IHS Division of Oral Health COVID-19 Response Information

The IHS DOH does not recommend entering the re-opening phased approach until dental clinics have secured an adequate supply of PPE and are able to sustaining the adequate supply of PPE. The PPE must be in compliance with OSHA regulation and CDC recommendations.

Slow speed and rubber cup is considered an aerosol generating procedure. CDC recommends the following in this situation:

During aerosol-generating procedures conducted on patients assumed to be non-contagious, consider the use of an N95 respirator* or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators, if available. Respirators should be used in the context of a respiratory protection program, which includes medical evaluations, training, and fit testing. Of note, it is uncertain if respirators with exhalation valves provide source control. If a respirator is not available for an aerosol-generating procedure, use both a surgical mask and a full-face shield. Ensure that the mask is cleared by the US Food and Drug Administration (FDA) as a surgical mask external icon. Use the highest level of surgical mask. If a surgical mask and a full-face shield are not available, do not perform any aerosol-generating procedures.

CDC Guidance for Dental Settings:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html Exit Disclaimer: You Are Leaving www.ihs.gov 

N95 Extended use guidelines:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Regarding the processing of the N95’s: Here is a link to the fact sheets for Battelle. This process is FDA approved and could be considered by all DHCP.
https://www.battelle.org/inb/battelle-critical-care-decontamination-system-for-covid19 Exit Disclaimer: You Are Leaving www.ihs.gov 

CDC Decontamination and Reuse of Filtering Facepieces:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html Exit Disclaimer: You Are Leaving www.ihs.gov 

The IHS DOH recommends the dental clinics first contact their Area Office concerning fit testing. If the Area office is unable to offer this service, they may be able to recommend potential Fit Testing options nearby.

Regarding Fit Testing of masks:
OSHA requires employers to have employees fit tested for masks in situations where fit tested masks are required. All DHCP should be in contact with their employers to find out how to conduct fit testing since it is the responsibility of the employer under OSHA. Here is a link to OSHA respirator fit testing guidance:
https://www.osha.gov/video/respiratory_protection/fittesting_transcript.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Resources for Respiratory Protection Program
www.osha.gov/Publications/OSHA3767.pdf Exit Disclaimer: You Are Leaving www.ihs.gov 
www.cdc.gov/niosh/topics/respirators/default.html Exit Disclaimer: You Are Leaving www.ihs.gov 
https://www.youtube.com/watch?v=6qkXV4kmp7c Exit Disclaimer: You Are Leaving www.ihs.gov 
https://www.osha.gov/Publications/OSHA3789info.pdf Exit Disclaimer: You Are Leaving www.ihs.gov 

American Association of Occupational Health Nurses offers Respiratory Protection Program Training and Resources: http://aaohn.org/respiratory-protection Exit Disclaimer: You Are Leaving www.ihs.gov 

There are no known studies to confirm that wearing a surgical mask outside the N95 will help prolong its usability. Note however that this may affect the breathability dental of the mask and the previous results of the N95 fit test.

NIOSH recommends:

If extended use of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination (e.g., use of barriers to prevent droplet spray contamination)

Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission after donning:

• Discard N95 respirators following use during aerosol generating procedures.
• Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
• Discard N95 respirators following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.
• Consider use of a cleanable face shield (preferred3) over an N95 respirator and/or other steps (e.g., masking patients, use of engineering controls) to reduce surface contamination.
• Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit). Extended use alone is unlikely to degrade respiratory protection. However, healthcare facilities should develop clearly written procedures to advise staff to:
• Discard any respirator that is obviously damaged or becomes hard to breathe through.

The IHS DOH does not recommend entering the re-opening phased approach until dental clinics have secured an adequate supply of PPE and are able to sustaining the adequate supply of PPE. The PPE must be in compliance with OSHA regulation and CDC recommendations

Link to guidelines for extended use of N95: Strategies for Optimizing the Supply of N95 Respirators

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html Exit Disclaimer: You Are Leaving www.ihs.gov 

"When practicing extended use of N95 respirators, the maximum recommended extended use period is 8–12 hours. Respirators should not be worn for multiple work shifts and should not be reused after extended use. N95 respirators should be removed (doffed) and discarded before activities such as meals and restroom breaks."

https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html Exit Disclaimer: You Are Leaving www.ihs.gov 
As the provided link notes:

Follow the employer’s maximum number of donnings (or up to five if the manufacturer does not provide a recommendation) and recommended inspection procedures.

https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Slide #21 of the presentation “Re-Opening Dental Clinics & Infection Control Issues" was used as a sample of an IFU given by a manufacturer pre COVID-19 pandemic. During COVID-19 pandemic, an N95 mask should be used for aerosol generating procedures, otherwise a level 3 mask should be used, because endodontic procedures often involve a restorative component.
Follow manufacture IFU for mask limitations and uses.

The level of isolation gown used should be in accordance with OSHA standards. The types of PPE required during a COVID-19 outbreak will be based on the risk of being infected with SARS-CoV-2 while working and job tasks that may lead to exposure.

Several fluid-resistant and impermeable protective clothing options are available in the marketplace for HCP. These include isolation gowns and surgical gowns. When selecting the most appropriate protective clothing, employers should consider all of the available information on recommended protective clothing, including the potential limitations. Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19. In times of gown shortages, surgical gowns should be prioritized for surgical and other sterile procedures. Current U.S. guidelines do not require use of gowns that conform to any standards.

Information on isolation gowns:
https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/medical-gowns Exit Disclaimer: You Are Leaving www.ihs.gov 

The table reviews the gown levels.
https://www.cdc.gov/niosh/npptl/topics/protectiveclothing/#table3 Exit Disclaimer: You Are Leaving www.ihs.gov 

Current CDC Guidance dictates:

Put on a clean isolation gown upon entry into 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. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. There is no guidance for donning a used gown. It is recommended that a new gown is used for each patient.

Ref:https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE Exit Disclaimer: You Are Leaving www.ihs.gov 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Even with implementation of a comprehensive screening of our dental patient’s it is not possible to know if someone is truly negative for SARS-CoV-2 on the day of their visit without point of care testing. CDC does warn of the limitations of POC testing. IHS DOH recommend Standard Precautions be used for all patients and transmission based precautions as indicated.

Ref: https://www.cdc.gov/infectioncontrol/guidelines/isolation/recommendations.html Exit Disclaimer: You Are Leaving www.ihs.gov 

IV.B.1.c. Before leaving the patient’s room or cubicle, remove and discard PPE.18, 739 Category IB/IB
IV.B.3.b. Do not reuse gowns, even for repeated contacts with the same patient. Category II
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Exit Disclaimer: You Are Leaving www.ihs.gov 

For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g., a few minutes), any risk to HCP and subsequent patients likely dissipates over a matter of minutes. However, for a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.

For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by the airborne route (e.g., measles, tuberculosis) and to restrict HCP and patients without PPE from entering the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. General guidance on clearance rates under differing ventilation conditions is available.

In addition to ensuring sufficient time for enough air changes to remove potentially infectious particles, HCP should clean and disinfect environmental surfaces and shared equipment before the room is used for another patient.

Anything disposable should be discarded after each patient or disinfected according to the manufacturer’s instructions. If there are no instructions for disinfection, it should be discarded.

Standard precautions PPE required.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed.

Current CDC interim guidance for Dental Setting the CDC interim guidelines recommends states that a full face shield or goggles should be worn for all procedures.

Currently the CDC does not list Head and Shoe covering in their recommendations for using PPE. The IHS DOH national infection control committee, however does recommend head and shoe coverings during aerosol producing procedures. It is also recommend that they are removed before leaving treatment area.

OSHA
Engineering Controls Engineering controls involve isolating employees from workrelated hazards. In workplaces where they are appropriate, these types of controls reduce exposure to hazards without relying on worker behavior and can be the most cost-effective solution to implement. Engineering controls for SARS-CoV-2 include:

• Installing high-efficiency air filters.
• Increasing ventilation rates in the work environment.
• Installing physical barriers, such as clear plastic sneeze guards Installing a drive-through window for customer service.
• Specialized negative pressure ventilation in some settings, such as for aerosol generating procedures (e.g., airborne infection isolation rooms in healthcare settings and specialized autopsy suites in mortuary settings).

CDC
Design and install engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include:

• physical barriers or partitions to guide patients through triage areas
• curtains between patients in shared areas
• air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are properly installed and maintained

IHS DOH recommends consulting with your clinic’s/hospital’s facility engineers and environmental health officer in regards to air filtration, laminar air flow and airborne isolation rooms.

Engineering Controls

When urgent or emergency dental care is needed, use engineering controls to shield dentistry workers, patients, and visitors from potential exposure to SARS-CoV-2. This includes easily decontaminated physical barriers or partitions between patient treatment areas (e.g., curtains separating patients in semi-private areas).

If dental offices are equipped with the capability, use local exhaust ventilation to capture and remove mists or aerosols generated during dental care.

If possible, use directional airflow, such as from fans, to ensure that air moves through staff work areas before patient treatment areas—not the reverse. A qualified industrial hygienist, ventilation engineer, or other professionals can help ensure that ventilation removes, rather than creates, workplace hazards.
https://www.osha.gov/SLTC/covid-19/dentistry.html Exit Disclaimer: You Are Leaving www.ihs.gov 

Consider the use of a portable HEPA air filtration unit while the patient is actively undergoing, and immediately following, an aerosol-generating procedure.

• The use of these units will reduce particle count (including droplets) in the room and will reduce the amount of turnover time, rather than just relying on the building HVAC system capacity.
• Place HEPA unit within vicinity of patient’s chair, but not behind DHCP. Ensure DHCP are not positioned between the unit and the patient’s mouth. Position the unit to ensure that it does not pull air into or past the breathing zone of the DHCP.

IHS DOH recommends consulting with your facility engineers and environmental health officer in regards to air cleaners.

The IHS DOH Interim re-opening guidance recommends the use of rubber dams, diligent four handed dentistry and use of HVE suction during dental procedures. Internal and external HVE systems may be of use in reducing aerosolizing procedures, but additional research is needed on this topic.
Effectiveness of Two Isolation Techniques Exit Disclaimer: You Are Leaving www.ihs.gov 

The IHS DOH Interim re-opening guidance recommends the use of rubber dams, diligent four handed dentistry and use of HVE suction during dental procedures. Internal and external HVE systems may be of use in reducing aerosolizing procedures, but additional research is needed on this topic.

All parts of the nitrous system that can be autoclaved should be. Follow manufactures Instructions for disinfecting and sterilizing.

To impede fear purchasing, IHS DOH recommends strictly following OSHA and CDC guidance. Any device that that is going to be purchased per OSHA and CDC guidance must be vetted and cleared by the FDA. All purchases with infection control and safety implications shall also be evaluated by the facility’s designated infection control officer (or infection control procurement committee) for concurrence to ensure efficacy, feasibility, and adherence to MIUs is achievable; particularly cleaning/disinfecting between patients and sterilization, where applicable and potential adverse impact to the health delivery system or processes. Clinical, quality, and organizational data should be readily available for use in product decision-making processes. Product decision processes should incorporate a focus on clinical, financial, and operational outcomes. A post-implementation review should be practiced to ensure success and to drive future facility implementation-as well as unforeseen potential impact on associated processes. FDA Continues to Combat Fraudulent COVID-19 Medical Products Exit Disclaimer: You Are Leaving www.ihs.gov 

Due to the quantity and variance of testing protocols and risks differences from area to area, DOH IHS recommend that clinics coordinate with their local clinics and area to determine proper policies and procedures related to the elapsed time between test results and proceeding with an aerosol generating procedure following strictly to OSHA and CDC guidance.

Depending on testing availability and how rapidly results are available, facilities can also consider implementing pre-admission or pre-procedure testing for COVID-19, which might inform implementation, especially in the situation of PPE shortages. Limitations of this approach should be considered, including negative results from patients during their incubation period who could become infectious later, and false negative tests depending on the test method used.

Ultrasonic Scaling should be considered in the clinics second or third phase of re-opening. Local service units and areas should determine when risk levels are low enough to resume the use of ultrasonic scaling. Dental hygienists have been listed by various sources as the profession that is at the highest risk for COVID-19.

The CDC continues to recommend the avoidance of aerosol-generating procedures whenever possible. IHS DOH National Infection Control Committee recommend avoiding patient involved OHI until phase 2 or phase 3 of the reopening of your dental clinic. OHI may be limited to models at this time.

There are currently no plans for an IHS consent form in regards to risk of receiving dental treatment and potentially contracting COVID-19. The current guidance from IHS counsel is that there is no need for separate COVID consent and that we should only ask the questions the CDC recommends as a screening tool that is documented in the note, no need for another form.