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COVID-19 Management in the Ortho Practice: FAQ

You Asked. We answered.  Below find answers from the “Coronavirus Management in the Ortho Practice,” by Jackie Dorst, webinar questions. From Personal Protective Equipment (PPE) protocols to aerosol questions, we’ve got you covered. 

AEROSOLS | PERSONAL PROTECTIVE EQUIPMENT (PPE) | PATIENT HEALTH | OTHER

COVID-19 GENERAL

Why are we seeing such a massive response to this virus when we did not see anywhere near this level of response to H1N1 10 years ago, which was a much more severe illness?

H1N1 was geographically contained.  SARS-CoV-2 is much higher infectivity.

Is the fatality rate from influenza higher than with Coronavirus?     

Numbers yes, percent no. The total will depend on the number of infected patients. It’s increasing daily.

Can you get Covid-19 more than once? Since the level 3 mask is not airtight, if we can get the virus more than once, is it responsible for us to be seeing patients since we can spread it to patients?

It’s possible. Check with your State Dental Board.

 

AEROSOLS

After debond how long is aerosol in the air?      

Aerosol suspension depends on room airflow, particle size . It could be 45 minutes to several hours.

How are we at a lower risk category than those types of dental offices?              

Orthodontists normally sees a larger number of patients, but orthodontic procedures create less aerosols than dental procedures.

If we continue to see patients now, should we completely avoid any aerosols with debondings and bondings? 

Reducing aerosols as much as possible is a wise precation.

How long does the droplets stay in the air?  How long is the virus in aerosol status?

Not known exactly. Speculation is 45 minutes to several hours.

I’ve read that aerosols can remain airborne for 3 hours, and that patients should be scheduled an hour apart after a procedure that creates aerosols if using the same room. Can you comment on this?

It depends on the volume of contamination with the procedure.  And the air exchanges per hour in your facility.

HAND WASHING

If you have a choice which is preferred – soap and water or alcohol-based hand cleaners?

Depends on contamination.  Both should be available.

With the shortage of hand sanitizer, can we make our own with aloe and isopropyl?

No, use soap and water if you do not have ABHR.

My assistants only want to use the antimicrobial soap only. Can I tell them they must also wash their hands?    Do you mean ABHR? 

Soap and water wash should be performed after every 10 applications of ABHR and whenever hands are soiled.

PATIENT HEALTH

How long after having become infected is the patient safe to be seen.  

14 days.

I’m hearing recommendations to have patients use mouthwash before being seen. Is this beneficial? If so, which kind(s) of mouthwash do you recommend?

Not an evidence-based recommendation – However, not harmful and can reduce the oral microflora – chlorohexdine.

How long does a patient positive for coronavirus remains contagious after the disease?              

Possible 14 days estimate at this time.

Are infected patients that are asymptomatic contagious?

Possible.

Do the people that became in contact with somebody who had traveled to high-risk countries but has not developed symptoms yet, need to self-isolate? Should we see them at the office?

No.

The contagious period…. is that from the time of fever or exposure?

Time of exposure through 14 days.

What did you say the fever threshold was in degrees?

100.4.

Should we really be asking about travel at this point? It is HERE. I think we need to be asking about domestic travel.

You are correct, ask about all air travel.

Are patients contagious even if they have no symptoms? If so, when can we be confident to treat pts while creating aerosols?           

Yes, people have tested positive who do not have symptoms of fever, cough, shortness of breath.

How effective is to measure the temperature to the patients arriving to the office?

It’s an indication of infectivity, not a guarantee of non-infectivity.

Would you recommend any specific mouthwash for patients to use prior to their appointment?

Chlorohexidene is an antimicrobial mouth rinse.

What should existing COVID 19 aligner patients do with their current aligner?  Does it pose a risk of reinfecting them?  If they stop aligners until they are healthy, there is a good chance that there will be relapse.

I suggest making a new aligner and deliver in a “Drive By.”

PERSONAL PROTECTIVE EQUIPMENT

Are level 3 surgical masks sufficient to protect against aerosolized coronavirus?  If not, do we need to use N95s?

N95 respirator used for treating SARS-CoV-2 infected patients. Treatment only for emergency procedures.

Is a white clinic jacket for the doctor acceptable versus a close collared high neck jacket?

The open neck area on traditional white medical doctor exam jacket does not provide adequate protection for oral aerosols.

Do we need to change our mask with each patient?

Yes. One mask per patient has been the CDC Guidelines – Standard Precautions since 2003. FDA mask approval is single-use.

If unable to get Level 3 masks- should we be treating patients at all?

If you don’t have masks, then you don’t treat patients.

What PPE are we to use for all our patients now? Even for those that appear asymptomatic Face shield? Level 2 masks? Gowns?

I recommend Level 2 mask for procedures with splatter, splash and aerosols.

Do we need N95 masks when we go back to work if we are creating aerosols?

It’s not necessary for orthodontic treatment of asymptomatic patients.

What do you do if you can’t get these Level 1, 2, or 3 masks?

Don’t treat patients if you do not have a mask.  For emergency patient care – call other professionals and the hospital. Routine ortho care can be delayed.

Where do we get these high filtration masks you speak of?

Dental/medical suppliers.

Most suppliers are out of masks. Will go through our supply very quickly when/if offices reopen. Options then?

Manufacturers are working around the clock – supplies will increase.

Please define the types of masks recommended to protect from aerosol generated from high speed handpiece use.               

If the handpiece uses water as coolant – Level 3.

Can you double a level 1 mask if higher levels are not available?             

No.

Is there a difference between the N95 mask vs. N95 respirator?

https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf

How do we get access to N95 facemasks?

Order from your dental supplier – however, there are no “fit tests kits” available at this time.  FDA & OSHA have temporarily suspended the fit test requirements.

Is it ok to have an open box of gloves out at each station?

I recommend open glove boxes stored out of the “contamination zone.”  Consider in a drawer.

Should we wear gloves when taking photos and or xrays?

Yes.

What is a level 3 mask?

https://www.crosstex.com/sites/default/files/public/educational-resources/products-literature/guide20to20face20mask20selection20and20use20-202017.pdf

Can a mask be re-used as long as it is not being pulled down to the chin between patients? I have heard that the same mask left in place could be used longer.

Are you asking can you use the same mask with multiple patients? No.

How do you feel about no gloves on keyboards or mice then wipe these down after each patient?

Very difficult to impossible to effectively clean keyboard keys unless the keyboard is “solid surface.”

We use level 2 masks. Should we now change to Level 3 across the board?

During normal orthodontic treatment a level 2 mask is adequate.

Do you have any resources for ordering masks these days? We are being limited by our vendors to 2-4 boxes per order (that’s per week at best). As you know, in orthodontics, we go through them at a much higher rate than 2-4 boxes per week.

No, supplies are low.  Masks supplies are priority for front line Health Care providers at hospitals at this time.

Why the objection to an 95 respirator if doctor can wear it?

N95 respirators are in short supply. All team members should wear an N95 when providing emergency treatment for an infected patient.

Which mask is efficient to filter coronavirus? Is FFP3 the only efficient one, and should it be changed after every patient?

FFP3 mask is a dust mask and does not provide fluid protection. Use an ASTM level 2 or 3 https://www.crosstex.com/sites/default/files/public/educational-resources/products-literature/guide20to20face20mask20selection20and20use20-202017.pdf

Can I do an extraoral exam (palpate TMJs) and then do the intraoral exam without changing gloves?

Yes.

You mentioned the importance of wearing a jacket or a gown when seeing patients. Would you recommend changing it in between patients?

Depends on the volume of contamination with the procedure.

So, if there is a shortage of all these cleaning products, thermometers, masks, etc., how are we expected to follow all these instructions and realistically be able to resume work in a couple of weeks?

If supplies are not available and the number of cases is great, then precautionary time could be extended. The purpose is to reduce the number of critically ill patients so that the hospitals can take care of those patients and not be overwhelmed.

We usually change gowns between each patient. Is it ok to keep same disposable gown?           

It depends on the volume of contamination with the procedure.

What are the risks of keeping the same mask on while treating different patients, as long as the mask is not removed?          

When the mask stays on for a long time, moisture accumulates on the inside. A wet mask does not provide protection. Microorganisms and fluid pass through a wet mask.

WAITING ROOMS

What to do about cloth-covered chairs inpatient waiting area? We had a patient’s parent ask us to remove those chairs today, which we did, but could they be sanitized by spraying with Lysol

No.

How often should we be wiping down the office if we aren’t seeing patients, but 3 staff members are here?

If no traffic through the office, then at the beginning and end of the day.

 

OTHER

M11 autoclave – drain the water? Or leave water in?

Check with the Midmark instruction book – most sterilizer manufacturers recommend clean and drain. I’m creating a closure for an equipment-recommendation list with the help of a service tech. Ask your service tech if he/she has a checklist.

What do you recommend regarding patients who are waiting for their retainer delivery?           

Consider dropping of retainer as a “Drive By.” Hopefully, it fits and does not need adjustment.

What about leaving the AC fan on not auto?

Probably ok – check the air filters for cleanliness.

How necessary is it to update our private treatment rooms to negative pressure? Will this become the standard?

Not recommended at this time.

Does a pre-rinse of 1.5% hydrogen peroxide aid in decreasing viral counts/ make it safer to proceed with procedures?

Unknown – no evidence-based research.

If an emergency patient needs to be seen, what steps should we take before allowing them to be in the office (ex- questions to ask, temperature taking, etc.?)

Use the triage questions. Give them a mask and only take off mask for treatment and after treatment. Replace patients mask and escort the patient out of the office.

If you place shower cap on keyboard, is it then ok to cavicide that plastic surface in between patients?

No, disinfecting barriers is not acceptable.

Which 14 states do not use the CDC guidelines?              

Most of the 17 have a State specific IC standard such as California’s minimum Standard of IC or don’t cite a standard.

Is Optim33 effective against the coronavirus that causes COVID-19? How about Caviwipes?

Optim 33 has a longer wet contact time – use the Optim 1 – it’s one-minute Caviwipes look on the EPA site (look for the registration number).

Do you have the shower cap on the keyboards changed out between every single patient? Or if it’s just a simple adjustment with no aerosol, is it ok to wipe the plastic barrier/shower cap?

Changed between each patient which adds up to a lot of $ cost savings using a solid surface keyboard approved for disinfection and cleaning.

No fans–Is it advisable to keep windows open to help fresh air circulation or will this have the same effect as a fan spreading aerosol?

Possible – open windows introduce other contaminates.