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Dental Surgeons of Ontario
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COVID-19: Managing infection risks during in-person dental care

The RCDSO’s guidance, COVID-19: Managing infection risks during in-person dental care, assist dentists in preparing their offices to safely provide in-person care. We've also prepared a list of FAQs on COVID-19. The College continues to monitor and update this guidance as necessary, including in response to additional guidance or announcements from the Provincial Government and changing rates of community transmission of COVID-19.

Updated September 20, 2021. 

Contents

  1. COVID-19 update

  2. Key updates to the College's guidance

  3. Introduction

    - This guidance is informed by the direction of public health authorities and available clinical evidence
    - The college is acting in partnership
    - Ontario’s oral health regulators are working together to provide consistent guidance
    - Additional resources

  4. Principles

  5. Guidance

  1. Preparing the Office
  1. Patient Intake
  1. Providing In-Person Care
  1. Aerosol-Generating Procedures
  1. Patient Departure and Office Sanitization
  1. COVID-19 Exposure in the Practice

COVID-19 update

Ontario is making progress in the fight against COVID-19 and some public health restrictions are being lifted.

As community transmission of COVID-19 declines, so does the risk of transmission of COVID-19 occurring during oral health care.

The College is updating its guidance for managing infection risks during in-person dental care. These updates include preliminary steps to ease precautions for dentistry in light of available evidence, in compliance with the direction of public health authorities, and in alignment with our regulatory colleagues.

The College continues to evaluate the risks present in the oral healthcare environment and will amend this guidance as appropriate.

Key updates to this guidance

  1. Minor amendments to ensure consistency with the guidance of Ontario’s other oral health professions, including dental hygienists, denturists, and dental technologists (see below: “The College is Acting in Partnership”).
  2. The Ontario Ministry of Health’s COVID-19 screening tool has been updated for dentists and dental office staff (Point 10).
  3. Dentists’ obligation to record and retain information concerning the screening results of individuals attending the office has been clarified (Point 10a and 28a).
  4. Some precautions have been reduced for patients who have screened negative for COVID-19 including aerosol-generating procedures and reduced PPE requirements (see Table 1).
  5. New guidance for when a parent or caregiver may wish to be present during an aerosol-generating procedure, including PPE requirements (Point 50-51).
  6. The percentage target for airborne contaminant removal has been reduced from 99.9% to 99% which shortens fallow times (see Table 2).

Introduction

Dental offices are at a high risk for spreading COVID-19 given the aerosol generating nature of dental procedures, the proximity of the operating field to the upper respiratory tract, and the number of patients seen per day. All dentists providing in-person care must comply with the direction of government and the College to maintain the safety of patients and staff.

This guidance is informed by the direction of public health authorities and available clinical evidence

The College’s guidance aligns with the directives of the Chief Medical Officer of Health, the Minister of Health, and other relevant public health authorities.

This guidance is also informed by current best practices and the best available evidence. Where professional consensus is lacking or the available evidence is unclear, the College’s guidance takes a precautionary approach that prioritizes the safety and well-being of patients, staff, the broader public, and dentists.

As Ontario’s landscape evolves, including updates to Provincial directives and the emergence of updated evidence, the College will revise the guidance contained in this document.

The college is acting in partnership

Responding to the COVID-19 pandemic is a multi-stakeholder effort involving partners throughout the healthcare landscape, including the Ontario Dental Association, academic researchers, municipal, provincial, and federal governments, and front-line health care workers, among many others.

Ontario’s oral health regulators are working together to provide consistent guidance

Ontario’s oral health regulatory Colleges are committed to working together to provide consistent guidance for the safe and effective provision of oral healthcare during the COVID-19 pandemic.

This ongoing collaboration, which involves the Royal College of Dental Surgeons of Ontario, the College of Dental Hygienists of Ontario, the College of Dental Technologists of Ontario, and the College of Denturists of Ontario, aims to provide Ontario’s oral health professions with clear and consistent expectations for the provision of in-person care. This means that oral healthcare providers can be assured that their regulatory Colleges have reviewed and agreed upon consistent expectations for overlapping areas of practice (e.g., use of PPE), and that these expectations are reflected consistently in each College’s updated guidance material

Building upon the work undertaken to-date, Ontario’s oral health regulatory Colleges will continue to work together to produce clear and consistent guidance and to promote safe and high-quality care for patients.

Additional resources

This document should be read in conjunction with related RCDSO Guidance Documents and Standards of Practice.

The College’s guidance is written to align with the positions and direction of the Chief Medical Officer of Health, Federal guidance, the Provincial Government and Ontario's other oral health regulatory Colleges.

Additional Applicable Resources Include:

Principles

The following principles form the foundation for this guidance:

  1. The health and safety of patients, the public, and practitioners is our top priority.
  2. Guidance will be based on the best available evidence and data. In the absence of clear evidence, guidance will prioritize caution and safety.
  3. Continuity of care must be preserved. Patients of record must have reliable access to their oral healthcare providers to ensure they receive appropriate guidance, support, and care.
  4. Patient access to oral healthcare must be balanced against the risk of spreading COVID-19.
  5. Technology should be used to assess risks and triage patient needs remotely (e.g., teledentistry).
  6. Communication with patients is critical. Risks or changes to care related to COVID-19 must be highlighted.

Guidance

1. Preparing the office

Review of personal protective equipment

  1. Dentists should keep an inventory of personal protective equipment (PPE) to help inform the volume and scope of care that can be safely provided.

General staff requirements

  1. Dentists must meet with staff and thoroughly review and explain the guidance contained in this document as well as any new office policies and procedures.
  2. Dentists are advised to limit the number of staff in the practice at one time.
  3. Dentists are advised to ensure that staff breaks are structured in a way to support physical distancing.
  4. Dentists and staff must maintain physical distancing of at least of 2 meters except as required to provide patient care.
  5. Dentists and staff must wear PPE appropriate to their role (see Table 1 below).
  6. Because clothing worn in the office can become contaminated with COVID-19, dentists and staff must change into office clothes (e.g., scrubs) and footwear immediately upon reporting to work.
    • Clothes worn in the office must not be worn outside of the office (e.g., home), and should be laundered after every shift (for more information on the laundering requirements for scrubs and isolation gowns, please see the College’s COVID-19 FAQ).
    • Laundry bins/containers should be lined with a barrier (such as a garbage bag) to avoid cross-contamination during the storage and transportation process.
  7. Dentists and staff must wear an appropriate mask at all times except as needed for eating and drinking (see Table 1).
  8. Dentists and staff must conduct hand hygiene frequently using an alcohol-based rub (70–90% ABHR) or soap and running water (especially before and after any contact with patients, after contact with high-touch surfaces or equipment, and after removing PPE).
  9. Dentists and staff must be screened for COVID-19 prior to each shift using the COVID-19 screening questions developed by the Ontario Ministry of Health.
    • Dentists must ensure that all screening results are recorded and retained in accordance with the requirements for administrative or office records set out in the College’s Dental Recordkeeping Guidelines.
  10. Dentists and/or staff who screen positive for COVID-19 must:

Office setup

  1. Dentists should ensure that points of entry into the office are limited (e.g., by designating a single entrance door).
  2. Dentists must ensure that the office and operatories are clean and disinfected.
  3. Dentists must ensure magazines, toys, and any other non-essential items are removed from the office, reception area, and operatories.
  4. Dentists must post signage in common areas (e.g., at the main entrance and in the waiting area) communicating relevant expectations for patients (see the Ministry of Health’s COVID-19 Operational Requirements: Health Sector Restart document). Signage must include any requirements for:
    • office capacity,
    • hand hygiene (e.g., a requirement to wash and/or sanitize hands upon entry to the practice),
    • respiratory hygiene (e.g., a requirement to wear a mask within the practice), and
    • physical distancing (e.g., a requirement to maintain a minimum distance of 2 meters, except as required for the provision of care).
  5. Dentists must post signage at the entrance to the office and at reception describing the signs and symptoms of COVID-19, along with instructions for patients who screen positive for COVID-19.
  6. Dentists must develop and post a COVID-19 Workplace Safety Plan.
  7. Dentists must ensure the availability of 70-90% ABHR at all entry points to the office as well as the reception area for use by staff.
  8. Dentists must ensure that patients and staff have access to tissues and receptacles lined with garbage bags.
  9. Dentists are advised to consider installing physical barriers at key contact points to reduce the spread of droplets, including reception (e.g., a plexiglass shield).

2. Patient intake

Scheduling appointments and preliminary screening

  1. To schedule in-person appointments for assessment and/or treatment, dentists must ensure that they can meet the PPE and operatory requirements outlined in this document.
    • Since each office is arranged and functions differently, the College relies on the professional judgment of dentists and their staff to adjust their practice for the enhanced protection of themselves and others.
  2. If a dentist is unable to meet the applicable PPE and operatory requirements, and the patient requires in-person treatment, the appointment must be deferred until the PPE and/or operatory requirements can be met, or the patient must be referred to another available practitioner.
  3. Dentists must ensure that appointments are scheduled and managed to support requirements for physical distancing, and to avoid or limit direct, face-to-face interaction with others, including staff and other patients (for example, by staggering appointment times).
  4. Dentists must ensure that patients are triaged and appointments are scheduled by phone or via teledentistry, not in person or via walk-in except as may be necessary in an emergency (see the College’s FAQ for definitions of emergency and urgent care).
  5. Prior to scheduling an appointment, dentists must ensure that patients are screened for COVID-19 using the COVID-19 screening questions developed by the Ontario Ministry of Health.
  6. Patients who screen positive for COVID-19 must not be treated in-person except as needed for emergency or urgent care that cannot be delayed (see the College’s FAQ for definitions of emergency and urgent care).
    • Patients who screen positive for COVID-19 should be advised to self-isolate and contact their primary care provider or Telehealth Ontario at 1-866-797-0000 to determine next steps or visit an assessment center to get tested.
    • COVID-19 is a designated disease of public health significance, which means that dentists are subject to reporting requirements under the Health Protection and Promotion Act. Public Health Ontario has advised that dentists must report “probable” and “confirmed” cases of COVID-19 to the public health unit in which the professional services were provided (see the following link for more information). Public Health Ontario has further advised that dentists are not required to report every patient who screens positive for COVID-19 when scheduling or attending a dental appointment.
  7. Dentists must record the results of the patient’s screening in the patient’s record; a written notation summarizing the conversation and screening results is sufficient for record keeping purposes.

Patient arrival protocol

  1. Before entering the office, patients and any other visitors must be screened a second time for COVID-19 using the screening questions developed by the Ontario Ministry of Health.
    • Dentists must ensure that all screening results are recorded and retained in accordance with the requirements for administrative or office records set out in the College’s Dental Recordkeeping Guidelines.
  2. Patients who have screen positive for COVID-19 must not be treated in-person except as needed for emergency or urgent care that cannot be delayed (see the College’s FAQ for definitions of emergency and urgent care).
    • Patients who screen positive for COVID-19 should be advised to self-isolate and contact their primary care provider or Telehealth Ontario at 1-866-797-0000 to determine next steps or visit an assessment center to get tested.
    • COVID-19 is a designated disease of public health significance, which means that dentists are subject to reporting requirements under the Health Protection and Promotion Act. Public Health Ontario has advised that dentists must report “probable” and “confirmed” cases of COVID-19 to the public health unit in which the professional services were provided (see the following link for more information). Public Health Ontario has further advised that dentists are not required to report every patient who screens positive for COVID-19 when scheduling or attending a dental appointment
  3. Dentists are not required to take or record temperatures as part of routine screening, however, they may choose to do so at their own discretion (e.g. using a non-contact infrared thermometer). Refer to the College’s COVID-19 FAQ for more information concerning temperature taking.
  4. Dentists must require patients and visitors to wear their own mask at all times while in the office (e.g., a procedure/surgical mask, cloth covering, or other appropriate face covering). For more information on the requirement to wear masks, including limited exceptions, see the College’s COVID-19 FAQ.
    • Patients who arrive without a mask must be provided one by staff prior to entering the office or be required to schedule a new appointment.
  5. Dentists must ensure that patients do not remove their mask, except as required for treatment, and do not leave their mask in waiting areas or anywhere else inside the office.
  6. Dentists should require individuals accompanying a patient to wait outside the practice unless absolutely required (e.g., a parent accompanying a young child or a patient who requires accommodation).
  7. Dentists must require patients (and guests) to perform hand hygiene with either 70-90% ABHR or soap and running water upon initial entry to the office.
  8. Dentists should minimize patient contact with all surfaces.
  9. Except as needed when providing care, a physical distance of at least 2 meters must be enforced between all people in the office.

Emergency or urgent care of a patient who has screened or tested positive for COVID-19

When in-person care cannot be avoided for a patient who has screened or tested positive for COVID-19 (i.e., the provision of urgent or emergency care), dentists must adhere to the following additional requirements when managing the patient’s arrival:

  1. When the patient has screened or tested positive for COVID-19, the patient’s appointment should be scheduled at the end of the day to decrease the risk to other patients.
  2. Patients who have screened or tested positive for COVID-19 must don a procedure/surgical mask (minimum ASTM Level 1) prior to entering the office (for more information on the requirement to wear masks, including any limited exceptions, see the College's COVID-19 FAQ).
    • Where the patient does not have their own procedure/surgical mask, they must be given one by staff.
  3. Patients who have screened or tested positive for COVID-19 must immediately be placed into an operatory alone with the door closed.
    • Patients who have screened or tested positive for COVID-19 must not be placed within 2 meters of any other patients in the office (e.g., in the waiting room).
    • Where an operatory is not available and/or physical distancing cannot be maintained, patients who have screened or tested positive for COVID-19 must be instructed to return outside (e.g., to their vehicle or a parking lot if available and appropriate) and informed they will be notified when a room becomes available.

3. Providing In-Person Care

Use of personal protective equipment

Dentists must ensure that all clinical staff wear PPE that is appropriate for the anticipated procedure or activity (see Table 1).

Table 1: Requirements for the Use of Personal Protective Equipment (PPE)

Setting

Procedure/Activity

Type of PPE

Change from Previous Guidance

Operatory or other treatment area

Non-aerosol generating procedures (NAGPs) when the patient has screened negative for COVID-19

  • ASTM level 2 or 3 procedure/surgical mask
  • Gloves
  • Eye protection: goggles or face shield
  • Isolation gown (optional)
  • Use of isolation gown no-longer required.
  • Clarification: eye protection includes either goggles or faceshield

Non-aerosol generating procedures (NAGPs) when the patient has screened or tested positive for COVID-19

  • ASTM level 2 or 3 procedure/surgical mask
  • Gloves
  • Eye protection: goggles or face shield
  • Isolation gown
  • None.

Aerosol generating procedures (AGPs)  when the patient has screened negative for COVID-19.

 



  • Clarification: eye protection includes either goggles or faceshield

Aerosol generating procedures (AGPs) when the patient has screened or tested positive for COVID-19.

 



  • None.

Cleaning and disinfection of operatory or other treatment area

  • Minimum ASTM level 1 procedure mask
  • Gloves
  • Eye protection: goggles or face shield
  • None.

Reprocessing area

Reprocessing of reusable instruments

  • ASTM level 2 or 3 procedure/surgical mask
  • Heavy duty utility-gloves
  • Eye protection: goggles or face shield
  • Isolation gown
  • None.

Reception area

Reception duties and screening

  • Minimum ASTM level 1 procedure mask
  • Maintain physical distancing.  Physical barrier recommended. 
  • Clarification: staff in reception area must wear a procedure mask (minimum ASTM level 1).

Common and staff areas

Administrative and other tasks

  • ASTM level 1 procedure mask OR maintain physical distancing
  • None.
  1. Dentists must ensure that clinical staff are trained in and use proper donning and doffing procedures for PPE (e.g., review Public Health Ontario’s Recommended Steps for Putting on and Taking Off Personal Protective Equipment).
  2. Dentists must ensure that operatories are cleaned and disinfected between each patient appointment.

Pre-procedural oral rinses

While there is a lack of direct evidence that pre-procedural oral rinses prevent infections in dental care providers, they have been shown to reduce the level of oral microorganisms in aerosols and spatter from rotary handpieces.

  1. Given the lack of direct evidence, the College does not currently require or recommend the use of pre-procedural oral rinses, however, dentists may choose to use them at their own discretion. Refer to Public Health Ontario’s COVID-19 in Dental Care Settings document for more information concerning the use of oral rinses.

Intra-oral radiographs

  1. When treating a patient who has screened or tested positive for COVID-19, dentists should minimize the use of intra-oral radiographs and consider using extra-oral radiographs.

4. Aerosol-Generating Procedures

When a patient undergoes an aerosol-generating procedure (AGP), high concentrations of droplets smaller than 5 µm (droplet nuclei) are generated that may remain suspended in the air for significant periods of time, move with air currents, and come in contact with others. This creates a risk for opportunistic airborne transmission of COVID-19, even if the virus is not otherwise able to spread by the airborne route. While there is no conclusive evidence at this time that opportunistic airborne transmission of COVID-19 occurs after AGPs, the College has adopted a precautionary approach that prioritizes safety.

Aerosols may be generated by high-speed, low-speed and other rotary handpieces, ultrasonic and other similar devices, and air-water syringes.

Preparing the operatory for aerosol-generating procedures

  1. Dentists must minimize the contents of all operatories in which AGPs may be performed, including unnecessary equipment, supplies, plants, and artwork.
  2. All AGPs must be performed in an operatory that is capable of containing aerosol. This requires floor-to-ceiling walls and a door (or other barrier) that must remain closed during and after such procedures. Temporary walls and doors are permitted, provided they create an area to contain aerosols and are constructed of materials that can withstand repeated cleaning and disinfection.

Use of PPE during aerosol-generating procedures

  1. When performing AGPs, dentists must ensure that all clinical staff wear appropriate PPE (see Table 1).
  2. Dentists must ensure that clinical staff are trained in and use proper donning and doffing procedures for PPE (dentists are advised to review Public Health Ontario’s Recommended Steps for Putting on and Taking Off Personal Protective Equipment).

    Clearing the Air of Aerosol (Fallow Time) Following Aerosol-Generating Procedures

    1. Following all AGPs, dentists must:
      • Ensure that the operatory is left empty (with the door closed) to permit the clearance and/or settling of aerosols.
      • Ensure that the operatory remains empty for a length of time that achieves 99% removal of airborne contaminants (dentists must use Table 2 to determine the length of time necessary to achieve 99% removal of airborne contaminants based on air changes per hour [ACH]).
      • If dentists have not had the rate of air changes for their office confirmed by an HVAC professional, dentists must assume a rate of 2 air changes per hour and adhere to a minimum fallow time of 138 minutes.

    Table 2: Time Required for Removal or Settling of Aerosols by Air Changes per Hour (ACH)

    Air Changes Per Hour (ACH)

    The Time Required for Removal or Settling of Aerosols in Minutes (99%) Efficiency

    2

    138

    4

    69

    6

    46

    8

    35

    10

    28

    12

    23

    15

    18

    20

    14

    25

    12

    30

    10

    35

    8

    40

    7

    50

    6

    Adapted from: Centers for Disease Control and Prevent, Guidelines for Environmental Infection Control in Health-Care Facilities (2003): Table B.1. Air changes/hour (ACH) and time required for airborne-contaminant removal by efficiency. Available at: https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

    1. Dentists should consult an HVAC professional to assess the existing HVAC system and calculate the actual ACH for the dental practice. Dentists may use the actual ACH to calculate a fallow time using Table 2.
      • Dentists should retain copies of any documentation supporting the HVAC assessment and any need for engineering controls.

    Options to improve ACH (and further reduce the fallow time) may be explored, including:

      • Consulting an HVAC professional to determine whether changes to the existing HVAC system are possible to improve ACH for the dental practice.
      • If changes to the existing HVAC system are not possible or adequate, dentists may consider the use of an in-operatory air cleaner (e.g. HEPA filtration) to increase the effective air changes per hour (eACH) for a specific operatory.
      • If an in-operatory air cleaner (e.g. HEPA filtration) will be used to increase the effective air changes per hour (eACH) for a specific operatory, the HVAC professional must also take into account several additional factors, including:
        • any structural changes that may be necessary to contain the spread of aerosols (e.g., the addition of floor to ceiling walls or barriers),
        • the type of unit being considered (e.g. fixed versus portable),
        • the cubic feet of the operatory and airflow rate of the unit, and
        • the optimal placement and operation of the unit.

    Additional Considerations: PPE Requirements for Visitors Present During an Aerosol Generating Procedure

    In limited cases, it may be necessary to permit a visitor to accompany a patient undergoing an aerosol-generating procedure (e.g., a parent accompanying a child).

    1. If the visitor is a member of the patient’s household (e.g., a parent/child), general PPE is not required. Dentists must ensure that the visitor wears a procedure/surgical mask (minimum ASTM Level 1) for source control.
    2. If the visitor is not a householder member (e.g., a worker who supports a client with disabilities), the visitor must stand at least two meters from the dental chair where the work is being performed and don:

    Additional Considerations: Performing an Aerosol Generation Procedure on Patients who have Screened or Tested Positive for COVID-19

    If a patient has screened or tested positive for COVID-19, care must not be provided in-person except as needed for emergency or urgent care (see the College’s FAQ for definitions of emergency and urgent care).

    1. When providing in-person care for a patient who has screened or tested positive for COVID-19, dentists must follow the requirements for aerosol-generating procedures set out above as well as the following additional requirements:
      • Avoid AGPs whenever possible,
      • Use the lowest aerosol-generating options when necessary, and
      • Utilize the enhanced precautions for PPE set out in Table 1 for patients who have screened or tested positive for COVID-19.
    2. When performing aerosol-generating procedures on patients who have screened or tested positive for COVID-19, dentists should use a rubber dam with high-volume suction to minimize aerosols and possible exposure to infectious agents.

    5. Patient Departure and Office Sanitization

    Patient Departure Protocol

    1. Patients should be asked to disinfect their hands with 70-90% ABHR before leaving the dental practice.
    2. Patients should be asked to inform office staff if they experience any symptoms of COVID-19 within 14 days of their appointment.

    Office Sanitization

    1. Dentists must ensure that operatories are cleaned and disinfected between each patient appointment.
    2. Dentists must ensure that general office housekeeping, including cleaning and disinfection of high-touch surfaces, occurs at least twice per day, including at the end of the day following the departure of the last patient (high-touch surfaces include, as examples: door knobs, elevator buttons, light switches, toilet handles, counter tops, hand rails, touch screen surfaces, and plexiglass barriers).

    6. COVID-19 Exposure in the Practice

    1. If dentists or staff suspect they have been exposed to COVID-19 they must immediately self-isolate and contact their primary care provider or Telehealth Ontario at 1-866-797-0000 to determine next steps or visit an assessment center to be tested. Dentists must also contact their local public health unit for further guidance.
    2. If a patient contacts the office to report symptoms of COVID-19 within 14 days of having attended an appointment, dentists must contact their local public health unit for further guidance.