April 26, 2020

Attention to all Kentucky Dentists

Governor has just approved 
our back to work plan!

The Governor has just approved our plan for dentists to get back to work. As he said, if you are not ready to go or do not have the proper PPE, you are not required to open. As always, dentists are expected to use professional judgment and seek guidance from the KY Board of Dentistry when necessary. Look for more information from KDA in the coming days.
Phase I Healthcare Services Reopening: 
Dentistry's Plan

The length of the global pandemic due to coronavirus caused dentists, dental hygienists and dental specialists to be eager to get back to work. They and their dental teams have taken an extreme and difficult hit to their businesses while waiting for this pandemic to subside.

In order to resume the business of dentistry, the risks of this unknown and highly contagious virus must be weighed with the risks of the declining oral health in our patients. We understand that urgent care is still being delivered, but non-emergent dental needs are impacting the dental and overall health of our patients. Many dental procedures postponed as a result of the Secretary Friedlander's directive are now more urgent and medically necessary.

Beginning April 27, Kentucky's licensed dental professionals will be able to provide services to their patients by resuming non-urgent, non-emergent dental services. We understand that the dental profession is responsible for adopting the Commissioner's standard of patient encounters, but more importantly for developing enhanced aerosol protections in our dental healthcare settings. This document outlines the efforts that will protect the dental team and the patients.

Addressing Commissioner Steve Stack's Points of Concern:

While a 'resume date' of April 27th was provided, the profession recognizes that each practice may work toward a phased, gradual reopening of services. It is also recognized that a COVID-19 resurgence may require adjustment to the provision of dental services, especially if Personal Protection Equipment (PPE) returns to being in short supply for the front line healthcare workers, thus the dental community.

Dentists have already embraced teledentistry for some triage, assessment, educational and counseling visits. The workgroup promotes the continued growth in the new method of treating dental disease, but also recognizes its limitations and sees it as a valuable adjunct in our new world of patient management.

Dental practices, both those that continued to see urgent patients and those that will be resuming comprehensive care in the next few days, have drastically changed the patient experience. Dental offices are taking pertinent health histories and screening for COVID-19 during the time the appointment is made. Waiting rooms are no longer used for their traditional purpose, but have become empty as patients now wait in their cars to be called to the treatment area. Only a parent or guardian of children or special needs adults are allowed to accompany patients to the office. They may stay in the waiting area during treatment. Only when it is imperative to patient management can the parent or guardian accompany the patient to the treatment area. Masks or fabric face coverings will be worn by non-dental team members at all times within the dental office, both in waiting areas and treatment areas.

Patients will be screened upon entry to the dental office. Persons accompanying the patient will be screened for COVID-19 or other Aerosol Transmitting Disease (ATD). This screening includes temperature taking.

At any time in the office, the social distancing of patients to dental team members or other patients will be observed, using standard of a distance equal to or greater than six feet between persons. Dental offices will redesign their patient flow and treatment arrangement to assure that at least six feet exists between patients or that impermeable barriers exist between patients to contain any aerosolization that may occur during dental procedures.

The dental profession is committed to the control of COVID-19 or other ATDs by incorporating the following procedures in their daily work.

Every member of the dental team will be screened every day for symptoms and body temperatures and will be recorded and retained in the office; end-of-day temperature records are encouraged. Staff that are ill will be required to stay home. Anyone on the dental team that has contracted AND recovered from COVID-19 will return to work using the Department for Public Health's "Guidance for Healthcare Workers Returning to Work."

Dental offices will be sanitized and disinfected in an enhanced manner including disinfecting surfaces in treatment areas between each patient and at the end of the business day. Sanitization and disinfection also includes focused attention to other areas of the office such as the entrances, waiting areas, check in, check out and restroom areas.

Handwashing and other hand hygiene measures should be enhanced for both the members of the dental team and patients (and necessary visitors). This may include ready access of hand sanitizer throughout the practice for everyone and assuring that hand washing stations are well-stocked for proper cleaning.

Appropriate PPE must be available in the dental facility to adequately protect the dental team members and the patients alike. It is recognized that at the release of this plan, the securing of PPE for the resumption of comprehensive dental care is a challenge. The supply chains that dentists usually work through are still concentrating on providing PPE to the more front line healthcare workers and have put dentists on hold. With the Governor's date of April 27th, we anticipate that this will ease up some, but PPE will remain a grim challenge for most offices for a period of time.  

Masks (of some level) at all times will be the standard of this 'new normal' for protections against COVID-19. All dental team members will wear surgical or appropriate procedural mask while in the dental office. All patients (and limited visitors) will wear their own surgical mask, a cloth mask or other appropriate face covering while anywhere in the dental office, even in the waiting areas.

In addition to enhanced hand hygiene, dental team members will wear non-latex gloves and change between patients, preferably disposed of in the treatment area in which the gloves were used.

The dental profession appreciates the Commissioner and his team in recognizing that some dental procedures include high-aerosol production. This section reviews steps that dental offices will be taking to increase the safety of all to potential pathogens that may be in the aerosol produced by dental equipment. Some of our steps are also included in previous section of this plan, but repeated to satisfy the Administration's request for additional input on this matter. We also understand that the science of aerosol mitigation is evolving and look forward to future developments that dentists can embrace in the future that will even better assist dental professionals in protecting themselves, their employees and their patients.

There are steps that each office can adopt in order to reduce and control aerosols in the dental office. Each office is arranged and functions differently and we rely on the professional judgement of the dentists, the dental hygienists and the rest of the dental team that work daily in their own unique environment to adjust their practice for the enhanced protection of others.

For enhanced aerosol protection, we offer the following recommendations for different aspects of the dental experience.

Reduced interaction between the patient and the dental team begins with the repurposing of the waiting room-to be used only for one necessary visitor, who is masked. When multiple persons need to occupy that area (pediatric practice), the six foot rule must be enforced.

Dental team members will be masked at all times in the dental office.

Social distancing is vital to aerosol mitigation; its implication in a dental office is outlined earlier in this document.

Dental procedures, when possible, should include aerosol controlling measures such as rubber dam use, and high speed evacuation. The addition of atraumatic restorative procedures should be considered that both arrest dental disease and have no aerosol-generating aspects to them.

N95 masks offer an elimination of 95% of airborne particulates. An equal efficacy of an n95 mask is found in a combination of already-used dental armamentaria. The same reduction of aerosols can be achieved with a combination of a Level III surgical mask, a face shield and a High Speed Evacuation (HSE) System that uses a disposable tip that is a minimum of 8 mm for its interior bore, or lumen. The HSE tip should be attached to a vacuum system that meets the manufacturer's guidelines for evacuation volume. (Point-in-time evacuation volumes depend on the number of HSE tips in use at any one moment. Dental Equipment Technicians can assure the optimal evacuation volumes of existing systems.) This combination, used correctly, will offer the same protection of the n95 masks, reserving them for other healthcare personnel. And reduce the amount of particulate that reaches the surfaces of the treatment area.

If an n95 mask is to be used, its use should comply with recommendations and requirements of the Center for Disease Control and Prevention, the Occupational Safety and Health Administration and the National Institute for Occupation Safety and Health. Requirements for appropriate use of this type of mask include the wearer being medically cleared to wear them and the recognize that there is required "fit testing" that must be done initially and annually thereafter. This is to be complied with for each wearer of this type mask in the dental office.

Patients that are COVID-19 positive may still need dental care and reappointment may not be in their best interest. Treatment of a positive patient should be appointed for the last appointment of the day and dental team members should be in a gown, gloves, n95 mask (or above-described combination), goggles with side protection, face shield, and hair covering.
Dental surfaces will be disinfected both after the patient is dismissed and then again before the first patient of the morning.

While COVID-19 positive patients should be the last patient of the day, seeing the medically vulnerable during the first appointments of the day protect them from a day's worth of airborne viruses and other pathogens.

Appropriate PPE will be respected for different dental procedures. Accompanying this document is a grid that describes the appropriate PPE for different dental procedures. This is included with permission from the University of Washington's School of Dentistry. It is highly recommended that dental professionals consider these scenarios of treatment for informed decisions relative to PPE.

Other methods of airborne virus load that could be considered are treatment boxes that fit over a patient's head, still with access to the mouth, HEPA filters, UV lights and ozone generators that can be used between patients and/or overnight in treatment areas. Applied science in this area is changing constantly and dentists will be ready to explore emerging technologies. This plan does not want to limit their opportunities in infection control.

Miscellaneous Recommendations for the Dental Office that weren't a direct part of Dr. Stack's requests:

While the date of April 27th was announced for dental offices to be able to resume dental care, it is recognized that many offices are not prepared for this date. The workgroup commends these offices that are working on adaptations to their practices and patient management to continue to flatten the curve of the current coronavirus pandemic. In all of this, so much still resides in the professional judgement of the dentists and dental hygienists.

The dental community looks forward to the time that testing for COVID-19 is plentiful and accessible to dentists for in-office, 'point-of-care' testing. Until then, dentists may request that a patient present proof of a negative test that is less than 72 hours old. When this is not available, robust screening and temperature taking must be rigidly adhered to.

To best treat patients in the future, dentists would benefit from access to any register of citizens that record COVID-19 status. If this is possible, the Department for Public Health's Oral Health Program can assist in teaching dental offices how to access this database appropriately and effectively. Coupled with that, the dental community should be an active participant in 'contact tracing' of their staff, their patients and anyone moving their office space.

Remote and advanced registration of patients, including payment arrangements and initial health history/COVID-19 screening should be encouraged and take place outside the office, perhaps on-line, through a text application or by telephone. This will reduce exposure time between the patient and the dental staff.

Placement of a Plexiglas or other clear barrier between the front office/check out desk and the waiting areas will reduce air-borne viruses and bacteria. If not feasible, consider the office staff being both masked and gloved and the same time. Pens used by patients and visitors should be considered the property of the user, once used. Credit cards should be disinfected before their use by office staff.

Offices may offer a 'follow up screening' of their patients 2-3 days after their dental treatment for signs and symptoms of COVID-19 and take appropriate steps when their conditions have changed.

Appropriate attention will be focused on the sterilization of instruments and disinfection of equipment and surfaces to eliminate the coronavirus from the dental environment.

Signage explaining the changes being made in the dental environment is encouraged to educate patients and reflect the commitment of the dental professionals regarding protections during dental treatment. Using social media to explain the changes will help the dental team more comfortably provide safe care for their patient.

This pandemic is changing how we provide dental care to address and reduce disease. It is also clear that situations, policies and recommendations are changing by the hour. Kentucky's licensed dental professionals will continue to adapt as situations present themselves. Professional judgement, based on education, training and experience will come into play as dental offices change the way they practice. As importantly, they will continue to abide by standards and recommendations from the Centers for Disease Control and Prevention, the Center for Medicare and Medicaid Services and the American Dental Association.

This workgroup welcomes comments and suggestions for our intent to provide safe dental care.
  Submitted by the following entities:
Kentucky Dental Association
Kentucky Dental Hygienists Association
Kentucky Board of Dentistry
Kentucky Department for Public Health
Kentucky Oral Health Coalition
University of Kentucky College of Dentistry
University of Louisville School of Dentistry