The Centers for Disease Control and Prevention (CDC) has updated infection control guidelines for COVID-19 in dental settings, including new information on facility and equipment considerations and using test-based strategies to inform patient care.1
Michele Neuburger, DDS, MPH, a dental officer at the CDC, reviewed the guidelines at a recent webinar.
“You should proactively communicate to both personnel and patients that they need to stay home if sick and know the steps to take if a patient with COVID-19 symptoms enters your facility,” she said.
“The biggest change to our guidance was the inclusion of recommendations for resuming non-emergency dental care during the pandemic.”
Continue to practice universal source control (masking) and actively screen for fever and symptoms of COVID-19 for all patients, visitors, and staff who enter the dental facility. Ensure that staff have sufficient personal protective equipment (PPE) and supplies to treat the volume of patients safely.
For universal source control, dental personnel always should wear a face mask or a cloth face covering while they are in the dental setting, Neuburger said. “You should take steps to prevent self-contamination and perform hand hygiene immediately before and after any contact with your face mask or cloth covering,” she said. “Dental settings should provide personnel with training about when, how, and where face masks and cloth coverings can be used, and you should also request that patients and visitors wear a cloth face covering or provide a face mask if supplies are adequate.”
The guidelines are broken into three tiers, based on the level of coronavirus transmission in the communities:
- None to minimal community transmission
- Minimal to moderate community transmission
- Substantial community transmission is defined as large-scale community transmission, including communal settings (e.g., schools, workplaces)
“Some infected individuals might not be identified based on clinical signs and symptoms,” Neuburger said.
“So, facilities can consider using a tiered approach to using PPE based on the level of transmission in the community. For example, in areas where there is moderate to substantial community transmission, this might include considering having dental personnel wearing N95 or higher level respirators for higher risk procedures like aerosol-generating procedures.”
Consider implementing preadmission or preprocedure testing for COVID-19, which might inform implementation of PPE use, especially in the situation of PPE shortages, the CDC recommends.
“However, there are limitations to this approach, including negative test results from patients who are in their incubation period and might later become infectious, and also false negative test results,” Neuburger said.
Ask patients to inform the dental clinic if they develop symptoms or are diagnosed with COVID-19 within 14 days after the appointment, the CDC notes.
Ensure that all patients, visitors, and staff adhere to respiratory hygiene and cough etiquette, and take the following actions to reduce infection risk:
- Place chairs in the waiting room at least six feet apart.
- Remove toys, magazines, and other frequently touched objects that cannot be regularly cleaned or disinfected.
- Minimize the number of persons waiting in the waiting room.
- Review the manufacturer’s instructions for reinitiating use of all equipment and devices after a period of non-use.
“Whenever possible, dental personnel should remain with one patient until dental care is complete and minimize the practice of one personnel providing care to multiple patients at once,” Neuburger said. “Set up operatories, so that only the supplies and instruments needed for the procedure are readily accessible.”
Avoid aerosol-generated procedures, such as the use of dental handpieces, air water syringe, and ultrasonic scalars, she added. “If they are necessary for dental care, use [assistants for] ‘four-handed’ dentistry, high-evacuation suction, and dental dams to minimize droplet spatter and aerosols.”
Dental facilities should implement sick leave policies that are flexible, nonpunitive, and consistent with public health guidance for dental personnel. Dental personnel should not come to work if they suspect they have COVID-19, and they should regularly monitor themselves for fever and symptoms consistent with COVID-19.
“If a patient arrives at your facility and is expected or confirmed to have COVID-19, defer dental treatment and give the patient a mask, if they’re not already wearing one,” the CDC states. “If the patient is not acutely sick, send them home and instruct them to call their primary care provider. If the patient is acutely sick — for example, has trouble breathing — refer the patient to a medical facility or call 911, as appropriate.”
Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient. “To clean and disinfect the dental operatory after a patient without suspected or confirmed COVID-19, we recommend that you wait 15 minutes after completion of clinical care and exit of the patient to begin to clean and disinfect the room surfaces,” Neuburger noted. “Now, this was developed as an interim recommendation specific for dental settings,” she said. “We understand that this is a longer period of waiting than other healthcare settings, and we’re continually reviewing this.”
There is concern that dental care generates aerosols and splashes that could contaminate the room and expose workers.
“There are a lot of unknowns about the risk of aerosols, but what we do know is one of your greatest risks occurs during clinical procedures when you have the potential of getting splashed directly and the surfaces directly around you get contaminated,” she says. “So, the most important thing to focus on is your standard precautions and any other additional transmission-based precautions that are recommended.
In general, sterilization protocols do not vary for respiratory pathogens.
“You should perform routine cleaning, disinfection, and sterilization,” Neuburger said. “Follow the manufacturer's instructions for the times and temperatures recommended for the sterilization of specific dental devices.”
- Centers for Disease Control and Prevention. Guidance for dental settings. Coronavirus Disease 2019 (COVID-19). Updated May 19, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html