The guidelines listed below are general recommendations for dental offices to consider as they design and implement their own protocols. Every practice is unique and their solution will be as well. We offer these guidelines for the initial phase of each practice’s “soft launch”. As we learn how to treat patients within our new circumstances, offices should expect to return to a full schedule.
Looking to the Future in Dentistry
The COVID virus has been extremely difficult for all of us. Beyond the devastation to people’s health and well being, dental offices are experiencing complete shutdowns in some places.
This will lead to poorer health over time since good oral hygiene is directly linked to better overall health.
As dentists, we need to prepare for a new “future” in dentistry for the time being. The proper time to reopen involves many factors.
- State regulations, practice location
- Outbreak significance in your area
- Emergency dentistry provided
- Dental team health
- Employee availability
All these factors need to be considered before the decision to reopen or “soft” reopen is made.
In the meantime, dental practices and dentists need to prepare for the new polices they will need to put into place to begin seeing patient’s again.
Here are 10 points to consider and implement to protect yourself, your team and your patients. Please share your thoughts and ideas to help others in the dental profession work toward a safe reopen process.
10 Points to Consider when Reopening Dental Office
- Patient Communication: Most Important Step. Explain how the use of Personal Protective Equipment (PPE) Works to every patient.
- Stagger Patients: Do not stack dental appointments – Ramp-up slowly. Only use chairs 1-3-5.
- Change Appointment Confirmation Style: Explain new safety policies over phone appointment confirmation calls. Ask if patient has any symptoms of fever.
- Modified Patient Check-In: Reception room is closed. Check-in is done over the phone. Patients wait to be called-in for an appointment once the previous patient is gone and sanitation is complete.
- Office Entry Restricted: Only patients may enter office for appointment. Spouses, friends caregivers and parents need to wait outside. They can assist patients to the front door and hand-off to Sanitization / Disinfection Technician.
- Remove Non-essential Items: Any non-clinical items should be stored. Dental display models, flyers, brochures, nightguard samples, implant displays, etc.
- Dental Supply Deliveries: All supply deliveries from package carriers or dental suppliers must be accepted outside and sanitized once in practice.
- Contain all Aerosol Spray: Use rubber dam to contain spray. Dental Hygienists should have an dental assistant help them and use a high volume ejector (HVE) for hygiene procedures.
- Sanitization Technician / Environmental Dental Assistant: A new dental position. A roaming dental assistant is most qualified for this new job. They are responsible for sanitizing all areas of concern.
- Take Patient Temperatures: Most difficult for dentists. You are not diagnosing or recommending medical steps to the patient based on temperature. You are simply protecting yourself, your team and your patients.
I just want to sincerely THANK YOU for this article brainstorming the steps necessary to soft open dental offices in this new age of Covid-19. Such information and discussion is desperately needed by the dental community. I am a RDH in NC. I have heard little to no discussion and the regulatory groups have been silent so far regarding needed changes in practice in order to reopen safely. Thank you again for recognizing the vital need for a clear plan and providing relevant and timely suggestions.Sophia
COVID-19 Communication in Dental Practices
This is a fluid and evolving situation. When these situations exist communication with your dental team and patients is the most important thing to constantly have.
Refining the process you use to reopen will be different for offices 5 to 1000 miles away. The ten steps above are a guide or “rough draft” to reference for reopening a dental practice.
Once you determine the proper steps that fit your practice the next phase is to try a “soft opening”.
“Soft-Opening” a Dental Practice
We have to start somewhere. Dental practices are not going to be closed forever. Protecting your patients is the most important thing. Protecting them from COVID-19 is essential.
Maintaining their oral health is also important. Using the following dental protocols can help you “soft open” or test how the new procedures can work for your practice.
Here is a PDF you can use to brief and review with your team before a soft-opening.
CLICK HERE – Dental Practice “Soft” Opening Recommendations
Urgent Patients Only
Defined as patients who require, in the treating dentist opinion, urgent care.
A dental procedure that was recommended a month or two ago will become urgent.
- Only see 5 hygiene patients per day (1 Patient every 90 minutes). Have a dental assistant assigned to High Volume Suction for the hygienist to eliminate aerosol spray.
- For dental procedures add an additional 20-30 minutes per patient, per procedure to help mitigate any contamination and allow for the best patient/team management
Guidelines for Practice
All employees will wear PPE.
This includes a mask, gown, gloves, face shield and shoe covering.
Patient & Employee Protocols:
All patients must be called prior to their office in order to inform them of the mandatory protocols
Dental Team Protocols for Office Visits
- Patients and/or their Parent/Guardian “Check-In” from their car upon arrival at the office
- The Patient and/or their Guardian/Parent will wait in the car until the office calls the patient into the office
- The patient (if a minor) will be escorted to the office door by the parent/guardian.
- Only the patient is allowed in the office
- The Parent/Guardian will “Hand-Off” their minor child to the dental auxiliary at the door
- Proper Patient protection will be at the door for the patient to put on before entering the office
- Protective gear, mask and gloves will be provided
- The temperature of every patient will be taken before they come into the office
Patient must be cleared by the Office Administrator to enter the Dental Office.
First Patient Interaction:
- A “greeter” (sterilization tech) from the office will escort the patient directly to the treatment area/chair (after hand sanitizer)
Patient Post Treatment:
- Upon completion of the dental service, the patient’s guardian/parent will be notified by phone to come to the front door.
- The Patient will use hand sanitizer when leaving the office (They use it twice; arrival and departure) if needed (they should be wearing gloves)
- The patient will be “Handed-off” to their parent/Guardian who is outside by the door and NOT in the office
- If a payment is required, the patient will be required to make the payment before leaving the office
- A follow up appointment will be given at the time of payment
End of Day: Dental Team Procedures
- Please remove disposable lab coat before you remove your gloves
- If desired, please bring a change of clothing to change into and properly store your garments in a plastic bag so you can wash when you return home
- After you dispose of you PPE please wash your hand with soap and water for at least 45 second
After each visit every place the patient goes will be wiped down with Cavicide or an equivalent surface disinfectant.
If a follow up appointment was not made please make an appointment over the phone while the patient or guardian/parent is in their car.
Reason to Soft-Open
Patients need care and the need for care will continue to increase as optional dental procedures become critical over time.
Dentists need to teach themselves and their team how to start treating patients in the new era of COVID-19.
There will no longer be a 100% safe certainty but every patient that enters your dental practice should be considered to be a COVID patient. This way your protocols and procedures protect everyone.
The same as the AIDS epidemic in the 1980s. When every patient that enters a dental office is treated like they have the virus team members follow procedures to protect themselves.
As Doctors and healthcare professionals, dental offices are the most prepared to keep patients safe and reopen. They already have been following Federal and State infection controls procedures for decades.
The reason to “soft open” is to help patients and find out which safety protocols work for you and your team.
Thank you for all you’re doing!! I’m feeling more comfortable returning to work. Take care!!! I will definitely reach out if I have any additional questions. Thank you!Jeanne F. – Dental Assistant
How to Soft Open with Dr. Balanoff
Clinical Questions Review
Addressing the clinical safety in Dentistry
Addressing the clinical safety concerns of reopening or “soft” reopening is key for all dental professionals.
Dental professionals have brought a number of excellent comments and suggestions that we want to share and dive deeper into.
How small offices can cope with additional clinical hygiene recommendations?
Using an High Volume Evacuator (HVE) is not something commonly used in hygiene. In fact, it is nearly impossible for a dental hygienist to properly use an HVE while performing.
Using an HVE is a recommendation that will most likely become a requirement in the new COVID era.
There are two methods smaller dental practices can use to overcome the additional burden this new technique will cause.
- Adding a roaming dental assistant to assist hygienist during HVE treatments
- Staggering appointments and adding time to appointments allows time for a dental assistant to roam.
How & should we use gowns?
Gowns are recommended for all clinical team members. This provides an additional layer of PPE.
These should be changed out and reused properly. The best way to think of gown use is in an operating room setting.
When hygienists treat patients a gown should be used. When a hygiene check needs to be completed by the doctor the hygienist should do the following.
- Remove the gown and leave the gown in the room. Gown should not be worn in common areas (common area)
- Gowns can be reused when working on the same patient.
- Doctors should switch gowns when moving between operatories
- Once treatments and procedures are done gowns should be discarded
Treating operatories as operating rooms is recommended.
Establish common areas where PPE and gowns are not used. If additional rooms are available, a lunch room or storage room, it is recommended these can be used as a common COVID clean.
Hallways, reception rooms and similar sections of a dental office should be considered common areas.
Using & reusing a Face-shield & Masks
Dental face-shields should be used for all dental treatments. This includes hygiene and routine examinations.
Face-shields are a reusable if disinfected. Wiping down with medical grade disinfectant will effectively clean the shield.
CaviCide and other disinfectants will cause shields to be cloudy. Use soap and water after disinfecting.
By using a face-shield, masks can also be reused. The primary use of masks is to protect others (patients) from getting infected by the wearer.
Early indications show COVID-19 is a heavy virus and when combined with heavier aersol spray settles quickly on countertops and surface areas.
Viruses tend not to linger in the air for long periods of time when combined with other materials.
Air Purification & HEPA Filters
Numerous dental suppliers and dental practices area advising and even inferring the air purification systems are required.
Air purification systems are not required at this time in dentistry. While they provide a higher perceived level of safety, real safety only exists between the patient and the team member.
PPE provides the best level of protection. Air purification systems would never be used alone without PPE.
PPE is the defensive measure to use and rely on when it comes to disease transmission.
Air filtration systems are good but they do not provide direct safety.
The recommendation is dentistry can be performed without them as long as direct protection methods are being used.
Use of Rubber Dam & Benefits
The use of a rubber dam or dental dam is a highly recommended technique to use for all dental procedures.
Dams provide a higher level of protection for patients, dental teams and the dentist.
Utilizing a rubber dam can be tricky at first. Once mastered it can be a PPE preventative tool that reduces aerosol spray and contamination.
A question dentists have is, “can they use dental dams during crown and bridge procedures?”. The answer is Yes.
Here are the steps:
- A Rubber Dam allows for Tooth isolation.
- You can prep the tooth / teeth to 1 mm above the desired finish line.
- Rubber Dam allows for 90% of preparation
- Remove rubber dam
- Complete final preparation to the desired finish line
This may seem like more dentistry than is required (and it is) but with COVID holding us back we need to ensure safety for everyone.
The use of a dental dam will also help improve your overall dentistry.
Extending Appointment Times
This is a “soft” opening or pre-opening safety strategy. New protocols and methods need to be tried out and perfected.
Beyond that, the entire dental team, especially those communicating with patients, need to understand the additional safety measures so they can confidently explain those to patients.
The reason for extra time is to allow for more communication from everyone in your practice to your patients.
Making patients feel comfortable and safe will provide the avenue to start slowing opening a dental practice.
The additional time per appointment does not need to be long. Adding 10-15 minutes is plenty to allow for compassionate communication.
Inform as you perform. This includes contacting patients. Tell them all the things you’re doing to keep everyone safe.
Dental Reopen Q&A Video – Part 1
Types of Care – Emergency, Urgent & Routine
Government Agencies, Dentistry Boards and Dental Associations are doing their best to handle the COVID-19 outbreak.
Part of that is recommending dental practices only see emergency or urgent patients or neither depending on the local and state guidelines.
Dentistry is being broken down into three categories that can be very nebulous.
- Emergency Care
- Urgent Care
- Routine Care
We say nebulous because these types of care are not well defined and can overlap. For example, routine care like a hygiene cleaning can turn into urgent care when decay is found.
Attempting to define these types of care and furthering the discussion will help clarify what to do, not only during this crisis, but going forward.
This is very common in dentistry. Offices and Doctors were already seeing emergency patients long before COVID-19.
Emergency care is generally defined as a necessary procedure to eliminate patient pain or suffering.
Emergency Care typically includes:
- Broken Tooth / Teeth
- Severe Jaw or TMJ pain
- Inter-oral bleeding
A majority of dental practices never completely closed because they are responsible to handle their patients’ emergency care.
Precisely defining urgent care can vary from doctor to doctor. Most agree however that a prolonged closure of dental practices will lead to more urgent care.
Dental offices should consider contacting and scheduling active treatment patients to avoid potentially harmful outcomes from lack of care.
General definitions to follow when determining if urgent care is needed include:
- Patients in active care
- Wearing temps
- Occlusal adjustments
- Treating active disease
- Treating Active Orthodontic Patients
Without treatment urgent care will become emergency care and will cause irreversible harm.
Decay and periodontal disease, along with other pathosis, are usually discovered and diagnosed during routine care. Patients have an urgent need to treat the disease.
Delaying urgent care will cause the treatment to be more complex and expensive.
Routine care provided by dentistry is truly amazing.
Dentists work constantly to put themselves out of business by providing preventative oral health initiatives.
This prevention is achieved through the routine preventative care and hygiene visits patients receive 2-4 times per year.
Routine care commonly includes:
- Polishing Teeth
- Retainer Check-ups
- Annual Check-ups
- Annual Radiographs
These treatments provide dentists and hygienists the opportunity to prevent patients from needing urgent or emergency care.
Without routine care, urgent care cases will increase as patients oral health declines.
The solution is a reopening for emergency, urgent and routine care for dental and hygiene patients using the COVID strategies outlined in this article.
To soft-open your hygiene department staggered appointments are recommended.
How to Stagger Hygiene Appointments
How to stagger patients is the most common question from dental professionals.
Block scheduling is common in dentistry. Offices schedule all appointments and operational hours to coincide.
This will need to change for the COVID crisis. Staggered scheduling of dental team members and patients will help avoid excess contact between people.
This should be done using a slow and continuously improving process that allows for correction and modification to fit your practice’s safety and operational needs.
Steps & tips for staggering appointments.
- Vary Hygienist Working Hours. Breaks and Lunches are taken separately. For example: 8-2 | 9-3 | 10-4
- Patient Appointment scheduling. 20-30 minutes separation between patients per hygienist. For example appoint hygiene at:
- Hygienist 1 – 8:20
- Hygienist 2 – 8:50
- Hygienist 3 – 9:20
- Block-out additional time to cover overages and communication delays. Especially important during soft open. See patients every 1.5 hours.
This process goes against everything talked about in normal dental practice management, but these are not normal times.
Patient care, team safety and practice survival demand a new approach to dentistry.
Something that was commonly used in dentistry is seeing resurgence: Pre-treatment rinse.
Pre-Treatment Rinse – H2O2
Gaining popularity in implant and surgical dentistry before the COVID outbreak was the use of a pre-treatment rinse.
Patients would use a mouth rinse which attempted to kill bacteria in the patients’ mouth.
The COVID outbreak has seen an increase in this technique and it is recommended.
Some reports show that rinsing with a hydrogen peroxide (H2O2) can reduce or eliminate the COVID-19 virus. These reports are not proof and more research is recommended.
You don’t want to make any claims that it will protect patients and team members 100%, nevertheless it is helpful.
The reason to use an H2O2 rinse is that it will potentially kill COVID-19 in the mouth and is very low risk to patients.
This added protocol makes for a great addition to your patient appointments and provides another layer of protection for everyone.
Surface Disinfectants & COVID-19
What is safe? What works? Who knows the answers?
The tough answer is we are not 100% sure and scientific studies have not proven what works yet.
In cases like this medical and dental professionals rely on what has worked.
While extremely caustic chemicals can kill everything they do not have a practical use in operatories.
Chemicals like chlorine bleach will damage equipment and PPE.
A commonly used medical grade disinfectant called CaviCide has shown remarkable success in combating viruses for years.
CaviCide has been shown as an effective deterrent for use against the SARS virus.
Since SARS is a member of the coronavirus family just like COVID-19, as Doctors and healthcare professionals, we are going to use what has historically worked until current or other methods are proven.
Additionally in the news Lysol and other disinfectant sprays have been reported to work.
The recommendation is to use what has been used traditionally and what has worked. Infection control is nothing new in dentistry.
This is another version of coronavirus dental and medical professionals have had to deal with.
Open Operatory Settings
Unlike medical practices, dental office construction began designing open bay practice layouts.
Operatories were no longer separated into individual rooms. Cabinetry became the divider and does not completely separate treatment rooms.
The short term solution for this is to purchase and hang a “drop-cloth” type of plastic barrier. Home stores will typically sell this in the paint department.
Use fasteners and tape to install the barrier around the open area where cross-contamination can occur.
The plastic visqueen barrier should be used to separate clinical treatment areas. This is an additional step to make your practice safer.
Front Desk Barriers
Protecting your entire staff is important of course, and this includes the admins at the front.
Face to face Administrator interaction should be limited or non-existent.
Taking information and accepting payment should be done over the phone or electronically (email).
The reception room is closed. Patients will wait in their car until the clean and disinfected operatory is ready.
Admins can then call to request the patient come in the practice for their appointment.
When patients enter the office they should be greeted by the disinfection control dental assistant or hygienist and taken back to the clinical room.
When greeted patients should wash their hands and have a mask on.
Re-appointments should be done in the operatory, not in open common areas.
If interaction must take place then physical barriers, like tables or chairs, should be placed to ensure 6′ of separation. Patients should also be wearing their mask at this point.
All exchanges of payment should be sanitized with disinfectant spray.
Dental Reopen Q&A Video – Part 2
Phased Dental Business Plan to Reopen
Strategies to consider for practice survival. Dental offices need to focus on preservation mode.
Dentists and dental practices need to focus on economic survival during COVID-19. Increasing revenue, getting new patients and profits should take a back seat for the time being.
Focus on the business portion of your practice.
Additional Equipment vs Additional Time
Dramatic and expensive changes to current equipment is not necessary.
Dental offices can use the same protective equipment and machinery they have always used. The increase in equipment cost will come from using more of the PPE already in use.
This cost will be negligible compared to the cost in time and labor. Time cost will be difficult to actually pin down at first.
Time / Labor Cost
Learning your new time and labor cost need to be figured out during the soft opening. Estimating an additional 10 minutes per procedure is a good number to start with.
During the soft opening and over the next 30 days closely monitor your time. Do not rush patients or staff. Be patient with everyone and discover the real time costs.
Initial Dental business plan over the next few months:
Phase 1 (1-2 months): Soft open.
- Start seeing urgent care patients. As a Doctor you decide who are urgent care patients.
- Stay current about new safety processes. Evaluate new time constraints and scheduling challenges.
- Get team members back to work slowly and safely.
- Stagger overdue routine care appointments.
- Continually research and seek out any funds available for small businesses “PPP”, State and Local Funds.
- Contact vendors for payment relief and better terms.
Phase 2 (2-3 months): Soft to Medium open
- Use Morning huddles & End of Day Debriefs to refine protocols that fit your patients and team’s needs.
- Put what you learned in Phase 1 into action.
- Increase workload methodically.
- Begin adding routine care to avoid an increase in urgent care cases.
Phase Phase 3 (3-6 months): New Normal
- Continue to evaluate your new costs for time & equipment.
- Increase fees and start billing out accordingly.
- The business goal is to cover some or all of the overhead.
- These reopen phased recommendations will vary by region and by practice.
- No two dental offices are the same.
Provide Care | Limit Costs | Find Money
For the next couple of months dental practices need to be in preservation mode. Preserving your patient base, dental team and the future of your practice is first in mind.
Preservation mode bifurcates into three business categories.
- Provide Care
- Limit Expenses
- Find Money
Following these three parameters will help you preserve your practice.
Patients need to be seen. An escalation of declining oral health is already occurring. Routine care will turn into urgent care which turns into emergency care.
Providing safe care will ensure your practice will maintain its patient base. Patients are scared. Patients may not want to come in.
The most important aspect of care now is communicating all the safe measures you put in place to protect them.
Expenses will have to be modified. Labor costs should be adjusted to fit your needs.
Recommendation other Dentists have suggested.
- Request relief from vendors. Ask for better terms. Patterson, Schein and others will delay or postpone payments to help you.
- Lower maintenance cost.
- Work with your landlord to limit rent expense.
- Postpone Advertising & Marketing spend.
- Doctors should reach out to patients directly.
Government funds are difficult to find but are available. The Paycheck Protection Program does work. We received funding and you can too.
Tips for accessing State & Federal Funds
- Be prepared – Get all your financials from your Accountant
- Do not rely on your accountant to file for funding. Do it yourself.
- Know your banker not your bank. Find a real bank rep you can contact.
- Add Government program links to all your devices so you are ready to submit.
- Have documentation in multiple forms to submit at a moment’s notice.
- Have access to completed forms on all devices.
The Government is completely overwhelmed and daily diligence will be required. Don’t wait for them.
While it is necessary to find all the revenue you can from the government, saving yourself and your practice using the soft reopen strategies is recommended.
It is truly amazing that grocery stores, fast food restaurants, hardware stores, coffee shops, etc. are open but dental offices, with trained infection control healthcare professionals, are being forced to close.
Dental offices are safe and have been safely treating patients with disease for decades.
Who has COVID-19 in Dentistry?
Introduction to the concept of “Everyone”.
One of the most important factors when providing safety is to assume that every patient is infected.
Not only with COVID, but with far more virulent diseases like HIV, Hepatitis or Tuberculosis.
This concept of “everyone has it” was used effectively in dental offices during the HIV/AIDS epidemic in the 1980s and is continuing to be used.
By thinking of disease this way all dental team members and patients are continuously conscious, careful and respectful of the new safety measures.