Keeping a dental practice and patients safe from Coronavirus

It’s almost impossible to turn on the television, open a newspaper, or log on to social media without hearing about the 2019 Novel Coronavirus (2019-nCoV). As with any public health concern, healthcare professionals are especially susceptible to the dangers-but dental professionals may be even more so.

Stay safe

The best way for dental professionals to protect themselves-and their patients-against the spread of the 2019-nCoV is through basic, tried-and-true Infection Control 101.

“It goes back to the same, old-school system of washing your hands with soap and water for at least 20 seconds,” infection control consultant and speaker Leslie Canham, CDA, RDA, observes. “After the Swine Flu pandemic in 2009, the general public was advised to wash their hands more frequently. If they don’t have soap and water to use alcohol hand sanitizer. People were also advised to avoid touching their eyes, nose, and mouth with unwashed hands, also not to come in close contact with people who are sick, and finally stay home when they are sick. 

“Healthcare workers want to make sure to follow standard precautions. Standard precautions are a group of infection prevention practices that include hand hygiene, use of gloves, masks, eye protection, and respiratory hygiene/cough etiquette. In addition, cleaning and disinfecting surfaces thoroughly after every patient is crucial. For surfaces that are difficult to clean and disinfect, plastic barriers should be used. For our patient population, we can advise them to cover their mouth and use a tissue when they sneeze or cough, and stay home when they are sick.”

One of the challenges with something like 2019-nCoV-also known as COVID-19-is that it shares so many of its symptoms with other diseases. Knowing how to differentiate between these maladies is important for staff and patients alike.

“Did you know the initial stages of measles looks just like a cold,” Karen Daw, “The OSHA Lady”, speaker and consultant, observes. “How would someone be able to tell if the person hacking, coughing and sneezing all over the waiting area has measles, flu, Tuberculosis, 2019-nCoV, or just a common head cold? Take the guesswork out of it and have an office policy that demonstrates how we plan on protecting our employees from airborne transmissible diseases. For example, educate patients with a statement in their new patient packet regarding when it would be appropriate to call in and reschedule an appointment. Include language regarding symptoms, and that definitely if running a fever, to not come in. Let them know that it’s for their health, though we know it is as much as for our health as well not to be exposed to someone who is ill.”

Signs and symptoms

For confirmed 2019-nCoV infections, reported illnesses have ranged from people with little to no symptoms to people being severely ill and dying. Symptoms can include:

• Fever

• Cough

• Shortness of breath

Centers for Disease Control (CDC) believes at this time that symptoms of 2019-nCoV may appear in as few as two days or as long as 14 after exposure. This is based on what has been seen previously as the incubation period of MERS viruses.

Common human coronaviruses, including types 229E, NL63, OC43, and HKU1, usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. Most people get infected with these viruses at some point in their lives. These illnesses usually only last for a short amount of time. Symptoms may include:

• Runny nose

• Headache

• Cough

• Sore throat

• Fever

• A general feeling of being unwell

Human coronaviruses can sometimes cause lower-respiratory tract illnesses, such as pneumonia or bronchitis. This is more common in people with cardiopulmonary disease, people with weakened immune systems, infants, and older adults.

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Stay home

They best way to avoid trouble is to ensure those exhibiting signs and symptoms just stay home. Taking the opportunity to share illness information with patients shouldn’t just be limited to when they walk through the front door.

“Confirmation calls and texts can also reiterate that if the patient is unwell, to please call immediately and reschedule and that we are happy to accommodate them at another appointment soon,” Daw observes. “But don’t be surprised if they don’t take you up on the offer. For example, you may have a single mom with an unaccommodating boss giving her flack about taking time off from work to bring her kids in for their hygiene appointments. This happened to us once. It was clear that mom and her kids were under the weather. She also shared she was unable to take more time off from work without repercussion. We felt awful for her, however our policy was that we weren’t going to see anybody that was capable of spreading an airborne virus, because our practice was not equipped with proper air exchanges or respirators. And truly, she should’ve stayed in bed as badly as she sounded. It was clear that she was running a high temperature. Fortunately, our dentist had a policy that we will do our best to accommodate any patient that must reschedule due to illness. The following week he stayed a little late and saw her and her children when they were feeling better and everyone was happy. This, easily, could’ve turned into a disaster, but the entire team was trained on this exact scenario and understood the importance of educating our patients so that it was unlikely someone would come in sick.”

The same logic applies for employees, and the practice is advised to facilitate those decisions.

“On the flip side, if the employee is not well, the practice should have a policy that does not penalize them for wanting to stay home,” Daw says. “In fact, if they arrive at work sick, the manager or employer should advise them to return home. Train employees on when it is and isn’t appropriate to call in. Advise all employees to stay home if they are sick until at least 24 hours after their fever is gone without the use of fever-reducing medicines. Again, while this is basic information on influenza protection, the principles apply to preventing any type of infectious airborne disease, like 2019-nCoV.”

It may also occur that, if employees are exposed to sick patients, that OSHA could get involved. 

“OSHA can possibly cite a practice under the General Duty Clause if the state does not have a specific standard regarding protecting employees from airborne diseases,” Daw says. “Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards that are causing or are likely to cause death or serious physical harm. If the practice insists on seeing a patient with flu-like symptoms, the CDC recommends a fit-tested N95 disposable respirator while performing high-risk, aerosol-generating procedures and have a written respiratory protection program that meets OSHA standards. This includes a medical evaluation. Those who are wearing the N95s must be trained in the proper use, fit and disposal and this is in addition to engineering and work practice controls. So for most practices, it’s just easier to have a policy in place that says ‘If we suspect flu, we don’t see the patient’.”

Lessons learned

But even though news about the 2019-nCoV seems to be everywhere, practices don’t need to do anything out of the ordinary to accommodate this threat-adhering to established protocols seems to provide sufficient protection. That said, this time can be used as a teachable moment.

“It’s the same precautions that we use for influenza, which is far more likely to be a visitor to a dental practice than would Coronavirus,” Canham says. “But it does give us a wakeup call of how quickly these viruses can spread. I was surprised when I first heard about Coronavirus in mid-January when there were around 2,000 cases and, within a week or so, it jumped to over 20,000 cases. As of mid-February, there are over 60,000 confirmed cases with 1,370 deaths linked to the virus. It’s amazing how quickly something like this can spread.”

Coronavirus concerns can be used to underscore the necessity for proper infection prevention protocols, especially as they are related to the sorts of diseases that circulate every year.

“Certainly, people should be concerned, however, the likelihood of coming in contact with someone infected with Coronavirus is low. You’re more likely to come in contact with influenza. Centers for Disease Control estimates that as many as 56,000 people die every year from influenza,” Canham says. “ During cold weather, we spend more time indoors, where we are in close contact with other people and can be exposed to aerosols that are generated from people who are sick.”

Some states take the transmission of airborne diseases very seriously and have Aerosol Transmissible Disease (ATD) standards, administered by OSHA.

“In California, we have a unique ATD, or aerosol transmissible disease standard that is an OSHA requirement for workers who may be exposed to people who have an aerosol transmissible disease. OSHA requires employees to screen patients prior to providing treatment,” Canham says. “We have certain steps that we have to follow in order to comply with this standard. In addition, we’re required to have written plans on how to conduct the screening as part of our injury and illness prevention program. OSHA requires that employees be trained on that screening procedure. Finally, we may not perform aerosol-generating dental procedures on a patient who has an active, infectious ATD unless a physician or healthcare provider determines that that they’re not currently infectious.”

The ATD screening steps are based on the 2003 CDC Infection Control Guidelines For Dental Healthcare Settings under the section for M.tuberculosis. 

“The following are the steps from CDC that help us screen our patients for aerosol transmissible diseases,” she says. “The first step is, while taking patients’ initial medical histories and at periodic updates, dental health care providers should routinely ask all patients whether they have a history of TB disease or symptoms indicative of TB. Then these are the other signs to look for: 

• A patient has a cough for more than three weeks that’s not explained by non-infectious conditions.

• If a patient exhibits signs and symptoms of flu-like illness – that might include coughing or other respiratory symptoms, fever, sweating, chills, muscle aches, weakness and malaise.

• The patient states that they have a transmissible respiratory disease, excluding common cold or seasonal flu.

• The patient states that they have been exposed to someone who has an infectious aerosol transmissible disease.

Patient protection

Something that would go a long way toward stymieing infectious disease transmission is providing an “infection prevention station” in the reception room.

“I’m a big fan of making sure that patients see tissue paper, alcohol hand sanitizer, and masks that they may want to put on, right in the reception room,” Canham says. “If the patient is coughing or sneezing or encounters another person who’s coughing or sneezing, they can access tissues, hand sanitizers, or masks without having to ask anyone. Be sure to keep a waste receptacle nearby to put those dirty tissues into. The infection prevention station sends the message to patients that we care about infection transmission, not only for big events, like Coronavirus, but also for the events like seasonal flu that we can encounter regularly.”

 “I would also advise to have several waste receptacles located nearby,” Daw adds. “The last thing you want is for someone to sneeze into the tissue and then place the tissue on an end table or, even worse, hand it off to someone at the front desk to dispose of. Also, have signage in place in the waiting area encouraging people to cover their cough. Free posters are available from the CDC and are a great reminder to patients to follow proper cough etiquette. In addition, include disinfection procedures in the OSHA manual regarding how to disinfect those surfaces, touched by someone who is not well. Disinfecting pens used to sign in, door handles both coming and going, and maybe even arm rests can help prevent the spread of germs from highly touched surfaces.”

2019-nCoV certainly gets a lot of press, but keeping it at bay is as simple as observing best practice infection control protocols.