Questions to ask your dentist in the time of Covid19:
By Ann Ossinger, RDH, BSDH, EPP
Unfortunately, we cannot eliminate risk, but we can mitigate the risk as much as possible. Personally, I wish every dental provider, clinic staff, and patient could be tested for Covid19 prior to anyone entering the dental clinic. That is not currently possible, at this time. I hope to see instant “chair-side” tests, to reduce the risks of treating asymptomatic patients soon.
You will have to ask yourself about your own personal risk (age, underlying conditions, etc.) to be weighed against the risk of any untreated dental concerns. At this time, I only recommend emergency (pain & infection) and possibly urgent (non-emergency, yet really needed) treatment at this time. I might change my recommendations within the next few weeks as this is a dynamic situation that is changing on an almost daily basis. Teeth cleaning DOES become more urgent as time go by, but waiting a few weeks right now is best. We will learn a lot about dental clinics, Covid19 and risks in the next few weeks ahead.
Dentists and hygienists are also trying to thread the needle between risks of NOT treating oral conditions and the risk of Covid19. We know that inflammation, bone loss, pain, infection, and other conditions can lead to even more systemic problems. Do No Harm.
There really aren’t WRONG answers to these questions, they are meant to elicit thoughtful answers and hopefully make you feel safer if the process has been well thought through.
Basic Infection Control covers a lot more territory than what this is meant to cover, but most dental clinics are well versed in blood borne pathogens, sterilization and other infection control issues. This is meant to discuss the more recent changes given the new Covid19 reality. Infection Control in this letter covers Administrative, Engineering, and PPE in this context.
CDC (Center for Disease Control) link to recommendations to open dental clinics https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html?fbclid=IwAR2keR4cUJ7hoRr8AY82qRyfIR5t9VUmi_mXoabIfPpnf4Zd_HfhBqdV470
- Administrative Controls
Things will look and feel a little different, you will mask, check in by phone, won’t sit in the waiting room, asked to wash hands, someone will take your temperature and ask you if you have Covid19 symptoms. But some of these questions will differentiate the good dentists from the better dentists.
Do they follow up with you or do they trust you will call them if you come down with any Covid19 symptoms within 14 days of treatment? I think an active phone call from the clinic 14 days after your appointment is better than relying on patients to self-report back to the dentist.
If another patient does report having Covid19 within 14 days of being seen in the dental clinic and IF you were seen as a patient the same day but AFTER they were seen, will you be notified? Example, they were seen at 1:00 and you were seen at 2:30 on the same day. All patients seen after a potentially infected Covid19 patient should isolate themselves for 14 days.
How have you changed patient appointments? How much time is allowed for droplets to settle in patient rooms and rooms to be sanitized between patients? Answer should be about 25 minutes. 15 minutes for aerosols to settle, 10 minutes to clean and disinfect.
Does the clinic have sick leave for staff? Are sick leave policies non-punitive, flexible, and consistent with public health guidance? Because you don’t want staff to feel they have to come in if they are not feeling well!
How are aerosol-generating procedures being limited?
Is there a designated person in the clinic whose job is to stay on top of CDC, OSHA, ADA, ADHA, and State Dental and Health Authorities on changing guidelines, recommendations and requirements?
- Engineering Controls
What upgrades have been done to the HVAC system? More fans? Better and more outside air exchange? New, upgraded, HEPA filters? How often will filters be replaced? Has a HVAC professional been consulted to increase filtration and maximize supplied outdoor air? Has airflow direction been evaluated? (air flow should go from non-contaminated areas such as the front reception area toward contaminated areas such as operatories, not the other way around). Fans should be set to always on, not temperature triggered.
How is the air being filtered and cleaned in the operatory, especially during aerosol generating procedures? Some offices are adding additional portable HEPA air purifying systems. These are being recommended by the CDC, however none are FDA approved or, more importantly, really tested by a 3rd party or OSHA, but dentists are trying to get inventive. I guess I would rather see dentists take initiative in terms of trying to keep on top of the technology.
What is the air exchange rate of the HVAC system? Standard is about once per hour and recommendations have been 3-4X per hour. This is fresh outside air replacing the air inside the clinic. Even just opening a window can make a huge difference in the number of aerosol particles.
Have doors or partitions or other barriers been placed between operatories/patient rooms? Older clinics used to have doors. In the last 20 years “open concept” has been embraced for dental clinics. Now the old style is better! If not doors, barriers such as plastic curtains or glass partitions need to delineate between patient rooms. We know that using a number of dental instruments (air/water syringe, drills, polishers, scalers, etc.) will aerosolize infectious particulates. Basically, you don’t want to be infected by another patient in the next room. It really is asking how air flow is working within a clinic, from one operatory to another and to the rest of the clinic.
Are you using UVGI light disinfection? Some clinics have added Ultraviolet Light Germicidal Irradiation to sanitize their operatories. CDC recommended (not required) but again, untested, unproven, and this should be in ADDITION to the spray/wipe clean, spray/disinfect cleaning routine as the UV light will not reach any area of shadow from the light. But if your dentist has added it, it means your dentist is doing everything possible to keep things as clean as possible. You can’t have UV light disinfection unless you have staggered your appointments, since no one can be in the room while the UV light is on. It takes a few minutes.
What kind of HVE system do you have? HVE is High Volume Evacuation. You know when your hygienist is juggling 3-4 instruments at once? Scaler, mirror, light, and suction? She might hang a low volume suction off your lip/cheek? Well now recommendations are that there should be HIGH volume suction, not LOW volume suction. And those high-volume suctions need a system to work at their best. Here is a partial list of HVE systems that should be employed (a clinic would have ONE of these system for each patient room/operatory) ReLeaf, DryShield, Isolite/Isovac, Mr. Thirsty, and Izolation. These systems help reduce the number of aerosolized particles in the air by sucking them directly out of the mouth. It doesn’t eliminate them, but it does reduce them by a considerable amount. Dentists can use these too, with dental dams and an assistant to reduce aerosols.
Does the clinic now have a PPE donning and doffing area? Most dental clinics are small and cramped, but recommendations are to have a specific area for donning and doffing.
- PPE. Personal Protective Equipment,
Does the clinic have a Comprehensive Respiratory Protection Program? Is it documented? Who is the person responsible for it?
Have all providers (meaning the dentists, hygienists, and assistants) been FIT TESTED for their N95 respirator masks?
How are they obtaining their respirator masks? Many county health departments are managing N95 mask inventory for the entire county, including hospitals, EMT, police, fire, and other first responders, including dental clinics. I worry about counties that have left inventory completely up to the dentists themselves because there is a slew of counterfeit KN95 masks that the CDC/OSHA has declared unfit and unusable for use. All N95 respirator masks should be NIOSH certified.
Are all N95 or KN95 respirator masks being used NIOSH certified?
Given so few N95 masks are available, how is the inventory conserved and rotated? EXAMPLE: Most offices now have given each provider a respirator mask for each day of the week, so a full-time dentist/hygienist would have a Monday mask, a Tuesday mask, and so forth and re-use those masks the following week. When the mask get visibility dirty or if straps break, you need to replace the mask. As opposed to say an odd/even rotation, which means wearing the same mask every odd day and a different one every even day. I would rather they re-use their masks only once a week. In the past, N95 masks were once considered one-time use/disposable. Another unknown is just HOW many times CAN an N95 mask be continually reused? We don’t know. At some point, the filter will be “full up” of particles, blocking airflow, and reducing the filter’s ability to filter Covid19 particles. But we DON’T KNOW when and we don’t know how to test the masks for their ability to continually to filter. Hope we learn soon.
Are gowns changed between each and every patient? Clinics should either have tons of disposable gowns, or tons of reusable, washable gowns. Dentists have installed washers/dryers and dressing areas so providers can change before beginning and ending their day.
Ask to have instant chair-side Covid19 tests when they are available!
Patients: should be given protective eyewear when in the treatment chair.
Patients: should wear a face mask when not in the treatment chair.
Stay safe out there!
Ann Ossinger, RDH, BSDH, EPP