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Dental Surgeons of Ontario
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COVID-19 Frequently Asked Questions

Our Practice Advisory Service receives many emails and phone calls daily from dentists and the public about COVID-19. Below is a list of FAQs compiled by the Practice Advisory team to assist you in getting up-to-date information in a timely manner.

Updated June 19, 2020.

What level of care can I now provide to my patients? 

Following the requirements of the revised Directive #2, issued May 26, 2020 by the Ministry of Health:

  • Dentists can now provide in-person care for all deferred, non-essential, and elective services, in addition to emergency and urgent care.
  • All deferred and non-essential and elective services carried out by Health Care Providers may be gradually restarted.

Refer to the College’s latest guidance: COVID-19: Managing Infection Risks During In-Person Care.

Examples of emergency, urgent, and non-essential care are available here.

Since clinical advice is rapidly evolving, we ask that you check this page frequently.You are expected to put your patients’ interests and the safety of the community first.

Are dentists now allowed to provide non-essential care through teledentistry during this pandemic?

Yes, teledentistry enables the remote provision of “non-essential” care to patients while ensuring ongoing physical distancing.

Detailed guidance for in-person patient appointments is available here.

Does the teledentistry platform I’m using (e.g. Zoom, FaceTime, Go-to-Meeting, Skype, Microsoft Teams etc) comply with privacy requirements?

The College does not review, endorse nor approve of any specific technical platforms for teledentistry. To ensure that the platform you use complies with current privacy legislation, please contact the Information Privacy Commissioner: https://www.ipc.on.ca/about-us/contact-us/

You should protect the privacy and confidentiality of the patient’s personal health information, specifically by: 

  • using technology that has privacy and security settings in accordance with the Personal Health Information Protection Act, 2004. At minimum, technology must have controls to ensure only the intended patient has access to the appointment and where personal health information is stored and/or transmitted, strong encryption must be used. If unsure, dentists can confirm with the service provider that the technology meets Ontario privacy requirements.
  • conducting the teledentistry appointment in a private environment that will ensure patient information is not overheard or seen by other individuals; and
  • confirming with the patient that they are in a private setting and that the technology they are using is secure.

During this pandemic can we prescribe outside of the College’s recommendations for the management of dental pain for our patients? 

Dentists must continue to practice within the College's Guidelines with respect to writing of narcotics and opioids.

The Guidelines provide guidance regarding the suggested maximum number of tablets for a single opioid prescription. However, it also states that in some situations, practitioners may consider exceeding the suggested maximum number of tablets. Practitioners are expected to exercise reasonable professional judgment in determining when this is justified, which should be documented. Please refer to our latest guidance  

Please ensure that you keep a record of any patients that you speak with over the phone so that you can provide documentation in the patient record once you return to the office.

Can I remotely provide a prescription to new patients (i.e. who are not existing patients of the practice) on an emergency basis over the phone or by video?

In order to prescribe medication for a new patient, technology with both audio-video capacity will be required to allow for an adequate assessment prior to prescribing medication. This means that you cannot provide a prescription to a new patient who does not have video conferencing capability.  

Please review the College Guidance on COVID-19 - Guidance for the Use of Teledentistry

Where can I get more information about the fees and procedure codes used for teledentistry?

Please contact the Ontario Dental Association (ODA) by phone at 416-922-3900 or by email at info@oda.ca.

What are the COVID-19 screening questions we should ask our patients?

See the Ministry of Health COVID-19 Patient Screening Guidance.

At what temperature do we consider that a patient has a fever?

According to the Ministry of Health, fever is a temperature of 37.8°C or greater.

What is fallow time?

Fallow time is the amount of time, measured in minutes, needed for the clearance and/or settling of infectious viral particles after performing an aerosol generating procedure.  This time depends on the number of air changes per hour and the possible use of an in-operatory air cleaner (e.g. HEPA filtration) to increase the effective air changes per hour (eACH) for a specific operatory. Fallow time begins when patients and staff have exited and the operatory is vacant.

How should the operatory be managed after performing an AGP for a patient who screens COVID-19 negative?

At the end of the procedure all staff and patients exit and the operatory is vacant. 

PPE are doffed outside the operatory. Following the fallow time, the operatory may be cleaned and disinfected, and prepared for the next patient.

How should the operatory be managed after performing an AGP for a patient who screens COVID-19 positive?

At the end of the procedure all staff and patients exit and the operatory is vacant. 

PPE are doffed outside the operatory. During the fallow time, dentists must not remain in the operatory to write up patient charts. Following the fallow time, the operatory may be cleaned and disinfected, and prepared for the next patient.

Unless otherwise calculated, the fallow time is three hours, timed from when the staff and patients exit and the operatory is vacant. The fallow time may be reduced following an HVAC assessment and if additional mitigating measures have been implemented. See the guidance document for further details

At the end of the fallow time, appropriate PPE is donned and the operatory is cleaned and disinfected, especially clinical contact and other high-touch surfaces, using an appropriate hospital-grade low-level disinfectant.

What do we tell a patient if they screen positive for COVID-19? 

A patient who screens positive for COVID-19 infection should 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.

Do I need to notify Public Health about patients who screen positive?

Although COVID-19 is a designated disease of public health significance and reportable under the Health Protection and Promotion Act, dentists are not required to report patients who screen positive to the local public health unit. Only probable and confirmed cases of COVID-19 must be reported. Please refer to the link below for the definition of a probable case: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_case_definition.pdf

Some patients, like some essential health care workers, international truck drivers, pilots etc. will always screen positive.  The Ministry is in the process of updating screening guidance to address such individuals.  In the meantime, you can adapt the current screening tool to further clarify risk.  Please refer to questions 4 and 5 of the long-term care home screening tool for an example of how to adapt the questions.

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_screening_guidance.pdf

For anyone who screens positive, the Ministry still advises that if possible the appointment should be deferred. When care is provided to a patient who screens positive, HCW must use droplet and contact precautions for non-aerosol generating procedures (non-AGP) and enhanced airborne precautions if conducting an AGP.

What should we do if I or my staff screen positive for COVID?

Dentists and staff must self-monitor daily for any symptoms of COVID-19 and use the COVID-19 screening questions developed by the Ontario Ministry of Health.

You and/or your staff should self-isolate and contact your primary care provider or Telehealth Ontario at 1-866-797-0000 to determine next steps, or visit an assessment center to get tested. You should also contact your local public health unit to self-report.

For more information: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_covid_testing_guidance.pdf

If I or my staff member have tested positive for COVID, when can we return to work?

If you or your staff have tested positive for COVID-19, self-isolate immediately. The self-isolation period will be determined by the seriousness of the case.

For mild to moderate cases where a health care worker self-isolates at home, the waiting period is 14 days from symptom onset (or 14 days from when swab was taken if persistently asymptomatic).

For serious cases where the health care worker has been hospitalized, the requirement is two consecutive negative specimens collected at least 24 hours apart.

For more information: COVID-19 Quick Reference Public Health Guidance on Testing and Clearance

For case specific guidance on safe return to work, contact your local public health unit directly.

Are there any restrictions for treating patients who screen negative for COVID-19?

Patients who screen negative for COVID-19 may be treated using standard IPAC protocols, for all procedures, both aerosol and non-aerosol generating.

The minimum PPE required for treating these patients includes: eye protection OR face shield, gloves and ASTM level 2 or 3 procedure/surgical mask.

If desired, dentists may choose to use a fit-tested N95 mask and a protective gown when treating patients who screen COVID-19 negative.

Are N95 respirators required for all treatment?

Refer to our latest guidance: COVID-19: Managing Infection Risks during In-Person Dental Care.

Fit-tested N95 masks are only required for aerosol-generating procedures on patients who have screened or tested positive for COVID-19.

For those patients, care MUST be provided using enhanced precautions (i.e. fit-tested N95 mask [or equivalent, as approved by Health Canada), gloves, eye protection and face shield and protective gown).

  • If possible, use a rubber dam to decrease possible exposure to infectious agents.
  • If possible, use high-speed evacuation to minimize aerosols.

For patients who have screened negative for COVID-19, they may be treated using standard IPAC precautions (procedure/surgical mask, eye protection and gloves), for both aerosol and non-aerosol generating procedures. However, dental personnel have the option, for these patients, to use a fit-tested N95 mask, a face shield and a protective gown if desired.

Do N95 respirators require fit testing?

N95 respirators require a tight fit for protection against aerosols. Fit testing is required for each clinical staff member and for each brand or model of N95 respirator. In other words, the fit test is only applicable to the specific respirator model, unless the manufacturer indicates otherwise.

Where can I get information or training on fitting N95 respirators?

The occupational health department of your local hospital may provide fit testing.

Below is a list of some companies that provide fit testing.

Public Services Health & Safety Association: https://www.pshsa.ca/company

Levitt Safety

Dental Practice Safety

https://www.ekginc.com/

Hot Zone Fit Testing 

Martech Group

Enviro EH&S Consulting Inc.

Partner Safety

Majors McGuire Fit Testing

For additional information about fit testing:

3M offers a fit test kit for sale

See this YouTube video on the mask fitting process

Note: The College does not endorse any particular company, but provides this information to assist dentists. Some companies may have suspended in-person fit testing, while others are assessing each request individually.  Dentists must provide their own N95 masks for fit testing.

Please contact the manufacturer or refer to the Manufacturer’s Instructions for Use (MIFUs) if you have any technical questions.

Can N95 respirators be used past their expiry date?

Health Canada has issued a document on “Optimizing the use of masks and respirators during the COVID-19 outbreak”.

According to this document, there is no specific timeframe beyond the expiry dates for N95 respirators at which they would no longer be considered suitable for use. In times of increased demand and decreased supply, consideration can be made to use these expired N95 respirators. An expired mask can still be effective at protecting a health care provider if:

  • the straps are intact
  • there are no visible signs of damage
  • they can be fit-tested

Health care providers should inspect the mask and perform an appropriate seal check.

The Ministry has issued a Guidance document on “Information on the Use of N95 Filtering Facepiece respirators beyond the manufacturer-designated shelf life”.

Can I reuse N95 respirators?

N95 respirators are disposable. However, it is possible to extend the use of N95 respirators under certain circumstances.  Extended use refers to the practice of wearing the same N95 respirator for several patients, without removing the respirator between patient encounters. Extended use over one day is possible for non-AGP by protecting the N95 respirator with a level 2 or 3 mask, or a face shield. For AGP, N95 respirators are single use.

Click here for more information.

There is a shortage of N95 respirators, can we use KN95 or other “equivalent” masks instead?

Health Canada has advised that equivalent alternate standards may also be acceptable. This includes respirators that are approved or certified under standards used in other countries that are similar to NIOSH-approved N95 respirators.

For example, this includes both medical and commercial (non-medical) KN95 or medical FFP2 respirators (including those with head band or ear loops) that meet standards:

  • EN 149-2001 (Medical FFP2)
  • GB 2626-2006* (Commercial KN95) *(standard will be replaced with GB 2626-2019 on July 1, 2020)
  • GB 19083-2010 (Medical KN95)

Some concerns have been recently identified with some KN95 respirators (specifically those with ear loop design) that pose a difficulty in achieving a proper fit, which is essential for use.

Health Canada has asked manufacturers and importers to stop the sale of any products that do not meet the filtration criteria of 95% and re-label them as face masks.  KN95s that meet the filtration criteria may continue to be sold and used as respirators.

Health Canada maintains a list of NIOSH N95 alternatives.

Prior to selecting a respirator mask, dentists should review Health Canada’s respiratory guidance or check Public Health Ontario for selection guidance.

Can we use P95 or P100 respirators if N95 respirators are not available?

Health Canada accepts the NIOSH certification as an appropriate quality standard for N95 masks. Equivalent alternate standards are also acceptable.

Find out if the brand, model number/product line of your P95 or P100 respirators is listed under the Centers for Disease Control and Prevention (CDC) listing of NIOSH-approved P95 or P100 respirators.

NIOSH-Approved P100 Particulate Filtering Facepiece Respirators

NIOSH-Approved P95 Particulate Filtering Facepiece Respirators

NIOSH-Approved Particulate Filtering Facepiece Respirators

Before selecting a respirator mask, dentists should review Health Canada’s respiratory guidance or check Public Health Ontario for selection guidance.

How do I know if the N95 respirator is a counterfeit?

  • Confirm that your product has been certified by NIOSH by entering the approval number, which can be found on the respirator, in the NIOSH database.
  • Review the product package and respirator to ensure it has the appropriate markings and details, as required by NIOSH. This includes the TC (Testing and Certification) approval number (a number set by NIOSH), the name of the manufacturer, the NIOSH name or logo, the model number, and filter efficiency (N95).
  • Look at product markings, such as the name of the manufacturer, to determine whether there are any obvious signs that the product is counterfeit (e.g., incorrect spelling).
  • Check for the presence of this symbol on the mask:

  • If your mask is fraudulent or unauthorized, stop using it as it may not protect you against COVID-19.
  • Report information on the potential false or misleading advertising or sale of unauthorized products to Health Canada.

For more information: Fraudulent and unauthorized N95 respirators may not protect consumers against COVID-19

Have some KN95 respirators have been recalled by Health Canada?

Yes. Health Canada has determined that KN95 Filtering Facepiece Respirators (“respirators”) which have failed to demonstrate a 95% filtration rate and are possibly being imported into Canada, pose a health and safety risk to users.

Do not use KN95 respirators on the following list in situations where a minimum 95% filtration rate is required (e.g. aerosol-generating procedures). They will not provide the same level of protection as NIOSH approved N95 respirators. These KN95 respirators can still be used as regular procedural face masks where a 95% filtration is not needed.

KN95 respirators recall

NPPTL Respirator Assessments to Support the COVID-19 Response

KN95 models that meet the filtration criteria continue to be sold and used as equivalent to NIOSH-certified N95 respirators. Health Canada maintains a list of NIOSH N95 alternatives.

What type of dental procedures require dentists to wear gowns?

For the purpose of aerosol and non-aerosol-generating procedures performed on patients who screen COVID-19 positive, isolation gowns are sufficient.

Isolation gowns protect the exposed skin and clothing of health care providers. They also protect visitors and patients because they prevent the transfer of microorganisms and body fluids.

For major surgical procedures (e.g. osteotomies, use of rigid internal fixation, etc.), sterile surgical gowns are required. Surgical gowns are sterile textile gowns (i.e. have gone through the sterilization process). Health care providers wear these gowns when they are working in a sterile environment.

Reference: Health Canada Personal protective equipment against COVID-19: Medical gowns

Can dentists and their staff use washable/reusable gowns instead of disposable gowns?

Yes, both disposable and reusable/washable gowns are acceptable. As with any personal protective equipment (PPE), attention must be paid to the donning and doffing procedure in order to avoid contaminating the user.

For more information on donning and doffing of PPE, click here

Reusable/washable gowns must be changed and laundered after each patient use. 

Please note: reusable/washable gowns must be laundered either on-site or at a commercial laundry facility. Home laundering is not permitted.

Public Health Ontario (Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings) and the Canadian Standards Association (http://shop.csa.ca/en/canada/sterilization/z314102-15/invt/27030462015) have listed the following requirements for the on-site laundering of reusable/washable gowns in dental offices:

  • There must be a dedicated space, physically separate from other areas of the laundering facility.
  • The space must contain a sorting area for soiled items that is kept under negative pressure.
  • If the dental office is unable to comply with these requirements, another option is to use a commercial laundry service.
  • Household laundering and laundromats do not meet these requirements.
  • While awaiting on-site laundering or pickup for transportation to a commercial laundry facility, reusable/washable gowns should be stored in laundry bins/containers lined with a barrier (such as a garbage bag) to avoid contamination.
  • For on-site laundering, use hot water and an appropriate detergent. If the items are heavily soiled, a disinfectant (e.g. chlorine bleach) may be added.

Scrubs worn as clinic attire may be laundered at home.

Can I charge patients for additional use of PPE?

Please contact the Ontario Dental Association (ODA) by phone at 416-922-3900 or by email at info@oda.ca.

What type of clothes and PPE are receptionists required to wear?

Like clinical staff, staff who do not have clinical responsibilities must change their clothes and shoes upon reporting to work and when leaving to return home.  Non-clinical staff may wear casual shoes and clothes for work or scrubs, as per the office policy.  Clothing worn in the office must not be worn outside of the office and should be laundered after each shift.

If there is a physical barrier at reception, no additional PPE is required.

If there is no physical barrier, an ASTM level 1 procedure mask is required. 

Physical distancing should be maintained among all staff, including when in the reception area.

Are we allowed to use sedation?

Confirm sedation is required and that the treatment cannot be provided without it.

Technique

Oral sedation used alone can be a sedative technique that minimizes aerosols vs. other sedative techniques. However, patient acceptance and an effective dose is key to prevent coughing, crying etc. that could also create more aerosols with any conscious sedation technique. You must stay within your level of authorization for the sedation dose provided.

Nitrous Oxide Oxygen

If oral sedation alone is not sufficient and nitrous oxide oxygen is used, a viral filter may be placed between the tubing and the machine. This may require a special connector, depending on the type of machine you have. It may be advisable to use a disposable nasal cannula, nasal hood or other oxygen delivery device. All tubing should be properly cleaned and disinfected following the manufacturer’s instructions for use. Try to limit gas flows to the minimum required to prevent surplus gas from the patient contaminating the air. Similarly ensure the nasal hood fits snugly to minimize gas leaks.

Monitoring and Emergency Equipment

Try to use disposable emergency equipment where possible. All equipment for monitoring of the patient must be cleaned and disinfected according to manufacturer’s instructions for use. In the unlikely event of cardiopulmonary resuscitation, a viral filter should be placed on the bag-valve-mask to protect the equipment from contamination if used. If oxygen delivery is required, it is advisable to use disposable nasal cannula/nasal hood or other oxygen delivery device. All tubing should be properly cleaned and disinfected as per the manufacturer’s instructions for use. Try to limit gas flows to the minimum required to prevent surplus gas from the patient contaminating the air. Similarly ensure the nasal hood fits snugly to minimize gas leaks.

There is a shortage of disposable gowns. Can I use a fabric lab coat instead of a gown?

The use of lab coats instead of gowns is discouraged and should only be used as a last resort because they do not provide the same degree of protection. Most lab coats have V-necks and/or do not have elastic bands at the wrists. Because of their design, they can expose the healthcare worker’s skin/clothing at the neck and wrist area.

The front buttons of lab coats can also pose risks of contamination during the donning and doffing procedures.

In the event of a disposable gowns shortage, reusable gowns would be the preferred alternatives.

References:

US Centers for Disease Control and Prevention – Strategies for Optimizing the Supply of Isolation Gowns

Public Health Ontario -  Recommended Steps for Putting On and Taking Off Personal Protective Equipment

Must I have floor-to-ceiling walls and a door that can be closed in all my operatories?

No.

Patients who screen COVID-19 positive must be treated in an operatory that is capable of containing an aerosol, which means floor-to-ceiling walls and a door or other barrier that can be closed.

Patients who screen COVID-19 negative may be treated in your existing operatories.

Please note: The requirements for office preparation, appointment scheduling, patient arrival, PPE, cleaning and disinfection and aerosol-generating procedures, as outlined in the Guidance Document, apply for all patients.

Is the College providing a support fund or any financial relief for dentists experiencing loss of income and business during the pandemic? 

The College does not provide employment advice or related financial advice. We suggest you seek legal advice from an employment lawyer.

You can obtain additional information by logging into your ODA member’s account

You may wish to review the financial assistance packages announced by both the Ontario and Canadian Governments, as well as seek professional advice on your obligations. 

Also review, the Federal COVID-19 Economic Response Plan: Support for Canadians and Businesses to check if you or your staff are eligible: https://www.canada.ca/en/department-finance/economic-response-plan.html  

I am aware of individuals/corporations price gouging essentials products related to COVID-19, including PPE. Who do I contact?

The Government of Ontario has taken action to protect consumers from being exploited for products needed in response to COVID-19. Visit their website to submit an online Price Gouging Report. Questions related to price gouging in Ontario should be sent to the Ministry of Government and Consumer Services at Consumer@ontario.ca.