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COVID-19 ND Board of Dental Examiners: GUIDANCE
March 19, 2020, 10:00 AM CDT
At its March 19, 2020 meeting the North Dakota Board of Dental Examiners unanimously passed the following guidance for all ND dental practitioners:
The North Dakota Board of Dental Examiners recognizes the unprecedented circumstances dental professionals face due to the COVID-19 pandemic, which is causing shortages of personal protective equipment and creating an increased risk of infection for both dental patients and practitioners. The Board is closely monitoring actions taken by other states regarding the practice of dentistry and recommendations from the Centers for Disease Control and North Dakota Department of Health. While the Board does not have the statutory authority to mandate the closure of dental offices across North Dakota, in order to limit the spread of COVID-19 and ensure personal protective equipment is available for healthcare professionals on the frontline of the pandemic, the Board is providing the following recommendations to North Dakota dental practitioners:
The North Dakota Board of Dental Examiners encourages dental practitioners within the state, to discontinue providing routine, non-essential, and elective procedures through effective March 19, 2020, at the end of the business day, through April 4, 2020. This recommendation coincides with guidance issued by both the Center for Disease Control and the American Dental Association. Among other guidance, the American Dental Association has clarified routine, non-essential, and elective procedures. Dentists should continue to monitor and comply with any future federal directives as well as any requirements mandated by the State of North Dakota and its Department of Health related to the COVID-19 outbreak.
During this time all practitioners must continue to provide patients emergency care. Providing emergency care means more than just providing patients access to phone number or another healthcare institution but rather to facilitate the emergency care. Failure to provide the appropriate emergency contact information or emergency care for your patients of record may result in disciplinary action.
Information is changing rapidly at both the national and state level. Please continue to frequently monitor the Board’s website as any updates to recommendations will be posted as soon as available. The Board recognizes and appreciates the long history of compassionate care provided for the benefit of North Dakota citizens and encourages all dentists to extend urgent care beyond that of their own patients of record when circumstances might make it necessary and helpful.
CDC & ND Dept of Health Recommendations
A message from the ND Board of Dental Examiners March 16, 2020 5:00 PM CDT
As the State of ND continues to evolve in its response to COVID-19, the ND Board of Dental Examiners recognizes that ambulatory dental surgery offices have growing concerns specific to delivery of dental health care. States have taken various levels of precautionary action to control the spread of the virus. Early reports of COVID-19 suggest person-to-person transmission primarily via respiratory droplets produced when the infected person coughs or sneezes, transmission of the disease via small aerosols or droplet nuclei, working within close proximity to patients and use of aerosol producing devices is all cause for great concern in the dental community.
The spread of the COVID-19 virus will strain all aspects of our work lives, not to mention the toll on the day to day lives of our communities. It is therefore incumbent on our dental community to assess preparedness and be prepared to successfully address issues specific to dental offices and treatment of dental patients and for the dental community to exercise caution based on the CDC’s guidelines. At this time all other state dental boards are exploring similar situations and deciding what advisement or recommendations should be provided to practitioners. Many dental offices may not have N95 masks and/or HEPA filtration systems to protect both the dental providers/staff and/or patients of COVID-19. Many states have shared their concerns, and some boards are deciding to recommend temporary closure of dental offices or at least limit procedures provided beyond emergency care.
The NDBDE will keep practitioners informed as developments come to light regarding additional measures or recommendations offered by the NDBDE.
Many of the recommendations described in this guidance should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-10 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.
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
- 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 (https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf
- 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 this document have been provided by the following:
COVID-19 Resources for Practitioners
CDC Developing Guidelines Regarding Responding to COVID-19 in Dental Settings
March 10, 2020
As the expanding global outbreak of Coronavirus Disease 2019 continues, the federal government continues to work closely with the state, local, tribal, and territorial partners, as well as public health partners across the globe to respond to this public health threat.
The Centers for Disease Control and Prevention (CDC) Division of Oral Health (DOH) is diligently working with CDC's Emergency Operations Center to develop tailored COVID-19 guidance for dental health care personnel (DHCP). Once this guidance is available online, DOH and partners will promote these resources as well as any related events (e.g., informational webinar, Clinician Outreach and Coummunication Activity) to the dental community.
It's unknown at this time what the full impact of COVID-19 will be in the US; however, CDC is preparing as if this were the beginning of a pandemic. All healthcare facilities should take steps now to prepare for the possibility of a widespread and severe COVID-19 outbreak to prepare their practices and protect both their patients and staff. CDC urges providers to be familiar with the information on CDC's COVID-19 website. Specific information is available for Healthcare Professionals, including a Healthcare Professional Preparedness Checklist, instructions on Evaluating and Reporting Persons Under Investigation (PUI), and a page on What Healthcare Personnel Should Know. DHCP can also consider signing up communications from CDC's Health Alert Network, which is CDC's primary method of sharing cleared information about urgent public health incidents.
Standard precautions, including the use of proper personal protective equipment, should be followed when caring for any patient. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients.