Inthe early days of the Covid-19 pandemic, when almost all U.S. dentists had temporarily closed their doors, Ravina Kullar’s mother shut down her dental practice for good. At 70 years old, she was ready to stop practicing — but as it became clear that both her age and profession placed her at particularly high risk, the pandemic “kind of pushed her into retirement,” says Kullar, PharmD, a Los Angeles, California-based infectious disease specialist, epidemiologist, and Infectious Diseases Society of America spokesperson.

To date, no cases of Covid-19 have been attributed to any dental practices in the U.S., according to Kullar and the American Dental Association (ADA). But the practice of modern dentistry places oral healthcare practitioners and their patients in a uniquely dangerous position — and as practices reopen, people are facing decisions about whether and when to see a dentist.

Here’s what you need to know if you’re one of them.

Why dental practices are uniquely high-risk

The novel coronavirus spreads when virus-contaminated saliva droplets from a symptomatic or asymptomatic person find their way into another person’s nose, mouth, or eyes, conveyed there either by inhaling droplet-filled air or by second-hand contact with a surface (as when a person wipes their nose with their hand after touching a contaminated doorknob).

The issue is that dentist’s offices create huge amounts of saliva droplets. “Look at some of the instruments that they use, such as the drills, the scalers, the air-water syringes,” says Kullar.

When used in the mouth, all of these instruments create sprays of tiny droplets and aerosols containing not only water but saliva — which contains high levels of virus, blood, and microorganisms. The smallest of these particles can stay in the air for hours, while larger ones can land on surfaces like doorknobs and dental chairs.

Together, these characteristics make aerosolized oral secretions powerful potential vectors of Covid-19 in dental practices.

Because dental practices are such high-risk environments, the U.S. Centers for Disease Control and Prevention (CDC) recommended against providing all but emergency dental services in March. And indeed, during the first few months of the pandemic, fewer than 5% of U.S. dentists were open for non-emergent visits, according to a member survey conducted by the American Dental Association.

As the pandemic has evolved, however, more dental practices have reopened for business: As of mid-July, about 42% of practices nationwide were conducting business as usual, according to the survey.

What practices are (or should) be doing differently

Many of the CDC’s recommendations — like those related to surface cleaning and the personal protective equipment worn by the hygienists, dentists, and other professionals who actually poke around in mouths — were already part of many dental professionals’ practices pre-Covid-19, says Kullar. But other infection control practices might be new to some, among them the CDC’s recommendation to consider using HEPA filters and ultraviolet irradiation of upper-room air to kill any potential circulating germs during aerosol-generating procedures.

A portion of the CDC guidelines are dedicated to ensuring that neither sick patients nor staff show up to dental offices to begin with, which includes actively screening “for fever and symptoms of Covid-19 for all people who enter the dental facility.” That’s a key infection control practice Kullar hopes will become a standard well after Covid-19 transmission is a concern. “Going into the workplace when you’re sick and plowing through it should never happen, and I really hope that people learn from that with Covid,” she says.

The ADA has released a toolkit to help dental professionals safely return to work in compliance with the CDC’s guidelines for infection control in dental settings. In a written statement, ADA president Chad Gehani, DDS, noted the organization had also released a hazard assessment checklist to help its membership identify risks to workers in dental offices. “Simply going through the process makes a safer office environment for patients,” he wrote.

Most dental practices are taking the maximum precautions — including installing HEPA filters — because they want to be safe and to be back at work, says Mary Govoni, a former dental assistant and hygienist who now specializes in dental practice infection control. Additionally, she says, in many states there are legal ramifications for dentists who do not comply with the CDC’s infection control recommendations.

Meanwhile, shortages of personal protective equipment have severely affected dentists across the country, says Govoni. Although she says practices should ideally have at least two to four weeks’ worth of N95 respirator masks in stock, the ADA survey indicated only 55% of practices had at least two weeks’ worth of these materials available.

Many dental practices thought that “when they got the okay by their state to open back up, they’d go in, turn the lights on, turn all the equipment on, and it’s business as usual with as full a schedule as they’ve ever had and it’s fine,” says Govoni. “It’s not fine.”

Ultimately, the question is really whether the practice is pacing its patient visits to avoid running out of personal protective equipment and putting their patients and staff at risk.

How to decide whether to go in for a routine check-up or a cleaning

Because Govoni knows her dentist adheres to strict infection control practices and because she’s located in a part of Michigan with a low and decreasing number of Covid-19 cases, she would feel comfortable going in for a regular dental checkup.

But given the recent surge in Covid-19 cases in Los Angeles, Kullar says she would not see her dentist for anything other than an emergency. She recommends that people avoid preventive (i.e. nonemergency) dental care if cases are high or increasing in your area.

But local pandemic dynamics shouldn’t be the only consideration for people considering a routine dental visit. Kullar suggests being mindful not only of the county you’re in, “but also, who are you?” If you’re part of a population at high risk for bad outcomes of Covid-19 infection — if you smoke, are over 65, or have lung conditions like asthma, for example — consider waiting to get preventive dental care until after the pandemic, she says.

If you do find yourself needing emergency dental care, or if you live in an area where Covid-19 numbers are low and decreasing, it’s not unreasonable to consider seeing your dentist, says Kullar.

Ask questions

Before you make an appointment, both she and Govoni suggest asking about the office’s infection control practices, starting with what happens before the visit. Inquire whether patients are screened over the phone before coming into the office. They should be — and if they’re not, that’s a big red flag, says Govoni. Kullar also suggests asking whether staff are routinely tested for Covid-19, a practice that may reduce transmission in clinical settings (although CDC guidelines do not recommend routine testing of asymptomatic staff).

What’s more, waiting rooms’ many high-touch surfaces and crowded airspaces make them perfect environments for spreading Covid-19. For that reason, Kullar recommends asking whether the practice limits the number of people allowed in the waiting room at one time. The ideal number will vary by the practice but should allow for at least six feet of distance from others in the waiting room.

She also recommends asking how frequently both the waiting room and the clinical space are cleaned. Clinical spaces should be cleaned after each patient, and other common spaces should be cleaned several times throughout the day, says Govino.

Lastly, ask what the practice does to prevent aerosolized virus from being in the practice’s airspace: Does the clinical area have a HEPA filter in place? Does the staff have enough personal protective equipment? Do both staff and patients wear masks at all times?

If the answer to all of these questions is “yes,” you can feel relatively at ease going to the dentist’s office, as measures have been put in place to keep the environment as safe as possible, says Kullar. But if not, she says, she’d think twice before going.