Best practices for the new normal include sticking with good old infection control

When news broke early this year about a deadly virus in China, few around the globe could have imagined the damage it would inflict both economically and in terms of loss of life around the world.

The scary new COVID-19 pandemic hit so hard in large part because of the uncertainty surrounding it. Health officials, government leaders and the general public searched for information, while different countries and different organizations provided varying opinions on the spread and on methods to combat the coronavirus.

What became clear eventually, around the world, is that steps needed to be taken to slow the spread of COVID-19, and early on things such as social distancing and extensive handwashing and sanitizing became the best known methods of defense. Soon thereafter came the closure of most businesses and stay-at-home shelter orders, which effectively put dental practices throughout the U.S. on hold, only allowing emergency treatments in most states.

All the while this uncertainty left a lot of questions unanswered, some of which have yet to be effectively answered. The CDC, ADA, OSHA and state dental boards all offered advice and in some cases mandates clearly outlying what procedures would be allowed during the shutdowns. The latest CDC guidelines can be viewed here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

Fast forward a couple months and states are re-opening businesses with new protocols in place to attempt to fend off another huge spike in COVID-19-even while the numbers of reported cases have increased in several states in recent weeks. As dental practices began to open in many states in early May and are expected to be delivering elective procedures in every state by the end of June, we once again have plenty of guidelines offered up to practices. 

While most clinicians appreciate the guidelines sent out by the likes of the CDC and the ADA, again there is some concern about what is actually required and what is suggested, and that there is enough science to back up some of the newer suggested protocols such as the need for extraoral HEPA vacuum systems to safely reduce aerosols. Another concern and cause for some confusion surrounds which masks really work best for protecting staff, and whether things such as face shields and disposable gowns are best for every procedure. 

The dental industry has always been on top of infection control, and has implemented new safety measures along the way when health concerns have developed, for instance during the start of the AIDS pandemic decades ago. Gloves, goggles, regularly tested autoclaves, and well cleaned operatories have been regular practice for many years now.

But how can these dental practices reopening be best prepared for a post COVID-19 protocol and are the guidelines they are being bombarded with providing the best information and advice as to what is required and what works best?

Related reading: Preprocedural rinses, extraoral HEPA vacuum systems could key dentistry’s fight against COVID-19 

“I’m relying pretty heavily on the ADA. They've been pretty good about sending out emails and updates kind of as soon as a new guideline comes out, and then summarizing them in their own guidelines. So I've really been following that, and I found it really helpful,” says Dr. Jennifer Sanders, who owns Frenchtown Dental in Montana, a state with one of the lowest numbers of reported COVID-19 cases in the country.

That said, Sanders says it would help to have additional information about combatting potentially risky aerosols, among other things. 

“There are a lot of things that just aren't covered. Some things that people are talking about but that just aren't addressed, for example, there's been a lot of talk about like, ‘Okay, if we do an aerosol producing procedure, how long does it take to clear the air? Are we worried about clearing the air or are we worried about leaving the office clear for you know X amount of time?’” she asks.

Another popular discussion these last few weeks centers around the need and the effectiveness of air filtration systems. A number of systems are available, and Sanders uses one in her practice, but wonders just how effective-and therefore necessary-their use really is. Another hot topic addresses how long operatories need to be cleaned and vacant between patients, and whether staff should be required to switch out PPE each time they enter a new room. Currently Sanders sticks with one patient start to finish, when in the past she’d see multiple patients overlapping appointments in different rooms at the same time.  

“So, I'm trying to schedule in such a way that once I'm with the patient I just stay with that patient. That's my biggest challenge right now is that I'm staying with the patient,” she says.

Not being able to see a second patient, for example, while one is in the process of waiting for the anesthetic to set, can hit her production a bit. But it may allow the staff more time to clean and prep one operatory following a procedure while the dentist shifts to another room.

Like Sanders, Dr. Jeff Lineberry of the Carolina Center for Comprehensive Dentistry, would like to see more proof that suggested equipment such as extraoral HEPA vacuum systems really are worth the investment. He notes that COVID-19 itself has baffled scientists and experts as varying reports of how the virus spreads and how best to fight it have changed on a regular basis the last several weeks.

“If you read through the guidelines and recommendations that's exactly what it is, it all talks about recommendations,” Lineberry says. “You know, we don't know for sure about the transmission of COVID-19. There's a lot of recommendations, but then there's no science behind some of it so to me it's like, I don't understand why they would make so many recommendations and make decisions about things other than that it just looks good on paper.”

Lineberry suggests dentists continue with their strict infection control protocol, add in the obvious extra protections like masks, clean gowns, patient screenings and such, and then stay on top of the guidelines from trusted sources while also making sure there is enough science backing up these newer guidelines.

“The bottom line is they have some inkling to these guidelines, but to me it's like being reasonable and using common sense and not going over the top about some of the recommendations,” he says. “You’ve got some people going out there putting in air purifying systems and changing their system so they have positive air pressure rooms and all kinds of things that, you know, realistically, we don't even know that that's an issue but yet they're spending a lot of time and dollars.”

Lineberry, whose practice reopened to all types of care just over three weeks ago, says the hygiene department has been pretty much booked up the last couple of weeks, but has focused primarily on hand scaling and polishing, avoiding ultrasonic treatment that produces a lot of aerosols. Clinical procedures, on the other hand, are lagging a little behind the pre-pandemic times.

Dr. Jason Goodchild, who practices in Havertown, Pennsylvania, and also is the vice president of clinical affairs for Premier Dental Products, Co., admits that organizations like the CDC and ADA have a difficult task constantly updating guidelines and regulations, especially during a pandemic that caught everyone around the globe off guard.

In terms of the N95 mask requirements, the industry was hit with some confusing information as some OSHA and CDC guidelines said the surgical grade N95s should be used for all procedures, and then differing suggestions came from the Department of Health and some other dental boards. A shortage of high quality masks available for practitioners has only added to the problem.

“You know, a friend of mine used the comment that ‘We're, you know, we're building the plane as we fly it, so to speak,’ We're figuring it out on the fly. That's why it's really incumbent upon each practitioner to really be able-and it's hard to because of all the other stuff we've got going on-to be reading things constantly because things are updating by the minute sometimes and you know you have to really stay up to date on what's going on.”

When it comes to aerosols, there needs to be more data showing how risky some procedures may or not be in terms of COVID-19, according to Goodchild.

“Aerosolization or aerosols has really been the buzzword but you know you really just can't paint that with a broad brush because not all procedures aerosolize things the same way, right,” he says. “Highspeed handpieces and ultrasonic instruments are going to be some of the worst, but don't forget that we aerosolize when we breathe. So what level of aerosols are we comfortable with, and then how to mitigate, accordingly. That's where there's some of the confusion as you just can't treat them all the same way.

“But, you know, dentistry has been a resilient profession in that we dealt with the AIDS pandemic. And we adjusted accordingly and I'm sure we'll do the same with this.”

So, while there are a lot of guidelines out there, some of which are overridden or may conflict with state dental board regulations, Goodchild says the industry has a great head start when it comes to safety and infection control.

“We're very well equipped to handle this stuff,” he says reflecting on dentistry’s history of strong infection control routines. “But again it’s the unknown so there's the unknown of whether our existing PPE and our existing infection control procedures are enough or are they not enough.”

The ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission addresses dentists and dental team preparation, screening for COVID-19 Status and Triaging for Dental Treatment, Instructions for Patient Arrival, as well as guidelines for during and after dental care is provided. To read more on the ADA’s Return to Work Interim Guidance Toolkit click here.