C.E. Credit: Safe Dental Care During the COVID-19 Pandemic

0.5 C.E. Credit

Eve Cuny, MS, is executive associate dean at the University of the Pacific, Arthur A. Dugoni School of Dentistry. She is an internationally recognized expert in patient safety and infection control. Conflict of Interest Disclosure: None reported.

The COVID-19 pandemic has challenged the world in unprecedented ways. Never in our lifetime have we seen such massive shutdowns of businesses, waves of illness followed by waves of deaths periodically overwhelming the most advanced medical systems in the world and a near halt to global travel that all occurred during the spring and summer of 2020. Dentistry in the U.S. was profoundly impacted during the early months of the pandemic. According to a survey conducted by the American Dental Associate (ADA) Health Policy Institute, 19% of dental offices were completely shut down by March 23, 2020, and 76% offered only emergency care. [1] As the profession began planning a return to patient care, dental health care personnel (DHCP) and patients had many questions about maintaining infection control in the midst of a pandemic. Of particular concern were procedures that are known to generate aerosols, such as ultrasonic scaling, highspeed handpieces and air/water syringes. [2]

Evolution of Infection Prevention Practices in Dentistry

DHCP who were part of the profession in the 1980s will remember the uncertainty and fear of that time due to another emerging viral disease, HIV. Despite numerous clusters of hepatitis B viral infection associated with dental settings, standards and guidelines for infection control practices in oral health care settings were very limited before the mid-1980s. [3–9]

Particularly alarming to patients was the report of a possible transmission of HIV from an infected dentist to one of his patients in 1990. [10] Follow-up investigation by the Centers for Disease Control and Prevention (CDC) in 1991 resulted in an additional four patients being identified as HIV positive. [11] At least three of these five patients had viral strains that were closely linked to that of the HIV-infected dentist who had performed extractions and other routine dental procedures for these three patients. A review of the dental team’s infection control practices revealed some lapses in recommended practices. These included sometimes washing gloves instead of changing between patients, handpieces wiped with alcohol rather than heat sterilized and single-patientuse items occasionally disinfected for reuse on subsequent patients. The investigation also pointed out that the dentist received prophylactic treatment from the dental hygienist in the practice. The dentist did not keep records of accidental percutaneous injuries, so it was unclear whether he had potentially sustained a sharps injury that could have caused bleeding while working intraorally or if a handpiece or other device or instrument used during his prophylaxis could have spread contamination from him to subsequent patients. [11]

In 1986, the CDC issued its first guidance on infection control in dental health care settings. [12] This brief document with 21 references was the first official recommendation for DHCP to wear personal protective equipment (PPE), routinely sterilize handpieces, decontaminate surfaces between patients and use care in the handling of sharp contaminated instruments and needles. These guidelines were updated and expanded in 1993 and again in 2003 with stronger recommendations regarding disinfection and sterilization, management of dental unit attachments and dental waterlines, disposal of singleuse disposable instruments, safe use of lasers and handling of biopsy specimens in addition to others. [13,14] The 2003 infection control guidance was the most comprehensive yet, with more than 470 references, a working group consisting of six authors, a large advisory group, CDC consultants and other federal consultants.

Dental Infection Control in the Era of COVID-19

By the middle of March 2020, the number of new cases of COVID-19 in the U.S. was doubling every six days. Health authorities became alarmed that unchecked growth in new cases would quickly overwhelm existing health systems with sick and in some cases dying patients. With a virus that had quickly turned into a pandemic, the Occupational Safety and Health Administration (OSHA), the ADA and the CDC all cautioned dentists to limit care to the most essential needed for patients with pain or infection. [15–17] Of particular concern were aerosol-generating procedures (AGP) common in dentistry that have the potential to carry infected particles longer distances (FIGURE 1). By the end of March 2020, many county and state health departments were requiring dental practices to suspend provision of routine dental care and limit procedures to urgent or emergency needs only. What was needed was a close look at existing evidence-based precautions for droplet and airborne pathogens to develop reasonable infection control practices to prevent the spread of COVID-19 in a patient care environment that generates aerosols and droplets containing oral fluids.

As the U.S. and the rest of the world dealt with the first wave of the pandemic, DHCP looked for answers to pressing questions about how to safely return to performing patient care. Amid a pandemic caused by a virus thought to spread primarily through droplets released from a person’s mouth, the prior CDC guidance for dentistry to use standard precautions during dental procedures was likely not adequate to protect against transmission via the droplet or airborne route. Standard precautions are only intended to protect against disease transmission that could result from direct or indirect contact of infected body fluids with a DHCP’s mucous membranes or nonintact skin or via a percutaneous injury with a contaminated device or instrument. Standard precautions are used in the care of all patients regardless of known or suspected infection. [18] Transmissionbased precautions are the next level of infection control practices that are used in addition to standard precautions for patients who may be infected or colonized with certain pathogens for which additional precautions are needed, such as those spread by the droplet or airborne route. [19] Elements of transmission-based precautions were added to the CDC interim infection control guidelines. Because all potentially infected individuals cannot be identified through screening and testing, certain precautions are necessary to reduce the risk of transmission in the dental setting.

As dental offices began to resume more patient care through the remainder of 2020, the CDC and the ADA regularly updated guidance on how to safely manage patient care. This included a focus on ventilation, pandemic-specific precautions such as distancing, screening, testing patients prior to certain procedures and enhanced PPE for DHCP. Many of these new precautions are elements of transmission-based precautions (TABLE 1). The use of respirators (including N95 respirators), PPE donning and doffing sequences, ventilation control and patient positioning are all recommended for treating patients in dental settings during the pandemic and are elements of transmission-based precautions. These appear to have been effective control measures as evidenced by the low number of reported clusters of infection associated with dental practices and some limited studies of prevalence of infection among dentists. [20]

California-Specific Requirements

The COVID-19 pandemic also warranted a closer look at the existing OSHA regulations related to airborne transmissible diseases. In its guide to aerosol transmissible diseases, Cal/OSHA addresses the need for specific controls to reduce the risk of airborne disease transmission to exposed workers (ATD standards). Though California dental practices have historically been exempt from the respiratory protection required by ATD standards due to an ability to accurately screen for airborne illnesses, such as measles, and defer treatment, consistently high levels of community transmission of SARS-CoV-2 and its ability to be carried and transmitted by asymptomatic individuals who cannot be reliably identified through screening radically altered the level of respiratory protection required for dental treatment during the pandemic. Clinical dental personnel are required to wear respiratory protection during the provision of aerosol-generating dental procedures unless they can meet the four specific conditions outlined in TABLE 2 for ATD exemption. Additionally, dental offices were required to amend their illness and injury prevention plans (IIPP) to include COVID- 19-specific information.

On July 26, 2021, the California Department of Public Health issued an order requiring all health care facilities, including dental offices, to verify the vaccine status of all workers in the facility. Proof of vaccination includes the official vaccination record card, a photo of the card or an image stored on a phone or electronic device, a digital vaccine record that includes a QR code or documentation of COVID-19 vaccination from a health care provider. Unvaccinated or partially vaccinated workers are required to undergo weekly diagnostic screening testing with either antigen or molecular (PCR) tests. The dental practice must have a plan for tracking both the vaccination status of employees and the results of testing. [20]

Safe Dental Care

The question regarding the safe delivery of oral health care may well remain on the minds of some patients and DHCP. There is some evidence to show that the risk of spreading COVID-19 in dental settings is not greater than that of the community in general. [21] In a six-month longitudinal study published in the Journal of the American Dental Association, [21] results of six surveys collected over a six-month period (June 2020 to November 2020) showed that the infection prevalence rate among dentists was 2.6%. The rate of infection per month among these dentists ranged from 0.2% to 1.1%. It is important to note that this is self-reported COVID-19 positivity and some respondents could have had asymptomatic infections. A large study carried out by the National Institutes of Health from May 2020 to July 2020 found that estimated seroprevalence for COVID-19 was anywhere from 1.6% to 14.2%, depending on demographics such as age, location and race. [22] Because these two studies were done within a similar time period, prevalence among dentists as a group appears to be on the low side.

Conclusion

Interim CDC infection control guidelines to control the spread of COVID-19 encompass all health professions, including dentistry. There are no longer separate interim guidelines from the CDC for providing dental care, signaling a positive trend toward inclusion of dentistry as part of the health care system in the U.S. [23] These guidelines provide a path to continued safe delivery of patient care in all settings, including dental. The guidelines outline precautions including vaccination, source control, isolation for infected individuals, NIOSH-approved N95 or equivalent respirators for aerosol-generating procedures, ventilation, testing and other important considerations. DHCP can continue to provide safe care to patients and a safe work environment for the dental team.

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C.E. CREDIT QUESTIONS

February 2022 Continuing Education Worksheet

This worksheet provides readers an opportunity to review C.E. questions for the article “Safe Dental Care During the COVID-19 Pandemic” before taking the C.E. test online. You must first be registered at cdapresents360.com. This activity counts as 0.5 of Core C.E.

1. In what year did the U.S. Centers for Disease Control and Prevention issue its first guidance on infection control in dental health care settings?

a. 1978

b. 1982

c. 1986

d. 1989

2. The CDC’s first set of infection control guidelines for dental health care personnel included all of the following disease transmission precautions except:

a. Use of PPE

b. Routine handpiece sterilization

c. Environmental surface decontamination

d. Dental waterline management

e. Sharps safety

3. By the end of March 2020, many state and county health departments required dental practices to temporarily suspend provision of routine dental care and limit care to urgent or emergency dental needs because:

a. It was necessary to evaluate existing evidence-based precautions for droplet and airborne pathogens considering the COVID-19 pandemic.

b. Time was needed to develop the infection control practices necessary to prevent the spread of COVID-19 in a patient care environment that generates aerosols and droplets that contain oral fluids.

c. Dental offices were operating under standard precautions guidelines, which were likely inadequate for protecting against transmission of COVID-19.

d. All of the above.

4. All of the following statements are true regarding standard precautions except:

a. Standard precautions are used in the care of all patients regardless of known or suspected infection.

b. Standard precautions are intended to protect against disease transmission that could result from dirt or indirect contact of infected body fluids with a dental provider's mucous membranes or broken skin.

c. Standard precautions are intended to prevent disease transmission through percutaneous injury with a contaminated device or instrument.

d. Standard precautions are intended to protect against respiratory droplet and airborne disease transmission.

5. Which of the following is not part of standard precautions protocols?

a. Hand hygiene

b. Aerosol management

c. PPE

d. Safe injection practices

e. Sterile instruments and devices

6. Transmission-based precautions include specific recommendations for contact, droplet and airborne routes of disease transmission. Standard precautions are more comprehensive for all routes of transmission and build upon transmission-based precautions.

a. Both statements are true.

b. Both statements are false.

c. Only the first statement is true.

d. Only the second statement is true.

7. Which of the following protocols for treating patients in a dental office were added during the pandemic and are part of transmission-based precautions?

a. Routine patient screening

b. Ventilation control

c. Use of respirators, such as N95 respirators

d. All of the above

8. The new transmission-based precautions implemented during the COVID-19 pandemic:

a. Appear to be effective in controlling COVID-19 transmission in dental offices based on preliminary studies and dentist self-reported rates of COVID-19 infection.

b. Appear to have been only minimally effective in controlling clusters of COVID-19 outbreaks among dental health care personnel.

c. Appear to have done very little in preventing transmission of COVID-19 in dental offices.

9. Patients known or suspected to be infected with pathogens that can be transmitted through airborne routes and cause diseases such as measles, tuberculosis or COVID-19 should be:

a. Treated in the dental office using standard precautions.

b. Treated in the dental office using droplet transmission-based precautions.

c. Referred for treatment to a facility that has an airborne infection isolation room.

10. According to the OSHA Risk Pyramid, which of the following are true?

a. Urgent or emergency care without aerosols is considered low risk.

b. Aerosol-generating procedures on patients who are well are considered moderate risk.

c. Procedures that do not generate aerosols are considered high risk on patients with COVID-19.

d. All of the above are true

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REFERENCES

1. American Dental Association. COVID-19: Economic Impact on Dental Practices (Summary Results). Health Policy Institute. Apr 3, 2020. Accessed Sept. 9, 2021.

2. Occupational Safety and Health Administration. Hazard recognition. 2020. Accessed Sept. 9, 2021.

3. Ahtone J, Goodman RA. Hepatitis B and dental personnel: Transmission to patients and prevention issues. J Am Dent Assoc 1983 Feb;106(2):219–22. doi: 10.14219/jada. archive.1983.0416.

4. Hadler SC, Sorley DL, Acree KH, et al. An outbreak of hepatitis B in a dental practice. Ann Intern Med 1981 Aug;95(2):133–8. doi: 10.7326/0003-4819-95-2-133.

5. Centers for Disease Control and Prevention. Hepatitis B among dental patients – Indiana. MMWR 1985;34:73–5.

6. Levin ML, Maddrey WC, Wands JR, et al. Hepatitis B transmission by dentists. JAMA 1974;228:1139–40. doi:10.1001/jama.1974.03230340041029.

7. Rimland D, Parkin WE, Miller GB, et al. Hepatitis B outbreak traced to an oral surgeon. N Engl J Med 1977 Apr 28;296(17):953–8. doi: 10.1056/ NEJM197704282961701.

8. Goodwin D, Fannin SL, McCracken BB. An oral surgeonrelated hepatitis B outbreak. Calif Morbid 1976;14.

9. Reingold AL, Kane MA, Murphy EL, et al. Transmission of hepatitis B by an oral surgeon. J Infect Dis 1982 Feb;145:262–8. doi: 10.1093/infdis/145.2.262.

10. Centers for Disease Control and Prevention. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990;39:489- 93.

11. Centers for Disease Control and Prevention. Epidemiological notes and reports update: Transmission of HIV infection during an invasive dental procedure – Florida. MMWR 1991;40(2):21-27,33.

12. Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry. MMWR 1986;35:237-42.

13. Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry, 1993. MMWR 1993;42(No. RR-8).

14. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings – 2003. MMWR 2003;52/No.RR-17.

15. Occupational Safety and Health Administration. COVID-19 control and prevention. Dental workers and employers. 2020. Accessed Sept. 11, 2021.

16. Centers for Disease Control and Prevention. Coronavirus Disease 2019. Dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. March 26, 2020.

17. Burger D. ADA recommending dentists postpone elective procedures. ADA News.

18. Centers for Disease Control and Prevention. Infection control. Standard precautions for all patients. Accessed Sept. 12, 2021.

19. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

20. CDPH. Health Care Worker Protections in Hight-Risk Settings. July 26, 2021. Order of the State Public Health Officer Unvaccinated Workers In High Risk Settings (ca.gov). Accessed Dec. 8, 2021

21. Araujo MWB, Estrich CG, Mikkelsen M, et. al. COVID-19 among dentists in the United States. A six-month longitudinal report of accumulative prevalence and incidence. J Am Dent Assoc 2021;152(6):425–433. doi: 10.1016/j. adaj.2021.03.021. PMCID: PMC8142320.

22. National Institutes of Health. NIH study suggest COVID-19 prevalence far exceeded early pandemic cases. Accessed Sept. 14, 2021.

23. Centers for Disease Control and Prevention. COVID-19. Infection Control Guidance. Sept. 10, 2021. Accessed Sept. 13, 2021.

THE AUTHOR, Eve Cuny, MS, can be reached at ecuny@pacific.edu.