COVID Essentials

By Leslie Shu-Tung Fang, MD, PhD

As the nation re-opens in stages and dental offices slowly resume full service, it may seem like there are questions around every corner—chief among them, “How can my staff handle the added burdens involved in preventing COVID-19 infection in our practice?”

Thankfully, rigorous research and resourceful innovation have produced myriad solid patient protection solutions you can implement immediately. Fighting the coronavirus doesn’t have to be overly difficult or expensive.

Among several strategies, we highlight three that can ensure your patients receive the safest care possible, while inspiring the peace of mind they need to make and keep their dental appointments.

  1. Fogging: Aerosol production in everyday life is less common than in clinical settings. “WHO recommends taking specific precautions against aerosols only in hospital settings during specific procedures such as inserting a breathing tube into a patient.”1 Unfortunately, “due to the unique nature of dentistry, most dental procedures also generate significant amounts of droplets and aerosols, posing potential risks of infection transmission.”2 While conventional disinfection remains important, ultra-low-volume hypochlorous acid fogging provides an extra dimension of decontamination that addresses the airborne threat.
  2. Virtual waiting rooms: Reducing patient-to-patient contact is an important risk-reduction strategy. Having a “virtual lobby” system in place for your scheduler helps ensure smooth and orderly transitions from parking lot to dental chair.
  3. Single-use disposable nitrous masks: Sterilizing hose and mask delivery systems is time consuming, and OSHA warns that repeated sterilization of traditional nitrous oxide systems creates micro fractures compromising the integrity of the hoses, exposing dentists and their teams to unnecessary gas exposure risks. Single-use masks eliminate risk of contamination between patients and evacuate residual gas better than any other system with no sterilization required.

These tools can help streamline the new protocols and relieve your staff and patients of unnecessary risks. Let’s look at each one in more detail as using all three together will give you a winning strategy for safe and efficient operations.

Ultra-Low Volume Fogging for Disinfection of Indoor Spaces

D. Jamie Menhall, Tracey Wong Menhall and Leslie S.T. Fang MD PhD, co-authored an article entitled S.T.A.R. WARS: Ultra-Low Volume Fogging of Hypochlorous Acid To Address the Vexing Issue of Aerosols in Dentistry, for Incisor on June 8, 2020. The following is an excerpt.

To fog a liquid is to create a mist of very small particles. The mist is released into an enclosed space. Over several minutes, the mist lands on surfaces, where it helps kill bacteria and viruses, before evaporating shortly thereafter. Foggers use large amounts of low-pressure air to aerosolize liquids before dispersing the mist through a nozzle. Traditional spraying creates particles in the 50-micron range while fogging a liquid can result in fine particles under 20 microns in size.

With the ongoing pandemic, fogging is increasingly important in augmenting conventional disinfection.

Fogging, rather than directional spraying, has superior surface area coverage: the fog lingers, allowing it to fully envelop a space, including hard-to-reach areas. The process is relatively automated and very little labor is involved except for filling the solution tanks and moving the fogging machines…Ultra Low Volume fogging’s ability to create small particles is crucial.

With the ongoing pandemic, fogging is increasingly important in augmenting conventional disinfection to allow for inexpensive, quick, and effective disinfection of large areas. In all instances, fogging is not a replacement for traditional spray-down and wipe-cleaning protocols, but it is a potent complementary technology.

Many sectors have started using chemical fogging to help combat the coronavirus, including airlines, hotels, hospitals and cruise lines. Fogging is also an important adjunct in disinfecting trains, buses, schools, nursing homes, offices, warehouses, and grocery stores.

Virtual Waiting Rooms

Virtual Waiting Rooms

The ADA published a Return to Work Interim Guidance Toolkit on June 9, 2020 that recommends reducing the number of patients in the reception area at any one time. The Toolkit further advises, “If suitable given your office design, you might consider having your patients wait in their car and you can call or text when they should enter the practice.”

As doors reopen to treat patients, we are doing everything possible to help practices manage the new workflows that now include the “blacktop waiting room” required by State social distancing guidelines.

Michael Boerner, CEO of Dental Innovations says that “virtual lobbies” can help practices re-launch as they open with COVID-19 patient workflow protocols. His company launched an SMS texting system earlier this year that gives a practice the ability to manage patient staging in the parking lot, convey relevant information including brief videos to the patient, and send a text message when it’s time to enter the building.

Learn Sedation Dentistry

“We recognize that COVID-19 and statewide stay at home orders have materially impacted practices and staff teams. As doors reopen to treat patients, we are doing everything possible to help practices manage the new workflows that now include the ‘blacktop waiting room’ required by State social distancing guidelines,” according to Boerner.

Disposable Nitrous Mask Systems

Reusable nitrous oxide hose-and-mask delivery systems are one potential source of COVID-19 infection in the dental office. In addition to the viral and bacterial risks, repeated chemical or steam sterilization of hose delivery systems breaks down the integrity of the materials, resulting in leaks of nitrous oxide gases into the operatory, exposing dentists and their teams to unnecessary health risks.

Despite best efforts to sanitize equipment, pathogens can and do survive in reusable systems.

Adding the numerous COVID protocols to the routine of cleaning, disinfecting, and sterilizing equipment after each use begs for a safe, less labor-intensive solution. Many practices spend considerable time between patients, disinfecting nitrous oxide equipment, disassembling multiple pieces, washing them in soapy water, autoclaving, then reassembling for the next patient.

Despite best efforts to sanitize equipment, pathogens can and do survive in reusable systems. Particularly, multiple connectors in the hose system tend to gather pathogens and are very difficult to disinfect.

In April of 2020, the American Academy of Pediatric Dentistry published Re-emergence Pediatric Dentistry Practice Checklist: A guide for re-entry into practice for pediatric dentists during the COVID-19 pandemic. Among the recommendations was switching to Single-Use Equipment as part of your point-of-care operatory environment: Identify one-time disposable armamentarium that has sterilizable and multi-use counterparts and solutions such as nitrous oxide circuits/masks and laundered gowns.

Going Forward…Safely

Fortunately, the dental industry has been pulling out of lockdown phase, and more practice are welcoming back patients, albeit in smaller numbers than pre-covid.

As the virus continues to run its course, it is important to continue extra measures to protect the elderly, those with comorbidities, and the public at large to help prevent transmission. These three methods provide an excellent addition to the dentist’s arsenal against the invisible enemy.



  1. Transmission of SARS-CoV-2: Implications for Infection Prevention Precautions. Scientific brief, July 9, 2020. WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.3
  2. Ge, Zi-Yu et al. “Possible aerosol transmission of COVID-19 and special precautions in dentistry.” Journal of Zhejiang University. Science. B vol. 21,5 (2020): 361-368. doi:10.1631/jzus.B2010010
  3. Daily COVID-19 Deaths in the U.S. Have Fallen Dramatically Since April. July 22, 2020.
  4. Rademake, April M., et al. Journal of the American Dental Association. “Evaluation of two nitrous oxide scavenging systems using infrared thermography to visualize and control emissions.” Vol. 140, February, 2009.
DOCS Membership

Learn Sedation Dentistry

Upcoming Events
October 01- 02, 2021
San Francisco
November 12- 13, 2021
February 18- 19, 2022

More Articles