Leslie S.T. Fang, MD PhD
Massachusetts General Hospital
Harvard Medical School
On March 16, the ADA issued the following statement:
“The American Dental Association recognizes the unprecedented and extraordinary circumstances dentists and all health care professionals face related to growing concern about COVID-19. The ADA is deeply concerned for the health and well-being of the public and the dental team. In order for dentistry to do its part to mitigate the spread of COVID-19, the ADA recommends dentists nationwide postpone elective procedures for the next three weeks. Concentrating on emergency dental care will allow us to care for our emergency patients and alleviate the burden that dental emergencies would place on hospital emergency departments.”
“As health care professionals, it is up to dentists to make well-informed decisions about their patients and practices.”
Various local dental societies have issued statements echoing these recommendations. It is unlikely that these limitations would be lifted soon.
Coronavirus has a global reach, is in over 200 countries and in all 50 states, causing unprecedented havoc in every phase of our lives. Aggressive steps at containment changed to mitigation but escalating deaths are grim recognition of the pandemic. Researchers and clinicians are racing to come up with a solution and more than 50 drugs are being investigated clinically.
COVID-19, the disease caused by SARS-CoV-2, is highly contagious with a rapid velocity of transmission. The disease appears to have a fatality rate that is lower than its predecessors, SARS-CoV-1 and MERS-CoV-2, and the majority of the fatality is in elderly patients and in patients with pre-existing underlying chronic diseases such as cardiovascular disease, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. However, there are innumerable young and healthy patients succumbing to the disease, heightening the fear of this disease.
In 80% of the cases, COVID-19, particularly in young, healthy patients, is mild and those affected would have symptoms similar to those of a cold or flu. In 15% of the cases, the development of progressive respiratory symptoms may necessitate hospitalization. In 5% of the cases, the patients are critically ill and would require intensive care unit support. The overall fatality is estimated to be about 2%.
The modes of transmission include droplets, surface contact, fecal-oral route and by aerosolization during procedures. An increasing prevalence of asymptomatic carriers and transmission by asymptomatic carriers have been reported.
Although vaccines have been developed at warp-speed pace in the United States, Israel, Queensland and in China, it is expected that it would take too long for the vaccines to be deployed during this epidemic because of the time it takes for safety testing and for clinical trials. Clinical trials with antiviral agents such as Remdesivir, chloroquine, hydroxychloroquine, hyperimmune globulin, convalescent blood, stem cell therapy, and others are in place and would hopefully help with the development of effective therapeutic agents.
As of now, the best protection for the dental professional is a heightened sense of awareness, avoiding unnecessary contact with patients that may have coronavirus, the use of appropriate personal protective equipment, and increased attention to personal hygiene.
Recommendations continue to be predicated upon information that arises daily and you should be mindful of the situation in your local community and the continuing evolution of the disease globally.
Risk to the Dental Professional
We are aware of the risk to healthcare workers from the data coming out of Wuhan. Of the initial 44,672 cases, 3,019 (6.75%) were health workers and 7 of those have died as of February 11, 2020. With increasing awareness and the uniform adoption of personal protective equipment, the risk has progressively decreased in Hubei Province.
The dental professional is particularly at risk if one is working on an infected patient or an asymptomatic carrier because of close contact with the patient and the risk of blood, saliva and droplet exposure. In Italy, there were 7 dental professionals who died of COVID-19 during the pandemic.
Currently, a fair number of dental offices are closed. There are offices that continue to address dental emergencies and it is critical that extra precautions are taken during this period.
Centers for Disease Control and Prevention (CDC) Recommendations
The CDC Recommendations are designed for all health workers. Because of the unique situation the dental professional is in, I have made modifications to tailor the recommendations to the dental professional.
The most important difference between the medical and dental professionals in this situation is that a great deal of dentistry can be deferred to a later time whereas the medical professional is obligated to see the patients when they are sick. The modifications to the recommendations have been made to minimize the likelihood of contact with an infected patient and to minimize transmission of disease.
Coronavirus and the Dentist: Recommendations for the Dental Professional
The CDC, OSHA, AGD, and ADA have all made recommendations for dental professionals. The following is a culmination of these recommendations with an eye towards addressing important practical issues.
- Administrative Controls
- Engineering Controls
- Environmental Hygiene
- Correct Work Practices
- Personal Protective Equipment
- Strict Adherence to Standard, Contact and Airborne Precautions
Note that we have made modifications to reflect the circumstances unique to dentistry.
This is an airborne infection that can be borne by asymptomatic or pre-symptomatic carriers. Respiratory precautions are of paramount importance.
While there are a number of parts to the recommendations, it is critical that you go out of your way to ensure patient safety and the safety of yourself and your staff. Every attention to detail will reflect well upon the practice. Lapses can result in unwarranted infection with a virus that can be deadly.
- The Overarching Question
- Is this an emergency?
- Assess the urgency of the patient visit, including pain, swelling or trauma.
- All elective dental procedures should be deferred.
- The patient should be rescheduled 30+ days down the road.
- Although this is an imposition on the staff and the patient, everyone will be appreciative of your concern for their welfare.
- Is this an emergency?
- Prior to the Patient’s Arrival
- In general, one should avoid walk-in visits.
- When the patient calls for an appointment, the front desk should ask if:
- They are sick with fever, cough, sore throat, muscle pain, GI symptoms, anomsia (loss of smell and taste) and profound fatigue.
- They have had travels to endemic areas within the past 30 days: these include New York City and virtually all overseas travel.
- They have been on a cruise
- They have been in contact with patients diagnosed to have COVID-19
- All patients who answer in the affirmative should not have dentistry—even if it is an emergency—because of the risks to other patients and staff. They should be referred to a setting where proper isolation is possible.
- Instruct patients to take their temperature before coming to your office. Encourage these patients to reach out to their medical doctor for evaluation and management.
- Instruct patients to arrive on time for appointments, not early, to minimize waiting in our office and to decrease the number of people present.
- Inform them that their escorts will be asked to wait in the car. They will be called when the patients are finished with their procedures.
- While all of these are impositions, they will be reassuring to the patients since you are clearly concerned about patient safety
- Upon Patient’s Arrival
- Make every attempt to keep the waiting room empty.
- Have patients’ escort wait in their car, until the patient is finished
- Indicate that you will call or text the driver at the appropriate time
- The patient should be given a surgical mask.
- There should be a prominent sign directing the patient to use a hand sanitizer from a non-touch dispenser stand and to vigorously rub their hands for 20 seconds.
- Anyone who is sick should be given a mask and be asked to seek medical help.
- Take the patient’s temperature, anyone with a fever should be given a mask and be asked to seek medical help.
- While this is an imposition on the staff and the patient, all will appreciate your concern for their collective welfare.
- Make every attempt to keep the waiting room empty.
It is important to stress that even with all these precautions, an infected patient might still slip through, particularly with the increasing awareness of asymptomatic or pre-symptomatic patients. It is therefore important to take every precaution one can to protect the office and the staff.
The hope is to be able to optimize ventilation in the operatory. Ideally, air exchange of the operatory 6 times an hour during operating hours would reduce issues with undue exposure.
There are offices that are considering HEPA system with ultraviolet light units. This is an expensive proposition but is probably of help.
Air purifiers with UV-C lamps will help with aerosolized pathogens and are visible cues in the operatory reminding patients that you are indeed attentive to the air quality.
Because the coronavirus can stay alive on surfaces for 24 hours+, it is important to keep all surfaces clean and sanitized. While this pertains to the waiting room, the bathroom, all common areas and the front desk, it is particularly important to disinfect the operatory as frequently as is feasible.
Common cleaners such as 0.1% sodium hypochlorite, 0.5% hydrogen peroxide or 62-71% ethanol have all been shown to be effective.
Hypochlorous acid is a popular cleaning agent for the operatory since it would evaporate from the surface without wiping.
Correct Work Practices
Special attention should be paid to good hand hygiene:
- Good hand hygiene is the most important protection for the dentist and the staff:
- Thorough handwashing with soap and water
- Lather hands with soap
- Lather the back of hands, between the fingers and under the nails
- Scrub hands for at least 20 seconds
- Rinse off
- Dry hands with a clean disposable towel or air dry
- Try to minimize aerosol effects using a rubber dam and high-speed suction
- Consider oral rinsing with chlorhexidine, Listerine or povidone-iodine 1% antiseptic
- Pay even more meticulous attention to:
- Sharps safety
- Injection safety
- Waste disposal
- Sterile instruments and devices
Personal Protective Equipment
Dental Professional and Staff
During this period of heightened concern, all members of the office and the patients should be masked with surgical masks.
Dental professionals are used to working with a mask, gown, and gloves on. Because the coronavirus is a virus that can be aerosolized with procedures, conventional surgical masks would not be adequate. Depending upon the potential exposure, the dental professional and the staff should use:
- N95 Mask/Respirator
- Ordinary surgical masks have pores of about 2-10 microns, while the N95 has pores of about 0.3 microns
- The coronavirus is about 0.12 microns in diameter, but the droplets are larger
- Face shield protection (welder-style shield)
- Proper donning and duffing procedures
Front Desk Staff
- Front desk staff should be wearing masks
- A barrier should be established between the patient and front desk staff.
- Understand office policies and procedures regarding staff health issues. Know your leave time policy for staff members who may have a medically compromising condition.
- Maintain a safe social distance (6 feet away) at all times.
Full contact and respiratory precautions should be in place, including the deployment of:
- N95 masks/respirators
- Face Shields
- Hand hygiene
- Sharps safety
- Injection Safety
The recommendations outlined here are obviously subject to change as the clinical scenario evolves. However, they are certainly reasonable cornerstones to help dental professionals navigate these troubled times.
Good luck and take good care of yourself and your patients.
Dr. Leslie Shu-Tung Fang is the John R. Gallagher III and Katherine A. Gallagher Endowed Chair in Clinical Excellence at Massachusetts General Hospital and Harvard Medical School.
He is a world-renowned physician, educator, businessman, and speaker. He received his Ph.D. in Physiology and Biophysics from the University of Illinois and his Doctorate of Medicine from Harvard Medical School. He is board-certified in both Nephrology and Internal Medicine and has been repeatedly honored as one of “America’s Top Doctors” and “The Best Doctors of Boston.”