EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

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COVID-19: Part 2— Is there something in the air? and prevention/control in the dental office

A peer-reviewed continuing education course written by Maria L. Geisinger, DDS, MS

PUBLICATION DATE: OCTOBER 2020

EXPIRATION DATE: SEPTEMBER 2023

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS

COVID-19: Part 2—Is there something This continuing education (CE) activity was developed by Endeavor Business Media with no commercial support. in the air? Aerosols and infection This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and prevention/control in the dental office web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity. No Abstract manufacturer or third party had any input in the development of the Dental procedures that employ handpieces, lasers, electrosurgery units, ultra- course content. Requirements for successful completion: To obtain three (3) CE sonic scalers, air polishers, prophy angles, hand instruments, and air/water credits for this educational activity, you must pay the required fee, syringes can create and spatter. Ultrasonic scalers and high-speed review the material, complete the course evaluation, and obtain an exam score of 70% or higher. handpieces produce more airborne contamination than any other instruments CE planner disclosure: Laura Winfield, Endeavor Business Media in , but much is still unknown about the nature and infectivity of such dental group CE coordinator, neither has a leadership nor commercial interest with the products or services discussed in this educational aerosols. As dental procedures and technologies have evolved, the incidence activity. Ms. Winfield can be reached at [email protected]. of -creating procedures has increased. Inhalation of airborne particles Educational disclaimer: Completing a single continuing education course does not provide enough information to result in the participant and aerosols produced during dental procedures may cause adverse respira- being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that tory health effects, including high-consequence infectious (HCIDs) allows the participant to develop skills and expertise. spread by airborne routes. While transmission-based precautions may mini- Image authenticity statement: The images in this educational mize risk to dental health-care providers, the evidence to support the most activity have not been altered. Scientific integrity statement: Information shared in this CE course effective interventions and the guidance for infection control and prevention in is developed from clinical research and represents the most current regard to airborne transmission is rapidly evolving. During the initial information available from evidence-based dentistry. Known benefits and limitations of the data: The information stages, limiting dental practice and minimizing aerosol-generating presented in this educational activity is derived from the data and procedures was critical, but as the current pandemic evolves, it has highlighted information contained in the reference section. Registration: The cost of this CE course is $59 for three (3) our understanding of potential modes of airobone disease transmission in the CE credits. dental office and effective methods to mitigate such risks. Going forward, den- Cancellation and refund policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting tal health-care providers should be aware of invisible risks within their opera- Endeavor Business Media in writing. tories and stay abreast of evolving infection prevention protocols before, during, Provider information: Dental Board of California: Provider RP5933. Course registration and after patient care. This course seeks to review up-to-date infection control number CA code: 03-5933-20001. Expires 7/31/2022. “This course recommendations and emerging evidence for ongoing infection control when meets the Dental Board of California’s requirements for three (3) units of continuing education.” delivering dental care, particularly in relation to the COVID-19 pandemic.

Endeavor Business Media is a nationally approved PACE program Educational objectives provider for FAGD/MAGD credit. Approval does not imply acceptance Upon completion of this course, the dental professional should be able to: by any regulatory authority or AGD • Explain the risk factors and basic properties of aerosols generated during endorsement. 11/1/2019 to 10/31/2022. routine dental procedures Provider ID# 320452 • Describe what types of dental procedures result in significant dental aero- AGD code: 148 sol production • Understand the types of pathogens and resultant illnesses associated with

such aerosols Endeavor Business Media is designated as an approved provider by the American • Differentiate between standard and transmission-based precautions and Academy of Dental Hygiene Inc. #AADHPNW (January 1, 2019–December 31, 2020). Approval does not imply acceptance by a state or provincial board of dentistry. Licensee their utility in the dental office for safe delivery of care should maintain this document in the event of an audit. • List infection control and aerosol mitigation techniques that may reduce the risk of cross-contamination to patients and providers Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of dental continuing education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

Go online to take this course. DentalAcademyofCE.com QUICK ACCESS code 20001 DENTAL ACADEMY OF CONTINUING EDUCATION

Introduction infection control measures that can be Airborne droplets: aerosols A novel β-coronavirus (SARS-CoV-2), pur- implemented during dental practice to versus spatter portedly originating in a seafood market block the person-to-person transmission Aerosols are defined as liquid or solid par- in Wuhan, Hubei province, China, is caus- routes through standard, transmission- ticles less than 50 micrometers in diam- ing severe and potentially fatal pneumo- based, and potentially novel precautions.21 eter.16,17,26,27 Particles of this size are small nia (COVID-19) and has demonstrated enough to stay airborne for an extended pandemic spread throughout the globe.1–3 Aerosols in the dental office: period before they settle on environmen- The World Health Organization (WHO) has What are the risks associated tal surfaces or enter the respiratory tract stated that modes of transmission include with dental procedures? after inhalation.16,17 Smaller particles of contact, droplet, airborne, and Airborne transmission of various an aerosol (0.5 to 10 μm in diameter) have routes. The US Centers for Disease Control pathogens, including and the potential to enter the and settle and Prevention (CDC) further states that measles, has been reported in various within the bronchial passages, reaching most cases are spread by close person-to- health-care and community settings.22,23 as far as the pulmonary alveoli.16,17 These peson interaction within six feet through air- Furthermore, viral transmission of droplets, due to their capacity to remain borne respiratory particles produced during common after airborne droplets/ in the air, may prompt a shift in infection many common activities including - particles have settled on surfaces has also prevention and control practices employed ing, sneezing, speaking, and even breath- been shown.22,23 Air quality evaluation in the dental office.26,27 ing.4-8 Additionally, while an airborne route within dental operatories has revealed the Spatter describes airborne particles, of transmission is suspected for SARS-CoV-2, the exact nature and conditions necessary to allow for this kind of transmission are cur- Average rently unknown. Given these transmission bacterial size routes, there has been a renewed interest 0.2 μm in aerosols in the practice of dentistry and Particles may their risk to dental practitioners and den- 70–100 μm penetrate the lower tal patients, as well as mitigation strate- respiratory tract gies for risks associated with reducing 1 μm viral contamination and infection due to dental procedures. Currently, dental practitioners, 50 μm members of the dental team, and their 30–40 μm patients are exposed to risks associated Fine aerosol with aerosols in the dental office due to the (may remain frequency of face-to-face communication, suspended in air) exposure to saliva, blood, and other body 5 µm fluids, and—indirectly—by the touching of instruments and other surfaces that may FIGURE 1: Relative sizes of airborne droplets serve as (any inanimate object that if contaminated with or exposed to an infectious agent can then transfer that presence of multiple pathogens capable usually a mixture of air, water, and/or solid agent to a new host).9-12 Previous studies of aerosol transmission, indicating a substances, larger than 50 μm in diameter, have shown that in risk to dental health-care professionals, which may be up to several millimeters in the mouth and respiratory tract can be staff, and patients through these routes diameter and visible to the naked eye.16,17 transported in the aerosols and spatter of transmission.24,25 It is currently unclear These particles have been shown to behave generated during dental procedures and under which circumstances, if any, SARS- in a ballistic or projectile manner.16 Thus, can contaminate the skin and mucous CoV-2 can be transmitted via dental these particles or droplets are ejected forc- membranes of the mouth, respiratory aerosols, and no reported cases of COVID- ibly from their origin in an arc and travel passages, and eyes of dental personnel as 19 transmission have been traced to the along a bullet-like trajectory until they well as surfaces and materials exposed to direct provision of dental care. This type contact a surface or fall to the ground due such aerosols and droplets.13–20 As such, of transmission may be dependent upon to gravitational forces.16 Unlike aerosols, dental professionals can play an important many factors, including overall viral load these particles are too large and contain role in preventing disease transmission in the aerosol/spatter, proximity of dental too much mass to become suspended in within the dental practice.13–20 This course personnel to an infected patient, type the air and are airborne only briefly.16,17 seeks to explore potential risks posed by and effectiveness of personal protective Because of this, they demonstrate limited aerosols in the dental office and assess equipment (PPE), and host susceptibility. penetration into the respiratory system.16,17

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Figure 1 demonstrates the relative sizes of can also serve as a repository for microbiota patient coughing, and even the capture of droplets commonly produced during den- within aerosols or other airborne contami- intraoral radiographs have all been shown tal procedures. nation.31 Dental handpieces, ultrasonic scal- to create aerosols in the dental setting.32 It Within the dental office, these airborne ers, and air-water syringes are all capable of is also important to note that while these droplets, both splatter and aerosols, may producing aerosols, which are usually a mix procedures may produce large volumes of present risks to dental practitioners and of air and water derived from these devices aerosols, the majority of aerosolized mate- patients, which may vary based upon the and the patient’s saliva.32 It should also be rials likely is not derived from salivary or amount and types of droplets produced.26,27 noted that these aerosols are always accom- respiratory sources, but rather the lavage The type of exposure encountered during panied by spatter (table 1).28 from the instrumentation used. This may dental care and needed PPE may vary based The oral environment is naturally wet result in a dilution of the infectious agents upon the level of aerosols produced. Addi- and has a high level of contamination with within patient secretions, thus lowering the tionally, droplet contamination of porous and other microorganisms. Dental infectious bioload.34 and nonporous surfaces after dental treat- plaque is a major source of such organisms, Use of barrier protections, such as a rub- ments is dependent upon the type of pro- containing more than 700 known patho- ber dam, and high-speed evacuation may cedure and the resultant airborne droplets gens,33 but the mouth also harbors bacte- reduce overall aerosol exposure during produced. Because aerosols can remain in ria from elsewhere in the respiratory tract, such procedures.26 Additionally, the use of the air for a long time and may be trans- including the nasopharynx and the lower preprocedural mouth rinses has demon- ported with air flows for long distances, they pulmonary system.26 Microscopic blood strated a reduction in the overall micro- are capable of contaminating wide areas droplets, gingival crevicular fluid, debris bial load detected in aerosols generated within the dental operatory.26–28 Conversely, from tooth preparation, and dental mate- during dental procedures.35 Because of the spatter particles are generally deposited on rials all may be aerosolized during dental ability of aerosols to remain suspended in surfaces closer to their origin, an estimated procedures and cause threats of disease the air for several hours, they may not be 15–120 cm from the source.29,30 Spatter par- transmission.29,30 Any dental procedure that able to be completely removed from the ticles are, therefore, a risk due to their contact with mucous membranes Dental devices/procedures Airborne contamination potential Potential mitigation for droplet/aerosols and close surfaces, including den- Considered to be the greatest High-volume evacuation during tal practitioners and dental assis- Ultrasonic/sonic scalers source of aerosol contamination powered scaler use reduces airborne tants.27,28 In some instances, however, in dental practice contamination by > 95% hardy microorganisms may survive Airborne bacterial counts indicate High-volume evacuation during within the material in spatter as the Air polishing aerosol production nearly as powered scaler use reduces airborne droplet evaporates, and these organ- high as with ultrasonic scalers contamination by > 95% isms may even become re-airborne 27,28 Airborne bacterial counts indicate High-volume evacuation during as dust particles. It is currently Air-water syringe aerosol production nearly as powered scaler use reduces airborne unknown which, if either, of these high as with ultrasonic scalers contamination by > 95% droplet types may represent signifi- Minimal airborne contamination Tooth preparation with Use of a rubber dam and high- cant risks within the dental office if proper placement of a air turbine handpiece volume evacuation is indicated. as the viral bioload of SARS-CoV-2 rubber dam is in place within these particles and the neces- Microbial contamination sary viral exposure for development Tooth preparation is unknown. Extensive Use of a rubber dam and high-volume of infection are, as of yet, unknown. with air abrasion contamination with abrasive evacuation is indicated. particles has been shown. Dental procedures and their ability to produce aerosols TABLE 1: Dental devices and procedures known to produce airborne contamination (Adapted from Harrel and 26 Airborne contamination may be Molinari, 2010) due to a variety of procedures com- monly performed in dental practice. Micro- has the potential to aerosolize saliva can environment during commonly used sur- organisms of salivary, oral, and respiratory cause contamination with microorganisms face decontamination and could cause dis- sources may be transmitted through spatter from these sources.28–30 ease in others through an airborne route of and/or aerosols during dental instrumenta- The most intense aerosol and spatter transmission or via fomite transfer, even tion.31 Dental instruments, surfaces within emission has been shown to occur during after the infected person is no longer in the dental operatory, and dental unit water use of ultrasonic scalers and high-speed the immediate area.32,36–38 Furthermore, lines, when improperly sterilized, stored, or handpieces without a rubber dam.26,28,29 because aerosols may travel significantly cleaned, can serve as a source of organisms While these procedures are associated with farther than spatter, they may contami- within aerosols, and those microbes can the highest levels of aerosol production, use nate distant surfaces, and certain micro- be passed from one patient to another and of low-speed handpieces, air/water syringes, organisms (e.g., SARS-CoV-2) can survive

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44 on such environmental surfaces for pro- between microorganisms. The R0 is the exposure in dentistry has also be associated longed periods of time.32,39 In the case of number of cases, on average, an infectious with an increased risk of other pulmonary SARS-CoV-2, the may survive on plas- patient will cause during their infectious diseases, including idiopathic pulmonary tic or metal surfaces for up to two or three period. The R0 is often described as either fibrosis (IPF), although causation has not days. Therefore, dangers could arise from “basic” (reproduction in a wholly suscep- been established.48 Given the potential for contaminated surfaces, and the potential tible population) or “effective” (dependent long-lasting risks to dental personnel, care could exist for inhalational exposure if a upon the population’s current susceptibil- should be paid to establishing safety proto- prior infectious patient received treatment ity). In other words, in real-world model- cols that allow for the greatest mitigation and the air within the treatment room was ing, R0 is influenced by vaccination rates, of occupational risk. not exchanged, filtered, and/or sanitized. previous infection rates, cross-immunity from similar diseases, population behaviors Standard and transmission- Infectious diseases known or (e.g., social distancing), and the novelty of a based precautions: best practices suspected to be associated pathogen.44 Lastly, the likelihood of trans- for dental professionals with aerosols: What mission is also influenced by the suscepti- In 1985, the Centers for Disease Con- influences infectivity? bility of the host and, in certain instances, trol (now the US CDC) introduced the Several types of bacteria and have this may be related to overall health status, concept that all blood and body fluids demonstrated airborne person-to-person genetic influences, immunocompetence, that might be contaminated with blood transmission. Microorganisms transmit- vaccination/infection history, and previous should be treated as infectious.49 Infec- ted by aerosols can cause diseases such as exposure to similar diseases.45,46 tion control precautions were introduced influenza (influenza viruses types A and B), While continued discussion about the largely because of the human immuno- the common cold (rhinoviruses and other immediate threat of COVID-19 infection deficiency virus (HIV) epidemic and have viruses), tuberculosis (Mycobacterium tuber- in the dental office exists, there are addi- been updated in the intervening years. culosis), Legionnaires’ disease (Legionella tional concerns about damage subse- Such precautions have been sequentially pneumophila), severe acute respiratory syn- quent to such an infection, even one with titled “universal” and now “standard” pre- drome (SARS, SARS-CoV-1), and early data mild and/or subclinical symptoms, and the cautions, and they are designed to prevent suggest COVID-19 (SARS-CoV-2) may also be long-term effects of aerosol exposure on transmission of HIV, hepatitis B virus transmitted in such a manner (table 2).9,21,40–43 dental personnel. For example, a temporal (HBV), hepatitis C virus (HCV), and other For many of these microorganisms, association between occupational expo- blood-borne diseases.50,51 Additionally, the their transmissibility in aerosols is depen- sure to contaminated dental unit water Occupational Safety and Health Admin- dent upon a myriad of factors. The over- line (DUWL) output water with aerobic istration (OSHA) bases its blood-borne all microbial load within secretions may bacterial counts of more than 200 colony- pathogens standard on the concept of be variable based upon the disease course forming units (CFU)/ml at 37° C and the standard precautions.52 and the particular bacteria/virus.7–9,21 This subsequent development of asthma has variability can influence the likelihood of been demonstrated in a subgroup of den- Standard precautions exposure in aerosol. Additionally, the repro- tists who were followed longitudinally after Generally, standard precautions are the 47 duction number (R0) differs significantly entering dental training. Occupational minimum infection prevention practices that apply to all patient care, regardless of Disease Causitive microbe Method of transmission suspected or confirmed infection status of the patient, in any setting where health care Most transmission was through an insect vector (flea), Pneumonic plague Yersinia pestis but also person-to-person via bacterial inhalation is delivered. These practices are designed to both protect dental health-care providers Droplet nuclei expelled fron an Tuberculosis Mycobacterium and prevent practitioners from spreading tuberculosis infected patient by coughing infections to patients. Current recommen- Influeza virus May be associated with coughing but Influenza dations for standard precautions in the den- types A and B more likely with direct patient contact tal office include:53 Aerosolization has been associated with • Proper hand hygiene Legionnaires’ disease Legionella HVAC systems and hot tub spas, which pneumophila • Use of appropriate personal protective have been linked to outbreaks equipment (e.g., gloves, masks, eyewear, Severe acute respiratory Spread by aerosolized droplets, through disposable gowns, etc.) SARS-CoV-1 syndrome (SARS) fomite transfer, and by direct contact • Respiratory hygiene/cough etiquette • Sharps safety and other engineering and Spread by aerosolized droplets, through COVID-19 SARS-CoV-2 work practice controls fomite transfer, and by direct contact • Safe injection practices (e.g., aseptic tech- nique for parenteral medications and TABLE 2: Diseases known to be spread by droplets or aerosols (Adapted from Harrel and Molinari, 2010)26 sharps management)

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• Sterile instruments and devices for use Given the novel nature of SARS-CoV-2 • Assess and triage patients using tele- in patient care and the high level of uncertainty sur- dentistry prior to an in-person dental • Clean and disinfected environmental rounding the risks of transmission in the visit and upon arrival in the dental office. surfaces utilizing approved disinfec- dental office, current guidance is interim Assess the nature of the patient’s den- tion techniques and likely to change as data emerge. It is tal needs, underlying systemic health While standard precautions alone cannot assumed that infected individuals may be and risk factors, and any symptoms prevent all disease transmission, they rep- asymptomatic and/or presymptomatic, related to COVID-19. Patients with con- resent minimal standards to be applied to but the viral loads and transmissibility of firmed or suspected COVID-19 should all patients, even those who report low risk the virus from asymptomatic individuals is be referred to contact the hospital emer- and/or appear asymptomatic. They may be poorly characterized. As such, until more gency department to determine the opti- supplemented with transmission-based definitive recommendations are devel- mal patient care options, even for dental precautions. oped, it is recommended that the CDC’s emergencies. precautions regarding infection prevention • DHCPs should assess the likelihood of Transmission-based precautions and control in dental offices be used on an aerosol production during care and con- In some circumstances, patients may empiric basis and protocols reviewed and sider mitigation strategies, including: 1) have a documented infection or may be updated often.60 reducing aerosol bioload, 2) barriers and suspected of having an infection with PPE that reduce droplet deposition and specified highly transmissible pathogens Strategies to mitigate airborne aspiration for dental health-care provid- for which standard precautions cannot disease transmission risk ers, and 3) reduction of aerosol droplets completely eliminate risks associated in the dental office in room air. with airborne or droplet transmission or Given the present uncertainty about viral • If the needed procedure is unlikely to transmission by contact with skin or con- transmission in dental offices, current produce aerosols, DHCPs can use rou- taminated surfaces. A second tier of pre- infection control protocols and routine tine PPE and the procedure is consid- cautions, referred to as transmission-based PPE used for dental procedures may not ered low risk. precautions, is commonly employed in be adequate and cannot be relied upon • If aerosols are likely to be produced, the these cases to prevent or mitigate the risk until further data are available. Based following recommendations should be of disease transmission. There are three upon emerging evidence regarding SARS- employed: categories of transmission-based precau- CoV-2 and previous investigations study- --Use of four-handed dentistry, high- tions: airborne, droplet, and contact.54-56 ing other coronaviruses, spread is thought velocity evacuation suction, and den- Typically, dental settings are not to occur mostly person-to-person via tal dams to reduce and/or minimize be designed to carry out all of the respiratory droplets among close con- droplet splatter and aerosols. transmission-based precautions (e.g., tacts. Close contact can occur while deliv- --Consider the use of HEPA air filtration airborne precautions for patients with ering patient care and is currently defined in treatment areas to reduce aerosol suspected tuberculosis, measles, or by the CDC as: 1) being within approxi- concentrations in the room. chickenpox) that are recommended mately six feet (two meters) of a patient --Be sure to account for cleaning time for hospital and other ambulatory care with COVID-19 for a prolonged period of surfaces in patient areas between settings.53 Patients, however, do not of time (30 minutes) or 2) having direct patient visits. usually seek routine dental outpatient care contact with infectious secretions from a --Utilize appropriate PPE, including sur- when acutely ill with diseases requiring patient with COVID-19. Infectious secre- gical and/or respirator masks and eye transmission-based precautions. SARS- tions may include sputum, saliva, serum, protection, and consider PPE supply CoV-2 in its presymptomatic phase may blood, and respiratory droplets.60 optimization strategies. be an exception to such recommendations CDC and American Dental Association • Practice how to properly don, use, and require dental health-care providers interim recommendations updated on June and doff PPE in a manner to prevent to develop and carry out systems for early 17, 2020, for infection prevention and con- self-contamination. detection and management of potentially trol include:60–62 • Perform hand hygiene with alcohol-based infectious patients at initial points of • Dental health-care providers (DHCPs) hand rub before and after all patient con- entry to the dental setting. It should be and patients should stay at home if expe- tact, contact with potentially infectious noted that early data from Singapore riencing COVID-19 symptoms and seek material and before putting on and upon suggest that transmission associated with medical care as recommended based removal of PPE, including gloves. Use presymptomatic carriers accounted for upon symptoms and health-care pro- soap and water if hands are visibly soiled. approximately 6.4% of locally acquired vider assessment. • Clean and disinfect clinical surfaces with cases,57 and rates of COVID-19 in health- • Use of face coverings by patients and approved disinfection protocols and uti- care providers in the US and worldwide are maintenance of social distancing in non- lizing disinfectants from EPA-approved noted to be significantly lower than those clinical areas and when not engaged in emerging viral pathogens claims (List N).59 of the broader community.58,59 active receipt of patient care. • Screen all DHCPs at the beginning of their

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shifts for fever and respiratory symptoms. be ideal to reduce disease spread and maintenance of such reduction over Document shortness of breath, new or have the potential to eliminate disease acceptable time frames to accomplish change in cough, and sore throat. If a as has been seen with other formerly dental procedures in a clinical setting. DHCP is ill, have him/her put on a face endemic diseases such as polio and 7. Enhanced air filtration systems and/or, mask and leave the workplace. smallpox. in some cases, installation of negative 2. Point-of-care rapid screening tests to pressure environments to provide spe- Interim special precautions for identify both asymptomatic carriers cialized care to high-risk patients may high-aerosol procedures (known and those who may carry immunity be warranted. or suspected COVID-19 cases) to COVID-19 via adequate antibody Further research is necessary to fully eval- If emergency dental care is medically neces- titers may allow improved risk reduc- uate the practicality and efficacy of such sary for a patient who has, or is suspected tion for dental practitioners and dental novel infection prevention and control pro- of having COVID-19, airborne precautions patients seeking dental care. cedures in dental practice. including the following:60,61 3. Identification of practical, lower-cost • DHCP in the room should wear an N95 disinfection protocols against SARS- Clinical recommendations or higher-level respirator, eye protection, CoV-2 to be implemented in dental In summary, available evidence suggests gloves, and a gown. practice. These could include the use of the following: • The number of health-care providers UV radiation, hydrogen peroxide vapor, 1. Aerosols are generated by all indi- present during the procedure should be and/or other novel techniques. viduals during many routine activi- limited to only those essential for patient 4. Improved barriers, particularly for den- ties, including speaking, eating, and care and procedure support. All other tal procedures that produce high levels breathing. individuals should avoid contact within of aerosols. Currently, hospitals have 2. Aerosols are also created during many six feet of the patient. implemented the use of impermeable dental procedures, particuarly those • Procedures should ideally take place barriers during delivery of high-risk that use powered scalers, dental hand- in an airborne infection isolation room treatments, such as intubations and pieces, air polishers, and the air-water (AIIR). otolaryngeal procedures, for COVID- syringe. The nature of these aerosols, • Clean and disinfect procedure room sur- 19 positive or suspected cases. Given the aerodynamics of aerosols in the faces promptly using approved protocols that rubber dam use can significantly dental office, and the pathologic bio- and disinfectants identified by the Envi- reduce aerosols, it is conceivable that loads of those produced during various ronmental Protection Agency as effective additional barriers may have efficacy dental procedures are not well-defined. against SARS-CoV-2.62 to reduce aerosol spread and mitigate 3. The bioload in aerosols correlates with Dental treatment should be provided in a both direct and indirect transmission disease severity for respiratory dis- hospital or other facility that can treat the risks. eases, but the overall viral bioload of patient using the appropriate precautions. 5. Improved respirators/masks with addi- SARS-CoV-2 in airborne droplets pro- tional filtration. While surgical masks duced in the dental office and its capa- Emerging evidence regarding are appropriate for droplet protection, bility to cause fulminant disease is infection control updates the use of additional filtration may be currently unknown. in dental practice imperative given the increased risks 4. Several methods are effective in As science and our understanding of the from aerosols. While current N95 res- mitigating the production of dental SARS-CoV-2 virus evolves and the pan- pirators are not widely available and/ aerosols and in reducing bioload. Chief demic subsides, it is likely that we may or used during dental procedures, among these are the use of high-volume find ourselves in an endemic situation in improved designs and supply chain evacuators, air flow and filtration which lower levels of this virus or similar availability may improve the ease of optimization, and pre-procedural pathogens exist in the global population, use in dental settings. mouth rinsing, but effectiveness may demonstrating periodic or even seasonal 6. Use of effective preprocedural mouth vary based upon implementation within spikes in infection. In this scenario, it will rinses to decrease viral load in oral dental practices. also be imperative that we develop more secretions, particularly for patients 5. Similarly, several barrier techniques targeted methods to interrupt the chain who require aerosol-producing proce- are effective in protecting the occu- of infection. There are several strategies dures. Such mouth rinses could include pants of the dental operatory from that are currently promising for use in povidone iodine, hydrogen peroxide, direct and indirect aerosol exposure. practical application in the dental office. and/or hypochlorite. In vivo investiga- These include commonly used PPE 1. Vaccination development and wide- tions on the efficacy of preprocedural such as surgical masks/respirators, spread implementation for health-care mouth rinses in symptomatic and face shields, fluid impermeable gowns, providers and individuals in the popu- asymptomatic patients will provide and gloves. lation. Effective inoculation techniques guidance to quantify the achievable 6. No evidence exists to suggest that den- that are well accepted in society would levels of viral load reduction and the tal health-care professionals are at a

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higher risk of airborne viral disease 4. Lu C-W, Liu X-F, Jia Z-F. 2019-nCoV transmission 18. Holbrook WP, Muir KF, Macphee IT, Ross PW. transmission than the general popula- through the ocular surface must not be ignored. Bacteriological investigation of the aerosol tion, and emerging evidence suggests Lancet. 2020 Feb 22;395(10224):e39. doi. from ultrasonic scalers. Br Dent J. 1978 org/10.1016/S0140-6736(20)30313-5 Apr;144(8):245–247. that the risk may be lower during the delivery of dental care than in other 5. World Health Organization. Transmission routes of 19. Pollok NL 3rd, Williams GH 3rd, Shay DE, Barr CE. SARS-CoV-2: implications for infection prevention Laminar air purge of microorganisms in dental aerosols. health-care settings. precautions. Scientific Brief. July 9, 2020. Accessed J Am Dent Assoc. 1970 Nov;81(5):1131–1139. 7. Nonclinical areas within the dental September 20, 2020. https://www.who.int/news-room/ 20. Bentley CD, Burkhart NW, Crawford JJ. Evaluating office and/or community exposure of commentaries/detail/transmission-of-sars-cov-2- spatter and aerosol contamination during dental dental personnel may pose a significant implications-for-infection-prevention-precautions procedures. J Am Dent Assoc. 1994 May; risk within the dental office and adher- 6. Centers for Disease Control and Prevention. 125(5):579–584. ence to public health guidelines is criti- Coronavirus Disease 2019 (COVID-19): How COVID-19 21. Peng X, Xu X, Li Y, et al. Transmission routes of cal to limit spread of airborne illness. spreads. Accessed September 20, 2020. https://www. 2019-nCoV and controls in dental practice. Int cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/ J Oral Sci. 2020 Mar;12(1):9 doi.org/10.1038/ Summary how-covid-spreads.html s41368-020-0075-9 The global pandemic caused by the SARS- 7. Rothe C, Schunk M, Sothmann P, et al. Transmission of 22. Kenyon TA, Valway SE, Ihle WW, et al. Transmission CoV-2 has highlighted the risk of airborne 2019-nCoV infection from an asymptomatic contact in of multidrug-resistant Mycobacterium tuberculosis disease transmission, particularly in the den- Germany. N Engl J Med. 2020 Mar;382:970–971. doi. during a long airplane flight. N Engl J Med. 1996 tal office. There is established evidence of org/10.1056/NEJMc2001468 Apr;334(15):933–938. airborne transmssion via droplets and/or 8. Wax RS, Christian MD. Practical recommendations for 23. Bloch AB, Orenstein WA, Ewing WM, et al. aerosols from infected individuals during critical care and anesthesiology teams caring for novel Measles outbreak in a pediatric practice: airborne person-to-person contact. Given the high coronavirus (2019-nCoV) patients. Can J Anaesth. Feb. transmission in an office setting. Pediatrics. 1985 incidence of droplet and aerosol production 12, 2020. doi.org/10.1007/s12630-020-01591-x Apr;75(4):676–683. during dental procedures and the close con- 9. To KK-W, Tsang OT-Y, Yip CC-Y, et al. Consistent 24. Prospero E, Savini S, Annino I. Microbial aerosol tact dental health-care providers have when detection of 2019 novel coronavirus in saliva. Clin Infect contamination of dental healthcare workers’ faces and Dis. 2020;Feb. https://doi.org/10.1093/cid/ciaa149 delivering care, advanced methods to reduce other surfaces in the dental practice. Infect Control the risks to dental health-care providers and 10. Rodríguez-Morales AJ, MacGregor K, Kanagarajah Hosp Epidemiol. 2003 Feb;24(2):139–141. S, et al. Going global—travel and the 2019 their patients have been proposed as cur- 25. Araujo MW, Andreana S. Risk and prevention of novel coronavirus. Travel Med Infect Dis. 2020 rent best practices. Because this situation is transmission of infectious diseases in dentistry. Jan-Feb;33:101578. https://doi.org/10.1016/j. Quintessence Int. 2002 May;33(5):376–382. rapidly evolving, dental health-care provid- tmaid.2020.101578 ers are urged to continue close monitoring 26. Harrel SK, Molinari J. Aerosols and splatter in 11. Faecher RS, Thomas JE, Bender BS. Tuberculosis: a dentistry: a brief review of the literature and infection of emerging science and advisory state- growing concern for dentistry? J Am Dent Assoc. 1993 control implications. J Am Dent Assoc. 2004 ments from governmental and other agen- Jan;124(1):94–104. Apr;135:429–437. cies regarding best practices. Care should 12. Nash KD. How infection control procedures are 27. Szymanska J. Dental as an occupational be taken by dental health-care providers to affecting dental practice today. J Am Dent Assoc. 1992 hazard in a dentist’s workplace. Ann Agric Environ Med. utilize enhanced infection control protocols Feb;123(3):67–73. 2007;14(2):203–207. in addition to standard precautions when 13. Earnest R, Loesche W. Measuring harmful levels of 28. Leggat PA, Kedjarune U. Bacterial aerosols in the dental delivering care to patients. Dental care is bacteria in dental aerosols. J Am Dent Assoc. 1991 clinic: a review. Int Dent J. 2001 Feb;51(1):39–44. Dec;122(12):55–57. is an essential health-care service and the 29. King TB, Muzzin KB, Berry CW, Anders LM. The ability to safely deliver dental health-care 14. Travaglini EA, Larato DC, Martin A. Dissemination of effectiveness of an aerosol reduction device services is critical for patients, providers, organism-bearing droplets by high-speed dental drills. J for ultrasonic scalers. J Periodontol. 1997 the dental team, and the public as a whole. Prosthet Dent. 1966 Jan-Feb;16(1):132–139. Jan;68(1):45–49. 15. Miller RL. Generation of airborne infection ... by high 30. Bennet AM, Fulford MR, Walker JT, et al. Microbial REFERENCES speed dental equipment. J Am Soc Prev Dent. 1976 aerosols in general dental practice. Br Dent J. 2000; 1. Zhu N, Zhang D, Wang W, et al. 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50 DentalAcademyofCE.com DENTAL ACADEMY OF CONTINUING EDUCATION

medium=cpsalertbar&utm_content=cv-pm-ebd- 47. Pankhurst CL, Coulter W, Philpott-Howard JN, et al. 58. Kluytmans-van den Bergh MF, Buiting AG, Pas interim-response&utm_campaign=covid-19. Accessed Evaluation of the potential risk of occupational asthma SD, et al. Prevalence and clinical presentation of April 4, 2020. in dentists exposed to contaminated dental unit health care workers with symptoms of coronavirus 33. Kilian M, Chapple IL, Hannig M, et al. The oral waterlines. Prim Dent Care. 2005 Apr;12(2):53–59. disease 2019 in 2 Dutch hospitals during an early microbiome—an update for oral healthcare 48. Nett RJ, Cummings KJ, Cannon B, et al. Dental phase of the pandemic. JAMA network open professionals. Br Dent J. 2016 Nov;221(10):657–666. personnel treated for idiopathic pulmonary fibrosis 2020;3(5):e209673-e73. 34. Kumar P, Subramanian K. Demystifying the mist: at a tertiary care center—Virginia, 2000–2015. 59. Lai X, Wang M, Qin C, et al. Coronavirus disease 2019 Sources of microbial bioload in dental aerosols. J Morb Mortal Wkly Rep. 2018 Mar;67(9):270–273. (COVID-2019) infection among health care workers Periodontol. 2020;91:1113-1122. doi:10.15585/mmwr.mm6709a2 and implications for prevention measures in a tertiary hospital in Wuhan, China. JAMA Network Open 35. Gupta G, Mitra D, Ashok KP, et al. Efficacy of 49. Centers for Disease Control and 2020;3(5):e209666-e66. preprocedural mouth rinsing in reducing aerosol Prevention. Recommendations for prevention of HIV contamination produced by ultrasonic scaler: a pilot transmission in health-care settings. Morb Mortal Wkly 60. Centers for Disease Control and Prevention. study. J Periodontol. 2014 Apr; 85(4):562–568. Rep. 1987;36(SU02):001. Coronavirus disease 2019. Interim infection prevention and control guidance for dental settings during the 36. Al Maghlouth A, Al Yousef Y, Al Bagieh N. Qualitative 50. Centers for Disease Control and Prevention. Update: COVID-19 response. cdc.gov/coronavirus/2019-ncov/ and quantitative analysis of bacterial aerosols. J universal precautions for prevention of transmission of hcp/dental-settings.html. Accessed July 12, 2020. Contemp Dent Pract. 2004 Nov;5(4):91–100. human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. 61. American Dental Association. ADA interim 37. Grenier D. Quantitative analysis of bacterial aerosols in Morb Mortal Wkly Rep. 1988 Jun;37(24):377–382, guidance for management of emergency and two different dental clinic environments. Appl Environ 387–388. urgent dental care. ada.org/~/media/CPS/Files/ Microbiol. 1995 Aug;61(8):3165–3168. 51. Occupational Safety and Health COVID/ADA_Int_Guidance_Mgmt_Emerg-Urg_ 38. Legnani P, Checchi L, Pelliccioni GA. D’Achille C. Administration. Bloodborne pathogens. osha. Dental_COVID19.pdf?utm_source=cpsorg&utm_ Atmospheric contamination during dental procedures. gov/pls/oshaweb/owadisp.show_document?p_ medium=cpsalertbar&utm_content=cv-pm-ebd- Quintessence Int. 1994 Jun;25(6):435–439. table=STANDARDS&p_id=10051. Accessed July interim-flowchart&utm_campaign=covid-19. Accessed 39. Harrel SK, Barnes JB, Rivera-Hidalgo F. Aerosol 12, 2020. July 12, 2020. and splatter contamination from the operative site 52. Garner JS. Guideline for isolation precautions 62. US Environmental Protection Agency. Pesticide during ultrasonic scaling. J Am Dent Assoc. 1998 in hospitals. The Hospital Infection Control registration. List N: disinfectants for use against Sep;129(9):1241–1249. Practices Advisory Committee. Infect Control Hosp SARS-CoV-2. epa.gov/pesticide-registration/list-n- 40. Veena HR, Mahantesha S, Joseph PA, et al. Epidemiol. 1996 Jan;17(1):53–80. disinfectants-use-against-sars-cov-2. Accessed July Dissemination of aerosol and splatter during ultrasonic 12, 2020. 53. Centers for Disease Control and Prevention. Summary scaling: a pilot study. J Infect Public Health. 2015 of infection prevention practices in dental settings: May-Jun;8(3):260–265. MARIA L. GEISINGER, DDS, MS, basic expectations for safe care. cdc.gov/oralhealth/ is a professor and director of 41. Watanabe A, Tamaki N, Yokota K, et al. Use of ATP infectioncontrol/summary-infection-prevention- advanced education in bioluminescence to survey the spread of aerosol and practices/index.htmlAccessed July 12,2020. periodontology in the department splatter during dental treatments. J Hosp Infect. 2018 of periodontology in the University 54. Siegel JD, Rhinehart E, Jackson M, et al. 2007 Jul;99(3):303–305. of Alabama at Birmingham School guideline for isolation precautions: preventing 42. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping of Dentistry. Dr. Geisinger received transmission of infectious agents in health care review on bio-aerosols in healthcare and the dental her bachelor’s in Biology from settings. Am J Infect Control. 2007 Dec;35(10 Duke University, her doctorate environment. PLoS One. 2017 May;12(5):e0178007. Suppl 2):S65–S164 cdc.gov/hicpac/pdf/isolation/ from Columbia University School of Dental Medicine, and her 43. Volgenant CMC, de Soet JJ. Cross-transmission in the Isolation2007.pdf. Accessed July 12, 2020. master’s and certificate in periodontology and implantology dental office: Does this make you ill? Curr Oral Health 55. Harte JA. Standard and transmission-based from the University of Texas Health Science Center at San Rep. 2018 Oct;5(4):221–228. Antonio. Dr. Geisinger is a diplomate in the American Board precautions: an update for dentistry. J Am Dent Assoc. of Periodontology. She has served as the president of the 44. Delamater PL, Street EJ, Leslie TF, et al. Complexity of 2010 May;141(5): 572–581. the basic reproduction number (R0). Emerg Infect Dis. American Academy of Periodontology (AAP) Foundation and 56. Centers for Disease Control and Prevention. on multiple organized dentistry committees. She currently 2019 Jan;25(1):1–4. doi:10.3201/eid2501.171901 Coronavirus disease 2019 (COVID-19). For healthcare serves as chair of the American Dental Association’s Council 45. Chen Y, Li L. SARS-CoV-2: virus dynamics and host professionals. cdc.gov/coronavirus/2019-ncov/hcp/ on Scientific Affairs and is a member of the AAP’s board of response. Lancet Infect Dis. [ePub ahead of print] March caring-for-patients.html. Accessed April 4, 2020. trustees. Her research interests include periodontal and 23, 2020. doi.org/10.1016/S1473-3099(20)30235-8 systemic disease interaction, implant dentistry in the 57. Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. periodontally compromised dentition, and novel treatment 46. Zhou F, Yu T, Du R, et al. 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QUESTIONS

1. The person-to-person transmission routes 6. All of the following are true about spatter 12. SARS-CoV-2 may remain suspended in the air for COVID-19 of concern in dental practice droplets, except: once aerosolized: include all of the following except: A. Spatter particles are usually a mixture A. For up to one minute A. Direct transmission through airborne of air, water, and/or solid substance and B. For up to five minutes particles produced by a cough or sneeze are larger than 50 μm in diameter. C. For several hours B. Direct transmission through airborne B. They may become suspended in D. Indefinitely particles produced by dental procedures the air for long periods of time. C. Contact transmission after touching C. Spatter particles follow a ballistic pattern and 13. SARS-CoV-2 may survive on hard plastic or contaminated surfaces and then touching travel in an arc after they are emitted until metal surfaces for up to: oral, nasal, and eye mucous membranes they contact a surface or fall to the ground. A. 6 hours D. Fecal transmission D. They may be visible to the naked eye. B. 12 hours 2. A fomite is described as: 7. Unlike aerosols, spatter particles are too C. 24 hours A. Microbial particles capable large and contain too much mass to become D. 2–3 days suspended in the air and are airborne only of causing infection 14. All of the following diseases have been B. An infected individual who is briefly, so they demonstrate ___ penetration into the respiratory system. associated with transmission via aerosols capable of transmitting disease except: A. No C. Porous or nonporous surfaces or A. Influenza (Influenza viruses types A and B) objects that can become contaminated B. Limited B. Tuberculosis (Mycobacterium tuberculosis) and facilitate viral transfer C. Extensive C. Human immunodeficiency virus (HIV) D. An airborne droplet that can be D. Continuous inhaled and cause disease D. Legionnaires’ disease 8. While aerosols can remain airborne and travel (Legionella pneumophila) 3. Transmission of SARS-CoV-2 via dental long distances within dental treatment areas, aerosols has been shown in a clinical setting. spatter particles are generally deposited on 15. In response to the HIV epidemic, the Centers Aerosol transmission of SARS-CoV-2 may be surfaces closer to their origin, an estimated for Disease Control (now the Centers for dependent upon many factors including overall ___ cm from the droplet source. Disease Control and Prevention [CDC]) viral load in the aerosol/spatter, proximity introduced the concept that all blood and A. 1–5 body fluids that might be contaminated with of dental personnel to an infected patient, B. 6–12 type and effectiveness of PPE, and host blood should be treated as infectious. What susceptibility, among others. C. 15–120 year was this advice introduced? A. Both statements are true. D. 50–250 A. 1979 B. 1982 B. The first statement is true; the 9. The highest levels of aerosol and spatter second statement is false. emission has been shown to occur with the C. 1985 C. The first statement is false; the use of: D. 1991 second statement is true. A. Ultrasonic scalers 16. Standard precautions (formerly “universal D. Both statements are false. B. Intraoral radiograph capture precautions”) are designed to reduce 4. Aerosols are defined as liquid or solid particles C. High-speed handpiece use exposure to blood-borne pathogens and less than 50 micrometers in diameter. with a rubber dam include all of the following except: Particles of this size are small enough to stay D. Low-speed handpiece A. Hand hygiene airborne for an extended period, but can only B. Performing aerosol-generating procedures travel limited distances (less than 120 cm). 10. Dental aerosols are ___ accompanied by in an airborne infection isolation room (AIIR) spatter. A. Both statements are true. C. Proper use of personal protective A. Never B. The first statement is true; the equipment (PPE) second statement is false. B. Occasionally D. Handling contaminated materials C. The first statement is false; the C. Frequently or equipment in order to prevent second statement is true. D. Always cross-contamination D. Both statements are false. 11. All of the following have been shown 17. Standard precautions represent minimal 5. Smaller particles of an aerosol, those of to reduce microbial-containing aerosol standards to be applied to all patients, even ___ in diameter, have the potential to enter generation in the dental operatory during those who report low risks and/or appear the lungs and settle within the bronchial aerosol-producing procedures, except: asymptomatic. They may be supplemented passages, reaching as far as the pulmonary A. Use of barriers on surfaces with transmission-based precautions. alveoli, and are thought to convey the highest within the dental operatory A. Both statements are true. level of risk of infection transmission in the B. Use of a rubber dam B. The first statement is true; the dental office. C. Properly positioned high-speed evacuation second statement is false. A. 0.5–10 μm D. Preprocedural mouth rinses C. The first statement is false; the B. 25–50 μm second statement is true. C. 100–250 μm D. Both statements are false. D. > 250 μm

52 DentalAcademyofCE.com ONLINE COMPLETION QUICK ACCESS code 20001 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

QUESTIONS

18. Standard precautions apply to all patient care 23. The CDC recommends that health-care 27. All of the following are currently delivered in the following settings: workers take precautions to avoid direct recommended by the CDC when performing A. Hospital settings contact with infectious secretions from aerosol-producing procedures on COVID-19 B. Outpatient clinical settings patients who are known to be COVID- positive or suspected patients except: 19 positive or suspected to be COVID-19 C. Any setting where health care is delivered A. Limiting the number of health-care providers positive. All of the following are considered to those that are essential for the procedure D. A and B only infectious secretions except: B. Utilizing a surgical mask for all 19. Transmission-based precautions include all of A. Sputum procedures that produce aerosol the following categories except: B. Saliva C. Performance of aerosol-generating A. Airborne C. Blood procedures in an airborne infection B. Droplet D. Sweat isolation room (AIIR), where available C. Contact D. Clean and disinfect procedure room 24. CDC advice for the treatment of patients surfaces promptly using approved D. Distance who are known to be COVID-19 positive or protocols and disinfectants identified by suspected to be COVID-19 positive are: 20. SARS-CoV-2 poses a unique situation the Environmental Protection Agency as when delivering dental care in that it likely A. Assess and triage these patients with effective against SARS-CoV-2 (EPA List N) acute respiratory symptoms and risk requires additional transmission-based 28. Emerging strategies to augment infection precautions that many dental outpatient factors for COVID-19 to minimize chances of exposure, including placing a facemask control measures in dental practice to combat clinics may not be equipped to deliver. But, the COVID-19 pandemic include: unlike other diseases, like measles, patients on the patient and placing them in an may be able to spread SARS-CoV-2 during examination room with the door closed. A. Widespread vaccination the asymptomatic phase and may require B. Use standard and transmission-based B. Novel disinfection technologies dental health-care providers to develop and precautions when caring for patients C. Improved barriers, particularly for carry out systems for early detection and with confirmed or possible COVID-19. aerosol-producing procedures management of potentially infectious patients C. Perform hand hygiene with alcohol-based D. All of the above at initial points of entry to the dental setting. hand rub before and after all patient A. Both statements are true. contact, contact with potentially infectious 29. The ability to identify individuals who may B. The first statement is true; the material, and before putting on and upon be infected and asymptomatic as well as second statement is false. removal of PPE, including gloves. Use soap recovered individuals is currently not widely and water if hands are visibly soiled. available. Point-of-care rapid screening tests C. The first statement is false; the D. All of the above to identify both asymptomatic carriers and second statement is true. those who may carry immunity to COVID- D. Both statements are false. 25. The American Dental Association suggests 19 via adequate antibody titers are currently the use of ___ to perform initial assessments available to allow such screening of patients 21. Much of the current infection control for patients to determine 1) the likelihood of in a dental office. protocols in place in dental offices and the previous exposure to SARS-CoV-2 and 2) PPE used for dental procedures are designed A. Both statements are true. the nature of any dental emergency prior to B. The first statement is true; the to protect dental health-care providers from performing any in-person procedures. ___ pathogens. second statement is false. A. In office questionnaires and C. The first statement is false; the A. Airborne temperature screening B. Blood-borne second statement is true. B. Teledentistry interview D. Both statements are false. C. A and B C. An isolated treatment room D. None of the above D. Any of the above 30. Future research avenues focusing on quantification of the efficacy of emerging 22. The CDC states that close contact with a 26. Current CDC guidance suggests that mitigation strategies will allow for patient infected with SARS-CoV-2 conveys procedures that produce high levels of assessment of the risk-benefit analysis for significant risk for development of COVID- aerosols, in particular those that demonstrate such treatments. As science evolves, the best 19. The CDC defines “close contact” as: 1) exposure to infectious secretions or are practices for delivery of dental care in dental being within approximately 6 feet (2 meters) likely to induce coughing, should be avoided, practices will continue to evolve. of a patient with COVID-19 for a prolonged if possible. If such procedures must be period of time (30 minutes) or 2) having direct A. Both statements are true. performed, the CDC suggests use of an N95 or B. The first statement is true; the contact with infectious secretions from a greater respirator and other appropriate PPE. patient with COVID-19. second statement is false. A. Both statements are true. A. Both statements are true. C. The first statement is false; the B. The first statement is true; the second statement is true. B. The first statement is true; the second statement is false. second statement is false. D. Both statements are false. C. The first statement is false; the C. The first statement is false; the second statement is true. second statement is true. D. Both statements are false. D. Both statements are false.

DentalAcademyofCE.com 53 PUBLICATION DATE: OCTOBER 2020 ANSWER SHEET EXPIRATION DATE: SEPTEMBER 2023 COVID-19: Part 2—Is there something in the air? Aerosols and infection prevention/control in the dental office

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