New guidelines based on CDPH May 2020
ADA toolkit, ADHA , OSHA ,CDC
CDA Resource library/respiratory protection program
Also OSHA Respiratory protection program
Airborne precautions CDC /posters
And OSHAs 60 page guide to aerosol transmissible diseases
Posters from Dr.Ziv Simon, periodontist
Dentistry has become a high-risk exposure profession due to our closeness to our patient’s mouth.
We reviewed OSHA ‘contact and droplet precautions’ before and now we are adding ‘airborne precautions’.
- Coughing during intraoral radiographs
- Dental drills
- Aerosol spray from water used to cool drill points
- Air/Water syringes
- Polisher
- Ultrasonic scalers
- Prophy jet
Droplet and aerosol mediated disease transmission depends on the proximity to infected patients, duration of exposure, and the viral loads of infected patients, and symptomatic or asymptomatic.
Aerosols are mists of particles containing virus that travel into the air and drop mostly to the floor but remain partly airborne. They can travel up to 12 feet or more depending on airflow.
They can enter your body by mouth, nose or eyes.
In the operating room you are using head cover, goggles, n95 mask/P100, isolation gown and shoe covers.
kn95 is equal to n95 but FDA has recently started to test kn95 masks for leakage and made a list of approved masks.
Just remember: We are not hospital operating rooms but ambulatory care in a safe environment ??
Studies have shown a low infection rate of dental personnel of 0.46 % in the beginning of the pandemic because dental personnel is used to wear goggles, mask and gloves. After instituting airborne precautions infection rate went down to 0.
Interpersonal talk should not exceed 4-5 min since that is a threshold for infection. Infection spreads via airborne droplets by talk, sneeze and cough, singing...
Loud talking equals sneezing and coughing sending droplets in the air for 15 minutes.
Therefore, patients should wear their mask at all times they are in the office except during treatment. Mask should be worn whenever the patients want to interact with the Dr. or office staff.
At the end of the appointment, the dental assistant should remind the patients to put their mask on before they leave the chair.
If a patient does not have a mask, then assistant will provide one.
No cellphones are allowed, and we keep social distancing of 6 feet.
Use suction (high velocity evacuation) next to the handpiece (or cavitron) at all times as the suction is our first line of defense since the vacuum and air scrubbers are behind us and the patient.
If you can, stand behind the patient at 12 o’clock while working.
Saliva ejector is always in the area at the same time as the high volume suction tip.
USE WET GAUSE IF POSSIBLE INSTEAD OF AIR WATER SYRINGE (Avoid the spray)
During the business hours keep air purifiers/air scrubbers working at max and switch to standby at end of day
They do clean the air multiple times per hour in addition to your buildings air circulation . Unfortunately, we do not have windows we can open which would clear viral particles fast.
Has to do with hydraulic pressure within buildings.
During the times of the plague in the history, windows were kept open. Operatories should keep the bare minimum on the counters and have unused areas covered in plastic.
1.Pre-Screen by phone for the appointment and add 20 min to each restorative appointment
Minimize number of visits by patient(exposure)
Maximize production per visit leads to less room turnover and PPE
In office
Screen when patient enters office with questionnaire and touchless thermometer /patient log enter temperature no treatment if it’s above 100.4F/38 C and screen form is scanned into chart
No handshakes or fist bumps
No companions in the waiting room unless medically motivated. Companions are waiting outside the office.
Questions to patient:
Dear ....Before i book your appointment I have to ask you 7 short questions
1.Do you have a fever or felt feverish recently?
2.Any chills, muscle pain , congested runny nose, headache, sore throat or other cold or flu symptoms ?
3.Do you have a cough, shortness of breath or wheezing?
4.Any recent loss of taste or smell?
5.Any recent stomach upset or diarrhea?
6.Have you had contact with anybody among your family or friends with covid or covid symptoms during the last 4 weeks?
7.Did you travel within the last 4 weeks ?
(Rash, seizure and conjunctivitis are in a small percentage)
- Who will be bringing the patient to the appointment? Is the person over 60 and do they have heart disease, lung disease, kidney disease, diabetes, or any other autoimmune disorders?
- (We can use tele dentistry with Zoom,Facetime,Skype , Teamviewer for many consults)
During flu season in the fall more difficult to discern between flu or covid19.Flu is upper respiratory tract and covid is lower respiratory tract
Remember that asymptomatic patients can shed the virus too. Cough, sneeze or speech.
Patients with covid 19 or who have been exposed recently to covid 19 cannot enter dental office
They have to have a negative test first
Posters about cough etiquette and respiratory hygiene to be posted in waiting room
Patient instructed to have Booties, face mask and hand sanitizer Purell or Vionexus(or wash with soap and water)
before entering treatment area
tissues provided to patient
Booties to be worn by dental staff (not to take virus home, or car)
Post procedural Patient Exit:
Post-op instructions should include a reminder to report any sign or symptoms of COVID-19 within next 14 days
If the patient cancels due to a cold reschedule 14 days out
Above takes priority before answering phones or claiming business …because it’s the most important precaution we can take to protect staff and Drs. If any staff gets infected with the virus that staff member will not be able to work for at least 2-3 weeks until md gives clearance and the office has to close for 2 weeks
How about if you are busy with an important call or payment?
Ask back office to take over
Staff Screening
- Temperature will be taken.
- Advise your screener if you have had fever or chills, shortness of breath or cough, and have taken any fever reducing or symptom altering medication.
- If you have symptoms of acute respiratory illness notify the office. You will be instructed to stay home until you are free of fever, (less than 100.4° F) or have no signs of fever or any other symptoms for at least 24 hours without the use of symptom altering medicines.
- Do not come to work if you have any of these symptoms. Please call the office.
- If you are well but have a sick family member at home with COVID 19, please contact the office. Do not come to work.
- If you are confirmed to have COVID 19, we will inform the team of their possible exposure but maintain confidentiality as required by the Americans with Disabilities Act (AWDA).
Self-reporting requirements: Employees should report any symptoms of the virus they or a household/family member experience.
Symptoms include: fever, cough, shortness of breath, difficulty breathing, chills, muscle pain, headache, sore throat, new loss of taste or smell. Employees should also self-report if they have close contact with someone who is confirmed to have COVID-19. All personal health information will be kept confidential, except that confirmed cases must be reported to our local health department
Daily staff screening log for temperature kept in binder
Infected staff or staff taking care of family with covid have to quarantine until all members are negative.
Don On /Don off
Sequence don on:
1.Wash hands for 20 seconds
2.Wear booties
3.Place gown and secure straps
4.Place n95/kn95 mask using elastics on or surgical mask level 3/fitting of mask (mask should be worn maximum 4 hours due to moisture degrading fabric)
5.Headcover
6.Face shield
7.Gloves
8.Enter room
Sequence don off
1.New gloves
2.Remove gown +gloves (remove gown from inside, unty ? and let fall off)
3.Remove headcover and face shield
3.Remove booties and gloves
4.Remove N95/KN95 outside room using straps or keep them on
Wash hands for 20 seconds
Do not take off masks in the office because the virus cloud can linger for 3-17 hours
PPE is donned outside the room and taken off on the way out of the room by Dr. and after the wipe down by assistant
Waiting room is wiped down periodically and chairs in the waiting room at proper distance from each other-6 feet covered with plastic
Make it a habit to wash your hands every 60 minutes
Eliminate magazines…in the office (the clutter)
No waiting for patients -take them directly to treatment room/viral rinse first twice before treatment starts
Patients to be told when in the treatment room :
"Please do not use phone and keep mask on until treatment starts to minimize aerosols and droplets in the room
When your treatment is over please put back your mask”
Then you tell each patient of all measures taken for patients protection
“Have you received our email about what we have done for safety? let me tell you just a few:
We have Super Hepa filters in all rooms to clean the air from viruses. These airscubbers were used in hospitals during the SARS epidemic. We are also having chairside HEPA vacuum machines when we work, all of us wear n95 masks and protective equipment and we follow all new regulations to keep you safe.
Even the water we use during treatment is safe with NASA technology cartridges. Just wanted to give you peace of mind that you are in good hands
Doctor is setting up outside and he will be in shortly to start your treatment"
Doors are open between waiting room and operatories to minimize door knob touching
Lately CDC has reported that the surfaces are major sources of contamination
There is a chairside checklist in the ADA toolkit posted operatories
Wipe down of rooms
Virus can settle on different surfaces and be a source of infection (On surfaces they are called fomites.)
When room is wiped down and refreshed exit door /ppe off -ppe is not worn outside yellow tape areas
Use kitchen or double gloves, liberal amounts of disinfectant for a minimum of 3 min wet time
Do not pre wipe dirt use the disinfectant first for the kill and do second sweep after
Use a lot of plastic barriers to cover x ray units ,operating chair,control knobs,couter tops, barriers over tray tops,xray head,sensors, computer key boards ,cords,controls, light …etc
Clean and disinfect each room with an Environmental Protection Agency (EPA) -registered hospital disinfectant on list N of the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program from use against SARS-CoV-2. There are at least 500 chemical products proven to kill the virus: hypochlorous acid, hydrogen peroxide, quaternary ammonium, peroxyacetic acid, glutaraldehyde and sodium hypochlorite etc.
Doors and knobs need to be wiped down in addition to counters, chairs, cabinets and other surfaces. If using an ultrasonic cleaner to remove instrument debris, ensure a lid is on and fits tightly over the unit to prevent introducing aerosols into the area. Designate clean and dirty areas in the sterilization area. Heat-sterilize all critical and heat-tolerant reusable dental and dental hygiene instruments prior to use. Use chemical and biologic monitoring to ensure sterilization is effective. Keep all sterile instruments packaged until ready to be used for patient care.”
According to Christensen: For hard surfaces Lysol 3 for 10 min Germ Xtraa for 3min
Fogging:
Pure&Clean Hypochloric acid (miracle water) 460 ppm for hard surfaces or 200 ppm for porous
FDA approved 460 for the list of viruses it kills
2-300 ppm are also good for virus disinfection but not FDA approved
460 ppm has a shelf life of 30 days and 200 ppm has a shelf life of 18 months
Traditional spray particles are 50 micron compared to fogging 20.
Therefore it can be used for ultra low volume fogging It is used also by airlines,trains ,schools,buses,operating rooms and daycare centers. It is a supplement to traditional spray-down and wipe cleaning protocols: morning, lunch and evening for all surfaces that you are not able to reach (instruction unclear).
Fog lingers, allowing it to fully envelop the space, including hard to reach areas. Most foggers are electrostatic sprayers. Hypochlorous acid 200 ppm.
At 100 ppm it's more sanitizing then desinfecting In the human bloodstream and tissues, neutrophils produce hypohlorous acid against invading pathogens. This disinfectant discovered 1870 and made chemically stable in the 80s is on the EPA list and is extremely safe.(eye and skin friendly) No mask, gloves or eye protection needed. Leaves no residue and does not stain.
Neutralizing virus within 5 seconds. Faint chlorine smell that dissipates fast.
All plastics need to be changed between patients. That and the don on off sequence will add 20 min for now to each appointment
RUN ALL LINES FOR A MINIMUM 30 SECONDS AFTER EACH PATIENT INCLUDING HANDPIECE LINES
Lunches are staggered
Staff and doctors to keep mask on at all times while in the office even during no patient time and during interpersonal interaction due to any virus cloud remaining airborne long after the patient left.
(preferably goggles too like Google glasses) Keeping the mask on at office at all times - will also reduce the number of times you touch your face.
Special Considerations for Providing Dental Hygiene Care and restorative dental care
Once in the operatory, You may provide a one-minute pre-procedure rinse before starting any procedure. Mouth rinses containing 1% hydrogen peroxide or 0.2% - 1% povidone or 0.05 - 0.1% cetylpyridinium chloride have been recommended. Hydrogen peroxide diluted 2:1=1%
Latest study on Peridex says that two consecutive rinses 30 sec apart reduces the viral load in the saliva.
Aerosol procedure require four hand suction and aerosol capturing devices like xuction, lief if available • Use full-mouth rubber dams for placement of dental sealants and during dental restorative treatment. (Unless your sealants are hydrophyllic )
For restorative procedures we use rubberdam,xuction system ,lief , isolite or aerosol capturing device. After rubberdam placement disinfect the teeth with 3% hydrogen peroxide for 3 min. wipe with gauze
- Backflow can occur when using a saliva ejector; therefore, when possible, use four-handed technique and HVE for controlling aerosols and splatter.
Use auxiliary Xuction on second hve, or use the aerosol vacuumer ,lief suction device or assistant for limited amount of time. - Use hand instrumentation versus ultrasonic instruments for periodontal debridement and scaling procedures.
- Use selective plaque and stain removal versus full-mouth coronal polishing.
- Avoid air-polishing procedures.
- Do not use the spray functions on the air water syringe,
If you do surgery do not use a N95 respirator with an exhaust valve. It will contaminate the operating field.
Do not use face shield all the time because that will restrict airflow and contribute to hypoxia.
A nice face shield that clips on loupes -Google: Starmed-teknik.de/en/ Youtube:starPROtect shield Video
heavy on the ears though or 3/5 inch depth faceshields for loupes from american faceshields us. Also heavy
or https://store.whiteclouds.com/Dental-Personal-Protection-Equipment.html
Another one is made by Orascoptic and other companies
Alpha Pro Tech masks are recommended by Dr.Gordon Christensen for good seal
Touchless soap /disinfectant dispensers are preferred
At try in of crowns immerse into alcohol
Spray and disinfect work going to lab
Micrylium LeCloth wipe roll has fibers that will not deactivate recommended disinfectant Biosurf or GermExtra according to Christensen, do use alcohol content 60 or 70 % disinfectant
Do scheduling and charting outside operating room to minimize presence and time
No pens for patients. They are kept by patient or thrown
Remote payments as much as possible not to touch patients credit cards
Stay behind the front office sneeze guard when making appointment or taking payment
Have a barrier between you and patient and insist on patient wearing mask as soon as leaving the operatory
Patients to keep social distancing guidelines of 6 feet from each other
Fit check of masks yearly by employer to assess leakage and fit and there are guidelines from OSHA about medical questionnaire by employees who will wear respirators for medical contraindications
In that case a surgical mask is more appropriate
During periods of shortages N95 masks can be substituted by level 3 surgical masks
N95 masks or higher can leak so you have to adjust them properly to fit over nose and face with no leakage
And if desired cover your n95 mask with an ASTM 3 level surgical mask (Dr.Reznick-Director of the Oral Health Center of Grady Health System's of infectious diseases,at Henry Schein seminar)
That can provide extra protection and make sure your mask is not soiled so it can be reused.
However if you feel resistance to breathing and tired pm /exhausted it could be “hypoxia” from the mask (not enough oxygen)-which long term can damage lung alveoli so change mask to different type or to surgical mask /readjust mask
Use your N 95 mask 4-5 times or 4 hours to have a safety margin
SEAL CHECK OF RESPIRATOR-N95 mask
The individual who uses a tight-fitting respirator is to perform a user seal check to ensure that an adequate seal is achieved each time the respirator is put on.Either the positive and negative pressure checks listed in this appendix, or the respirator manufacturer's recommended user seal check method shall be used. User seal checks are not substitutes for qualitative or quantitative fit tests.
I. Facepiece Positive and/or Negative Pressure Checks.
A. Positive pressure check. Close off the exhalation valve and exhale gently into the facepiece. The face fit is considered satisfactory if a slight positive pressure can be built up inside the facepiece without any evidence of outward leakage of air at the seal. For most respirators this method of leak testing requires the wearer to first remove the exhalation valve cover before closing off the exhalation valve and then carefully replacing it after the test.
B. Negative pressure check. Close off the inlet opening of the canister or cartridge(s) by covering with the palm of the hand(s) or by replacing the filter seal(s), inhale gently so that the facepiece collapses slightly, and hold the breath for ten seconds. The design of the inlet opening of some cartridges cannot be effectively covered with the palm of the hand. The test can be performed by covering the inlet opening of the cartridge with a thin latex or nitrile glove. If the facepiece remains in its slightly collapsed condition and no inward leakage of air is detected, the tightness of the respirator is considered satisfactory.
II. Manufacturer's Recommended User Seal Check Procedures. The respirator manufacturer's recommended procedures for performing a user seal check may be used instead of the positive and/or negative pressure check procedures provided that the employer demonstrates that the manufacturer's procedures are equally effective.
PPE
In situation of severely limited or no available isolation gowns, the following pieces of clothing can be considered as a last resort for care of COVID-19 patients as single use. However, none of these options can be considered PPE, since their capability to protect HCP is unknown. Preferable features include long sleeves and closures (snaps, buttons) that can be fastened and secured.
- Disposable laboratory coats
- Reusable (washable) patient gown
- Reusable (washable) laboratory coats
- Disposable aprons
- Combinations of clothing: Combinations of pieces of clothing can be considered for activities that may involve body fluids and when there are no gowns available:
- Long sleeve aprons in combination with long sleeve patient gowns or laboratory coats
- Open back gowns with long sleeve patient gowns or laboratory coats
- Sleeve covers in combination with aprons and long sleeve patient gowns or laboratory coats
- N95 masks Masks should have a good filtration for at least 4 hours hours but …
- when you go to restroom or elevator wear a mask/and goggles because it is a confined space Avoid touching doorknobs and handles
- wipe down frontdesk phones and have plastic covers on computer keyboard
- Change clothes every day, wash them in hot water like 70 degrees Celsius 160 degrees Fahrenheit . Wash hands and Face when leaving and take a long shower as soon as you arrive home .
It is still required to have fit testing where you can be the fit tester if you follow guidelines outlined by cda “return to practice” at cda.org
Treat: emergencies
Potential emergencie
Provide essential dentistry to prevent future emergencies during second wave using your judgment
Use ppe during aerosol procedures
Chart and protocols to be found at cda.org/ADA toolkit
Follow also American Dental Association “What constitutes a dental emergency”
Avoid procedures on immunocompromised and patients with underlying medical conditions
Use saliva blocking supplies dry angles , Xuction, leaf suction , isolite, rubber dam
Four handed suction intraorally, medications to make the mouth dry... That is for zone 1 =intraorally
You share zone 2 with dental aerosol suctioning machine and you have your ppe to protect you zone 2= around dental chair
Zone 3=in the operatory you have a air purifying machine
Zone 4 =in the dental office generally you have air purifying
A recent European study of 1,420 patients admitted to 18 hospitals across Europe reported COVID symptoms in the following order of frequency:
- Headache 70.3%
- Loss of smell 70.2%
- Nasal obstruction 67.8% nasal dryness can be a prelude
- Cough 63.2%
- Weakness 63.3%
- Muscle pains 65.2%
- Runny nose 61.1%
- Loss of appetite 54.2%
- Sore throat 52.9%
- Fever 45.4%
Interestingly, groups of symptoms differed according to age and sex. - Younger patients more often had ear, nose, and throat symptoms.
- Older patients more often had fever, loss of appetite, and fatigue.
- Loss of smell, fatigue, headache, and nasal obstruction were more common in females.
In another recent publication in the BMJ, the authors studied 20,133 patients hospitalized with COVID-19. They found that symptoms appeared to be in clusters: A respiratory cluster (cough, shortness of breath, sputum, and fever), a musculoskeletal cluster (joint pain, headache and fatigue), and a gastrointestinal cluster (abdominal pain, diarrhea, and vomiting.)
Diverse: wipe your iphone down often and when going home iphone surface more prone
Before leaving for home wash hands and face
`According to research most severe complications occurred in patients deficient in Vitamin D3.
People with type 0 blood , asthma and smokers are more resistant to covid.
Regular conversation between 2 people leaves a lingering cloud of droplets for 15 min in the air
That is why authorities recommended talk 15 min max and 6 feet apart. However recent Korean study shows infection in restaurant between infected person and high school student after 5 min with 20 feet apart. The student was in the line of the air conditioners airflow and facing it. People that had their back to the airflow did not get infected.
So once the person leaves you can still not take off your mask.
Christman cautioned that even the way you breathe can affect how effective the mask is. “If you’re breathing more normally, you have more of a circuitous pathway to your mouth and nose,” he said. If you’re exerting yourself or otherwise breathing quickly, you’re more likely to pull air from around the mask.
Do not wear it home or when alone in or outside when no people around because restricted air flow
At a restaurant you are more likely to catch the virus so have your mask on between meals
If you hang clothing outside for 3 days and wash after- you pretty safe
Do not use disinfectants on food
One person had collapsed lungs after running 2 miles with mask
If somebody jogging in front of you they can leave a stream of 30 feet that you can inhale
If you are afraid to seem impolite just have the mask on before meeting neighbours…
Recirculated air buses( Chinese tracing) airplanes( 50%) can transmit the virus according to research
Environmental factors like airflow, humidity and temperature may prolong presence of SAES-cov-2 in flight cabins.
Only 60% of people who got covid developed antibodies
Antibodies last for 6 months to…?
Weak antibody or strong antibody response depending on number of antibodies
Blacks twice more then white
Over 65 and underlying medical conditions more severe
Young people get it too about 20%
Children have better cytokines against the virus but they can be asymptomatic spreaders especially
when schools are open
Surfaces which are contaminated are less likely to transmit compared to cough, sneeze and sing
Touching your face can transmit the virus
Talking 4-5 min to somebody increases the viral load and potential infection so time dependent
Infection occurred at a restaurant where several tables were in the same line of airflow from the air conditioning
Ab bloodtype more likely then other blood types likely to get it
70% of people with covid will not transmit compared to super spreaders
Virus stays longer on humid and cold surfaces versus dry and warm therefore an increase is expected during winter season
After touching a lot of surfaces like groceries sanitize your hands when entering your car because you are going to touch your face during the drive
you can get covid several times
Remdesivir shortens hospital stay and plasma treatment with antibodies looks promising
Hydroxy chloroquine trials were stopped due to severe complications maybe better as prophylaxis
Dexamethasone reduces cytokine storm for patients on oxygen or ventilators
There is research showing a bradykinin storm which explains the disease as circulatory as well
Regeneron is an antibody syntetic cocktail made up of two monoclonal antibodies to reduce virus levels. It was given to President Trump (Regen Cov2)
Elly Lilly’s monoclonal antibody called bamlanlvimab can be given as soon as symptoms and positive test result happen.
It will reduce hospitalizations , specially among elderly and immune compromised.
Long nasal canulas are now preferred to respirators
Antibodies seem to fade away after 3 months and only 80% have it
Many have a missconception that once they had covid they cannot have it again
In fact even during the period of immunity they can still spread the virus. We do not know how strong their immunity is so they should get vaccinated as well.
Clogged noses and a full set of teeth makes the more droplets go much farther then otherwise
Avoid gatherings like weddings, barbeques, closed roof restaurants , airplanes, bars ,hotels, churches and events.
The vaccines will quickly help to achieve herd immunity by slowing transmission.
They are 95% effective, will not change DNA for patients, do not contain live virus and have few side effects for 3-10% of patients
such as pain on site of injection, muscle pain, fever chills . Side effects should resolve within 2 days.
People with allergies and cosmetic fillers can have an allergic reaction to the vaccine.
Tests for covid have a high percentage of false results so repeated testing 2-3 times is more accurate.
Newer technology is emerging that can kill the virus within a short time in a room like Xenex UV light for $125 000,00 that some hospitals are acquiring
A leading nutritionist suggests the following to boost immune system:
1.Vitamin D
2.Vitamin C
3.Zink supplement stops viral replication and entrance to cells
4.Quercetin, a natural bioflavonoid opens cells so zink can get in.
Nowdays N95 masks are more available so you can buy them on Amazon. They should state FDA approved.
Use a kee or elbow for elevator buttons. Avoid door handles.
Before leaving work for home wash hands. After shopping for groceries disinfect hands.
