After nearly two months of shuttered offices or emergency-only work, California and Sacramento dentists are reopening this week to more patients.
That puts dental offices squarely on the front lines of the coronavirus pandemic and poses serious questions for patients, dental employees and dentists:
How safe is a dental visit? What precautions are needed? Should some patients wait a few more weeks before going in?
Dental offices involve close contact that produces aerosol particles that can carry the virus. That said, both the state Department of Public Health and the California Dental Association last week signaled to dentists they can ramp up with patient loads, if they follow coronavirus-safety guidelines.
It means dental office visits are going to be notably different now than they were a few months ago. Here is at look at the issues and likely changes:
What are dental offices now allowed to do?
That is up for debate. California Gov. Gavin Newsom’s coronavirus closure orders are not entirely clear, dental representatives say.
It’s clear that dentists have been able to do emergency care all along since the virus hit. As of last week, the state clarified that dentists can also do preventive care to forestall an emergency. Less clear is whether dentists can return to routine teeth cleaning. That likely will be a individual choice for dentists in the near term.
Who’s most at risk in a dental office?
The biggest risks are to dentists, dental hygienists and others working in the office because they deal with a constant flow of people all day, work at close range and use instruments that cause tiny droplets which could contain the virus to be suspended in the air around their immediate work space.
A state OSHA safety analysis places dental employees in the “very high risk” job category “when they are performing certain aerosol generating procedures.”
How are patients at risk?
Patients’ risk factor appears to be considerably lower for patients than for dental office employees, but they too face risk.
The worst case scenario, although unlikely, may be if the patient who had been in the room 10 minutes before them was infectious. In that case, the next patient could pick up the virus from ambient air, or from touching a contaminated surface, or from being touched by the hygienist or dentist.
That risk is notably reduced if dental offices take appropriate safety steps.
Dentists are required now to screen patients beforehand and potentially when they arrive at the office as well. That may include taking a patient’s temperature at the door, said Dr. Stephanie Sandretti, a Sacramento and Roseville dentist on the California Dental Association’s government affairs council.
“The likelihood of somebody coming in with COVID is dramatically reduced,” she said.
Dental offices will disinfect surfaces between patients. A slightly extended time between patients also will allow office air-filtration systems to work.
“A dental office has been a clean place and now it is going to be an even cleaner place,” Sandretti said.
What other measures are dentists being asked to take?
For their safety, dental employees will be wearing more protective gear, including a facial mask, as well as a visor or protective screen covering their entire face. They likely will wear protective clothing and may wear shoe coverings.
The new state guidelines suggests that dentists have a two-week supply of safety gear, also known as personal protective equipment, on hand: “This includes N95 respirators, face shields, goggles, surgical masks, and other infection control equipment.”
PPE shortage problems
That two-week PPE rule could prove problematic. Dentists, even more than others in health care, have had difficulty accessing personal protective equipment, amid supply shortages.
A recent Sacramento Bee review found that the state recalled a large shipment of masks for dentists, using it instead for other purposes, causing dental professionals to complain that they were being treated like second-class citizens during the coronavrius crisis, despite the fact that dental work is at higher risk.
Can dentists reduce aerosols?
Procedures, such as tooth drilling, that cause tiny or mist-like water droplets to exit the patient’s mouth are called aerosol procedures – and are considered a key risk factor for dental office employees. Some droplets are small enough to be suspended in the ambient air for brief periods.
The state last week warned to limit that kind of work for now:
“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.”
Four-handed dentistry involves the dentist and assistant working together with suction devices that reduces aerosols, Sandretti said.
Patients may find that their dentist will now put more absorbent materials in their mouths to reduce spray, and may use a device that holds the tongue back.
Face masks for patients
The state last week told dentists they should require patients to wear masks to their appointment. Also: “Dental offices should consider having a supply of face masks or cloth face coverings to provide to patients who arrive without their own,” state guidelines read.
No more waiting rooms, magazines
In some offices, patients will be asked to wait in their car or elsewhere outside the office for a text telling them their room is ready. That will allow them to walk directly into the operatory and skip sitting in the waiting room.
If the patient arrives with a driver, the driver should wait in the car during the appointment. If it’s a parent, dentists can consider allowing the parent to wait in the waiting room with a mask on, if social distancing is feasible.
Dentists likely no longer will have magazines for people to read. Many are installing glass or clear plastic barriers at counters between patients and office administrative and scheduling staff.
Disinfecting between patients
Some dentists are likely to reduce the number of patient appointments per day. That will allow the dental office to do take more time cleaning operatories with disinfectants between patients. That also gives time for the air filtration systems to recirculate air. And it will minimize the chance that patients will pass within 6 feet of each other or of staff.
When should you make an appointment?
Individuals dentists will have more or less restrictive rules on what types of patients they are willing to take in the next few months, as the virus continues to spread. State officials are telling dentists to prioritize urgency matters.
After handling emergency cases, dentists are advised to reschedule previously postponed appointments for work that, if left undone too long, could lead to dental or health emergencies.
The state points out that resuming preventive care could also reduce the need later on to do more risky work that creates more aerosols, such as drilling cavities.
Sacramento County rules
Sacramento County’s health chief has given local dentists the go-ahead to do “preventive” dental work, not just just emergency work. Dr. Peter Beilenson told The Bee that he is OK with dentists in the county to do routine teeth cleaning if the dental office is adhering to all state safety steps.