Novel Coronavirus & Dental CareFrank A. Roberts, DDS, PhD

Coronavirus

What is the Coronavirus?

• 2019 Novel Coronavirus (2019-nCoV) is a virus (more specifically, a coronavirus) identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China.

• The name coronavirus is derived from the Latin corona, meaning "crown" or "halo", which refers to the characteristic appearance reminiscent of a crown.

https://ncov2019.live/wiki

Transmission and Social Distancing

• Early reports suggest person-to-person transmission most commonly happens during close exposure to a person infected with COVID-19, through respiratory droplets produced when the infected person coughs or sneezes.

• These droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those nearby.

• The contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to transmission is currently uncertain.

Surface Transmission?

• Droplets are believed to fall from the air onto nearby surfaces, generally within about six feet of the infected person.

• Airborne transmission (from person-to-person over long distances) is unlikely. This is why “social distancing” of six feet is advocated as a safer distance.

• There is conflicting information whether COVID-19 is spread in the community from contaminated surfaces.

• It is clear that people should wash their hands and avoid touching their faces

Infection Control during Dental Care for Suspected or Confirmed COVID-19 Patients

• Adapted from: CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settingshttps://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

• SARS-CoV-2, which causes coronavirus disease 2019 (COVID-19), is spread primarily via respiratory droplets.

Dental Products Report

If patient has suspected or confirmed COVID-19

Minimize or completely avoid these aerosol generating procedures if possible.

Includes using high speed drill, Cavitron, air water syringe, high speed suctioning.

If patient has suspected or confirmed COVID-19

Use N95 or higher-level respirators during all aerosol-generating procedures

Always wear wear gowns, gloves, and eye protection (goggles or face shields, not eyeglasses or contacts)

On entering patient care area, wear a mask

Use N-95 respirator if available Surgical face mask is also acceptable

CDC recommends:

N95 Masks

• Use of N95 or higher-level respirators are recommended for health care providers who have been medically cleared, trained, and fit-tested (done by UW EH&S) in the context of a facility’s respiratory protection program.

• If the mask has not been fit-tested, it is unlikely to provide any more protection than a regular mask

washingtonpost.com

The N-95 respirator is the preferred airway protection from COVID-19

• To answer questions about N-95 respirators, see the respirator information from the CDC at: https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html

Airborne Infection Isolation Rooms (AIIRs) Negative Pressure Rooms

• The CDC also has updated guidance on airborne infection isolation rooms, more commonly known as negative pressure rooms, saying they are NOTrequired for COVID-19 patients undergoing aerosol-generating procedures.

• Patients with suspected or confirmed COVID-19 should be placed in a single-person room with the door closed - and ideally with a dedicated bathroom.

Who is suspicious for COVID-19?

• Most patients with confirmed COVID-19 have

• Fever (over 100◦ F) and/or

• Symptoms of acute respiratory illness especially

• Cough

• Difficulty breathing

• Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications.

Who Should Be Referred for COVID-19 Testing?

• patient’s signs & symptoms are compatible with COVID-19

• patient should be referred for testing

Clinicians should use their judgment to determine whether

• Symptomatic people at higher risk for poor outcomes

• Adults >60 and people with chronic medical conditions and/or an immunocompromised state

• Examples: diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease

• Anyone with close contact with a suspected or laboratory-confirmed COVID-19 patient within 14 days of symptom onset. This includes healthcare personnel.

• Anyone who traveled from an affected geographic area within 14 days of symptom onset.

Priorities for testing may include

PPE Points to Remember

RegisteredNurseRN https://www.youtube.com/channel/UCPyMN8DzkFl2__xnTEiGZ1w

PPE before entering

Put on all PPE including the respirator before entering the patient care room

No Touching

Keep your hands away from your face and don’t touch your PPE

Avoid touching areas in patient’s room

PPE when exiting

Remove PPE at patient’s doorway or immediately upon leaving room and wash your hands

Remove the respirator (if using) outside of the room AFTER closing the door

Wash your hands!

If your hands become contaminated while removing PPE, stop, wash your hands, and continue removing PPE

Avoid getting infected with the coronavirus and other viruses

• Wash your hands with soap for a minimum of 20 seconds and rinse with hot water

• Avoid touching your face

• Keep your distance from sick people

• Regularly clean frequently used surfaces

CDC Recommendations:Minimize Chance for Exposures

• Put policies and practices are in place to minimize exposures before the patient arrives, during the patient’s visit, and after they leave until the patient’s room is cleaned and disinfected.

• It is particularly important to protect people at increased risk for adverse outcomes from COVID-19 - older individuals with comorbid conditions - including healthcare providers who are in a recognized risk category.

General Principles:Minimize Chance for Exposures Upon Arrival and During the Visit

• UWMC prescreens those entering building at most entrances

• Pre-screen patients and their accompanying parties by telephone before appointment, and again as soon as they arrive

• Limit patients’ accompanying party to only those essential to completion of the appointment (for example, translator, parent or guardian, necessary support person)

• Everyone with symptoms of COVID-19 infection should be re-appointed and sent home wearing a face mask, advised to check for possible COVID-19 testing

• Supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub with 60-95% alcohol, tissues, and receptacles for disposal, are provided.

• Masks are to be kept at the desk and dispensed as needed.

• All patients’ temperatures will be taken by clinician to screen for fever

UWSOD Current Protocol:Minimize Chance for Exposure Before Arrival

• No routine dental care, only urgent and emergency care

• Day before appointment:

• Call patient - check symptoms for patient and all accompanying people

• No accompanying people unless essential for visit

• No children <16

• All people must be negative to all questions, or reschedule

UW SOD Elective Non-Aerosol Procedures

as of 3/15/2020

These elective procedures are not permitted until

further notice• Diagnosis and treatment planning

• Oral radiology

• Consultations

• Delivering a crown or bridge

• All removable prosthodontics other than preparing intraoral rest seats, guide planes, etc.

• Impressions

• Many pre-surgical implant procedures

• Periodontal probing

• Mouthguard delivery and adjustment

FamilyDentistTree

General Principles:Rapid Isolation of Sick Patients

• We have stopped all elective procedures and non-urgent visits

• We prescreen and screen again at arrival for symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough).

• Our front-line personnel have a supply of facemasks and tissues for patients with symptoms of respiratory infection. Anyone with symptoms of respiratory infection is to be immediately put into a facemask.

• At the time of check-in, all patients and their accompanying people are asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible COVID-19 patients.

• Every possibly COVID+ patient is put into a mask and seated alone in an examination room with the door closed. An Oral Medicine faculty member is paged to interview the patient.

UWSOD Current Protocol:Minimize Chance for Exposure On Arrival

• No routine dental care, only urgent and emergency care

• On arrival

• Check again that every person is adult and essential • if not they must leave

• Check symptoms of each member of group

• Non patients who are positive for symptoms must leave wearing a mask, advised to check for possible COVID-19 testing

• Patients who are positive for symptoms go to closed room alone wearing a mask. Summon OM faculty to see them right away.

• Patients who are negative for symptoms may proceed to operatory

UW SOD Procedure Permissions

1. Aerosol-generating procedures are permitted under selected conditions only in Dental Urgent Care Clinic.

2. Elective procedures that generate aerosols (use of a hand piece or ultrasonic units) are suspended.

3. The Oral and Maxillofacial Surgery Clinics at Sand Point and Harborview will continue operations per a special protocol established by the department chair

4. The Center for Pediatric Dentistry Clinic at Sand Point will continue limited operations per a special protocol established by the department chair

5. Elective procedures that do not employ aerosol-generating devices may proceed following this screening and infection control protocol.

UWSOD Current Protocol:Minimize Chance for Exposure During Visit

• No routine dental care, only urgent and emergency care

• In Dental Chair

• Take patient temperature

• If <100.00 F and NO aerosols will be generated, proceed with appointment using full PPE

• If <100.00 F and aerosols WILL be generated, treat with full PPE and use an N-95 mask. • Use rubber dam, high-speed suction, and four-handed

dentistry whenever possible.

• Caution not to splash saliva when removing the dam

• If > 100.00 F, patient must put on a face mask, moved to designated Isolation Room with closed door to wait alone for OM faculty member.

If patient says YES to any question and/or has temperature > 100.00 F

• Alert Oral Medicine Faculty member to come right away

• No students are permitted

• OM faculty must wear full PPE including N95 respirator if available or an N-95 mask before entering Isolation Room. • Takes patient temperature, if not

performed• Decides if/how to medically address

the patient’s dental symptoms• Arranges for dental follow-up• Informs appropriate authorities if

monitoring or COVID-19 testing needed• Manages needs medically or transfers

patient to UWMC Emergency, alerting them in advance

Postpone Non-Urgent Dental Treatment in COVID+ patients• CDC’s guidelines say if not

clinically urgent, try postponing non-emergency dental procedures if patient has signs or symptoms of respiratory illness.

• For urgent procedures in patients with apparent illness, dental and medical providers work together to determine appropriate treatment.

After the patient leaves the isolation room:

Staff must thoroughly disinfect the room before next patient, wearing full PPE including N95 respirator. The room should not be occupied by another patient

for at least 30 minutes.

This Photo by Unknown Author is licensed under CC BY-SA

Handwashing

https://www.youtube.com/watch?v=bG6zISnenPg

Hand Hygiene

Perform hand hygiene before and after all contact with patients or potentially infectious material, and before putting on and after removing PPE, including gloves.

Hand hygiene after removing PPE is particularly important. It removes any pathogens that might have been transferred to your bare hands when you took off your PPE.

Clean your hands with alcohol-based hand sanitizer with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to sanitizer.

Dental offices should ensure that hand hygiene supplies are readily available to all personnel in every care location.

Reusable Personal Protective Equipment (PPE)

Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses.

DonningPersonal Protective Equipment in the right order protects the patient:1. Wash hands2. Gown3. Mask4. Eyes5. GlovesWatch the video regarding proper procedures for donning and doffing PPE:

https://www.youtube.com/watch?v=bG6zISnenPg

Doffing contaminated PPE in the right order protects you:1. Gloves2. Eyes3. Gown4. Mask5. Wash hands

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PPE details when caring for a patient with known or suspected COVID-19

•Put on a respirator or facemask (if a respirator is not available) before entering the patient room or care area.

•Use N95 respirators or respirators that offer a higher level of protection instead of a facemask when performing or present for an aerosol-generating procedures.

•Remove and discard disposable respirators and facemasks after exiting the patient’s room or care area and closing the door.

•Perform hand hygiene after discarding the respirator or facemask.

• If you use reusable respirators (e.g., powered air purifying respirators [PAPRs]), clean and disinfect them according to manufacturer’s reprocessing instructions before you re-use them,

Respirator or Facemask

•Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) when entering the patient room or care area.

•Personal eyeglasses and contact lenses are NOT considered adequate eye protection.

•Remove eye protection before leaving the patient room or care area.

•Clean and disinfect reusable eye protection (e.g., goggles) according to manufacturer’s reprocessing instructions before re-use.

•Throw away disposable eye protection after use.

Eye Protection

PPE details when caring for a patient with known or suspected COVID-19

• Put on clean, non-sterile gloves when entering the patient room or care area.

• Change gloves if they become torn or heavily contaminated.

• Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.

Gloves

• Put on a clean isolation gown when entering the patient room or area.

• Change the gown if it becomes soiled.

• Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area.

• Discard disposable gowns after use.

• Launder cloth gowns after each use.

Gowns

Precautions When Performing Aerosol-Generating Procedures on a patient with known or suspected COVID-19

• Some procedures performed on patient with known or suspected COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible.

• If performed, the following should occur:

• Health care providers (HCP) in the room should wear an N95 or higher-level respirator, eye protection, gloves, and a gown.

• The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

• Should ideally take place in an Airborne Infection Isolation Room (AIIR—negative pressure room).

• Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.

• If restriction of all visitors is implemented, facilities can consider exceptions based on when a visitor is essential for the patient’s emotional well-being and care.

• Limit points of entry to the facility.

Environmental Infection Control

• Use dedicated medical equipment when caring for patients with known or suspected COVID-19 (room and equipment set up just for sick patients).

• Follow environmental cleaning and disinfection procedures consistently and correctly.

• 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.

• For example, use cleaners and water to pre-clean surfaces, then apply an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label.

• Refer to List N on the EPA website for EPA-registered disinfectants that qualify for use against SARS-CoV-2 https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

• Clean and disinfect all non-dedicated, non-disposable medical equipment used for patient care according to manufacturer’s instructions and facility policies.

• Manage laundry, food service utensils, and medical waste according to routine procedures.

Manage Visitor Access

and Movement Within the

Facility

Establish procedures for monitoring, managing and training all visitors, which should include:

• All visitors should perform frequent hand hygiene and follow respiratory hygiene and cough etiquette precautions while in the facility, especially common areas.

• Passively screen visitors for symptoms of acute respiratory illness before entering the healthcare facility

• Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) advising visitors not to enter the facility when ill.

• Informing visitors about appropriate PPE use according to current facility visitor policy

• May consider active screening of visitors before entry: triage station with symptom checks

All visitors to the School of Dentistry are prohibited until further notice. Patients may only be accompanied by support people who are absolutely essential to the completion of their visit.

All others are not permitted to enter the building.

Daily Health Self Assessment

All personnel, including faculty, staff, and students, must self-assess their health daily before reporting to the School of Dentistry. You should say “No” to all the following questions:

• Fever >100.00 F• Cough• Sore throat• Shortness of breath• Flu-like symptoms• Contact with a COVID19+ person in past 14

days? • International travel history in the past 2

weeks? If “Yes”, was it to or from: China, Iran, Italy, Japan, or South Korea? If none of these countries, treat answer as “No”.

If you may be ill or may transmit a communicable disease, or if your temperature is >100.0◦ F, you must not come to the School but must report in sick. You should complete the Catalyst survey to determine whether COVID-19 testing is appropriate at https://redcap.iths.org/surveys/?s=CD3DAFE8XD

What If You Feel Ill?

• I am a student and I do not feel well. What should I do?

• First, stay home. You may call Hall Health to speak to someone and discuss your symptoms. Do not come to the Hall Health Clinic if you are not feeling well. Call for advice. https://wellbeing.uw.edu/unit/hall-health/

• I am an employee (faculty, staff) and I do not feel well. What should I do?

• First, stay home. You should call your primary care provider to discuss your symptoms and receive advice. Alternatively, you are welcome to call the UW Medicine Coronavirus Information Line for advice: (206) 520-2285.

• My partner has a fever and cough. What should I do?• Stay home. Call your primary care provider, virtual clinic, or equivalent to find out whether

self-quarantine is required. Until you are advised otherwise, you and your partner should remain isolated from others for 14 days.

• You and your partner should not share a room if possible, and you should employ careful surface cleaning and decontamination with an antimicrobial solution.

• Monitor your own health for any symptoms on the screening list and your temperature. If you become symptomatic, begin this same protocol again.

• Home care details from the CDC are at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html#precautions. Home cleaning and disinfection details are available from the CDC at: https://www.cdc.gov/coronavirus/2019-ncov/community/home/cleaning-disinfection.html#isolated

How can I get questions answered?

The UWSOD dean has convened a COVID-19 task force to advise him and help to craft and update this policy. The members of the task force are:

Dr. Sara Gordon

Dr. E. Ricardo Schwedhelm

Dr. Mark Drangsholt

Dr. Rolf Christensen

Dr. Sue Coldwell

Dr. Mihwa Kim

Ms. Sandy Phillips

You are welcome to address questions to any member of the task force or directly to the dean. You can also send them to sodcovid19@uw.edu

Resources

• CDC Website, updated 10 March 2020• https://www.cdc.gov/coronavirus/2019-ncov/infection-

control/control-recommendations.html

• Johns Hopkins University• https://coronavirus.jhu.edu/map.html

• Mercer Island teen website that has educated the world!• https://ncov2019.live/

• University of Washington Coronavirus Information• https://www.washington.edu/coronavirus/

• UW Medicine Coronavirus Information• https://www.uwmedicine.org/coronavirus

• Recommended practices for terminal cleaning of rooms and PPE to be worn by environmental services personnel: Healthcare Infection Prevention and Control FAQs for COVID-19• https://www.cdc.gov/coronavirus/2019-ncov/infection-

control/infection-prevention-control-faq.html

• How coronavirus highjacks your cells—NY Times• https://www.nytimes.com/interactive/2020/03/11/science/ho

w-coronavirus-hijacks-your-cells.html

Appendix:Cough Etiquette

Let’s help everyone stay safe and healthy in 2020!Andy Watts/racingfotos.com/Shutterstock