Copyright © 2020 California Dental Association

B A C K T O P R A C T I C E

California Dental Association1201 K Street, Sacramento, CA 95814

800.232.7645 | cda.org ®

P R E P A R I N G Y O U R P R A C T I C E

0520

Date____________________________

Questions should be administered by the employer or designated senior management.

Employee NameTemperature(>100.4°F)

Shortness of breath

Dry cough

Runny nose

Sore throat

Loss of smell, taste

Chills Muscle pain

Headache Asked to go homeIf yes, note time dismissed

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

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Y

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Y

N

Y

N

Y

N

Y

N Y

Time:

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N

Y

N

Y

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N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

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Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

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N

Y

N

Y

N

Y

N Y

Time:

N

Y

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Y

N

Y

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Y

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N

Y

N

Y

N

Y

N Y

Time:

N

Y

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Y

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N Y

Time:

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N Y

Time:

Information contained on this form is confidential employee health information.

Employee Screening for COVID-19

Copyright © 2020 California Dental Association

B A C K T O P R A C T I C E

California Dental Association1201 K Street, Sacramento, CA 95814

800.232.7645 | cda.org ®

P R E P A R I N G Y O U R P R A C T I C E

0520

PPE Recommendations for Dental Practices

California Dental Association1201 K Street, Sacramento, CA 95814

800.232.7645 | cda.org ®

Dental Practice Scenarios

Surgical Mask

N95/ KN95

Face Shield

Eye Protection & Side Shield

Gloves Clinical Attire**

Gown Head Cover

Dedicated Shoes/Covers

Administrative Level 1 =

Pre-Visit Patient Temperature Screening

Level 1

Lab/Instrument Processing +

Level 2 Choose one

No Fluid ^ Level 1 Choose one

Low Fluid ^ Level 2 Choose one

Moderate- Heavy Spray/Aerosol Generating Procedures #

L3 if N95 unavailable

*

Recommended Optional Not Recommended While it is understood that aerosols are produced in various ways, both organically by the patient and through various dental procedures, it is still unknown how exactly the virus is transmitted. Based on current studies and guidelines, these recommendations reflect what levels of adequate PPE will protect patients and dental team members.

* During PPE shortage, surgical masks should be prioritized for dental team members providing direct patient care and may be an acceptable alternative in addition to a full-face shield when N95/KN95 or higher masks are not available. The use of a Level 3 mask instead of an N95/KN95 mask may carry a higher risk for transmission due to the lack of a respirator seal, without which limits the mask’s protection primarily to splatter and droplets.

** If consistent with office uniform policy, dental team members should change out of street clothes into clinical attire upon arrival to the office. Although clinical attire is not considered PPE under the dental practice act. Lab coats worn as the outermost garment that provide adequate protection for the employee may be considered PPE. A gown may be a more appropriate choice of protective attire for most dental procedures.

= Alternatives to a face shield may include the installation of a sneeze guard or the mandate that patients wear masks in the reception area. If such a policy is implemented, dental practices should consider providing Level 1 masks to patients who arrive without a mask.

^ PPE in these scenarios should be changed between patients when visibly wet or soiled.

# PPE, including gowns, should be changed between patients. Follow CDC guidelines for mask extended use, reuse, and decontamination.

+ For staff performing in-office laundering duties, it is recommended that a Level 1 or 2 surgical mask, face shield or eye protection, gloves, clinical attire, and gown are worn. Follow established protocols for donning and doffing for cleaning patient care areas.

Resources NIOSH-Approved N95 Manufacturers Authorized Imported Non-NIOSH Approved Respirator Manufacturers CDC Recommended Guidance for Extended Use and Limited Reuse of N95 Masks CDC Crisis Standards of Care Decontamination Recommendations for RespiratorsCDC Strategies for Optimizing PPE Supply

SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)

CS250672-E

ThetypeofPPEusedwillvarybasedonthelevelofprecautionsrequired,suchasstandardandcontact,dropletorairborneinfectionisolationprecautions.TheprocedureforputtingonandremovingPPEshouldbetailoredtothespecifictypeofPPE.

1. GOWN• Fullycovertorsofromnecktoknees,armstoendofwrists,andwraparoundtheback

• Fasteninbackofneckandwaist

2. MASK OR RESPIRATOR• Securetiesorelasticbandsatmiddleofheadandneck

• Fitflexiblebandtonosebridge• Fitsnugtofaceandbelowchin• Fit-checkrespirator

3. GOGGLES OR FACE SHIELD• Placeoverfaceandeyesandadjusttofit

4. GLOVES• Extendtocoverwristofisolationgown

USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION

• Keephandsawayfromface• Limitsurfacestouched• Changegloveswhentornorheavilycontaminated• Performhandhygiene

HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1ThereareavarietyofwaystosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Hereisoneexample.Remove all PPE before exiting the patient roomexceptarespirator,ifworn.Removetherespiratorafterleavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:

1. GLOVES• Outsideofglovesarecontaminated!• Ifyourhandsgetcontaminatedduringgloveremoval,immediately

washyourhandsoruseanalcohol-basedhandsanitizer• Usingaglovedhand,graspthepalmareaoftheotherglovedhand

andpeelofffirstglove• Holdremovedgloveinglovedhand• Slidefingersofunglovedhandunderremaininggloveatwristand

peeloffsecondgloveoverfirstglove• Discardglovesinawastecontainer

2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandor

earpieces• Iftheitemisreusable,placeindesignatedreceptaclefor

reprocessing.Otherwise,discardinawastecontainer

3. GOWN• Gownfrontandsleevesarecontaminated!• Ifyourhandsgetcontaminatedduringgownremoval,immediately

washyourhandsoruseanalcohol-basedhandsanitizer• Unfastengownties,takingcarethatsleevesdon’tcontactyourbody

whenreachingforties• Pullgownawayfromneckandshoulders,touchinginsideofgownonly• Turngowninsideout• Foldorrollintoabundleanddiscardinawastecontainer

4. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat

thetop,andremovewithouttouchingthefront• Discardinawastecontainer

CS250672-E

OR5. WASH HANDS OR USE AN

ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE

HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2

HereisanotherwaytosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Remove all PPE before exiting the patient room exceptarespirator,ifworn.Removetherespirator after leavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:

1. GOWN AND GLOVES• Gownfrontandsleevesandtheoutsideofglovesare

contaminated!• Ifyourhandsgetcontaminatedduringgownorgloveremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer

• Graspthegowninthefrontandpullawayfromyourbodysothatthetiesbreak,touchingoutsideofgownonlywithglovedhands

• Whileremovingthegown,foldorrollthegowninside-outintoabundle

• Asyouareremovingthegown,peeloffyourglovesatthesametime,onlytouchingtheinsideoftheglovesandgownwithyourbarehands.Placethegownandglovesintoawastecontainer

CS250672-E

A B

D E

C

2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandand

withouttouchingthefrontofthegogglesorfaceshield• Iftheitemisreusable,placeindesignatedreceptaclefor

reprocessing.Otherwise,discardinawastecontainer

3. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,

immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat

thetop,andremovewithouttouchingthefront• Discardinawastecontainer

OR

4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE

Copyright © 2020 California Dental Association

B A C K T O P R A C T I C E

California Dental Association1201 K Street, Sacramento, CA 95814

800.232.7645 | cda.org ®

P R E P A R I N G Y O U R P R A C T I C E

0520

N95 Fit Testing Requirements

California Dental Association1201 K Street, Sacramento, CA 95814

800.232.7645 | cda.org ®

The N95 respirator is the most common of the seven types of particulate filtering facepiece respirators. It filters at least 95% of airborne particles but is not resistant to oil. N95 respirators which are approved by the National Institute of Occupational Safety and Health (NIOSH) and also are cleared by the Food and Drug Administration (FDA) are referred to as “surgical N95 respirators.”i Additional information about the respirator is available on the CDC NIOSH website listed below. During the COVID-19 emergency, the FDA issued emergency use authorizations for NIOSH-approved, non-FDA cleared respirators and for specific respirators manufactured outside the U.S. that are considered N95-equivalent.ii

An employer who requires employees to wear respirators is required by OSHA and Cal/OSHA to have a written respirator protection program, to provide staff training and to have staff fit tested. Initial fit testing remains a requirement under the current emergency.iii

The applicable Cal/OSHA regulations are Aerosol Transmissible Diseases (Section 5199) and Respiratory Protection (Section 5144). If an employer requires an employee to wear an N95 respirator, then the following steps must be followed to comply with Cal/OSHA regulations:

1. Employer provides a medical evaluation to the employee to determine the employee’s ability to use a respirator. The employer must identify a licensed health care professional to perform the evaluation using a questionnaire. The questionnaire must gather the information described in Appendix C of the Respiratory Protection regulation.

a. The confidential medical evaluation must be conducted during normal working hours or at a time and place convenient to the employee.

b. The employer or supervisor may not view an employee’s responses to the questionnaire. The employee must be provided with an opportunity to discuss the questionnaire and examination results with licensed health care professional.

c. If an employee gives a positive response to any question among questions 1 through 8 in Section 2, Part A of Appendix C, the employer must provide a follow-up medical examination. The follow-up examination shall include any medical tests, consultations, or diagnostic procedures that the licensed health care professional deems necessary to make a final determination.

d. The employer shall provide to the licensed health care provider before the provider makes their recommendation:

i. The employer’s written respiratory protection program and a copy of the Respiratory Protection regulation.

ii. The type and weight of the respirator to be used by the employee.

iii. The duration and frequency of respirator use.

iv. The expected physical work effort.

cda.org/back-to-practiceN95 Fit Testing Requirements | 2 of 3

v. Additional protective clothing and equipment to be worn.

vi. Temperature and humidity extremes that may be encountered.

e. The licensed health care provider transmits a written recommendation to the employer regarding an employee’s ability to use the respirator. The recommendation shall only provide the following information:

i. Any limitations on respirator use related to the employee’s medical condition or related to the workplace conditions.

ii. The need for follow-up medical evaluations, if any.

iii. A statement that the employee was provided with a copy of the licensed health care provider’s recommendation.

f. If the respirator the employee is to use is a negative pressure respirator and the licensed health care provider finds a medical condition that may place the employee’s health at increased risk if the respirator is used, the employer must provide a powered air-purifying respirator (PAPR) if the medical evaluation finds that the employee can use one. If a subsequent medical evaluation finds that the employee is medically able to use a negative pressure respirator, then the employer is no longer required to provide a PAPR.

2. Additional medical evaluations are required, at a minimum, when:

a. An employee reports medical signs or symptoms related to their ability to use a respirator.

b. The licensed health care provider, program administrator or supervisor recommends reevaluation.

c. Information from the respirator program, including observations made during fit testing and program evaluation, indicates a need.

d. Change occurs in workplace conditions that may substantially increase the physiological burden on an employee.

3. Employer must perform either quantitative or qualitative fit tests in accordance with Cal/OSHA regulations. The test must follow the protocols described in Appendix A of the Respiratory Protection regulation. The following steps must precede the fit test:

a. The employee to select an acceptable respirator that will fit them.

b. The employee is shown how to put on the respirator and to ensure it is an acceptable and comfortable fit.

c. The employee performs seal checks.

d. The employee performs a series of exercises while wearing the respirator. The exercises are described in Appendix A.

cda.org/back-to-practiceN95 Fit Testing Requirements | 3 of 3

Fit test kits are available for sale, but a dental practice may want to consider hiring an industrial hygienist to conduct the test. Cal/OSHA requires employers to ensure that persons administering the qualitative fit test are able to prepare test solutions, calibrate equipment, perform tests properly, recognize invalid tests and ensure that test equipment is in proper working order. The requirements are similar if conducting a quantitative fit test.

When quantitative fit testing is performed, the employer shall not permit an employee to wear a filtering facepiece respirator or other half-facepiece respirator, unless a minimum fit factor of one hundred (100) is obtained. When fit testing single use respirators, a new respirator shall be used for each employee.

The employer must ensure that each employee who is assigned to use a filtering facepiece or other tight-fitting respirator passes a fit test:

1. At the time of initial fitting.

2. When a different size, make, model or style of respirator is used.

3. At least annually thereafter. Note that the annual fit test requirement is suspended for the duration of the COVID-19 emergency.

A dental practice may contact a local occupational medical clinic to conduct the medical evaluation and an industrial hygienist to perform the fit testing.

Resource

CDC NIOSH, Respirator Trusted-Source Information, Section 3: Ancillary Respirator Information, https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html#e, accessed April 15, 2020

i NIOSH-Approved N95 Particulate Filtering Facepiece Respirators, cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html.

i i U.S. FDA Emergency Use Authorizations, www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations.

iii U.S. Occupational Safety and Health, April 8, 2020 memorandum, https://www.osha.gov/memos/2020-04-08/expanded-temporary-enforcement-guidance-respiratory-protection-fit-testing-n95

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The CDC now recommends people over age 2 wear cloth face masks when outside theirhomes. Below are some frequently asked questions about the useof face masks for children during the COVID-19 pandemic.  

Why are people wearing masks right now? CDC recommends that people wear a cloth face covering over their nose and mouth inthe community setting during the COVID-19 pandemic, however, children youngerthan age 2 should not wear masks. 

The purpose of people wearing masks in public right now is to protect the community.Since so many people who have COVID-19 don’t have symptoms, wearing masks can helpreduce the possibility that someone with no symptoms could transmit the disease toothers. 

Since masks reduce the spray of that person’s spit or infectious respiratorydroplets, masks can help reduce this kind of spread of the virus. 

Masks also can protect you from others who may have coronavirus but areasymptomatic and who could come within 6 feet of you, which is the range oftransmitting infection through acts like sneezing or coughing. 

Is there a “right way” to wear and use a mask? Yes. For a mask to be safest and most protective for children andadults, they should securely cover the nose and mouth and stretch from before the ear tothe other side.  

Masks should not be worn when eating or drinking.  

Masks should not be touched when on. 

Hand washing should take place before and a�ter you remove a mask.  

Masks should be washed a�ter each wearing. Remove the mask from behind withouttouching the front of the mask.  

Should children wear masks?  

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The CDC does not recommend masks for children under age two.  

If children are at home with just the usual residents, they do not need to wear a mask,assuming that they have not been exposed to anyone with COVID-19. 

If children can be kept at least 6 feet away from others, and not be in contact withsurfaces that could harbor the virus, then they do not need a mask for the protection ofthemselves or others.   

For example, during a walk outdoors, as long as children can maintain socialdistancing of more than 6 feet and do not touch tables, water fountains, playgroundequipment or other things that infected people might have touched, then they will notacquire the infection and would not need masks. 

Especially for younger children who may not understand why they can’t run up towardother people or touch things they shouldn’t, the best approach is to keep them home andin spaces away from other people and common surfaces.

Places where a child would bene�t from wearing a mask are places where they are likelyto encounter other people at a closer than 6 foot range. For example, if you must takeyour child to the doctor, or the pharmacy or grocery store, and are unable to leave themat home, wearing masks in those settings could be bene�cial. 

Children with fever or respiratory or GI symptoms like a cough, congestion, runny nose,diarrhea, or vomiting should not leave home.  

Children with severe cognitive or respiratory impairments may have a hardtime tolerating a face mask, so special precautions may be needed with these children,such as monitoring with a pulse oximeter if available, and/or maintaining greaterphysical distance from others outside their home.  

Situations in which children should not wear a mask include:  Children under the age of 2 years, due to risks of su�focation.  

If the only face covering available is a possible choking or strangulation hazard.  

If the child has di��culty breathing with the face covering or is unconscious,incapacitated or otherwise unable to remove the cover without assistance.  

If wearing the face covering causes the child to increase risk of getting exposedto the virus because they are touching their face more frequently. 

/

What about infants or children with special health careneeds? 

If you must go outside or to a place where you are not able to practice social distancingwith an infant, cover the infant carrier with a blanket, which helps protect the baby, butstill gives them the ability to breathe comfortably. Do not leave the blanket on the carrierin the car or at any time when the baby and carrier are not in direct view.  

Children who are considered high-risk or severely immunocompromised are encouragedto wear an N95 mask to best protect themselves.  

Families of children at higher risk are encouraged to use a standard surgical mask if theyare sick to prevent the spread of illness to others.  

What if a child is scared of wearing a mask, or too young tounderstand not to tamper with it? 

If your child is scared of wearing a mask, parents should wear masks too so your childdoesn't feel alone. Some other ideas to help make masks seem less scary are: 

While wearing masks, look in the mirror and talk about it. 

Put a mask on a favorite stu�fed animal. 

Decorate a mask so it's more personalized and fun. 

Show your child pictures of other children wearing masks. 

Draw a mask on their favorite book character. 

Have your child practice wearing a mask at home �rst. 

For children under 3 years old, it’s best to answer their questions simply in language theyunderstand. If children ask about people wearing masks or other face coverings, parentscan explain that sometimes people wear masks when they are sick, and when they areall better, they stop wearing the mask.  

An important way to reassure children is to emphasize how you are taking steps to staysafe. Children feel empowered and less afraid when they know what to do to keepthemselves safe. 

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For children over age 3, try focusing on germs. Parents can explain that germs are specialto your own body and we need to make sure they stay within your body. The masks helpkeep your own germs to yourself. Some germs are good, some are bad – we can’t alwaystell which are good or bad, which is why you need to wear a mask. Some germs can makeyou sick. We to make sure you keep those germs away from your own body. 

One of the biggest challenges with having children wear masks relates to them “feelingdi�ferent” or stereotyping them as being sick. If this becomes more of a norm, it will helpchildren not to feel singled out or isolated, and they may feel strange not wearingsomething. 

What kind of material is best for a mask for the averageperson to wear? 

Homemade or purchased cloth masks are suitable for the average person to wear. For achild, especially a small child, ensuring the right �t is important.  

Pleated masks with elastic are likely to work best for children, but the right size isimportant. Adult masks are usually 6x12 inches, and even a child-sized 5x10 inch maskmay be too large for young children. Try to �nd the right size for your child’s face and besure to adjust it for a secure �t.   

Due to very limited supply now, professional grade masks like N-95 masks should bereserved for medical professionals on the front lines who have increased risk of exposureto coronavirus in close proximity.  

Last Updated 04/09/2020

Source American Academy of Pediatrics