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April 7, 2020 TO: California Dental Health Care Personnel SUBJECT: COVID-19 Guidance for Dentistry
This guidance is based on what is currently known about the transmission and severity of coronavirus disease 2019 (COVID-19) and the implications for dental practice. The California Department of Public Health (CDPH) will update this guidance as additional information becomes available.
This document aims to provide statewide guidance regarding the treatment of patients with dental emergencies. In alignment with the recommendations from the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA) and the American Dental Hygienists, we recommend the postponement of routine procedures, surgeries, and non-urgent dental visits during this period of the pandemic. Limiting dental practices to treating patients with emergencies will both reduce the risk of COVID-19 disease exposure and preserve the nation’s limited personal protective equipment (PPE) supplies.
Background
According to the CDC, COVID-19 is a new disease and is thought to spread mainly between people who are in close contact with one another (within about 6 feet) through respiratory droplets produced when an infected person coughs or sneezes. Dental procedures that use dental instruments (such as handpieces and ultrasonic scalers) and air-water syringes create a spray that can contain contaminated droplets. This spray can also contain aerosols. Therefore, caring for patients with COVID-19 requires Transmission-Based Precautions that are in addition to Standard Precautions. Therefore, we recommend that dental health care personnel:
Postpone routine procedures, surgeries, and non-urgent dental visits and direct patients to call the office for guidance if they feel they have a dental emergency. All dentists should be available for emergencies of their patients of record or have arranged coverage with another provider. Guidance from the ADA can be found on the ADA website (PDF).
Perform only those procedures that are needed to treat dental emergencies (e.g., uncontrolled bleeding, severe pain, trauma, cellulitis). The urgency of a procedure is a decision based on clinical judgement and should be made on a case-by-case basis. Guidance from the ADA can be found on the ADA website (PDF).
Screen all patients before they enter the dental office for COVID-19 risk, including fever, respiratory symptoms or potential exposure and triage appropriately. Patients with fever, respiratory symptoms or potential COVID-19 exposure who need to enter the dental office for urgent consultation should be provided a surgical mask and isolated from others.
Procedures for Patients with Known or Suspected COVID-19
For emergent procedures to be performed on patients with known or suspected COVID-19, dental health care personnel and medical providers should work together to determine an appropriate facility for treatment. Patients with active COVID-19 infection should not be seen in dental settings per CDC guidance. Procedures should be carried out in accordance with Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard.
Dental health care personnel should utilize recommended personal protective equipment (PPE): gown, gloves, eye protection (face shield or goggles), and respiratory protection (powered air purifying respirator or N95 respirator).
Any aerosol generating procedures required on persons with a suspected or confirmed COVID-19 infection should follow best practices and be performed in an airborne infection isolation room. A powered air purifying respirator (PAPR) with a High Efficiency Particulate Air (HEPA) filter must be worn by the dentist performing the aerosol generating procedure and all others present in the room during the procedure. If a PAPR is not available, dentist should wear an N95 respirator.
Dental procedures that are less likely to produce aerosols should be performed in an airborne isolation room, unless it is not feasible to do so, in which case they can be performed in a private room with the door closed. Dental health care personnel should perform procedures in a manner that minimizes aerosol production, such as appropriate use of high-volume evacuation. The dentist performing the procedure and all others present in the room during the procedure should wear a respirator at least as effective as an N95 filtering facepiece respirator. If surgical N95 respirators are not available, then industrial N95 with face shield would be an alternative.
If additional follow-up care or procedures are required following the emergent care to persons with suspected or confirmed COVID-19, dental providers should wait until after symptoms have resolved (72 hours since last fever without anti-fever medications, and improved cough or other respiratory symptoms) AND at least 7 days have elapsed since symptom onset. Following the ATD Standard respiratory protection requirements described above would be prudent under these circumstances.
Procedures on Patients who are Not Symptomatic for COVID-19 and Without Known Exposure to COVID-19
For procedures on patients with urgent dental problems who are not symptomatic for COVID-19 and without known exposure to COVID-19, the below mentioned PPE protocol should be adhered to where applicable including performing procedures in a manner to reduce aerosol generation. See Guidance from CDC (PDF) for infection control practices in dental settings.
Dental health care personnel should utilize recommended personal protective equipment (PPE): gown, gloves, eye protection (face shield or goggles), and respiratory protection (powered air purifying respirator or N95 respirator).
Powered air purifying respirators should be prioritized for performing aerosol generating procedures. In addition to their higher level of respiratory protection compared to an N95 filtering facepiece respirators, powered air purifying respirators have the added benefit of a built-in face shield.
If powered air purifying respirators are not available and treatment MUST be performed, dental health care personnel should wear the highest level respiratory protection available when providing care; N95 respirators are the most common respirator type used in health care.
Non-aerosol generating procedures should be prioritized to manage emergency treatment whenever possible.
To minimize potential for exposures, only essential staff should be in the room when performing procedures with potential for aerosol generation.
Dental providers should stay tuned to their local health department information about local testing availability. As testing resources and availability increase, community sites will become more available. Until community testing sites and processes are announced, symptomatic patients should be instructed to call their healthcare providers to request testing ahead of going to the medical office. If the patient does not have a primary care provider, refer them to an urgent care clinic. Many medical offices and clinics are providing call lines to help assess the need for testing and instructions for how and where to be tested if indicated.
During disruptions of the supply chain, please request supplies through your local Medical and Health Operational Area Coordinator (MHOAC). Please keep in mind that requests for supplies will need to be granted on a priority basis.
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