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COVID-19 and Dental Care and Anxiety Slide Set

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COVID 19: Patient and Provider Challenges
July 29, 2020
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Disclosures
"This Program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,879,101 with 0 percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government."

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The presenters have no disclosures.

WELCOMEOral Health Resource Centerwww.necaaetc.org
Howard Lavigne
Oral Health Consultant
315-247-2998
[email protected]

Stephen Abel, DDS
Dental Director Consultant
716-829-2836
[email protected]

Laura O'Shea
Project Coordinator
315-477-8124
[email protected]

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Oral Health Preceptorships
Audience: Dentist, Dental Hygienists and Primary Care Clinicians

Venue:Multiple sites in NY & NJ (Virtual and In-person)
Duration:1 day to multiple days

CDE/CEU: Provided

Cost: None

Enroll:Send email to: [email protected]
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Today's Presenters
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Francine Cournos, MD
Co-PI, NECA AETC
Professor of Clinical Psychiatry
Columbia University
Gwen Cohen Brown, DDS, FAAOMP
Faculty, NECA AETC
Professor/Dental Hygiene
New York City College of Technology

Stephen Abel, DDS, MSD
Dental Director, NECA AETC
Associate Dean for Student,
Community and Professional Initiatives
University at Buffalo

Dental Care and COVID-19:Psychological Challenges Among Patients and Providers
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Francine Cournos, MD
Co-PI, NECA AETC
Professor of Clinical Psychiatry
Columbia University

Fear and dread to make or attend a dental appointment; anticipating the appointment poses a threat or danger.

Anticipatory anxiety is a frequently encountered problem in dental care and can result in avoidance of care.

The COVID-19 pandemic has made anticipatory anxiety more common, and it now involves both patients and dental practitioners.

Weeks or months of quarantine can lead to anxiety about leaving home for any reason.

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Prior to a Dental Visit: Anticipatory Anxiety
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The patient may not know what to expect:
The office is likely to be reorganized in accordance with safety concerns, such as wider spacing of chairs, lack of toys or magazines, etc.
The staff may look unfamiliar in their protective gear.
The patient is most likely assessing whether the dental office and its staff look safe (wearing masks, cleanliness, anxiety about previous patients, etc.)
The patient may feel at a loss to make an adequate safety assessment.

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Patient Anxiety During a Dental Visit
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Fear of becoming infected while caring for patients
Fear of bringing infection home to family members
Uncertainty about recommended procedures and the degree to which they make dental care safe
Worry about loss of income
Degree of autonomy about returning to work.
Health care providers are trained to act strong, and no one wants to admit they're struggling
In a crisis it feels important to help and be useful

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Psychological Factors Affecting Dental Practitioners in the COVID-19 Pandemic
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The unknown is frightening. Anticipatory anxiety is reduced by providing accurate information.
Explain the new dental procedures that are in place to protect patients from COVID-19:
When reaching out by phone
On your website
In the form of a printable fact sheet sent by email and/or mail
Where possible, include pictures of safety precautions
Explain who can accompany the patient to a visit
Explain the need to arrive wearing a mask

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Helping Patients with Anticipatory Anxiety
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Provide potential scripts for staff who answer the phone
Acknowledge that the patient's anxiety/worry/anger/irritation is understandable
Explain the new safety procedures that keep patients safe during dental care
Explain why dental care is important and/or essential
Acknowledge that no one can achieve 100% safety, not even by staying at home, but
By following all recommended protocols the office is confident that there's a high degree of safety.

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Helping Patients with Anticipatory Anxiety con't
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Have masks available for patients who arrive without one
All office staff should be wearing masks covering their noses and mouths for all tasks
The waiting room should allow patients to stay 6-feet apart from one another
Clarify the cleaning procedures between patients
Explain how easily the virus that causes COVID-19 is killed by cleaning agents
Clarify how dental staff monitor their own health to reduce the risk to patients

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Reducing Anxiety During a Dental Visit
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Continuously and calmly narrate the new procedures taking place:
We're pleased to see you have your mask on
We'll begin your visit by first.
You'll take off your mask when
We've just cleaned your dental chair with
We give you a rinse before the procedure because
You'll notice I change my mask when
I wear this face shield because.
We've made this procedure safer by..

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Reducing Anxiety During a Dental Visit con't
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Address catastrophic thinking and emphasize safety measures
This office is in many ways safer than your home because we
Here's where we store the protective gear, gowns and
We handle the clothes you arrive in and the clothes you go home in by
We reduce aerosols by
So far, we're reassured by
Here's what you can do to reduce any risk to your family members when you arrive home

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Reducing Anxiety among Dental Practitioners in the COVID-19 Pandemic
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Feelings of numbness, disbelief, anxiety or fear
Changes in appetite, energy, and activity levels
Difficulty concentrating
Difficulty sleeping or nightmares and upsetting thoughts and images
Physical reactions, such as headaches, body pain, stomach problems, and skin rashes
Anger or short temper
Increased use of alcohol, tobacco, or other drugs

CDC : https://www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiet...

We're All in This Together: Signs of Distress During the COVID-19 Pandemic
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Providers checking in on clients by virtual means has been very comforting and meaningful to patients
Clients and health care providers alike need to follow similar guidelines to stay well in the COVID-19 pandemic:
Implementing current COVID-19 precautions
Accepting that some anxiety about COVID-19 is normal
Seeking social support from household members and/or through virtual means
Creating and maintaining a regular routine
Getting enough sleep, preferably with set times for going to sleep and waking up

Health Care Providers Without Mental Health Training Are Playing A Major Role In The COVID-19 Pandemic

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Maintaining nutrition, preferably with healthy food
Engaging in pleasurable at-home activities, such as listening to music, exercising, meditating, etc.
Engaging in productive at-home activities, such as cleaning a closet, learning a new skill, etc.
Focusing attention on things for which we're grateful
Making the psychological space to grieve losses
Avoiding activities that cause distress, including excessive exposure to the news
Avoiding excessive use of alcohol, drugs, tobacco and caffeinated beverages

Review COVID-19 Guidelines with Your Patients and for Yourself
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Mental Distress

Can occur in response to any adversity, including the COVID-19 pandemic.

Often does not meet criteria for a psychiatric diagnosis or require specialized mental health interventions.

Often responds well to supportive strategies and positive lifestyle changes.
Mental Disorders

Usually cause either persistent severe subjective distress and/or functional impairment.

Meets recognized diagnostic criteria (ICD, DSM).

Calls for evidenced informed mental health interventions such as medication and psychotherapy.

Distinguish between Distress and Disorder
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Screening Calculators & Tools: The HIV National Curriculum: www.aidsetc.org/nhc
You Can Screen to Determine Who Needs a Referral to a Behavioral Health Provider
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Practical Guidance for a Dental Visit in the COVID-19 Era
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Gwen Cohen Brown, DDS, FAAOMP
Faculty, NECA AETC
Professor/Dental Hygiene
New York City College of Technology

Evidence Based Guidelines and National Standards - CDC/ADA/ADHA/OSAP
CDC Guidance
CDC Guidance Infection Control Dental (2003)
Basic Expectations for Safe Care (2016)
CDC Guidance Sterilization (2008)
COVID-19:Interim Guidance for Dental Settings
Updated June 17, 2020
American Dental Association Return to Work Toolkit June 9, 2020
Aligned with CDC
American Dental Hygienists Association Task Force on Return to Work
https://www.adha.org/covid19
OSAP
Up to date links to consensus documents from all relevant organizations
https://www.osap.org/page/COVID-19

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Prior to Opening the Dental Office
Reopening involves many factors.
State regulations, practice location (NYS Dentists were allowed to open June 1, 2020, but they must follow the ADA Interim Guidelines)
Outbreak significance in your area if the curve is still going up it may not be the time to open fully.
Emergency dentistry provided how, when and by whom. What is considered an emergency, when should a patient be referred to a hospital for treatment.
Dental team health Have you reviewed your own teams health and their records, including flu shots, Covid testing, assessment of TB status, Hepatitis B status) as is it in their employee files
Employee availability do they have health issues, are they going to be able to work if their children's school isn't open, do they have fragile or older people living with them

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Spread of Covid-19 CDC/WHO
CDC states that person-to-person transmission occurs during close (within 6 feet) contact with a person with COVID-19, primarily from respiratory droplets produced when an infected person coughs or sneezes.
These droplets, particularly when aerosolized, can be deposited in the mouth, nose, or eyes of nearby people or be inhaled into the lungs.
People can also become infected with SARS-CoV-2 by touching surfaces or objects contaminated with the virus, and then touching their mouths, noses, or eyes.
Person-to-person spread is likely to continue to occur under current pandemic conditions.
There is still more to learn about the transmissibility, severity, and other features associated with SARS-CoV-2.
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https://www.osha.gov/SLTC/covid-19/dentistry.html

Dentistry and Exposure Risks
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https://www.osha.gov/SLTC/covid-19/dentistry.html

Prior to Opening the Dental Office
Before seeing patients review the revised infection control plan with the staff.
Designate an infection control compliance officer, it can be anyone in the office it does not need to be the dentist
If your office has been closed it may take some time to do everything you need to do prior to seeing patients.
Shock the waterlines, make sure your autoclave is working as well as dishwashers if you are using them. Keep records of instrument sterilization. Update your SDS binders, put batteries in your AED.

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Changes that may Present in the Dental Office
Prior to the patients visit you should call the patient and ask some basic Covid-19 related questions.
Ideally this should be done within 24 hours of the visit. During this call you should:
1) Review the reopening practice protocol (what the patient will expect)
2) Screen the patient for COVID-19 symptoms. The practice should verify as best it can that the patient does not currently have symptoms of COVID-19. Patients should be told their responses will be kept confidential
Go online for Medical Histories if possible (Hospitals do it all the time) less paper in the office equals less clutter.
Try to do as much paperwork as you can before the patient enters the practice.
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Create a script for your administrative staff to follow when conducting these calls.
Questions:
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches, shortness of breath f, loss of smell, loss of taste, fever at or greater than 100.4 degrees Fahrenheit?
Have you or anyone in your household tested positive for COVID-19?
Have you or anyone in your household traveled in the U.S. in the past 21 days? (Currently NYS has a 14 day quarantine restriction for over 30 states)
If patient answers "yes" to any question, their responses should be reviewed by a designated medical leader to assess whether the patient can keep the scheduled appointment.
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https://www.ama-assn.org/practice-management/sustainability/use-covid-19...

Day of Visit Assessment Questions
Assess all patients
Fever, cough, shortness of breath?
Take temperature, record temperature
Provide patient with a Face covering
If the patient demonstrates any COVID-19 Symptoms (+)
Make sure patient is masked
Send to physician, ER, or call 911

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Prior to entering the Dental Practice
If you are in a position to have your patients wait in their cars, please do so. You can call or text when the Doctor or Hygienist is available.
In City Offices this will not be possible so you may need to social distance your patients while the wait to be seen (6 feet or greater). Mark the chairs where people can and cannot sit.
Stress the importance to the patients of arriving to their appointment on time, not early, with enough time to review the Covid-19 pre treatment questions and have their temperature taken.
No Visitors! The practice should strictly limit individuals accompanying patients, but in instances where an accompanying individual is necessary (e.g. a parent of a child), those individuals should be screened in the same manner as the patient.
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Once you have entered into the Dental Practice
Office Entry Restricted: Only patients may enter office for appointment unless it is essential for the patient to be escorted.
Stagger Patients: Do not stack dental appointments. Only use every other chair. Don't have so many patients scheduled that you run behind.
Patients wait to be called-in for an appointment only once the previous patient is gone and sanitation is complete.
Do not overbook! You cannot have people waiting in your office so try to stay on time with all visits and allow time for infection control.
Allow time for emergency visits, perhaps at the end of the day or a designated time of the day.
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Front Desk and Waiting Room: Facilities
Remove Non-essential Items: Any non-clinical items should be stored. Dental display models, flyers, brochures, toothpaste samples, implant displays, etc. Remove toys, magazines, art work anything that will make it more difficult to clean between patients.
Have hand sanitizer available at front desk and at door.
Everyone Including the patients must wear a mask at all times while in the office except during treatment. They type and design of mask and other PPE will reflect the work being done.
Try not to use cash currency, use credit cards.
Have disposable pens available that you would like to give to the patient at the end of their visit (Office logo?)
Post signage available from CDC regarding Hand Washing

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Front Desk and Waiting Room: Facilities
Take patients temperature immediately at check in, use a Non-Contact Multi-Functional Infrared Digital Thermometer that is FDA Registered. It should be touch free and suitable for both children and adults.
The patient's temperature should be recorded on their patient chart.
If a patient has a fever >100.4 they should not be treated and they should be referred to their physician, ER or walk in facility for follow up.
The person taking the temperature should wearing appropriate PPE including a mask and face shield if they are not behind a barrier.
Patients should remain seated in the waiting room for minimal time and should be wearing a face mask (their own or provided by the office ) at all times while in the dental facility unless they are being treated.
There will likely be plastic barriers at the front desk to protect the staff and separate them from the patients.
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Non Touch Thermometer
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During Treatment
The patient will notice that there are increased physical barriers, some changes to routine policy and visible changes in PPE.
The dentist/hygienist/assistant will likely be wearing a length long sleeve disposable or washable gown, a head covering or hair net, a face shield, gloves, as well as a N95 or level 3 medical mask an protective eyewear.
N95 masks must be fitted before use and the ADA interim guidelines allows for a level 3 medical mask and face shield if N95 masks are not available.
The patient will also wear their mask until dental work is to begin.

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Pre-Procedural Rinse
A preprocedural rinse of either hydrogen peroxide or chlorhexidine is suggested by the ADA prior to treatment.
Use preprocedural rinse of peroxide. The concentration of any rinse used should be at least .5%. Over-the-counter peroxide is typically 2%, so it would need to be diluted.
Colgate Proxyl and Listerine Whitening Mouthrinse, are 1.5% peroxide
Rinse at the beginning of the appointment for 60 seconds and again after the appointment.
At this time, the ADA and CDC are only recommending peroxide to destroy the virus.
However, some papers are suggesting a preconditioning rinse using 1.5% hydrogen peroxide followed by rinsing with 0.2%chlorhexidine.

https://www.rdhmag.com/covid-19/article/14169838/recommendations-for-the...
https://www.bibliomed.org/mnsfulltext/28/28-1435731707.pdf?1595708901

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PPE
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N95 and Face Shields
You can wear a medical mask over an N95 if there are limited supplies
Face shield over N95: Accommodates the use of light and loupes. This will protect the N95 and allow for multiple uses if needed
Follow Manufacturer's IFU to clean or dispose of shield after each use

NIOSH Blog: https://blogs.cdc.gov/niosh-science-blog/2020/06/16/covering-n95s/

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Masks
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https://www.cdc.gov/niosh/npptl/images/infographics/FY17N95infographicWh...

Ventilation, UV lights, and open Bay plans
Many offices have increased their air exchange (following an evaluation by a qualified engineer) and portable HVAC systems may be present behind the head of the patient. Operate HVAC in fan mode
HVAC filter: Consider upgrading the filtration at the HVAC unit to MERV 13 or MERV 14 if possible. HVAC unit is oriented towards the entrance of the room
Use a portable HEPA filter located at the rear of the room
Make sure your dental vacuum system can handle continuous use.
Some offices may have installed UV light systems as well.
Some offices may also use Vaporous hydrogen peroxide and moist heat although these are not currently approved by OSHA
For open Bay offices purchase portable room dividers with adjustable heights

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Ventilation Set up
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PPE Burn Rate Calculator
PPE may be expensive and difficult to acquire at this point in time.
Re-use may be necessary although not ideal and re-use should be stopped when PPE becomes available.

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https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html

During Treatment
At this time following interim guidelines set out by the ADA, we support shorter patient visits so that less may be done during a single session.
We encourage you to see entire families at one time to lessen the likelihood of cross contamination.
The use of aerosol generating high speed drills, ultrasonic, and tooth polishing are discouraged at this time. Hygienists should be hand scaling.
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During Treatment
It has been confirmed that the virus is spread through aerosols so one goal of treatment is to decrease the amount of aerosol production.
Whenever possible a rubber dam should be used along with highspeed suction.
It is not the time to start a major reconstruction or a full set of anterior veneers unless absolutely necessary.
Nitrous oxide may not be a viable option unless disposable lines and hoods are available for each patient.

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After Treatment
The patient should replace their mask when the procedure is done.
The patient should be walked back to the front desk by the assistant if possible.
Try to use credit cards when possible to decrease the amount of paper in the office.
The patient should be called in 2 days to see how they are feeling and ask if they have any changes in their health. You should let them know that this will happen and that it is part of the new routine.
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After Treatment
After the patient has left the room, you may need to wait up to 15 minutes depending on your air flow exchange to clean and disinfect the room
Remove and replace any barrier protection
Disinfection products must be on the EPA N list
Current evidence suggests that novel coronavirus may remain viable for hours to days on a variety of surfaces. Frequent cleaning of visibly dirty and high-touch surfaces, followed by disinfection, can help prevent SARS-CoV-2 and other respiratory pathogens (germs) from spreading in workplaces

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Rules and Regulations
OSHA Guidance not regulations, Recommendations and mandatory health standards, helps provide a safe workplace
https://www.osha.gov/SLTC/covid-19/dentistry.html
CDC Guidance not regulations
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommen...
State Health Department and Local Health Department - Seek guidance from the State Dental Board & Local Dental Society
FDA - Manufacturers' Instructions for Use(IFU), including disinfection regulations
https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-agai...
EPA
ADA - COVID-19 State Mandates & Recommendations
https://success.ada.org/en/practice-management/patients/covid-19-state-m...

https://success.ada.org/%7E/media/CPS/Files/Open%20Files/ADA_COVID19_Den...

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Hierarchical Approach to Guidance of Safe Practice
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For organizations that use Joint Commission accreditation for deemed status purposes or that are required by state regulation or
directive, Conditions of Participation (CoPs) and /or Conditions for Coverage (CoCs) should be reviewed for applicable mandatory requirements.

Reference: Joint Commission Perspectives
September 2019

Questions?
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image: Freepik.com