DENTAL PRACTICE RESPIRATORY PROTECTION PROGRAM GUIDE

Both the general public and Dental Health Care Personnel (DHCP) have seen an increase in the conversations around the transmission of infectious disease and prevention efforts. The importance of proper infection prevention and control protocols is at the forefront for healthcare providers of all segments. This document is meant to be a guide for dental practices on the elements of a practice respiratory protection program to help prevent transmission in the dental practice environment.

What is a Respiratory Infectious Disease?

Infectious diseases are caused by germs — viruses, bacteria or other pathogenic microbes. Germs that can infect the respiratory system — lungs, throat, airways — can often be spread through mucus and saliva (also known as “respiratory secretions”) expelled when a person coughs, sneezes, talks or laughs. Another person can become ill when they inhale these microbes and have contact with their mucous membranes, when they touch secretions remaining on a surface or on someone’s hands, or through close contact with an infected person, such as sharing eating utensils or drinking from the same glass(1).

Guideline for dental practice respiratory disease prevention program

Infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections from spreading during healthcare delivery. All healthcare facilities must ensure that their personnel are correctly trained and capable of implementing infection control procedures; individual healthcare personnel should ensure they understand and can adhere to infection control requirements. *This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR to persons outside of healthcare settings(3).
Here are some of the elements of a dental practice respiratory protection program to support your facility in maintaining best practices and compliance:
Written Protocols: Policies and procedures should be tailored to the dental setting and reassessed on a regular basis (e.g., annually) or according to state or federal requirements. Development should take into
consideration the types of services provided by DHCP and the patient population served, extending beyond the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard to address patient safety and including employee workplace exposure prevention protocols(4)

Included in practice protocol manual
Respiratory Hygiene and Cough Etiquette patient protocol as recommended by CDC
PPE supply protocol, in the event of shortages
Employee Wellness Communication: Guidelines for preventing workplace exposures

Patient Pre-Screening Protocol

Patients and potential patients should be aware that they need to rearrange their appointment if they are feeling sick or unwell. Here are some example questions your dental team can ask patients in advance of them showing up for a scheduled appointment:

1. Have you been exhibiting any respiratory symptoms in the past 2-14 days?

Cough
Fever (101.4°F or higher)
Shortness of breath or difficulty breathing

2. Have you traveled outside the Country in the past 14 days?

If yes, where did you travel?
Areas of concern: China, Iran, Italy, Japan, South Korea.

3. Have you been in close contact with anyone who has traveled outside of the Country in the past 14 days?

If yes, what is your relationship to that person?
Where did they travel and when did they return?

4. Have you knowingly had close contact with a patient suspected to have or diagnosed with COVID-19?

Reception & Respiratory Hygiene Protocol

Respiratory hygiene infection prevention measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The strategies target primarily patients and individuals accompanying patients to the dental setting who might have undiagnosed transmissible respiratory infections, but also apply to anyone (including DHCP) with signs of illness including cough, congestion, runny nose, or increased production of respiratory secretions. DHCP should be educated on preventing the spread of respiratory pathogens when in contact with symptomatic persons(3).

Dedicated staff who will be educated on most current information to be available for communication with patients and dental team members. This person will most likely be the practice ICC.
Signs posted at entrances with instructions to patients with symptoms of respiratory infection to use respiratory hygiene etiquette and hand hygiene. Inform reception immediately of symptoms.3
Reception Area
- Provide respiratory cough/cold supplies.
  - CDC Cough/Cold Hygiene Etiquette Poster.
  - Alcohol-based hand rub.
  - Medical grade product containing at least 60% alcohol.
  - Motion-activated dispenser is preferred to reduce cross contamination.
  - Graphic hand hygiene poster to demonstrate appropriate use.
Single-use disposable masks.
- Aseptically dispensed, e.g. individual bags, single-touch pop-up dispenser, issued by the front desk upon arrival.
Ensure pop-up tissue boxes are available throughout the reception area.
- Instructions to throw used tissues into trash bins immediately.
Provide foot-operated covered trash-receptacles; a liner should be used. Check the trash bins midday for emptying; never reach into or push on the trash liner to compress contents. Leave the liner in the bin, close/pull, twist and tie a knot in the top of the bag before removal.
Separate reception staff from patients by a minimum of six feet or behind a physical barrier like glass or Plexiglass.
Complete a visual check throughout the day for items that are out of place.
Patient Seating.
- Designate an area off to the side or at one end of the room for patients self-reporting with respiratory symptoms.
- Designate a room with a door to be dedicated for patients experiencing respiratory symptoms.
- Patients exhibiting symptoms may be asked to return to their car. Staff can communicate with patients either standing away from the window (minimum 6’) or via cell phone.
  - Post hand hygiene signs and posters in washrooms.

Product Selection Best Practices

The Infection Prevention Coordinator should ensure that appropriate equipment and supplies are available and should maintain communication with all staff members to address specific issues or concerns related to infection prevention(3). Here are some things to consider to ensure your practice has appropriate products and equipment on hand:

Does the office have the correct ASTM level face masks for specific tasks being performed?
Are healthcare approved hand hygiene products being used?
Are EPA hospital grade surface disinfectants being used with appropriate dwell time?
Are surface disinfectant products compatible with the surfaces they are being used?
Are surface disinfectant kill claims suitable for the practice?
Are manufacturer IFUs for proper use being followed?
Does the office know how many of each item should be used per day/week/month and have an appropriate inventory level?

CDC Handwashing Recommendations(5)

Caring for your most precious instruments when the gloves come off becomes easy with a proper hand hygiene program. This includes the correct use of soap for cleansing, sanitizer for disinfection and lotion for skin nourishment. According to the CDC Guidelines hand hygiene substantially reduces potential pathogens on the hands and is considered the single most critical measure for reducing the risk of transmitting organisms to patients and HCP(7)

Written protocol for hand hygiene to include indications for hand hygiene, appropriate types of hand hygiene products, appropriate hand hygiene techniques, including handwashing and hand antisepsis.
Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.

System for Reporting

Providers who suspect COVID-19 in a patient should immediately notify infection control personnel at their facility and contact the local or state health department.

CDC phone numbers for Local and State Health Departments COVID-19
Healthcare providers should immediately notify their local or state health department in the event of a PUI (person under investigation) for COVID-19.

REFERENCES

1. North Carolina Department of Health & Human Services. 2019, December. Diseases & Topics: Infectious Respiratory Diseases
2. Centers for Disease Control & Prevention. 2020, February. Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings
3. Centers for Disease Control & Prevention. 2016, October. Summary of Infection Prevention Practices in Dental Settings
4. Centers for Disease Control & Prevention. 2020, February. Interim Guidance for Businesses and Employers: Plan, Prepare and Respond to Coronavirus Disease 2019
5. Centers for Disease Control and Prevention. 2020, February. Coronavirus Disease 2019 (COVID-19): Prevention and Treatment
6. Centers for Disease Control. 2016, March. Oral Health: Personal Protective Equipment
7. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings — 2003. MMWR 2003;52(No. RR-17):[14].
8. CDC Healthcare FAQ’s