Suggestions for Preparing Your Practice to Re-Open

On April 22, 2020, Governor Ducey issued Executive Order 2020-32, providing that “patients should be able to resume elective, non-essential surgeries [including dental surgeries]” on Friday, May 1. The entire order can be found at elective_surgeries.pdf

AzDA recognizes that the Order has various criteria that seem difficult for dentists to satisfy and/or would only seem to apply to hospitals and/or healthcare facilities.  Given these concerns, your AzDA has already reached out to the Governor’s Office and Arizona Department of Health Services to get clarification on how the Order applies to dentists and their practices.

We hope to have this clarification as soon as possible, given the May 1 date. Until we have an update, please be patient as we work with the Governor’s Office and Arizona Department of Health Services to provide you the information as soon as possible.

In the meantime, we wanted to send the following suggestions for things you can consider doing now to start preparing your practice to re-open. 

Please note that the COVID-19 situation continues to evolve, and these suggestions may also evolve and change.  Regardless, as a dentist, it is ultimately up to you to exercise professional judgment and make well-informed and appropriate decisions regarding your practice, your patients, and your team members.  The safety of you, your patients, and your team should be a priority when you exercise that professional judgment.  In making these decisions, AzDA will continue to provide information and resources from entities like the American Dental Association (ADA), Centers for Disease Control and Prevention (CDC), Occupational Health and Safety Administration (OSHA), Arizona Board of Dental Examiners (BODEX), and Arizona Department of Health Services (AzDHS).  We recommend regularly checking the websites for these entities, especially www.ada.org/virus.

Thank you for your AzDA membership.

Click on Each Link Below to Obtain More Information
 Order/Secure Personal Protective Equipment (PPE) for you and your staff as soon as possible 

The Governor’s Order states that a dentist will have a “continuing supply of PPE that will support the … provider [i.e. dentist and staff] for more than 14 days and that it is not reliant on state or a county health department.” While AzDA tries to get clarification on how the 14-day supply of PPE is calculated, we recommend dentists order/secure at least several weeks' worth of PPE for themselves and for their staff as soon as possible.   

The following resources discuss various PPE, including but not limited to, masks, gowns, gloves, eye protection (goggles or face shields), foot covers, and head covers.

Be sure to check with your suppliers and vendors to obtain PPE.


 Arizona Department of Health Services 

AzDHS states that “[w]hen in a room with a patient suspected or confirmed COVID-19 and NO aerosol-generating procedures are being performed . . . all healthcare personnel should wear:  surgical (medical) mask, gown, gloves, eye protection (e.g., goggles or face shield).”[1]  The ADA states that “[c]onsidering that patients who are asymptomatic may still be COVID-19 infectious, it should be assumed that all patients can transmit the disease.”[2]  “When in a room with a patient with suspected or confirmed COVID-19 and aerosol-generating procedures are being performed, all healthcare personnel should wear:  N95 respirator (or equivalent), gown, gloves, eye protection (e.g., goggles or face shield).”[3]  

AzDHS PPE Resources


 American Dental Association (ADA) 

The ADA’s Interim Mask and Face Shield Guidelines provide that dental professionals should “[u]se the highest level of PPE available when treating patients to reduce the risk of exposure.”[4]  “If masks with either goggles or face shields are not available, please understand there is a higher risk for infection; therefore, use your professional judgment related to treatment provided and the patient’s risk factors.”  “Considering that patients who are asymptomatic may still be COVID-19 infectious, it should be assumed that all patients can transmit disease.”  “The FDA has authorized the use of masks equivalent to N95 during the pandemic period [and] the [m]anufacturers approved can be found here: www.fda.gov/media/136663/."[5]  “Professional judgment should be exercised when considering the use of gowns, foot covers and head covers.”[6]  To understand various mask types visit ADA_COVID19_UnderstandingMasks.pdf.

ADA PPE Resources


 Centers for Disease Control (CDC) 

PPE use during clinical care

 Employers should select appropriate PPE and provide it to DHCP in accordance with OSHA PPE standards (29 CFR 1910 Subpart I)external icon. DHCP must receive training on and demonstrate an understanding of:
  • when to use PPE
  • what PPE is necessary
  • how to properly don, use, and doff PPE in a manner to prevent self-contamination
  • how to properly dispose of or disinfect and maintain PPE
  • the limitations of PPE
Dental facilities must ensure that any reusable PPE is properly cleaned, decontaminated, and maintained after and between uses. Dental settings also should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.

The PPE recommended for DHCP when providing emergency dental care to patients without COVID-19 includes:
  • Respirator or surgical mask:
    • Before entering a patient room or care area, put on one of the following:
      • An N95 respirator[5] or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRs), or elastomeric respirators.
      • If a respirator is not available, use a combination of a surgical mask and full-face shield. Ensure that the mask is cleared by the US Food and Drug Administration (FDA) as a surgical maskexternal icon.
    • During aerosol-generating procedures (e.g. use of dental handpieces, air/water syringe, ultrasonic scalers), put on one of the following:
      • An N95 respirator or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, powered air-purifying respirators (PAPRs), or elastomeric respirators.
    • After exiting the patient’s room or care area and closing the door (if present), take into consideration that most dental procedures generate droplets, spatter, and aerosols:
      • Remove and discard disposable respirators and surgical masks.
      • Perform hand hygiene after removing the respirator or facemask.
  • Eye Protection
    • Before entering the patient room or care area, put on eye protection (i.e., goggles or a full face shield that covers the front and sides of the face).
      • Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
      • If respirators are not available and surgical masks are used, wear a full-face shield.
    • After leaving the patient room or care area:
      • Remove eye protection.
      • Clean and disinfect reusable eye protection according to manufacturer’s reprocessing instructions prior to reuse.
      • Discard disposable eye protection after use.
  • Gloves
    • Before entering the patient room or care area, put on clean, non-sterile gloves.
    • Change gloves if they become torn or heavily contaminated.
    • Before leaving the patient room or care area:
      • Remove and discard gloves.
      • Immediately perform hand hygiene.
  • Gowns
    • Before entering the patient room or area, put on a clean isolation gown.
    • Change gown if it becomes soiled.
    • Before leaving the patient room or area, remove and discard the gown in a dedicated container for waste or linen.
      • Discard disposable gowns after use.
      • Launder cloth gowns after each use.
    • If there are shortages of gowns, they should be prioritized for:
      • Aerosol-generating procedures.
      • Clinical procedures where splashes and sprays are anticipated.
If a surgical mask and a full face shield are not available, do not perform any emergency dental care. Refer the patient to a clinician who has the appropriate PPE.

CDC PPE Resources


 Occupational Safety and Health Administration 

Dentistry workers must use proper PPE when exposed to patients. PPE differs for the care of well patient care during the COVID-19 pandemic versus PPE needed when providing emergency care to a patient with suspected or confirmed COVID-19 (See OSHA's PPE standards at 29 CFR 1910 Subpart I).

OSHA recommends the following PPE for dentistry during the COVID-19 pandemic:

Well patients Patients with suspected or confirmed COVID-19
Dental procedures not involving aerosol-generating procedures
Dental procedures that may or are known to generate aerosols
Dental procedures not involving aerosol-generating procedures
Dental procedures that may or are known to generate aerosols
  • Work clothing, such as scrubs, lab coat, and/or smock, or a gown
  • Gloves
  • Eye protection (e.g., goggles, face shield)
  • Face mask (e.g., surgical mask)
  • Gloves
  • Gown
  • Eye protection (e.g., goggles, face shield)
  • NIOSH-certified, disposable N95 filtering facepiece respirator or better*
  • Gloves
  • Gown
  • Eye protection (e.g., goggles, face shield)
  • NIOSH-certified, disposable N95 filtering facepiece respirator or better*
  • Gloves
  • Gown
  • Eye protection (e.g., goggles, face shield)
  • NIOSH-certified, disposable N95 filtering facepiece respirator or better*
 
*During extended procedures in which aerosols or other splashes/sprays of water, saliva, or other body fluids could cause moisture to collect in/on a filtering facepiece respirator, OSHA recommends using an R95, P95, or better filtering facepiece; elastomeric respirator with an appropriate cartridge; or powered air-purifying respirator (PAPR). Note that disposable N95 filtering facepiece respirators and certain cartridges for elastomeric respirators may be adversely affected by an increase in moisture and spray from certain work tasks.

Use respiratory protection as part of a comprehensive respiratory protection program that meets the requirements of OSHA's Respiratory Protection standard (29 CFR 1910.134) and includes medical exams, fit testing, and training.

When removing potentially contaminated PPE, such as an N95 respirator, do not touch the outside of the respirator without wearing gloves.

CDC has developed strategies for optimizing the supply of PPE, including specifically for: OSHA PPE Resources
Order/Secure Cleaning Products for Your Practice as soon as possible

The Governor’s Order involves the “Implementation of an enhanced cleaning process for patient and waiting areas.” While AzDA tries to get clarification on what is meant by an “enhanced cleaning process,” we recommend dentists at least order/secure several weeks worth of cleaning products as soon as possible.  The CDC states that dentists should “[c]lean and disinfect the room and equipment according to the Guidelines for Infection Control in Dental Health-Care Settings – 2003,” that can be found at www.cdc.gov.[9]  The CDC also states to “[u]se products with EPA-approved emerging viral pathogen claims [which can be found at www.epa.gov] on the EPA website for EPA registered disinfectants that have qualified under EPA’s emerging viral pathogens program from use against SARS-CoV-2.  That list can be downloaded here List_N_Products_with_Emerging_Viral_Pathogens_AND_Human_Coronavirus_claims_for_use_against_SARS-CoV-2.pdf.

AzDHS provides[10] that:

  • Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
  • Use a bleach-and-water solution (0.1% solution; 1:50 dilution) or disinfectant with a label that says “EPA approved” for killing bacteria and viruses.Always follow directions on product labels.
Order/Secure Other Products for Your Practice as soon as possible

On the ADA’s COVID-19 FAQ page - https://success.ada.org/ – the last question is “We already adhere to standard precautions:  can dentists do anything else to prevent transmission in their offices?”  In answering the question, the ADA states: 

Some common sense recommendations [that involve products or items] include:

  • Include temperature readings as part of your routine assessment of the patient prior to performing dental procedures.
  • Make sure the personal protective equipment you are using is appropriate for the procedures performed.
  • Use a rubber dam whenever possible to decrease possible exposure to infectious agents.
  • Use high speed evacuation for all dental procedures producing an aerosol.
  • Autoclave your handpieces after each patient.
  • Have your patient rinse with 1.5% hydrogen peroxide or commercially available rinses that contain 1.5% hydrogen peroxide just prior to beginning treatment.
  • Clean and disinfect public areas frequently, including door handles, chairs, and bathrooms.

The CDC also has recommendations for respiratory hygiene/cough etiquette, involving tissues, no-touch receptacles, masks, and hand sanitizer.[1]  For recommendations you plan on following that require the ordering of items from above or discussed in the next section (thermometers, rubber dams, hydrogen peroxide rinses, disinfecting wipes, tissues, no-touch receptacles, masks, hand sanitizer, liquid soap, individual phone headsets and keyboards, plastic covers for operatory items (example - keyboards, etc.), etc.), we recommend dentists order/secure at least several weeks worth of such products as soon as possible.

Prepare the Office Setting as soon as possible

Before patients arrive, other things you can consider doing to start preparing your office to re-open include, but are not limited to:

  • Print and place signage in the dental office (entrance, waiting areas, etc.) describing stopping the spread of germs - www.cdc.gov
  • Prepare your office for proper respiratory hygiene/cough etiquette - www.cdc.gov
  • Know how to contact your health department - www.cdc.gov
  • Assess and restock supplies now - www.cdc.gov
  • Consider and plan for providing more telemedicine appointments - www.cdc.gov
  • Place chairs 6 feet apart, when possible.Use barriers (e.g. between receptionist and patient) if possible.www.cdc.gov
  • If your office has toys, reading materials, or other communal objects, remove them - www.cdc.gov
  • Operatories should be free from clutter or any non-essential items being exposed (e.g. nothing unnecessary on shelves).
  • Print off and display in the staff area of your practice PPE donning and doffing instructions - www.tmcaz.com
  • Print off and display in the staff area a guide to putting on and taking off respirators - www.tmcaz.com
  • Prepare posters and training materials for your team on COVID-19 such as PPE use, hand hygiene (success.ada.org), etc. - www.cdc.gov
  • Set-up the office to minimize surfaces and items the patient has access to touching.The intake process should be as streamlined as possible, to include taking payment over the phone, when possible, electronic receipts should also be considered.
  • Forms that require the patient’s signature or patient’s review could be made available electronically and allow for electronic signature.
  • Individual phone headsets and computer keyboards for each team member involved with computer work and phone calls.
  • Stock up on paper goods to help with cleaning and disposable pens.

There has also been an array of materials involving COVID-19, which you can read and become familiar with.  It is suggested that you check your AzDA updates and www.ada.org/virus regularly.  Beyond what is already included on this webpage, some resources (but not all) are included below and AzDA will continue to provide additional information and resources:


ADA Resources


Arizona Department of Health Services

  • (PDF) Guidance on Screening Visitors for COVID-19 - www.azdhs.gov
  • (PDF) Updated Coronavirus Disease (COVID-19) Outbreak Personal Protective Equipment (PPE) Guidance - Strategies to Optimize PPE Contingent Capacity Use Recommendations* - www.azdhs.gov
  • (PDF) COVID-19 Infection Control and Personal Protective Equipment (PPE) Guidance for Arizona - www.azdhs.gov
  • (PDF) Clinician Fact Sheet - www.azdhs.gov
  • (PDF) What Healthcare Personnel Should Know - www.azdhs.gov
  • (PDF) Coronavirus Disease 2019 Outbreak and Infection Control Guidance for Healthcare Facilities* - www.azdhs.gov

CDC Resources

  • CDC’s Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response - www.cdc.gov
  • CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings - www.cdc.gov
  • Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19) - www.cdc.gov
  • Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) - www.cdc.gov
  • Using Personal Protective Equipment (PPE) - www.cdc.gov
  • CDC Statement for Healthcare Personnel on Hand Hygiene during the Response to the International Emergence of COVID-19 - www.cdc.gov
  • Frequently Asked Questions about Hand Hygiene for Healthcare Personnel Responding to COVID-2019 - www.cdc.gov
  • Optimizing PPE - www.cdc.gov
  • Personal Protective Equipment: Questions and Answers - www.cdc.gov
  • Steps Healthcare Facilities Can Take Now to Prepare for COVID-19 - www.cdc.gov
  • Healthcare Facilities: Preparing for Community Transmission - www.cdc.gov
  • Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19) - www.cdc.gov
  • Facemaskswww.cdc.gov 

OSHA Resources

  • OSHA’s Hazard Recognition (dentists are classified as very high risk exposure) - www.osha.gov
  • ADA Summary of OSHA Guidance:  Preparing Workplaces for COVID-19 - success.ada.org.  OSHA’s complete guidance can be found at - www.osha.gov.
  • Control and Prevention, Healthcare Workers and Employers- www.osha.gov
  • Signs and symptoms of COVID-19 - www.osha.gov
  • OSHA standards for COVID-19 - www.osha.gov
  • Workers’ Rights and Employers’ Responsibilities - www.osha.gov 
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