04/28/2020 NDBDE Recommendation | CDC Infection Control Guidance for Dental Settings | Important Resources & Links | Teledentistry | All States - Summary of Orders | April 1, 2020 - MMWR Release | ADA Resources | CARES Act Guidance - April 2 | Using PPE | N95 info | Professional Protection Plan for Dentists information | Executive Orders | ADA Resources | OSHA Guidance for Dentistry
Click here to find Flowchart to Identify and Assess for Novel Coronavirus Disease 2019 (COVID-19)
Click here to find the ADA Interim Guide for Management and Urgent Dental Care flowchart (updated 4/1/2020).
Click here to view Coronavirus COVID-19 global cases and data.
COVID-19 ND Board of Dental Examiners: GUIDANCE
At its 4/28/2020 meeting the ND Board of Dental Examiners issued the following guidance for all ND dental practitioners:
The North Dakota Dental Board (“Board”) has received numerous requests for guidelines for the reopening of dental offices. At this time, the Board is unable to provide such guidelines. However, in order to limit the spread of COVID-19 the Board recommends practitioners review information provided by the Centers for Disease Control and Prevention and American Dental Association for the duration of the COVID-19 pandemic. Practitioners are responsible for the safety of their patients and staff and must operate in a manner consistent with protecting their safety. Practitioners with specific questions regarding liability should consult their legal counsel and insurance providers. The Board has the authority to discipline practitioners for willful or negligent disregard for safety.
CDC Revisions - OSHA
Click here for Dentistry Workers and Employers OSHA Guidance
May 15, 2020 CDC guidance:
At the onset of the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) recommended that healthcare systems prioritize urgent visits and delay elective care to mitigate the spread of COVID-19 in healthcare settings. A consequence of the pandemic has been the under-utilization of important medical services for patients with non-COVID-19-related urgent and emergent health needs. As the pandemic continues, healthcare systems must balance the need to provide necessary services while minimizing risk to patients and healthcare personnel. Because the effects of COVID-19 varies among communities, healthcare systems will also need to consider the local level of COVID-19 transmission when making decisions about the provision of medical services. CDC has released a Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic to provide healthcare systems with a framework to deliver non-COVID-19 health care during the COVID-19 pandemic.
It is unknown at this time how COVID-19 may permanently change infection control practices in dental health care settings, but CDC continally assesses emerging scientific evidence for developing policies, guidelines, and recommendations. CDC is working to update its COVID-19 guidance for dental settings in preparation for resuming care. This is a rapidly evolving situation and CDC will relase updates as information becomes available. You can find the most up-to-date information about infection prevention and control practices on CDC’s COVID-19 page.
April 27, 2020 CDC guidance on PROVIDING DENTAL CARE DURING COVID-19
The CDC has updated the Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response to include guidance for emergency clinical care of patients with known or suspected COVID-19. This is an emerging, rapidly evolving situation and CDC will continue to update this guidance as more information becomes available.
Using Personal Protective Equipment (PPE)
The North Dakota State Department of Health is announcing that dentists are now able, as essential health care providers, to order PPE supplies, to include N95 respirators, from the ND state medical cache for dental emergency services only. Sign up to order supplies at http://hanassets.nd.gov/ (look in the COVID tile to order common PPE items). When ordering, you will need to identify your offices anticipated need for a 2-week period and will also need to indicate the number of employees who are providing direct care for emergency services on the Customer Note section at the very end of the online order form. All information is required. Contact the state Health Department Operations Center at 701-328-0707 and the Department fo Health website at https://www.health.nd.gov/ for more information.
Who Needs PPE?
- Patients need to be screened before doing procedures so it is known if they are low or high risk.
- Patients with confirmed or possible SARS-CoV-2 infection should wear a facemask when being evaluated medically.
- Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with SARS-CoV-2 infection. Recommended PPE is described in Infection Control Guidance
Respirator Trusted -Source Information - Fit Test FAQs
ADA - IMPORTANT LINKS
Recommendations to Minimize Chance for Exposures
1. Ensure facility policies and practices are in place to minimize exposures to respiratory pathogens including SARS-CoV-2, the virus that causes COVID-19.
Measures should be implemented before patient arrival, upon arrival, throughout the duration of the patient’s visit, and until the patient’s room is cleaned and disinfected. It is particularly important to protect individuals at increased risk for adverse outcomes from COVID-19 (e.g. older individuals with comorbid conditions), including HCP who are in a recognized risk category.
- When scheduling appointments for routine dental care (e.g., annual exam, elective procedures), instruct patients to call ahead and discuss the need to reschedule their appointment if they develop symptoms of a respiratory infection (e.g., cough, sore throat, fever) on the day they are scheduled to be seen.
- Ensure that, at the time of patient check-in, all patients are asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible COVID-19 patients.
- If the patient must come in for an appointment, instruct them to call beforehand to inform triage personnel that they have symptoms of a respiratory infection (e.g., cough, sore throat, fever) and to take appropriate preventive actions (e.g., follow triage procedures, wear a facemask upon entry and throughout their visit or, if a facemask cannot be tolerated, use a tissue to contain respiratory secretions).
- Post visual alerts.pdf icon (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and HCP with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
Upon Arrival and During the Visit
- Consider limiting points of entry to the facility.
- Take steps to ensure all persons with symptoms of COVID-19 or other respiratory infection (e.g., fever, cough) adhere to respiratory hygiene and cough etiquette (see appendix), hand hygiene, and triage procedures throughout the duration of the visit.
- Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
- Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
- Consider establishing triage stations outside the facility to screen patients before they enter. Ensure rapid safe triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough). Prioritize triage of patients with respiratory symptoms.
- Triage personnel should have a supply of facemasks and tissues for patients with symptoms of respiratory infection. These should be provided to patients with symptoms of respiratory infection at check-in.
- In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
- Incorporate questions about new onset of respiratory symptoms into daily assessments of all admitted patients. Monitor for and evaluate all new fevers and respiratory illnesses among patients. Place any patient with unexplained fever or respiratory symptoms on appropriate Transmission-Based Precautions and evaluate.
Patient Screening - The CDC recommends healthcare facilities, including dental offices, screen patients before proceeding within appointment. Information to take note of:
- Any individual who exhibits or reports signs of acute respiratory illness such as coughing, fever and shortness of breath.
- Recent travel to any locations that have a Level 3 Travel Health Notice for COVID-19. Verify when the patient returned to the United States. If the patient reports that at least two weeks have passed since their return from one of the identified regions and no symptoms have presented, the dental office can proceed with the appointment. When local, state or federal public health officials declare the disease is at the community level, screening for travel is not necessary.
- Close contact with an individual diagnosed with COVID-19.
- Dentists may also send a notice advising patients who are experiencing acute respiratory illness to remain home and reschedule appointments.
If you are evaluating a patient for suspected COVID-19, please contact your local health department immediately.
2. Adhere to Standard and Transmission-Based Precautions.
Standard Precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Elements of Standard Precautions that apply to patients with respiratory infections, including COVID-19, are summarized below. Attention should be paid to training and proper donning (putting on), doffing (taking off), and disposal of any PPE.
This document does not emphasize all aspects of Standard Precautions (e.g., injection safety) that are required for all patient care; the full description is provided in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
Health care providers (HCP-see Section 5 for measures for non-HCP visitors) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator or facemask, gown, gloves, and eye protection. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (e.g., tuberculosis, measles, varicella). Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19 (updated 4/30/2020)
- Hand Hygiene
- HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
- HCP should perform hand hygiene by using ABHR with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.
- Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location.
- Personal Protective Equipment
Employers should select appropriate PPE and provide it to HCP in accordance with OSHA PPE standards (29 CFR 1910 Subpart I)external icon. HCP must receive training on and demonstrate an understanding of:
- when to use PPE
- what PPE is necessary
- how to properly don, use, and doff PPE in a manner to prevent self-contamination
- how to properly dispose of or disinfect and maintain PPE
- the limitations of PPE.
Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. The PPE recommended when caring for a patient with known or suspected COVID-19 includes:
- Respirator or Facemask Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area.
- N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient’s room or care area and closing the door. Perform hand hygiene after discarding the respirator or facemask. For guidance on extended use of respirators, refer to Strategies to Optimize the Current Supply of N95 Respirators
- If reusable respirators (e.g., powered air purifying respirators [PAPRs]) are used, they must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use.
[During times of limited access to respirators or facemasks, facilities could consider having HCP remove only gloves and gowns (if used) and perform hand hygiene between patients with the same diagnosis (e.g., confirmed COVID-19) while continuing to wear the same eye protection and respirator or facemask (i.e., extended use). Risk of transmission from eye protection and facemasks during extended use is expected to be very low.
- HCP must take care not to touch their eye protection and respirator or facemask.
- Eye protection and the respirator or facemask should be removed, and hand hygiene performed if they become damaged or soiled and when leaving the unit.
HCP should strictly follow basic infection control practices between patients.]
- Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
- Remove eye protection before leaving the patient room or care area.
- Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use.
- Put on clean, non-sterile gloves upon entry into the patient room or care area.
- Change gloves if they become torn or heavily contaminated.
- Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.
- Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.
- If there are shortages of gowns, they should be prioritized for:
- aerosol-generating procedures
- care activities where splashes and sprays are anticipated
- high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
3. Patient Placement
- It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, infection control precaution and procedures need to be the same for everyone.
- During times of limited access to respirators or facemasks, facilities could consider having HCP remove only gloves and gowns (if used) and perform hand hygiene between patients with the same diagnosis (e.g., confirmed COVID-19) while continuing to wear the same eye protection and respirator or facemask (i.e., extended use). Risk of transmission from eye protection and facemasks during extended use is expected to be very low.
- HCP must take care not to touch their eye protection and respirator or facemask .
- Eye protection and the respirator or facemask should be removed, and hand hygiene performed if they become damaged or soiled and when leaving the unit.
- HCP should strictly follow basic infection control practices between patients (e.g., hand hygiene, cleaning and disinfecting shared equipment).
- Limit transport and movement of the patient outside of the room to medically essential purposes.
- Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient transport.
- Whenever possible, perform procedures/tests in the patient’s room.
- Consider asking patients to wait in their car for their appointment. Text them when you are ready to seat them in the operatory.
4. Train and Educate Healthcare Personnel
- Provide HCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.
- Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.
5. CDC Recommended Precautions When Performing Aerosol-Generating Procedures (AGPs)
- Some procedures performed on patient with known or suspected COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing should be performed cautiously and avoided if possible.
- If performed, the following should occur:
- HCP in the room should wear an N95 or higher-level respirator, eye protection, gloves, and a gown. Good link to understand the difference between surgical masks and N95 respirators CDC Infographic
- The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.
- AGPs should ideally take place in an Airborne Infection Isolation Rooms (AIIR).
- Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
Summary of Changes to the Guidance:
- Updated PPE recommendations for the care of patients with known or suspected COVID-19:
- Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.
- Facemasks protect the wearer from splashes and sprays.
- Respirators, which filter inspired air, offer respiratory protection.
- When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Facilities that do not currently have a respiratory protection program, but care for patients infected with pathogens for which a respirator is recommended, should implement a respiratory protection program.
- Eye protection, gown, and gloves continue to be recommended.
- If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
- Included are considerations for designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients and options for extended use of respirators, facemasks, and eye protection on such units. Updated recommendations regarding need for an airborne infection isolation room (AIIR).
- Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients undergoing aerosol-generating procedures (See Aerosol-Generating Procedures Section)
- Updated information in the background is based on currently available information about COVID-19 and the current situation in the United States, which includes reports of cases of community transmission, infections identified in healthcare personnel (HCP), and shortages of facemasks, N95 filtering facepiece respirators (FFRs) (commonly known as N95 respirators), and gowns.
- Increased emphasis on early identification and implementation of source control (i.e., putting a face mask on patients presenting with symptoms of respiratory infection).
Guidance provided in the above document have been provided by the following:
COVID-19 Resources for Practitioners
PPE resources from the Diers website
General tips on addressing COVID-19 with your patients and staff can be found in the PPP’s risk management article: Protocols for Dental Practice Management – nCoV, which we are attaching to this communication. Clinical and non-clinical inquiries can be submitted online at www.protectorplan.com/risk-management. You can also contact our risk management support line for clinical inquiries, 844-747-8543. W