An Ounce Of Prevention

Practice establishes measures to ensure patient safety amid pandemic.

As the world hopes to slowly move its way back to normalcy amid the coronavirus pandemic, medical professionals are finding their work to be incredibly challenging.

Richard Leong, DDS, has accepted that challenge as if he were ordained to do so.

Buoyed by his belief that the time he spent sheltered in place was an opportunity to better himself, grow closer to family and strengthen his faith, Dr. Leong spent part of his down time learning as much as he could about the coronavirus.

What he learned has greatly impacted the way he now runs his Melbourne-based practice, where he performs all aspects of dentistry, including periodontics, oral surgery and the placement of crowns, bridges and dental implants.

“What we now know is that this is a very transmissible disease and that many carriers of the coronavirus are asymptomatic,” Dr. Leong stresses. “Therefore, we must treat everyone that comes into our office as if they may have the virus.

“I want to emphasize that this is especially important inside a dental office, where aerosols have been generated already by the use of drills and ultrasonic cleaning equipment, and the risk of transmitting the virus is therefore much higher.

“That’s why to ensure the safety of our patients as well as the members of our staff, I have instituted a series of dramatic changes to our office, changes that I believe make our dental office safer than even your own home.

“I say that because these changes go far beyond the minimum guidelines recommended by the American Dental Association, the U.S. Centers for Disease Control and Prevention, and the Occupational Safety and Health Administration.”

The changes Dr. Leong has instituted include:3

Before Treatment

Patients will be notified of these measures in advance of their appointments, which will begin with a meeting in the parking lot, where their temperatures will be taken and they will be asked to sign a consent form. The practice asks that, if at all possible, patients come alone to their appointments. If that is not possible, anyone accompanying the patient will need to go through the same pretreatment as the patient. Also, appointments are now being scheduled so that no more than three patients are in the office at one time and so that no more than one patient is being treated by Dr. Leong or the hygienist at a time. In addition, waiting room chairs have been spaced at least six feet apart in accordance with CDC social distancing guidelines.

Preventive Measures

Patients will be required to wash their hands upon arrival at the office. For this purpose, hand soap and drying towels will be provided. In addition, the office has long been equipped with automatic on/off water faucets and paper towel dispensers that help prevent cross contamination of virus and bacteria. Also, for anyone needing to sign forms, a new pen will be provided that will be the patient’s to keep.

Cross-Contamination

Because a dentist and a patient can infect each other, Dr. Leong and his staff are being tested frequently to ensure they do not have the virus. Ideally, patients should be tested ahead of their appointment so as to avoid contaminating the dental office, staff and other patients. Because testing for every person is not feasible, first-line defenders such as dental personnel are being tested.

Personal Protective Equipment 

PPE, or personal protective equipment, refers to outer garments and face equipment that dentists and staff members must wear to protect themselves from virus contamination. Dr. Leong and his staff members are using the same PPE used by hospital personnel when treating COVID-19. That includes disposable gowns covering the entire body with long sleeves; gloves that cover the hands and pulled over the sleeves to prevent leakage of the virus onto the wrist and forearm; face masks with ventilators that have higher filtration to stop viruses from traveling to a staff member or patient; eye protection in the form of glasses/goggles or face shields to keep aerosols out of the eyes of the dentist and staff; and surgical head shields that prevent aerosols from getting into the hair.
Specific protocols are being followed in Dr. 0ong’s office to prevent virus contamination. For example, once an appointment has been completed, staff members are required to follow specific guidelines for removing PPE. This includes hand-washing before removing each specific article of PPE and donning a new gown, head piece and mask. In addition, each patient coming into the office will be met by dental staffers with new PPE so that no coronavirus is cross-contaminated from one patient to the other.

Proper Handwashing

For staff members, the universal method of handwashing for at least 20 seconds while covering all surfaces, including the wrists and under the fingernails, has long been in practice at Dr. Leong’s dental office. Dr. Leong and all assistants are required to wash their hands before, during and after each procedure to prevent cross-contamination and are now required to wash their hands four to five times when donning and doffing PPE.

Preparation of Each Operatory

Research has shown that aerosols from the use of a dental drill can spread as far as 30 feet from where the patient is seated. Therefore, decontamination of each operatory inside Dr. Leong’s practice will be done between each appointment to prevent the spread of virus and bacteria from one patient to another. The sanitation process will be done using alcohol and Lysol spray. These agents have proven to be the most effective in killing the virus and are being used on counters, surfaces around the room and in the air where the aerosol droplets remain. In addition, all handles on lights, cabinets or doors are covered ahead of or sterilized after each patient appointment.

Sterilization of Working Instruments

Dr. Leong’s practice has replaced all dental instruments that cannot be autoclaved with instruments that can so all instruments can be sterilized thoroughly after each use. This includes the three-way syringe used to squirt water and air into the patient’s mouth as well as the high-volume evacuator (HVE) or suction instrument.

“I made the decision to buy new instruments, because I thought about what I would want in my mouth if I were sitting in that chair,” Dr. Leong explains. “I would want the best sterilization possible so that I have the least chance of having coronavirus passed to me by an asymptomatic patient.

“Therefore, I purchased these new instrumentations because I know that no bacteria or virus will be passed between patients when using three-way syringes, HVE suction handles and saliva ejectors that can be and are sterilized.”

Air Filtration to Remove Aerosols

Because aerosols linger in the air for more than three hours, if they are not mechanically removed, filtration devices must be utilized to maintain proper patient flow. The practice has equipped each operatory with Blueair Pro L air purifiers. This air purifier has been rated the best on the market by Clinicians Report, an independent dental product-testing organization.

Dental Hygiene Visits

To further prevent the spread of aerosols during dental hygiene visits, the hygienist is limiting the use of the ultrasonic high-speed cleanser and prophy jet polisher, both of which spread large amounts of aerosols into the air during use.

High-Volume Evacuation

In an effort to reduce aerosols that may contain the virus,
Dr. Leong is now using a high-volume suction (HVE) instrument during all procedures involving a drill as well as cleanings. This special instrumentation, called Isolite, uses high-speed suction, and covers and protects the throat and tongue at the same time. When used in conjunction with the standard saliva ejector tube that hangs out of the corner of the patient’s mouth, the special HVE suction reduces the amount of aerosol produced by 95 percent.
HVE is the first line of defense for removing aerosols in the patient’s mouth. Other aerosols are removed by the air purification units. Very few dental offices have both HVEs in the mouth at the same time and few, if any, have air-purification units working in conjunction with HVEs to essentially remove up to 100 percent of aerosols in the air.

Rubber Dam Treatment

A rubber dam is a thin rubber mask that covers the throat and tongue and does not allow saliva and contents from the mouth to be exposed while drilling is going on. It is clamped onto the teeth adjacent to where the work is being done, which helps prevent aerosols from entering the dental environment. This type of mask is used most extensively when doing root canal treatments or fillings. It was an often-used protocol method even before coronavirus was a problem but is now being used more frequently.

Avoid Touching Objects During Treatment

Inadvertent actions such as straightening glasses, and touching computer keyboards or drawer handles can break the chain of prevention that has been set up to prevent cross-contamination. At Dr. Leong’s practice, several steps have been taken throughout the office to ensure that chain is not broken, including covering all keyboards and handles with plastic wrap between each patient visit.

Housekeeping After Hours

Each night, our maintenance staff spends approximately four hours cleaning and sanitizing the floors and walls of each operatory. Like the members of our dental staff, our maintenance team members have all been trained extensively regarding the use of PPE as well as hand-washing and cross-contamination techniques.

Bathroom Use

The practice respectfully requests that anyone utilizing a bathroom while on the premises notify the staff of their use so that the bathroom can be sterilized following each person’s use.

Internal Building Architecture

Operatories with open doors allow for the escape and free flow from that operatory of aerosols that can result in cross-contamination of the virus. Though the open-door concept does have many advantages, all operatory doors at Dr. Leong’s practice will be closed during procedures both for privacy purposes and to prevent any possible escape of the virus.

Internal Staff Communication

To further reduce the potential for cross-contamination of the virus, the staff is now using handsfree voice actuated communication devices that eliminate the need to touch intercoms or telephones.

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