all employees provided N95 masks as part of their PPE must go through medical evaluations and fit testing prior to use, as their effectiveness is highly dependent upon proper fit. N95 respirators are not recommended for routine use in a dental office and all facilities that use them must have a written respiratory protection plan in place