Infection Control: Re-Opening Dental Offices

Overview of the topics for re-opening dental offices

  • Infection Control during COVID19 and years past the pandemic
  • Soft Opening Steps and Details
  • May Schedule: ” Perfect Schedule in Not So Perfect World”

The goal of this training is to rethink high infection control measures, not just for COVID19. As oral healthcare professionals, we have survived AIDS, hepatitis, SARS, H1N1, and other epidemics that have affected our patients and potentially could have devastated our practices. Dentists will survive this present epidemic; doing so will require maintaining a standard of patient care at a high level.

Though it certainly has heightened awareness, the coronavirus (COVID-19) outbreak should not necessarily change dentists’ vigilance in following these protocols in their offices. What this devastating epidemic has done is forced dentists to reassess how they currently provide dental care. The OSHA guidelines will continue to be embraced while dentists will need to make some modifications to meet the challenges of a global pandemic.

To help our teams to understand that dental professionals had to apply the same infectious control steps as before the pandemic, but due to COVID19, we will take extra precautions in addition to our current infection control policies.

With a foundation based on past and emerging scientific evidence, and providing the proper protections and training for patients, team, and themselves, dentists can weather this storm together and proceed with their practice. Dental clinicians, including hygienists, are health professionals who are on the front lines of this battle, having extended, up-close contact with patients. As awful as the current environment may seem, dentistry’s challenge is no different than the risks faced in the past with the flu, H1N1, AIDS, SARS, and so on.

What have we done great during the pandemic?

     Qualities and building blocks of Nebraska Family Dentistry culture have been crucial during the crisis

Education, Science, and Exceptional Care have and will get us through this crisis and help us to remain healthy and well while being dental leaders in our community!

Kindness and Getting Used to the “New Normal”

Many patients, just like you, will have fear or concerns.  During this time of crisis, we have to remember to remain kind to patients and, even more importantly, to each other.

We Ask Each One of You To Be Kind to Each Other

Emergency Care In the Last 2 Months Has Prepared Us to Be Open and to Provide a Safe Environment:

  • Using N95 Masks 
  • Using  Face Shields
  • Disinfecting the Operatories 
  • Capturing aerosols/splatter
  • Pre-screening patients before they come into the office
  • Treating patients safely 
  • Following social distancing among team members

Great News About the Training of Dentists in Infection Control. Dental Offices Are Much Better Trained and Prepared than Most Other Healthcare Facilities to Handle Infectious Diseases

To date, in the United States, clusters of healthcare workers positive for COVID-19 have been identified in hospital settings and long-term care facilities. Still, no clusters have yet been reported in dental settings or personnel.

What about the medical team at the hospital? Do they get COVID-19 while performing aerosol producing procedures?

One study reviewed 40 Medical staff members that did an aerosolized surgery on a COVID-19 positive patient and NONE became positive for the virus

Why? They Used Proper PPE and Infection Control Protocols

What about the administrative team and their exposure?

In the study of the administrative team at the hospitals they found the viral particles are heavy and do not travel.  To keep the administrative team healthy, we have to follow universal guidelines on preventing cross-contamination from clinical areas to the business area.

The facts about COVID-19

This virus is a “new normal” for many dental and health professionals and is added permanently to the list of other infectious diseases. Medical and dental professionals have been trained to treat everyone as they have an infectious disease, including ourselves.  The best medical and dental practices have high infection control standards to keep them safe at all times, not just during the pandemic.  This specific virus is easily destroyed by heat, UV light, or even rubbing alcohol.  Applying high infection control standards, along with preventing aerosol/splatter, will keep us safe while we are at the office.

A word about social distancing and the outside world.

We can do excellent infection control measures and prevent the disease at our offices. We do not, unfortunately, have any control to help you to stay safe outside the office. 

Please be responsible and stay safe, healthy outside the office (Limit social gatherings)

High infection control standards: Our “New Normal” for Now and the Future

Only following infection control protocols coupled with the correct HVE use will lead to solid protection against pathogens in dentistry while at the office.

Below is our suggested workflow simulation from the moment patients confirm their appointment until they are dismissed.

Scheduling Principles

  • Scheduling practices will minimize the number of patients in the office.
  • Appointment blocks will be adjusted to allow for COVID-19 screening, increased PPE use, and proper infection control practices.
  • We will work to accommodate emergency patients, but this will not be at the expense of proper screening and infection control protocols.
  • We will give hygiene appointments extra time (RECALL/PM = 70 Min and SRP =110 Min) 
  • We have strategically placed Team Members at our offices to limit the total number of people at one location.
  • We want to avoid scheduling several patients per day and focus on scheduling fewer but with longer appointments, if possible.
  • We hope to avoid double-booking unless we have a patient that needs to get numb. 
  • The above suggestions may differ for each location and will depend on each location, number of providers, and hygiene patients at that office.

Pre Appointment Patient Pre-Screening Protocol

  • Screening questions should be asked while talking on the phone to patients to eliminate them coming in IF they are sick/have been exposed. 
  • COVID-19 consent forms will now be used with every patient.  They will need to be signed before being taken back.  See the consent form here.
  • Signs will be placed at the front desk instructing patients on standard recommendations for respiratory hygiene/cough etiquette and social distancing along with using hand sanitizer upon their arrival.  See it here
  • Prevent patients from bringing companions to their appointment, except for instances where the patient requires assistance—only the patient and parent of a guarantor. 
  • Temperatures will need to be taken on the patients as well as anyone that comes with them.  If greater than 100 degrees, we will need to reschedule for several weeks out.

Before Dental Care Starts

  • Check your own temperature in the morning and afternoon.
  • Please wipe your phone when arriving to the office.
  • Wash your hands as soon as you arrive at the office.
  • Remove magazines, reading materials, toys, and any non-essential furniture (other than chairs) that may be touched by others and which are not easily disinfected.
  • Arrange chairs to optimize social distancing.

During Dental Care: The Goal is to have the room clean and presentable to assure we create confidence among our patients when they look at the sink, floors, or light covers. Please spend the time checking for the cleanliness of the room to ensure the rooms look clean before each patient enters it. Infection control is essential, but having the room clean and picked up at all times is essential to gain confidence from our patients.

Just as before the pandemic and moving on, please look at the cleanliness of floors to avoid any alginate or trash on floors. Ensure the cleanliness of sinks and the trash is not overflowing. Assure that patient light is wiped and clean.

  • During treatment, hide blood and exchange your soiled gloves. We have plenty of gloves! 
  • Hide bloody gauze to create a better visual experience for patients and decrease the triggers for anxiety associated with dental treatments.
  • Hide needles to reduce general anxiety associated with dental treatment.
  • Patients will be more sensitive and excellent chair-side manners, while awareness of their experience is just as important during this time as before the pandemic. 
  • Treat yourself as you are infected and protect everyone around you.
  • Provide a preprocedural rinse of 1 -2%  peroxide to every patient/procedure.
  • Cover the chair arms with plastic wrap.
  • Avoid plastic tray and bur blocks to be out. Have only what you need out.
  • Avoid the combination of spraying non-critical surfaces along with using the Cavi wipe.  Simply use Cavi wipes instead to avoid bleaching out of non -critical areas.
  • Standard Precautions include Hand hygiene, use of PPE, respiratory hygiene/etiquette, sharps safety, safe injection practices, sterile instruments, and devices, clean and disinfect environmental surfaces.

Goal is To Prevent Cross Contamination

Let’s talk about taking PPE and how it can lead to cross-contamination even by taking off your mask. Please watch on taking PPE correctly.

Please watch the Video “If Saliva Were Red”

  • The goal is to prevent cross-contamination and avoid touching anything with dirty gloves. 
  • Take dirty gloves off to get what you need. 
  • Even to opening a drawer for cleaning supplies can be a source of cross-contamination.
  • Avoid touching your eyes, nose, or mouth with your hands at all cost, all day long ( unless you just washed them.)

Aerosols/ Splatter in Dentistry? Minimizing them

The concern of aerosols/splatter has been here way long before COVID-19, and the best thing for our wellness is to maintain protocols to prevent being exposed to any pathogens we may encounter. The goal is to catch aerosols/ splatter not just during COVID-19, but to get into the habits that will last for years after the COVID-19.

Check out the article: 10 Top Ways to Catch Aerosols/Splatter at our Offices

How to create a room with negative pressure at dental offices? Watch this video

How to handle aerosols without rooms with negative pressure at dental offices?


Conclusion of the article: The aerosols/splatter can be captured keeping medical/dental professionals healthy by combining PPE and universal infection control techniques only.

There is not one secure sure way to catch all aerosols without using PPE coupled with high infection control standards.

Practical Ways to Capture Aerosols/Splatter in Dentistry at every location if you can not use the room with negative pressure:

  • HVE- Needs to be opposite the high-speed spray (reduces aerosols up to 90%) and needs to be continuous
  • Hygiene Room: HVE adapters (Releaf for every procedure using ultrasonic)  plus Isolites. The best is to use Purevac HVE, but it is harder to use it. 
  • Rubber Dam
  • Pre-procedural rinse to reduce oral pathogens
  • 4-6 inches away from patient mouth: Stand-alone Air Purification Systems (IQAir air filtration system)
  • Using rooms with negative pressure if you have one available.

What is the Correct Use of HVE?

High-velocity evacuation, or HVE, used during all procedures, has made researchers aware of the potential effectiveness. HVE is effective in the control of aerosols when appropriately used. Some tests show a 95% reduction in aerosols with the use of HVE alone. Likewise, it is as effective when adjusted at optimal velocity and when positioned close to the operating site.

Reference: Aerosols and splatter in dentistry: A brief review of the literature and infection control implications STEPHEN K. HARREL and JOHN MOLINARI J Am Dent Assoc 2004;135;429-437

Hygiene procedures and aerosols

According to studies, HVE works only when used correctly. Consequently, it is easier to do so for dentists while working with a dental assistant. What about hygienists and collecting aerosols while they use ultrasonic instruments?

ReLeaf System or Isolite are forms of HVE.  Both do a great job of fluid management but don’t meet the requirement of having at least an 8mm bore opening for 95% aerosol management. 

Purevac HVE has a bore opening of 19.89mm. This is the better option to use for catching aerosols 95% of the time, but it is hard to use it, making it less efficient than the promised 95% rate of catching. Not every hygienist may like it. We will order only if you want one for sure.

Please watch videos that show that using HVE and Isolite can dramatically decrease the amount of aerosols/ splatter during hygiene procedures.

PPE we need to use for all aerosol producing procedures

  • N95 masks. Cover it with a surgical mask if you do not have a face shield. Store in a clean, protected brown paper bag (will be provided). Avoid storing in a plastic bag as it will create a moisture environment. 
  • Face Shields
  • Lab coats

Two layers of masks can make your body tired and can cause a headache due to the decreased airflow.  Pace yourself and know that it is common to feel more tired after working in two masks. Because of wearing N95 masks, we will not offer extra, extended hours to patients. All of the providers will be extra tired, and instead of working extra hours, we will try hard to work smarter by creating” Almost Perfect Schedule in A Non-Perfect World.”

Lab coats: We will use washable and reusable lab coats.

The goal in May will be to catch aerosol/ splatter up to 95-100% or even avoiding creating aerosol by doing hand scaling and minimizing cavitron as much as possible. Despite our plan, please wear lab coats to cover your arms and neck.

For non-aerosol procedures: Wear a surgical mask

Please wear a surgical mask all day long.

After Dental Care Is Provided In Between Patients

How to clean correctly: Please develop these habits for years to come, not just during the pandemic

For more steps and details on how to clean the room, to prevent cross-contamination and etc, refer to the full training module on Infection Control and Universal Precautions measures and our “new normal” for the years to come (coming soon.)

Please note: Do place items to sterilize on a tray and leave for 3 min all cords, primer, etch, adhesive, and anything that needs to be sterilized. Avoid just wiping, you have to disinfect all items for 3 minutes.

Post-operative Instructions for Patients

In light of the controversy regarding whether ibuprofen should be used for patients with a COVID-19 infection, it is recommended to use ibuprofen as normally indicated when managing any type of dental pain. For example, for the management of pulpal- and periapical-related dental pain and intraoral swelling in immunocompetent adults, it is recommended that NSAIDs in combination with acetaminophen (i.e. 400-600 milligrams ibuprofen plus 1,000 mg acetaminophen) can still be used.

Going Home After Work

  • Office attire should not be worn outside the office. 
  • Remove your lab coats along with your uniform, place them in a bag to take home to wash.  Shoes can also be removed and put in plastic bags.

Additional Notes and Answers to your CAQs:

Why to use consents for patients upon arrival instead of emailing them?

This form asks specific screening questions, and it provides two purposes:

This is a health questionnaire and consent to treatment at the same time. We have not had luck getting them back before their emergency care appointments. It is easier to have them ready for patients when they arrive at the office.

N95 masks: How to care for your N95

  • You may become more tired while wearing it.  
  • You need a fit test to ensure a tight fit for your face. 
  • Please always wear a surgical mask or face shield on top of it to keep it clean. 
  • The best is to prevent it from getting wet, and we need to avoid wearing makeup.
  • Store in a brown bag at the office (will be provided)
  • The “fit test” should be completed to assure your mask fits correctly

Face Shields: How to clean

  • Avoid using Windex.  It’s best to use water/soap between patients or alcohol wipes. COVID-19  is destroyed by rubbing alcohol.

Surgical mask: Stelizing and reusing

Due to the shortage, we can continue to reuse the same one if you’re directly just talking to patients. Please exchange it only if it gets soiled. Front desk-it is appropriate to use the same surgical mask all day long. Surgical masks can be autoclaved, and please use this option to keep them lasting longer.

More infection control training:

To solidify our new high control measures to remain in place after the pandemic, you can check any of those links.

Last Section of Orientation/Training Sessions: Scheduling guidelines:

Scheduling is the backbone of every successful dental practice. 

During this pandemic, we plan to apply the same principles in recreating the “Perfect Schedule In a Not So Perfect World.” Everyone on our team was in the habit of following the scheduling systems, and we will ask them to apply the same principles while recreating the new schedule. 

  • To confirm all appointments
  • To have solid financial discussions to avoid cancellations
  • To spend more time on financial discussions due to the financial burden many patients will be facing
  • To schedule operative patients for longer appointments. The goal is to limit the number of operative patients per day and to avoid many short appointments. By doing so, we can increase the amount of production per patient  
  • To allow more time for our hygienists during the first two weeks by adding additional time to their schedules
  • To follow block scheduling guidelines for the preferred procedures and timing for those procedures
  • Examples of colors can be found here and the example of the Perfect Scheduling here
  • Solid confirmations, avoiding no-shows and last-minute cancellations, collecting all co-pays the day of service, and scheduling longer operative appointments will be our goals for May.

What about the rescheduled hygiene patients due to the pandemic?

We are anticipating that some currently scheduled patients will likely choose to delay their appointment, creating openings for those who need to be rescheduled due to COVID-19. 

Every other dental practice will be experiencing the same demand for hygiene care. 

How do we plan to contact patients? We created a database with emails/cell phones for every patient that was rescheduled due to COVID-19.

Prior to contacting patients in the COVID-19 database, we will email confirmation reminders to our currently scheduled patients, informing them about our “Soft Opening” and limited schedule availability due to high demands. We will ask to confirm or let us know if they choose to wait. Here is the message to patients we will send out

  • Following receiving confirmation from scheduled patients in May, we will know available times to offer to COVID-19 rescheduled patients.  We will email them the online scheduling link offering to schedule. 
  • If we do not get a return on emails with offering to schedule online, we will call patients as the next step. 

Our goal will be to utilize online scheduling as much as possible to prevent overwhelming our scheduling coordinators. We also hope to avoid losing patients if we run out of time to contact them via phone. By directing our patients to utilize online scheduling, we believe we will succeed in handling the demands of the schedule for May.

What are our plans for scheduling hygiene patients after May?

Ultimately, not every patient will get their cleaning and may end up missing one. The majority of patients will understand. The goal is not to lose patients.  To overcome this problem, we will keep track of all patients and follow up with them regularly via emails and newsletters,  while continuing to offer online scheduling.

Conclusion of our meeting today:

Nebraska Family Dentistry Top Values  We ask everyone to remember our top values:

  • Empathy toward each other and patients, Teamwork and Compassionate Care and Being Kind 
  • Coming back and re-establishing our new normal may challenge us. We need to ask our teams to be kind, patient, and avoid gossiping.

Qualities and building blocks of our culture

Education, Science and Exceptional Care will guide us through this crisis and help us remain healthy and well, while being dental leaders in our community.

Thank you to each one of you for winning the Lincoln Journal Star Award and allowing us to carry ”Lincoln’s Best Dentist For 2020”

 Q: Comments and Question Session Q

Everyone on our team is super smart and please email us any needed changes or better ideas at nebraskafamilydentistry@gmail.com

Here is the after the opening survey for the infection control and safety of our teams we hope to accomplish. If you have any ideas or suggestions, please email at nebraskafamilydentistry@gmail.com

Area: Infection prevention policies and procedures specific for the dental setting during the COVID19 pandemic
Specific policies are available, current, and based on evidence-based guidelines by OSHA and CDC.
Yes or No

Area: All Necessary Supplies and PPE necessary for adherence to Standard

All necessary and appropriate PPE is available Yes or No

Supplies necessary for adherence to hand hygiene for routine dental procedures (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible. Yes or No

Hand Hygiene is Performed Correctly among all team members Yes or No

Personal Protective Equipment (PPE) is Used Correctly among all team members Yes or No

Teams have received adequate training on proper selection and use of PPE Yes or No

Area: Respiratory Hygiene/Cough Etiquette

Adequate training was provided to contain respiratory secretions in people who have signs and symptoms of a respiratory infection, beginning at the point of entry to the dental setting have been implemented. Yes or No

Area: Sterilization and Disinfection of Patient-Care Items and Devices

Team members responsible for reprocessing reusable dental instruments and devices are appropriately trained Yes or No

Cleaning, disinfection, and use of surface barriers are periodically monitored and evaluated to ensure that they are consistently and correctly performed Yes or No

Area: Environmental Infection Prevention and Control

Adequate training was provided for routine cleaning and disinfection of environmental surfaces (i.e., clinical contact and housekeeping) Yes or No

Area: Dental Unit Water Quality

Adequate training was provided to prevent cross-contamination from using water units. Yes or No

Area: Catching splatter/aerosols

Adequate training was provided about aerosols/splatter control Yes or No

Adequate systems installed for aerosols/ splatter control Yes or No

Area: Pre-screeening patients

The facility has a system for early detection and management of potentially infectious persons at initial points of the patient encounter Yes or No

The system of prescreening patients and identify high risks, rescheduling them in place is completed Yes or No

Area: Administrative team

All necessary steps to prevent cross-contamination from the clinical area to the administrative area have been done Yes or No

Necessary steps for keeping administrative steps have been established. Yes or No