Reopening Your Dental Practice

Meetu C. Soni, DMD, BDS—a board-certified pediatric dentist in North Brunswick, New Jersey—is blogging for Decisions in Dentistry about COVID-19.

In these trying times, providing dental care is stressful. Recommendations continue to change, leaving us with lots of gray and little black and white. Many of us are nervous about seeing patients for elective procedures. No one seems to have the answer to the question: “What do we need to do in order to conduct business as usual?”

What Is Usual?

We must be our own advocates when planning to reopen. We need to use clinical judgment regarding whether our patients need to be seen sooner rather than later, or if they can wait a little longer without treatment before ending up with a poor prognosis.

We also must decide what is right for us. Depending on our personal situations—such as underlying health conditions, child care needs, and willingness of staff to return to work—we have to gauge our level of confidence in the safety of our workplace, the need to return to work, and when to return to work. One size does not fit all. We must decide independently what works best for us. Business as “usual” may not return for a while or not at all. Regardless of how you decide to reopen, one thing is unequivacol: we must be prepared to serve patients in a safe and efficient manner.

Patients are also scared and may hesitate to return to the dental office. Dentistry is known to produce aerosols, but patients may not know that dental offices are highly skilled at infection control. Consider posting a video of your readiness to welcome patients back and sending an email with the changes you’ve made. This will increase their confidence and may motivate them to schedule an appointment.

Preparation, Analysis, Readiness, and Training

To safely see patients, we need to do our PART: preparation, analysis, readiness, and training.

Prepare

• Minimize contact between people
• Employ strict disinfection protocols in the office
• Reduce the number of patients in the office at a given time; avoid having two patients/families standing at the front desk together
• Perform active COVID-19 screening using COVID-19 questionnaire
• Screen team members, patients, and parents/caregivers for symptoms upon entering a facility by taking vitals
• Protect ourselves and our staff by providing appropriate personal protective equipment (PPE)

Analysis

Analyze your plan and make a list of equipment needed, changes in scheduling and confirming, etc.

Readiness

Use your list to make the office ready based on your analysis.

Training

Working in the new environment demands we learn new methods of safety and protection for our staff and patients. This can be achieved through ongoing training for our clinical and front desk staff members.

New Personal Protective Equipment Protocol

PPE protocol depends on the work performed and level of contact with patients. Front desk personnel should wear washable scrub jackets and surgical masks. Gloves should be donned while doing transactions with the patients, such as taking their insurance card, cash, or credit card. Avoid handling payment if possible and use online methods such as PayPal, Venmo, Zelle etc.

Clinical staff, including dental assistants, dental hygienists and dentists, are at high risk.  As such, take the PPE requirements for clinical staff to the next level. Everyone coming in close contact with the patients must wear N95 masks, surgical gowns (water-resistant disposable or washable), head coverings, and face shields. To increase the effectiveness of N95 masks, a fit test or check is necessary. Provide training on respiratory protection and conduct drills to ensure all staff members know the right way to don and doff PPE. This training is mandatory and should be documented.

Protocol for Checking Patients In and Out

• Patients should fill out a questionnaire about recent sickness history and contact with a COVID-19-positive individual and submit via email or your online portal at-least a day prior to their scheduled appointment.
• Inform parents/caregivers that only one adult is allowed with the pediatric patient. For adult patients, advise them against bringing a companion.
• Post a note on the main entrance door reminding patients to call the office on arrival to check in.
• Patients must remain in their car until called in.
• All paperwork, especially the COVID-19 questionnaire, must be reviewed by the front desk staff before calling the patient in.
• Any suspected cases must be asked to show proof of no infection.
• Patients must pay for services in advance using an online payment portal on the website to reduce time spent in the office.
• If using the credit card machine in office, do not take the card from the patient. Ask him or her to insert and remove it.

Sneeze guards should be installed at the front desk to avoid direct contact with patients. While taking insurance cards, staff should wear gloves and sanitize hands after handling. It’s preferable to send an email receipt of payment made. Email addresses must be confirmed and updated for each patient.

Wipe the transaction tops, scanner, and door knobs after every patient. Encourage staff and patients to use their own pens for signing. You can even provide giveaway pens with the practice’s logo.

Teledentistry is a helpful tool to reduce the number of non-urgent appointments. Patients with complaints such as a tooth erupting crookedly, ectopic eruption of permanent tooth without exfoliation of primary tooth, etc, can be addressed through teledentistry video calls, leaving your schedule free for more needy and productive patients with real emergencies and those needing urgent treatment.

Clinical Staff Readiness and Safety Protocol

Clinical staff is at high risk due to close patient contact; they are also responsible for turning over the treatment rooms and disinfecting them meticulously before bringing in the next patient. Establishing an infection control protocol and training staff are critical to providing a safe environment for both your staff members and your patients. Training staff to minimize contact is important.

Recommendation to Reduce Contact:

• Have staff open all doors for patients to prevent patients from touching them.
• Ask patients to sanitize their hands before entering the treatment area and record temperature using a no-contact thermometer.
• All patients must always wear face coverings while inside the facility. Provide masks if they do not have one.
• Reorganize the treatment rooms. Move what used to be on the counters into drawers or cabinets. This will help staff disinfect the room quickly and efficiently, as there will be fewer things to be wiped down.
• Nitrous tubing should be autoclaved between every patient. Hence, you may need to order more tubing, and use either an autoclavable nasal hood or procure disposable tubing and nasal hoods.
• To reduce contact with patients and parents/caregivers, take verbal consent for procedures. The dental assistant or dentist can sign the consent for nitrous, extraction, RCT, crown etc, on the patient’s behalf. Do not forget to document this on the patient’s chart.
• Once treatment plan is established, the dental assistant should set the room up with all that could be required to perform the procedure. This will avoid accessing drawers and cabinets while the procedure is in progress and reduce cross contamination.
• Disinfection of the treatment room must be meticulously performed after each patient. Training the staff for safe disinfection can help avoid transmission. Gloves should be changed frequently after handling used instruments and before disinfecting the room and surfaces. Ask them to remember to wipe the companion/parent chair, knobs, and handles.
• Barriers for lights, dental chairs, and drawer/cabinet handles must be changed between patients.

Clinical staff must always wear their masks properly with the nose and mouth covered, even while talking to patients or parents/caregivers. Clinical staff must wash their hands after every patient, and everyone in the dental practice needs to wash hands frequently.

Dentist Readiness and Protocols

Treatment must be prioritized based on need. Many dental issues have remained untreated as offices only provided emergency care. Untreated dental problems can turn into dental emergencies. Patients with the most serious issues should be treated first. In pediatrics, it is important review the recare list and make appointments for high-caries risk patients first.

Most dentists have avoided procedures that generate aerosols, but we will need to come up with ways to contain the aerosol. Possible strategies include suction, using intraoral suction equipment, installation of air purifying equipment, and ultraviolet lights. Many dentists have also devised innovative ways of containing aerosols by creating a containment chamber.

Some other points to remember are:

• Do as much treatment possible in one visit.
• Apply silver diamine fluoride treatment on children who cannot be treated in the office setting and need to be taken to a hospital setting for treatment.
• Always use an N95 mask with level 1 (or level 3 mask for aerosol-producing procedures) over it. Keep the N95 mask on and dispose of the top mask after every operative patient, especially after aerosol-producing procedures.
• Protect yourself by using surgical gowns and protective eye wear. Use a face shield or face hood with respirators while performing aerosol-producing procedures.
• Remember that your clinical auxiliary staff must have the same equipment you do.
• Ensure as little contact with the patient as possible. Use air high fives and elbow touches instead. Avoid passing out coins, stickers, or toys. However, if child needs this positive reinforcement, then only give a coin or toy that can be wiped and disinfected before handing it to the child. Take verbal consent from the parent before doing so.
• It cannot be stressed enough to wash hands frequently between patients and avoid touching your eyes or face.

It is time to live and function during the COVID-19 pandemic. Our awareness and readiness will be our best bets in these uncertain times. Use your judgment and follow your heart. Never forget that dentists know infection control better than another healthcare personnel. Practice with caution and stay safe!