Infection Control in Dentistry Before, During, and After COVID-19

Infection control has always been a relevant topic in dentistry, but dental practices’ and their patients’ awareness of its importance has increased significantly as a result of the COVID-19 pandemic. Let’s examine infection control practices before and during the pandemic, as well as project what they might look like going forward.

Before the Pandemic

Most dental practices took precautions, and some even adhered to best standards, but many likely did not fully appreciate the purpose and effectiveness of infection control and prevention measures and, as a result, may not have strongly enforced infection control policies. Consider the following:

Patient screening: This practice was limited or nonexistent. Patients would come into the office, even if they weren’t feeling well, and dental practices were not proactive about educating patients about the risks of coming to an appointment while feeling sick.

Waiting room practices: It was not common for dentists to post information about proper hand hygiene or cough etiquette in waiting rooms, although it was suggested by the Centers for Disease Control and Prevention (CDC).¹ Patients, some of whom could be suffering from a cold or other virus, were also able to sit close to each other.

Operatory setup and maintenance: It was not uncommon for dental team members to take patient-care items out of their packaging and set up the room in advance of a patient’s arrival. Additionally, dental team members may have been more prone to leaving unused items in open storage containers and on countertops until the next patient arrived.

Personal protective equipment (PPE): Dental staff may have worn surgical masks and gowns but rarely, if ever, wore N95 respirators and face shields.

Continuing education (CE): Infection control has always been a state-mandated CE requirement, but many dentists and their team members likely viewed infection control classes as a burden and just 1 of many topics they needed to obtain CE credits.

During the Pandemic

Once the authorities allowed dental practices to reopen after the onset of the pandemic in 2020, and after it was more understood that COVID-19 is spread more readily by airborne transmissions than contact with hard surfaces, infection control practices ramped up in the following ways:

Patient screening:Dental practices began screening patients for COVID-19 exposure and/or symptoms prior to their arrival at the office. Patients who disclosed exposures or symptoms were told to reschedule. These practices continue today in most dental offices.

Employee screening: In addition, dental practices started to require team members to self-screen for COVID-19 exposures and/or symptoms and to stay home if there are any. Some offices also began to inquire as to the vaccination status of their employees, which, although it is not a Health Insurance Portability and Accountability Act violation, it is a sensitive topic for some.

Waiting room practices: Dental practices began posting information about hand hygiene and cough etiquette in waiting rooms. Moreover, patients were told to call upon their arrival and stay outside offices until it was time for their appointments, which begs the question about the effectiveness of hygiene alerts posted in waiting rooms.

Operatory setup and maintenance:It became more common for dental team members to remove instruments from their packaging in front of patients rather than before their arrival. Not only does this limit exposure of these instruments to aerosols in the office but it also assures patients, who are understandably nervous about possible exposures to germs, that such instruments have been sterilized before their use.

PPE: N95 respirators and face shields became the norm rather than the exception, particularly for aerosol-generating procedures. With the use of N95 respirators, most practices also began adhering with requirements by the Occupational Safety and Health Administration (OSHA) to fit test their respirators, at least annually, as well as develop and train team members on their respiratory protection programs.²

CE: Infection control classes became coveted, rather than dreaded, and focused more heavily on use and disposal of PPE, how to protect yourself and the patient during the appointment, and how to effectively disinfect the operatory after the patient leaves.

Going Forward

Given that COVID-19 is likely to persist in some capacity rather than go away completely, and there are other illnesses from which we should protect ourselves and our patients, we would expect and hope that many of the infection control practices emphasized during the pandemic will continue, including the following:

Patient screening: As we’ve learned more about the symptoms of COVID-19 (ie, high temperatures don’t necessarily indicate a COVID-19 infection, and some patients who have COVID-19 may have few symptoms, if any), questions on screening forms have changed. A focus on exposures rather than symptoms may be more useful.

Employee screening: It is important for practices to train their team members on screening and communication policies. Otherwise, a team member who is sick may infect others, and an office may have no choice but to prohibit exposed team members from coming to work, informing patients of a possible exposure, and/or closing the office for a period of time—all of which can be detrimental to a practice.

Waiting room practices: With more people being vaccinated and the anticipated development of COVID-19 antiviral pills, it is more reasonable to envision a scenario where patients can come back into waiting rooms. Still, a dramatic increase in COVID-19 cases in the region or a single case in the office may require waiting rooms to remain sparsely populated.

Operatory setup and maintenance: It is in dental practices’ interests to properly set up and maintain operatories. Not only are patients’ worries about going or returning to the dentist heightened, but a shoddy presentation in the operatory may invite a nervous patient—or even a disgruntled employee or former employee—to take pictures with a handheld device and email them to OSHA or the state dental board.

PPE: Use of N95 respirators, face coverings, and gowns is probably here to stay. Annual fit testing also will continue as long as N95 respirators are being used.

CE: Dentists and their employees will want to continue to stay educated about infectious diseases and best practices in infection control, especially as things change from time to time.

When thinking about the COVID-19 pandemic and, in particular, its impact on dental practices, this quote by writer Archibald MacLeish might come to mind: “There is only 1 thing more painful than learning from experience, and that is not learning from experience.”

Those dental practices that came out of the COVID-19 pandemic with an appreciation of and renewed commitment to infection control best practices will maintain the trust of their patients and survive, whereas those that scoff at the costs of doing the right thing will not. It’s as plain and simple as that.

Source: Centers for Disease Control and Prevention

Lisa Kane, DMD, is the owner of Dental Office Compliance of New England LLC (DOC4NE). DOC4NE assists dental practices in complying with the myriad of regulations required by their state board, OSHA, and the CDC. She teaches infection control and OSHA training, creates personalized plans and protocols for dental practices, and helps them navigate the world of dental compliance.

References:

1. Alsaegh A, Belova E, Vasil’ev Y, et al. COVID-19 in dental settings: novel risk assessment approach. Int J Environ Res Public Health. 2021;18(11):6093. doi:10.3390/ijerph18116093
2. Dentistry workers and employers. Occupational Safety and Health Administration. Accessed November 29, 2021. https://www.osha.gov/coronavirus/control-prevention/dentistry