On March 16, the American Dental Association (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 these limitations will be lifted any time soon.

Coronavirus has a global reach. It is in more than 200 countries and 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, with more than 50 drugs 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 fatalities are in elderly patients and 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 fear.

In 80% of cases, COVID-19, particularly in young, healthy patients, is mild and those affected have symptoms similar to the cold or flu.  In 15% of cases, development of progressive respiratory symptoms may necessitate hospitalization. In 5% of cases, patients become critically ill and 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 aerosolization during procedures. Increasing prevalence of asymptomatic carriers and transmission by asymptomatic carriers have been reported.

Although vaccines have been developed at a warp-speed pace in the United States, Israel, Queensland and China, it is expected to take too long for the vaccines to be deployed during this epidemic because of the need for safety testing and 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 will hopefully help the development of effective therapeutic agents.

As of now, the best protection for dental professionals is a heightened sense of awareness, avoiding unnecessary contact with patients who may have coronavirus, use of appropriate personal protective equipment, and increased attention to personal hygiene.

Recommendations continue to be predicated upon information that arises daily. You should be mindful of the situation in your local community and the continuing evolution of the disease globally.

We are aware of the risk to health care workers from the data coming out of Wuhan, China. Of the initial 44,672 cases, 3,019 (6.75%) were health workers and seven have died as of February 11. With increasing awareness and the uniform adoption of personal protective equipment, the risk has decreased progressively in Hubei.

Dental professionals are particularly at risk if working on an infected patient or an asymptomatic carrier because of the close contact with the patient and the risk of blood, saliva and droplet exposure. In Italy, seven dental professionals died of COVID-19 during the pandemic.

Currently, a fair number of dental offices have closed, but there are offices that continue to address dental emergencies. It is critical for those offices to take extra precautions during this period.

The CDC Recommendations are designed for all health workers. Because of the unique situation dental professionals are in, I have made modifications to tailor the recommendations.

The most important difference between medical and dental professionals is a great deal of dentistry can be deferred to a later time, whereas medical professionals are obligated to see 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 disease transmission.

The CDC, the ADA, the Occupational Safety and Health Administration (OSHA) and the Academy of General Dentistry (AGD) have all made recommendations for dental professionals. The following is a culmination of these recommendations with the eye toward addressing important practical issues including:

• Administrative controls
• Engineering controls
• Environmental hygiene
• Correct work practices
• Personal protective equipment
• Strict adherence to standard, contact and airborne precautions

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 several parts to the recommendations, it is critical to go out of your way to ensure patient safety and the safety of yourself and your staff. Your attention to detail will reflect well on the practice. Lapses can result in unwarranted infection with a virus that can be deadly.

The Overarching Question

• Is this an emergency?
  • Assess urgency of patient visit, including pain, swelling or trauma.
• All elective dental procedures should be deferred.
• Elective dental procedures should be rescheduled for 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.

Prior to Patient Arrival

• In general, avoid walk-in visits.
• When patients call to make an appointment for an emergency, the front desk should ask if:
  • They are sick with fever, cough, sore throat, muscle pain, GI symptoms, anosmia (loss of smell and taste) and profound fatigue.
  • They have traveled to endemic areas within the last 30 days. This includes New York City and virtually all overseas travel.
  • They have been on a cruise.
  • They have been in contact with patients diagnosed with COVID-19.
• All patients who answer in the affirmative should not be treated, 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 leaving for your office. Encourage these patients to reach out to their medical doctor for evaluation and management.
• Instruct patients to arrive on time for appointments and not early. This minimizes waiting time in the office and decreases the number of people present.
• Inform patients their escorts will be asked to wait in the car and will be called when the procedure is finished.
• While impositions, taking these steps will reassure patients because it shows you are clearly concerned about their safety.

When Patients Arrive

• Make every attempt to keep the waiting room empty.
  • Have their escort wait in the car until they’re finished.
  • Indicate you will call or text them at the appropriate time.
• Give patients a surgical mask.
• There should be a prominent sign directing patients to use hand sanitizer from a non-touch dispenser stand and to rigorously rub their hands for 20 seconds.
• Anyone who is sick should be given a mask and be asked to seek medical help.
• Take their temperature. Anyone with a fever should be given a mask and 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.

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 possible to protect the office and staff.

The hope is to optimize ventilation in the operatory. Ideally, air exchange of the operatory six times an hour during operating hours minimize issues with undue exposure.

There are offices considering HEPA (high-efficiency particulate air) systems 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 you are indeed attentive to air quality.

Because the coronavirus can live 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 shown to be effective.

Hypochlorous acid is a popular cleaning agent for the operatory because it evaporates from the surface without wiping.

• Special attention should be paid to good hand hygiene:

Good hand hygiene is the most important protection for dentists and their staff:

• • Thorough handwashing with soap and water
  • Lather hands with soap
  • Lather the back of hands, between the fingers and under the nails
  • Pay special attention to the thumbs
  • 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 rubber dam and highspeed suction
• Consider oral rinsing with chlorhexidine, Listerine or povidone-iodine 1% antiseptic

• Be even more meticulous with:
  • Attention to sharps safety
  • Attention to injection safety
  • Attention to waste disposal
  • Attention to sterile instruments and devices

Dental Professional and Staff

During this period of heightened concern, all members of the office and patients should wear surgical masks.

Dental professionals are used to working with a mask, gown and gloves on.  Because the coronavirus can be aerosolized with procedures, conventional surgical masks are not adequate. Depending on potential exposure, the dental professionals and staff should use:

• N95 Mask/Respirator
• • Ordinary surgical masks have pores of about 2-10 microns while the N95 masks have 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)
• Goggles
• Gown
• Gloves
• Proper donning and duffing procedures

Front Desk Staff

• Front desk staff should also wear masks.
• A barrier should be established between patients and front desk staff.
• Understand office policies and procedures regarding staff health issues. Know what your leave time policy is for staff members who may have a medically compromising condition.
• Maintain social distance at all times.

Full contact and respiratory precautions should be in place including deployment of:

• Gowns
• Gloves
• N95 masks/respirators
• Goggles
• Face shields
• Hand hygiene
• Sharps safety
• Injection safety