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 guidance for resuming deferred and preventive dental care. It builds on the April 27, 2020, State of California Guidance, Resuming California’s Deferred and Preventive Health Care regarding prioritization and delivery of dental services. It is important to continue to monitor COVID-19, including case counts and hospitalizations and their impact on the health care delivery system.
To track trends in prevalent COVID-19 cases, deaths, new cases, hospitalization, and testing results, please visit the new data portal at COVID-19 Statewide Update. Many local health departments are also publishing community level data that may be helpful to your practice for assessing pandemic conditions in your community.
According to the Occupational Safety and Health Administration’s (OSHA) Guidance on Preparing Workplaces for COVID-19, dental health care personnel (DHCP) are in the very high-risk category for exposure to SARS-CoV-2 virus that causes COVID-19 when they are performing certain aerosol generating procedures. This risk requires a level of heightened awareness, training, preparation, and adherence to a combination of standard and transmission-based precautions as appropriate to ensure the safe provision of care. Employers of DHCP are also responsible for following applicable OSHA requirements, which in California include Cal/OSHA's Bloodborne Pathogens, Personal Protective Equipment, and Respiratory Protection standards. To address asymptomatic and pre-symptomatic transmission, dental offices should implement source control (i.e., require facemasks or cloth face coverings) for everyone entering the dental setting (dental healthcare personnel and patients), regardless of whether they have COVID-19 symptoms.
Patients with active COVID-19 infection should not receive dental treatment in a dental office. Dentists and medical providers should work together to determine an appropriate facility for treatment. Procedures on patients with COVID-19 should be carried out in accordance with Cal/OSHA’s Aerosol Transmissible Diseases (ATD) Standard.
The following guidelines were developed to assist dental practitioners to resume clinically necessary dental care for previously scheduled procedures or for those non-COVID patients who are likely to develop dental emergencies with the following considerations:
2. General considerations
Local Geographic Orders
- Depending on the conditions in a community, a local health officer may issue or update current “stay-at-home” orders; orders that are more stringent than the state’s public health orders must be followed.
- All practitioners should continually evaluate whether their region remains at a low risk of incidence and should be prepared to cease all but emergency procedures if there is a surge. The California COVID-19 Statewide Case Statistics dashboard has case information by county and should be accessed regularly by providers to stay current.
- Dentists must ensure they have adequate supplies including personal protective equipment (PPE) and sanitation supplies.
- It is strongly recommended that dental practices have a minimum 2-week supply of PPE for dentists and staff. This includes N95 respirators, face shields, goggles, surgical masks, and other infection control equipment.
- Dental offices should require the use of facemasks or cloth face coverings by all patients prior to entering the dental office and while they wait to be seen; this will minimize emissions of infectious particles by patients who are infected but asymptomatic. Dental offices should consider having a supply of facemasks or cloth face coverings to provide to patients who arrive without their own.
Screening & Testing
- All patients and dental practice staff must be screened for symptoms of COVID-19 prior to entering the dental facility.
- Screen all patients for COVID-19 symptoms or contact with a COVID-19 patient before the dental appointment using a telehealth platform to confirm non-COVID status. If necessary, consult the patient’s medical provider for the COVID-19 status and, for COVID-19 positive patients, coordinate with medical provider for appropriate treatment.
According to CDC, multiple symptoms may appear 2-14 days after exposure to the virus. Therefore, the screening should include an assessment of:
- Exposure to someone diagnosed with COVID-19 in the past 14 days; or,
- Cough, shortness of breath, unexplained fever (≥100.4º F), chills, repeated shaking with chills, muscle pain, headache, sore throat, and/or new loss of taste or smell within the prior two weeks.
- When necessary, consult the patient’s medical provider for obtaining COVID-19 infection test results for symptomatic patients when adequate testing capability is established; if available, patient testing should occur prior to care and this information should be combined with patient’s symptoms, clinical findings, and contact history to assess COVID-19 status. This combination of information is to be used to determine whether to proceed with treatment or postpone until symptoms resolve. This is especially important when a patient receives a negative result but shows symptoms consistent with COVID-19.
- Patients and staff with suspected or confirmed COVID-19 and those with potential COVID-19 exposure should not enter the dental office.
- For 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 10 days have elapsed since symptom onset.
- Staff with signs or symptoms of COVID-19 upon arriving for work or developed during the work shift should be sent home immediately and asked to self-isolate pending testing confirmation.
- Place visual alerts such as signs and posters at entrances and in strategic places providing instruction on hand hygiene, respiratory hygiene, and cough etiquette.
3. Dental specific considerations
The CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response provides essential guidance for resuming selected dental services and developing a protocol for dental treatment during the pandemic. The American Dental Association (ADA) recently published the Return to Work Interim Guidance Toolkit that contains many useful resources and the California Dental Association has established “Back-to-Practice” resources for California, including checklists for reopening dental offices and communicating with patients on resuming dental care, COVID-19 screening tools for both employees and patients, and checklists for needed protocols, supplies and equipment. These resources may be useful when implementing these recommendations. The following recommendations are provided to supplement the CDC Interim Guidance:
- Evaluate the necessity of the dental care based on urgency of dental problems. Clinicians should prioritize care that was previously postponed and for those conditions that are likely to lead to dental emergencies if treatment is not provided in a timely manner. As low community transmission rates and ample supplies of PPE and tests dictate, dentists can also begin to provide essential preventive care taking measures to minimize aerosol generation. Preventive services such as topical fluoride application, sealants, and scaling as well as minimally invasive restorative techniques may be considered.
- Have patient scheduling and flow protocols and infection control precautions in place to minimize exposure to and spread of COVID-19. Limit the number of patients in the office or clinic at any one time to maintain physical distancing of a minimum of six feet between patients. If physical distancing is not possible inside the waiting room, consider having patients wait outside.
- Ensure that all patients are wearing a face covering while in the office.
- Comply with the Cal/OSHA requirements under its Airborne Transmissible Diseases (ATD) standard which requires:
- Not performing dental procedures on patients identified as having COVID-19 or suspected COVID-19 cases. For suspected cases, proceed with care if patient has physician confirmation ruling out COVID-19 infection.
Updating the office Injury and Illness Prevention Program including a written procedure for screening patients for COVID-19 that is consistent with current guidelines issued by the Centers for Disease Control and Prevention (CDC) for infection control in dental settings. For more information visit the Guidance from CDC for infection control practices in dental settings. Patients must be actively screened on the spot for fever and symptoms of COVID-19 before they enter the dental setting in addition to screening when an appointment is set up.
Developing a Respiratory Protection Program as required by Cal/OSHA Section 5144; see CDA practice support webpage.
Ensuring that employees have been trained in the screening procedure in accordance with Section 3203 Injury and Illness Prevention Program. For a template, see CDA practice support webpage.
4. Provision of dental care to patients without COVID-19 during the COVID-19 pandemic
The CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response describes the elements for developing a protocol for providing dental care during this time. A critical aspect of this is to avoid aerosol generating procedures whenever possible. If aerosol generating procedures are necessary, employ aerosol management tools that may consist of the use of four-handed dentistry techniques, high evacuation suction, dental dams, or other appropriate equipment to minimize or capture spatter and aerosols. Respiratory protection should be worn to protect against infectious aerosols emitted during procedures on asymptomatic patients, since most dental procedures have the potential to generate aerosols. A fit-tested surgical N95 respirator offers respiratory protection with fluid resistance and should be worn under a full-face shield for eye and face protection. If surgical N95 respirators are not available due to supply shortages, an FDA-cleared surgical mask should be worn under a full-face shield. Because a surgical mask is not tightly fitted to the face, it will not provide protection against inhalation of small potentially infectious aerosols although it will block spatter from reaching the nose and mouth of the wearer. Information on implementing a respiratory protection program.
At a minimum, dental practitioners must follow the CDC recommendations for:
- Engineering controls and work practices;
- Infection control measures including;
Source control: DHCP should wear a facemask at all times while they are in the dental setting;
PPE use during clinical care including training and demonstration of understanding of PPE use, respirator or surgical mask, face shield, eye protection, gloves, and gowns;
Screening and monitoring of DHCP; and
For details regarding the above mentioned topics, see the CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response.
5. Clean and disinfect office spaces, patient treatment rooms and equipment according to the Guidelines for Infection Control in Dental Health-Care Settings —2003. Follow the CDC recommendations:
- Clean and disinfect room surfaces promptly after completion of clinical care.
- Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.
- Routine cleaning and disinfection procedures (e.g., using cleaners and water to clean surfaces before applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
- Refer to List N on the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.
- Manage laundry and medical waste in accordance with routine procedures.
6. Other considerations
During the pandemic, dental providers should regularly check their local health department website for information and important updates about COVID-19. Additionally, the California COVID-19 Statewide Case Statistics dashboard has case information by county, and dental providers should access this information regularly so they are aware early on should transmissions start to rise in their community.
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.
MHOAC Contact List
MHOAC Program Manual
7. Additional Resources
ADA Coronavirus Center for Dentists
ADA: What Constitutes a Dental Emergency
ADA Return to Work Interim Guidance Toolkit
ADHA COVID-19 Resource Center for Dental Hygienists
ADHA Interim Guidance on Returning to Work
CDA: COVID-19 (Coronavirus) Updates
CDA Practice Support News
CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response
CDC Recommendation: Postpone Non-Urgent Dental Procedures, Surgeries, and Visits
CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
CDC Checklist for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response
CDC COVID-19 Information for Healthcare Professionals
OSHA Workers and Employers
OSHA COVID-19 General Guidance for All Workers and Employers
Originally Published on May 7, 2020