Dental Providers Oral healthcare is recognized as an essential component of overall health. It’s critical that infection prevention and control practices are in place to protect the health and safety of patients and dental healthcare personnel (DHCP) during the COVID-19 pandemic. We continue to learn about the transmission and severity of COVID-19 and the implications for dental practice. DHCP have a very high potential for exposure to COVID-19 if performing certain aerosol-generating procedures on known or suspected COVID-19 patients. Therefore, when providing care, these patients should be isolated in a room with effective ventilation. Dental settings should balance the need to provide necessary services while minimizing risk to patients and DHCP. The Centers for Disease Control and Prevention (CDC) has developed a framework for healthcare personnel and healthcare systems for delivery of non-emergent care during the COVID-19 pandemic. DHCP should use their clinical judgment in determining those procedures that can be performed safely and effectively at this time. The Rhode Island Department of Health (RIDOH) recommends continued review of Guidance for Dental Settings from the CDC and defers to this guidance in areas of question. The following summarizes what DHCP need to do to assure safe care. Individual dental practices will need to review this guidance and customize it for their clinical setting. This guidance represents suggested minimum standards, and some practices will choose to exceed these standards: Depending on the conditions in any given community, the Governor may issue or update Executive Orders. RIDOH has created a searchable COVID-19 provider web page that has many useful resources for addressing the pandemic. Surveillance information and education is intended to promote recommended practices. Place signs and posters at facility entrances and in strategic places, such as restrooms, registration desk, waiting rooms, exam rooms, providing instruction on washing hands, wearing face coverings, and cough etiquette. Individual healthcare facilities can choose whether to require the use of face masks. RIDOH recommends wearing a mask in all healthcare settings. Questions are welcome and answered via email at [email protected]. Steps for Positive Cases Dental offices may learn that patients or staff who have been in the office later tested positive for COVID-19. Dental offices should request that patients contact the practice if they develop signs or symptoms or are diagnosed with COVID-19 within two days after their appointment. RIDOH may also inform dental offices about patients with COVID-19 who may have visited the office during their infectious period. The tools below help practices assess whether a staff member or patient who tests positive for COVID-19 may have exposed others in the practice. RIDOH encourages dental offices to use these tools to identify and inform staff and patients who are close contacts and should quarantine, and to instruct them to self-monitor for symptoms for 14 days from exposure. COVID-19 Quarantine and Isolation Guidance by Population. COVID-19 Close Contact Determination in Patient Care Settings; This document includes links to a spreadsheet to use for tracking potentially exposed staff and patients in the infectious period, and to English and Spanish letters to send to patients who were near the infected person but do not meet the criteria to quarantine. COVID-19 Isolation and Quarantine Calculator. Confirmed cases of COVID-19 should be reported to RIDOH. For questions and to report cases, call the RIDOH COVID-19 Unit at 401-222-8022 from 8:30 a.m. to 4:30 p.m. seven days a week or call 401-276-8046 outside of those hours. If a staff member is found to be positive for COVID-19, they should follow the guidance under Isolate if you have symptoms or test positive on the page When do I need to isolate or quarantine for COVID-19? Dental offices should continue high-quality infection control. Contact RIDOH at 401-222-8022 for assistance with risk assessment and determination of close contacts for need to quarantine. Clinical practices are asked to both expedite appropriate quarantine and isolation by providing guidance to unvaccinated staff and patients as needed and by reporting workplace close contacts of infected cases to RIDOH for necessary documentation and monitoring. Vaccination The most effective way to prevent the spread of COVID-19 and to protect against severe illness, hospitalization, and death is to stay up to date with your COVID-19 vaccinations. To find a COVID-19 vaccine near you, visit C19VaccineRI.org. Rhode Island regulations (216-RICR-20-15-7) require that healthcare workers are up to date with their COVID-19 vaccines, meaning a person has received all recommended doses of COVID-19—including any booster doses when eligible—or wear a National Institute for Occupational Safety & Health (NIOSH)-approved N-95 mask while working in licensed healthcare facilities when community transmission rates are greater than or equal to 50 cases per 100,000 people. Dental professionals who provide care in any licensed facility or nursing home need to wear an N-95 mask if they are not up to date with their vaccines and community transmission rates are greater than or equal to 50 cases per 100,000 people cases. Who is covered by the regulation? Healthcare workers: A healthcare worker is any person who is temporarily or permanently employed by a healthcare facility, or who volunteers in a healthcare facility, or any person who is compensated by a third party that has an agreement with a healthcare facility to provide staffing services, and has or may have direct contact with a patient in that healthcare facility. This may include, but is not limited to physicians, nurses, social workers, technicians, occupational speech therapists, laboratory personnel, dental personnel, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care but who may be exposed to infectious agents (e.g., clerical, housekeeping, laundry, security, maintenance, administrative, billing, and volunteers). Healthcare facilities: A healthcare facility is a facility as defined in R.I. Gen. Laws § 23-17-2(9) and includes assisted living residences, as well as adult daycare programs, as defined in R.I. Gen. Laws § 23-1-52 and stations, as defined in R.I. Gen. Laws § 23-16.2-2. Please note that dental offices, with the exception of those in hospitals, health centers, or joined with other medical services, are not considered licensed healthcare facilities, as defined in R.I. Gen. Laws § 23-17- 2(9). Additional resources: COVID-19 Vaccine Requirement web page Vaccination Requirement FAQ Medical Exemption Form Vaccinated and unvaccinated healthcare workers should follow quarantine and isolation guidance in case of exposure to COVID-19. Personal Protective Equipment (PPE) Dental offices can choose whether to require the use of face masks by all patients before they enter the office, while waiting to be seen, and upon completion of treatment. Masks minimize the spread of infectious particles by patients who may be infected but are asymptomatic. Dental offices should consider having a supply of face masks to provide to patients who arrive without their own. Dentists must ensure they have adequate PPE for staff. DHCP should Wear eye protection or a face shield, and a face mask, to ensure their eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters, including those where splashes and sprays are not expected. Protective eyewear like safety glasses and trauma glasses with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. Use an N-95 respirator or a respirator that offers an equivalent or higher level of protection during aerosol-generating procedures. It is strongly recommended that dental offices maintain, at minimum, a two-week supply of PPE, including face shields, goggles, surgical masks, gowns, N-95 respirators or respirators that offers an equivalent or higher level of protection, and other infection-control equipment. To protect the health and safety of staff and patients, it is important that DHCP understand the difference in healthcare provider mask types and recommended use based on anticipated risk. Use respiratory protection as part of a comprehensive respiratory protection program that meets the requirements of the Occupational Safety and Health Administration’s Respiratory Protection standard (29 CFR 1910.134) and includes medical exams, fit testing, and training. While fit testing is recommended, until that can be provided, users should perform a seal check at each use. When removing potentially contaminated PPE such as an N-95 respirator, do not touch the outside of the respirator without wearing gloves. Follow safe practices for putting on and taking off PPE. View a video on wearing and removing personal protective equipment in a COVID-19 environment. CDC has developed strategies for optimizing the supply of PPE, including specifically for Gowns; Eye protection; Face masks; N-95 respirators. Screening and Testing Screening DHCP Screen all staff for COVID-19 symptoms (can be self-screening). DHCP with multiple symptoms of COVID-19 that cannot be explained by chronic conditions such as seasonal allergies should not enter the dental office. They should get tested for COVID-19 and quarantine pending test results. Unvaccinated DHCP that are known close contacts of a person that has been clinically diagnosed with COVID-19 should quarantine, but may work if needed for staffing and in consultation with RIDOH. While at work, the worker must Wear a medical procedure mask at all times or higher-level PPE, as indicated. Monitor their temperature and other symptoms every four hours. Stop working and isolate immediately if symptoms develop. DHCP who develop COVID-19 symptoms during their work shift should get tested for COVID-19 and quarantine pending test results. All areas where the staff member worked and spent time should be cleaned and disinfected with a United States Environmental Protection Agency-approved (EPA) disinfectant immediately. If feasible, close off the work area for 24 hours, and if possible, open windows to increase ventilation. Follow RIDOH’s guidance on quarantine and isolation for unvaccinated DHCP with COVID-19 or who have been exposed to COVID-19. Testing DHCP RIDOH encourages surveillance testing of unvaccinated workers in close contact professions, including healthcare. DHCP may schedule testing through portal.ri.gov. Screening and Testing Dental Patients Screen patients and visitors for COVID-19 symptoms prior to appointments so they are appropriately triaged for their visit and are aware of infection prevention considerations. Patients with active COVID-19 infection, either symptomatic or asymptomatic, should only receive dental treatment from vaccinated providers. Dentists and medical providers should work together to identify an appropriate facility for treatment. Procedures on patients with COVID-19 should be carried out in accordance with the CDC guidance entitled Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response. Click here to learn more about COVID-19 testing. Providers who would like to administer rapid antigen tests in their office should contact RIDOH on steps for obtaining a CLIA waiver, registering as a reporter, and receiving test kits. For more information, email [email protected].ri.gov. Treating Suspected or Confirmed COVID-19 Positive Patients This guidance represents suggested minimum standards, and some practices will choose to exceed these standards: When assessing whether to treat dental patients who are not severely immunocompromised with a history of suspected or confirmed COVID-19, use the following strategies: If symptomatic, at least 24 hours have passed since the last fever without the use of fever-reducing medications and; Symptoms have improved and; At least 5 days have passed since symptom onset or; If asymptomatic, at least 5 days have passed since the first positive test. Dental Office Safety During aerosol-generating procedures, employ aerosol-management tools that may include the use of four-handed dentistry techniques, high-evacuation suction, dental dams, or other appropriate equipment to reduce or capture spatter and aerosols. Maintain physical distancing in common waiting areas so there is appropriate distance between individuals of different households. Create structured queuing (e.g., waiting in cars until ready to go into an exam room or separate care areas for symptomatic patients), particularly for symptomatic patients, as a strategy to minimize contact between individuals. Ensure that ventilation has been evaluated in all facilities and is optimized to prevent COVID-19 transmission (i.e., filtration and air exchanges). Review RIDOH’s guidance on indoor air circulation. Dental practices may engage a certified industrial hygienist or professional engineer who focuses on heating, ventilation, and air conditioning issues for help. For infection control, dental practices, at a minimum, shall Clean and disinfect operatory surfaces promptly after completion of clinical care for each patient. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Clean, by removing any visible dirt and grime, before using disinfectants. Disinfectants remove most germs and are most effective on clean surfaces or objects. Coronaviruses are relatively easy to kill with most disinfectants. EPA has published a list of disinfectants for use against the virus that causes COVID-19. When using cleaning and disinfecting products, always read and follow the manufacturer’s directions. Manage laundry and medical waste in accordance with routine procedures. Sterilization protocols do not vary for respiratory pathogens. DHCP should perform routine cleaning, disinfection, and sterilization, and follow the recommendations for Sterilization and Disinfection of Patient-Care Items in the Guidelines for Infection Control in Dental Health Care Settings - 2003. DHCP should follow the manufacturer’s instructions for times and temperatures recommended for sterilization of specific dental devices. Additional Resources ADA Coronavirus Center for Dentists RIDA COVID-19 Resources for Dentists American Dental Hygienists’ Association COVID-19 Resource Center for Dental Hygienists CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response Occupational Safety and Health Administration: Dentistry Workers and Employers Rhode Island Department of Labor and Training COVID-19 Information and Resources U.S. Department of Labor Wage and Hour Division: COVID-19 and the American Workplace American Board of Industrial Hygiene Frequently Asked Questions (FAQs) The spouse of a staff member tested positive. What should the office do? If they live together, the staff member, if not vaccinated, should quarantine and follow the guidance on the Quarantine and Isolation page under If you’re not up to date on your vaccines and someone you live with tests positive. Vaccinated contacts who are asymptomatic do not need to quarantine. When do I need to isolate or quarantine for COVID-19? Quarantining staff may work if their role is critical to the functioning of the office, and all other staffing options have been exhausted. If they work, they must check their symptoms and temperature every four hours while working, wear appropriate PPE, and return directly home after each shift to continue their quarantine. What should we do if a staff member tests positive? The staff member should follow RIDOH’s isolation guidance. Do we have to close our office if staff test positive or staff is quarantining? You will need to assess the ability of your office to function with remaining staff. The RIDOH COVID-19 Healthcare Team can help offices assess the risk of practicing and the need for other staff to quarantine based on PPE use, physical distancing of staff, and time spent in close contact with the staff member who tests positive. Clinical practices that have enough staff to maintain effective infection control can continue to see patients. RIDOH called to let us know we had a patient who was in the office and later tested positive. Determine if any staff members had close contact of a total of 15 minutes or more within six feet of the patient without adequate PPE using the COVID-19 Close Contact Determination in Patient Care Settings tool. The staff member should quarantine. Adequate PPE is a mask and face shield for non-aerosol generating procedure, and an N-95 mask and a face shield for aerosol-generating procedures. Consider whether extended aerosol-generating procedures with a brief break before the next patient and limited air filtration in that physical space could pose a risk for patients who followed the patient who later tested positive. If there was a risk, consider sending a letter to advise the patients who followed to watch for symptoms. A RIDOH template of this letter is available in English and Spanish to place on office letterhead. Medical letter template: English | Spanish Dental letter template: English | Spanish A patient called and “may have been exposed.” Should they still come in for their appointment? Review the definition of a close contact with the patient. Close contact means you’ve been within six feet of someone who has COVID-19 symptoms for a total of 15 minutes or more in a 24-hour period, or less time if the person had active coughing or spitting. If the patient is a close contact and unvaccinated, they should quarantine and not come in for their appointment. If the need is urgent, the dentist can assess the risk and benefit of an in-person visit, especially if working with vaccinated personnel. If they are not a close contact, they can come in if they are not symptomatic and if they follow masking and physical distancing guidelines. A staff member tested positive. Do we have to notify any patients? Offices should review which patients were in the office during the staff member’s infectious period, which is two days before the first symptom or, in the case of asymptomatic staff, two days before the positive test. New variants are believed to be more contagious. Patients who were within six feet of the infected staff member for a total of 15 minutes or more should quarantine. Even if staff were masked, the patient’s proximity to the staff member and their lack of protection put them at risk for exposure. For additional guidance, call 401-222-8022 to be connected with the Healthcare Team. For patients who were within six feet of the infected staff member for a total of less than 15 minutes, offices are advised to communicate to them that someone with COVID-19 may have been in the office during their visit and to watch for symptoms. Use the tools below to assess whether a staff member or patient who tests positive for COVID-19 may have exposed others in the practice. RIDOH encourages practices to use these tools to identify and inform staff and patients who are close contacts and should quarantine, and to instruct them to self-monitor for symptoms for 14 days from exposure. Close Contact Quarantine Requirements; COVID-19 Close Contact Determination in Patient Care Settings; This document includes links to a spreadsheet to use for tracking potentially exposed staff and patients in the infectious period, and to English and Spanish letters to send to patients who were near the infected person but do not meet the criteria to quarantine. COVID-19 Isolation and Quarantine Calculator. How far back do contact tracers go when looking at contacts? I read two days before symptoms, but I am not sure. The infectious period is two days before the first symptom or two days before the first positive test if there are no symptoms.