Enhanced Infection Control Practices

In 2016, the United States Centers for Disease Control and Prevention (CDC) established “basic expectations for safe care” in dental practice settings.³⁵ These expectations included a set of standard precautions, including hand hygiene, PPE, respiratory etiquette, safe injection practices, appropriate storage and handling of instruments, instrument sterilization, and disinfection of practice environments/surfaces.³⁵ Further, the CDC recommended additional transmission-based precautions, such as identification of infectious patients, contact precautions, droplet and aerosol precautions.³⁵ The COVID-19 based precautions for dental settings from the CDC and the American Dental Association built upon these protocols and incorporate engineering and administrative controls (Figure 1).^36,37 In response to the COVID-19 pandemic, awareness of aerosols within the dental office came into sharp focus and practices to reduce infectious aerosols were employed. Such practices include ventilation and practice layout, extraoral suction, advanced respirators and/or mask filtration, and pre-operative patient screening.³⁷ A survey deployed during the pandemic demonstrated high levels of adherence to enhanced infection control practices by dentists in their practice over a six-month period.³³ Longer studies conducted in the same manner also demonstrated low infection risks and high rates of adherence to enhanced infection control practices.³⁴ It is also likely that many of these practices have been incorporated into standard infection control practices post-pandemic.

Figure 1: Considerations for infection control in dentistry.

Figure 1: Considerations for infection control in dentistry.

Current recommendations from the CDC and regional/state dental boards include risk-based assessment of community infection rates and individual patient and practitioner risk assessments to reduce COVID-19 transmission in the dental office. The CDC recommends routine infection prevention and control (IPC) practices, including remaining up-to-date with all recommended COVID-19 vaccine doses. The following current best-practices to address continued risk for COVID-19 infection for healthcare professionals:²⁹

• Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 infection: Visual alerts in strategic places throughout healthcare facilities can alert patients and healthcare professionals to the infection control practices at the facility. Individuals should be informed of the policies if they have had a positive test for SARS-CoV-2, symptoms of COVID-19, or close contact with an individual with SARS-CoV-2 infection.

• Implement Source Control Measures: This includes the use of well-fitting facemasks or respirators to reduce the spread of respiratory secretions.

• Implement Universal Use of Personal Protective Equipment for HCP: This includes barrier protection for Standard and/or Transmission Based Protocols based upon suspected diagnosis. The CDC also notes that as SARS-CoV-2 transmission rates in the community increase, healthcare professionals should consider implementing broader use of respirators and eye protection.

• Optimize the Use of Engineering Controls and Indoor Air Quality: These include proper ventilation, physical barriers at reception/triage locations, appropriate disinfection,³⁸ intraprocedural evacuation as well as avoidance of crowded communal areas.

• Protocols to Address COVID-19 Infection in Practitioners: Ongoing self-monitoring and appropriate quarantine/infection prevention and control practices should be established a priori for all staff within the dental healthcare facility.

It should also be noted that the implementation and utilization of such protocols is currently being revised by OSHA and the CDC and dental healthcare workers are encouraged to regularly review all of the following:³⁹

• The level of ongoing community transmission of COVID-19 in their community. The CDC continues to monitor community levels of COVID transmission and track those in their COVID Risk assessment tool.

• The phase of reopening (if applicable) the community in which the dental practice is located has entered.

• The risk to dental practitioners and support staff of being exposed to sources of SARS-CoV-2, including suspected and confirmed COVID-19 cases and people who are infected with SARS-CoV-2 but do not have signs and/or symptoms of COVID-19 (but who may be able to spread the virus to others without knowing it).

• The availability and ability of the employer to implement controls to protect workers from exposure to sources of SARS-CoV-2.