Recommendations for the
re-opening of dental services: a rapid
review of international sources
6 May 2020
Substantial update 16 May 2020

COVID-19 Dental Services Evidence Review (CoDER) Working Group

Version 1.3 – 16th May 2020 includes 16 countries (5 new added)

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

PurposeThe COVID-19 pandemic has led to the closure of dental practices or a reduction of dental
services all over the world. Some countries are currently reopening or planning to reopendental services as part of an exit from the lockdown strategy.
In response to the urgent need for guidance, this rapid review has been undertaken toassist policy and decision makers with the production of comprehensive national guidance
for their own settings. The review summarises the main themes from recently produced
international sources and assesses the extent to which their recommendations were
supported by underpinning evidence.
In this evolving situation, information provided by each country may be subject to change.

Key messages•

This review reports on national recommendations for the re-structuring and reopening of dental services from 16 countries.

•

There is a highly variable level of detail given across international sources.

•

Most sources recommend patient triage by telephone; some recommend also
temperature screening at reception.

•

Most sources recommend avoiding aerosol generating procedures (AGPs), if
possible.

•

Most sources recommend surgical masks for non-COVID-19 cases not requiring
AGPs.

•

Most sources recommend filtering facepiece class 2 (FFP2, equivalent to N95)
masks for non-COVID-19 cases undergoing AGPs and all suspected or confirmed
COVID-19 cases undergoing any procedure.

•

Sources include recommendations on how to reduce the risk of transmission (e.g.
use of pre-operative mouthwashes; high volume suction; rubber dam; and PersonalProtective Equipment [PPE]).

•

Most sources recommend cleaning and disinfection procedures.

•

Across sources, for most statements there is no referenced, underpinning evidence
and some of them are unlikely to have strong (or any) research evidence.

•

All sources emphasise the need to focus on activities that minimise risk (tostaff/patients/public) but still support high quality clinical care.

•

There is a need to consider the inter-relationship between the appropriate use of
PPE (including donning and doffing), AGPs and interventions to reduce aerosol
generation.

Page 2 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

Background
The World Health Organisation (WHO) declared the coronavirus disease (COVID-19)
outbreak as a public health emergency of international concern on the 30 January 2020 anda global pandemic on the 11 March 2020.
COVID-19 spreads primarily through droplets and fomites. The close working environment
and the potential for aerosol spread of the virus through dental procedures, such as use ofhigh and low-speed handpieces, ultra-sonic scalers, air/water syringes, intra-oralradiographs or an infected patient coughing, places dental health workers at an elevatedrisk of infection.
Pandemic planning for dental services typically involves a step-down process, withcancellation of routine care first, then urgent care followed by the provision of emergency
care only. In many countries, the move to emergency care provision was rapid. For
example, on the 16 March 2020 the American Dental Association proposed that dentists
defer all elective dental care for 3 weeks; in Scotland, Wales and Northern Ireland, allaerosol generating practices were stopped on the 17 March and practitioners were told tostop all routine face-to-face dentistry on the 23 March. On the same day in New Zealand, allnon-essential and elective dental treatment was suspended. By the end of April 2020,
National and Regional Governments and professional organisations had publishedrecommendations or guidance for the re-opening/re-structuring of dental services.

Process
Between the 2 and 13 of May 2020, we conducted a rapid review of recently produced
guidance and reports containing recommendations from international organisations andprofessional bodies on the current requirements for the re-opening of dental services. Our
methods were based on the proposed approach for rapid reviews by the WHO and theAlliance for Health Policy and Systems Research.1
We conducted a grey literature search to identify relevant guidance documents and liaisedwith the information scientist of Cochrane Oral Health (COH), who last updated the regular
Cochrane search for dental guidelines on the 11 May 2020 (search strategy available on
request). We searched websites of dental organisations and departments of health. We
also contacted an international network of oral health researchers and decision makers
through the Global Evidence Ecosystem for Oral Health (GEEOH). The GEEOH wasfounded to reduce duplication of effort and create direct routes from evidence to policy andclinical practice and is currently coordinated by COH. The relationship between COH, theScottish Dental Clinical Effectiveness Programme (SDCEP) and our research groupresulted in rapid communication and assistance from several Chief Dental Officers andworldwide dental policy leaders. No language restrictions were applied to the searches andmembers of our research group were able to translate documents published in non-English
languages.

1 https://www.who.int/alliance-hpsr/resources/publications/rapid-review-guide/en/

Page 3 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

From the identified sources of information, we selected those that provided the most recent
and relevant recommendations for the re-opening of dental services. To be eligible,
guidance and recommendations needed to have explicitly addressed resuming dental careprovision post initial closure or restriction due to COVID-19 outbreak, in any area or setting
where clinical practice was limited to prevent community infection. National guidance,
where available, was prioritised over regional or local guidance. Due to the time constraints
in the preparation of this rapid review, we conducted single data extraction and did notformally assess the quality of the guidance documents or validate their sources. Attempts tolink recommendations to underpinning evidence were noted.
Prior to the extraction of information/data, the research group reviewed a sample of thesesources to identify common domains for policy making across reports. We used thesecategories to structure our analysis and present our findings.

Findings
We identified a total of 17 guidance documents from 16 countries produced between 18
March and 11 May 2020. The list of countries and details of the documents are presented inAppendix 1. We summarised the common themes and the relevant recommendations in thefive domains included within the guidance documents. The five domains identified were:
1. Practice preparation and patient considerations.
2. PPE for dental practice personnel.
3. Management of the clinical room.
4. Dental procedures.
5. Post-operative cleaning/disinfection/waste management.
The level of detail across international sources varied greatly. It is important to highlight that(1) the absence of a recommendation from a particular source does not imply its lack ofimportance and (2) that different national approaches are due to different epidemiologicalsituations and public health approaches. For the majority of recommendations addressing
specific COVID-19 concerns there was limited or no referenced, underpinning evidence.

Page 4 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

1. Summary of recommendations related to practice preparation and patientconsiderations
Theme

Recommendations

Re-opening tasks•

3/17 (18%) sources include general tasks such as how to
reduce risk of contamination e.g. legionella, staff training andmachine and equipment maintenance (e.g. IT).

Supply chain•

2/17 (12%) sources recommend confirming the availability ofsupplies including PPE.

Staff advice andscreening•

10/17 (59%) sources provide a range of advice or training inrevised protocols including checking that staff are free of
COVID-19 symptoms.
2/17 (12%) sources recommend the daily screening oftemperature.

•

Patient triage•

16/17 (94%) sources provide information on how to grouppatients mainly by telephone to include risk assessment ofpotential COVID-19 status (e.g. COVID-19 positive, suspected
COVID-19, asymptomatic, special need/shielding). Some also
recommend temperature screening at reception.

Patient advice•

7/17 (41%) sources provide information on what type of advice
to provide to patients attending the surgery (e.g. social
distancing, wearing mask, hand hygiene).

Patient scheduling•

9/17 (53%) sources recommend clear scheduling of patients
based on triage.
o Patients who are vulnerable or with special needs:
2/17 (12%) sources consider the scheduling of
appointments to avoid contact with higher risk patients.
1/17 (6%) source indicates that patients’ appointments shouldbe spread between 20-30 minutes to allow for enough time todisinfect all areas and avoid cross infection between patientsin waiting rooms.

•

Waiting area
reception•

15/17 (88%) sources consider social distancing,rearrangement of furniture, protective shields, patient
information posters, wearing of masks, hand sanitiser, removal
of magazines/toys and other unnecessary items.

Toilets•

2/17 (12%) sources advise patient use of the toilets only withpermission.

Patient discovered
COVID-19 positive
after treatment•

1/17 (6%) source suggests contact tracing and isolation ofclose contacts (i.e. dental staff providing treatment).

Page 5 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

2. Summary of recommendations for PPE for dental practice personnel
Theme

Recommendations

All staff••••

Unsuspected
COVID-19 patients

•
•
•
•
•
•
•

Unsuspected
COVID-19 patients
undergoing AGPs•

Suspected orconfirmed COVID19 patients•

17/17 (100%) sources recommend eye protection(glasses/goggles, face shields) and single use gloves.
14/17 (82%) sources recommend use of surgical masks with 2of them recommending higher specification if available.
3/17 (18%) sources recommend use of FFP2 masks orequivalent.
5/17 (29%) sources recommend disposable gowns orequivalent.
3/17 (18%) sources recommend single use aprons orequivalent.
5/17 (29%) sources recommend use of surgical hats orequivalent.
3/17 (18%) sources recommend shoes protection.

6/17 (35%) sources recommend use of surgical masks with 1of them recommending higher specification if available.
• 10/17 (59%) sources recommend use of FFP2 masks orequivalent.
• 11/17 (65%) sources recommend disposable gowns orequivalento 5/17 (29%) sources recommend single use aprons orequivalent in addition to gown.
• 6/17 (35%) sources recommend use of surgical hats orequivalent.

•
•
•
•

Page 6 of 45

11/17 (65%) sources indicate that all staff should wear a facemask at all times.
6/17 (35%) sources indicate that all staff should wear eye
protection at all times.
7/17 (41%) sources indicated that all staff should wear
dedicated working uniform.
2/17 (12%) sources indicate that work uniforms should belaundered on site or by laundry service.

3/17 (18%) sources recommend use of surgical masks with 1of them recommending higher specification if available.
9/17 (53%) sources recommend use of FFP2 masks orequivalent.
2/17 (12%) sources recommend use of FFP2 or FFP3 masksor equivalent
1/17 (6%) sources recommend use of FFP3 masks orequivalent
8/17 (47%) sources recommend single use gloves.

Recommendations for the re-opening of dental services: a rapid review of international sources••••
Suspected orconfirmed COVID19 patients
undergoing AGPs

•
•
•
•

6 May 2020

2/17 (12%) sources recommend double gloving.
8/17 (47%) sources recommend disposable gowns orequivalent.
7/17 (41%) sources recommend use of surgical hats orequivalent.
2/17 (12%) sources recommend shoes protection.
1/17 (6%) source recommends use of highest available mask
up to FFP2 or equivalent.
10/17 (59%) sources recommend use of FFP2 masks orequivalent.
3/17 (18%) sources recommend the use of FFP2 or FFP3
masks or equivalent.
2/17 (12%) sources recommend use of FFP3 masks orequivalent

3. Summary of recommendations for management of the clinical room
Theme

Recommendations

Use of spittoon•

3/17 (18%) sources state that the spittoon should not be usedin dental units.

Clear work surfaces,
minimise equipment
and cross infection
procedures•

8/17 (47%) sources provide information on how the work
surfaces in the clinical room should be kept clear. Examples
include limiting paperwork, covering notes with a barrier andremoval of artwork. This also extends to ensuring all
equipment in sight should be minimised to only that which isstrictly necessary to avoid viral cross-contamination. All
required equipment/materials should be prepared in advance.
5/17 (29%) sources indicate that common contact areas suchas the chair lamp, handles and keyboard should be covered
with a barrier (e.g. plastic film or aluminium foil).
2/17 (12%) sources indicate that supporting staff outside theroom should bring in clean instruments and necessary
materials.

••

From waiting area totreatment room

•
•
•
•

Page 7 of 45

2/17 (12%) sources recommends switching between different
treatment rooms if possible, especially following AGPs.
1/17 (6%) source reminds dental staff that there should be nohandshaking or contact with patients.
5/17 (29%) sources recommend keeping staff levels/entry to aminimum in surgery.
2/17 (12%) sources indicate that staff should have all the PPE
on before they enter into a treatment room.

Recommendations for the re-opening of dental services: a rapid review of international sources

Suspected orconfirmed COVID-19
patients••

6 May 2020

1/17 (6%) source indicates that suspected or confirmed
COVID-19 patients should be directed to the treatment roomand should not be allowed to wait in the waiting area.
1/17 (6%) source indicates that patient treatment should beundertaken in an isolation room with negative pressure.

Home visits•

1/17 (6%) source indicates that all patients should be asked
about symptoms of COVID-19 and social distancing andappropriate cross infection control should be adhered. This
includes cleaning of contact surfaces in the patient’s homeand contact surfaces in the dentist’s car.

Air quality•

9/17 (53%) sources acknowledge the importance ofventilation/air renovation of which 4/17 (24%) guidance
documents state between 15-30 minutes is required after
each patient for ventilation.
3/17 (18%) sources mention air conditioning. 1/17 (6%)
acknowledges that there is no consensus on the use of air
conditioning but states that if used, the filters should bechanged weekly; 1/17 (6%) recommends that air conditioning
should be switched off; and 1/17 (6%) recommends use of air
conditioning in extraction mode only (never in recirculationmode).
1/17 (6%) source indicates that a HEPA filter (level 13 or
higher) should be used for the suction system.
5/17 (29%) sources indicate that the door of the surgery mustremain closed to prevent viral spread. One guidance
document expands on this to state all drawers and cabinets
should also remain closed.

•••

Patient hygiene•

2/17 (12%) sources provide information on general patienthygiene in the clinic. For example, patients are requested todisinfect their hands at arrival, should be supplied withappropriate protection (e.g. plastic bib, eye protection) andmust perform hand hygiene on completion of treatment andleave the room as soon as possible.

Post-treatment•

1/17 (6%) source indicates that dental staff should leave thetreatment room and then remove their visor, eye protection
and masks.
1/17 (6%) source recommends the disposal of surgical gowns
and aprons into a sealed plastic bag.

•Page 8 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

4. Recommendations for dental procedures
Theme

Recommendations

Reduction of AGPs••

Risk reduction
interventions•••

High volume suction••

List of recommended
operative procedures••

Tailored advice forpatient groups•

17/17 (100%) sources include recommendations to reduceor avoid AGPs.
1/17 (6%) source recommends avoiding using the air-water(3-in-1) syringe.
17/17 (100%) sources include recommendations on how to
reduce the risk of transmission.
15/17 (88%) sources recommend rubber dam and highvolume suction
14/17 (82%) sources recommend the use of pre-operative
mouthwashes
16/17 (94%) sources recommend aspiration to specificallydecrease viral load generated by aerosols.
1/17 (6%) source indicates that the aspirator tip should becovered with a disposable cover.
6/17 (35%) sources explicitly recommend minimallyinvasive procedures.
5/17 (29%) sources include a defined list of procedures thatcan be carried out.
10/17 (59%) sources provide specific advice for different
patient groups (e.g. COVID-19 asymptomatic; shieldedgroups; suspected or confirmed COVID-19 positive
patients).

5. Summary of recommendations related to post-operative cleaning/disinfection/
waste management
Theme

Recommendations

Cleaning anddisinfection procedures

•
•
•
•

Page 9 of 45

11/17 (65%) sources recommend cleaning and disinfectionof all surfaces following every patient contact.
11/17 (65%) sources recommend cleaning and disinfectionof all non-clinical areas (reception, waiting area, toilets)
including door handles, chairs, and surfaces.
2/17 (12%) sources recommend clinical floor cleaning
ranging from 2-3 times daily.
2/17 (12%) sources recommend door should remain shutand air to settle for period of time (range: 20-120 minutes)

Recommendations for the re-opening of dental services: a rapid review of international sources

PPE duringdecontamination•••
Clinical waste disposal•••

Disinfection products

•
•
•
•
•

6 May 2020

5/17 (29%) sources indicate that staff should wear eye
protection, gloves and mask when performing
decontamination/disinfection procedures.
3/17 (18%) source recommends washing of garments at thehighest possible temperature (at least 60 degrees for 30
minutes or between 80 and 90 degrees with 10 minutes ofheat contact with clothes).
2/17 (12%) sources recommends scrubs be laundered onsite or by contracted service
5/17 (29%) sources recommend waste be disposed of as
per regulations of local system.
4/17 (24%) source recommend PPE and other disposable
contaminated material should be placed in a hard-lid
container.
1/17 (6%) source recommends double-bagging and storingclinical waste before evacuation
1/17 (6%) source recommends disinfection products forsurfaces, suction and instruments must mention ‘viricide
agents’ (EN 14476).
4/17 (24) sources recommend a hypochlorite/chlorinebased solution for disinfection.
4/17 (24%) sources recommend the use of alcohol (60-70%
ethanol) for disinfection.
1/17 (6%) source recommends the use of chloroxylenol(0.12-0.24%) for disinfection.
1/17 (6%) source recommends the use of Virkon®,
Perasafe® as disinfectants.

Existing policies on
decontamination•

3/17 (18%) sources refer to national guidelines fordisinfection and decontamination policies.

Hand washing•

4/17 (24%) sources recommend hand hygiene following
doffing of PPE/decontamination of environment.
1/17 (6%) source recommends hand washing with alcohol(60-95%) based hand rub or soap and water for at least 20
seconds.

•

Conclusion
This rapid review provides an overview of the international guidance documents on the reopening of dental services published to date. It summarises the main elements of theidentified documents and highlights several key messages intended to assist policy anddecision makers to produce comprehensive national guidance for their own settings.
Across international documents, for most of the statements addressing specific COVID-19
concerns, there was limited or no referenced, underpinning evidence.

Page 10 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

Working Group Members

Jan Clarkson,
Clinical Lead

Professor of Clinical Effectiveness, University of Dundee;
Director of SDCEP, NHS Education for Scotland (NES); JointCoordinating Editor, Cochrane Oral Health, University ofManchester

Craig Ramsay,
Methods Lead

Professor and Director, Health Services Research Unit
(HSRU), University of Aberdeen

Magaly Aceves

Research Fellow, HSRU, University of Aberdeen

Miriam Brazzelli

Reader, HSRU, University of Aberdeen

Thibault Colloc

Dental Core Trainee, Oral and Maxillo-facial Surgery,
Aberdeen Royal Infirmary, NHS Grampian

Manas Dave

NIHR Academic Clinical Fellow in Oral and Maxillofacial
Pathology, University of Manchester

Anne-Marie Glenny

Professor of Health Sciences, Joint-Coordinating Editor,
Cochrane Oral Health, Division of Dentistry, University ofManchester

Beatriz Goulão

Statistical Research Fellow, HSRU, University of Aberdeen

Thomas J Lamont

Clinical Research Fellow/Hon. StR in Restorative Dentistry,
School of Dentistry, University of Dundee

Derek Richards

Specialist Advisor, SDCEP, University of Dundee

Clare Robertson

Research Fellow, HSRU, University of Aberdeen

Gavin J Wilson

Chief Dental Officer’s Clinical Fellow, NHS England and NHS
Improvement; StR in Oral Surgery, Leeds Dental Institute

The COVID-19 Dental Services Evidence Review Working Group would like to thank andacknowledge the contribution of the following individuals for providing the advice andaccess to the international guidance documents necessary for this rapid review:
Colette Bridgman, Chief Dental Officer, Wales; Alonso Carrasco-Labra, Director, ADA
Science & Research Institute; Riana Clarke, National Clinical Director Oral Health, New
Zealand; Michael Donaldson, Chief Dental Officer, Northern Ireland; Tom Ferris, Chief
Dental Officer, Scotland; Sara Hurley, Chief Dental Officer, England; Marco Landi, Councilof European Dentists; Timothy Ricks, Chief Dental Officer, US Public Health Service;James Taylor, Chief Dental Officer, Canada; Benoit Varenne, Dental Officer, World HealthOrganization.
The COVID-19 Dental Services Evidence Review Working Group are grateful for the help
and support provided by Shona Floate, University of Glasgow; Anne Littlewood, Laura
MacDonald and Helen Worthington from Cochrane Oral Health; David Felix, Postgraduate
Dental Dean, NES and colleagues from NES’s Clinical Effectiveness workstream:
Samantha Rutherford; Douglas Stirling; Michele West; Linda Young.
Page 11 of 45

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

Appendix 1. Details of the identified international guidance documents for the re-opening of dental services
Reference
Country:
FranceSource:Ordre NationaldesChirurgiensdentistes(FrenchNational
Dentists
Association)
Date ofpublication:
30.04.2020
Latest update
05.05.2020
http://www.ordre-chirurgiensdentistes.fr/inde
x.php?id=161&t
x_ttnews%5Btt_
news%5D=999&cHash=8a653
37d9f447fe9737
45e3fb45d702f

Page 12 of 45

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Management of theclinical room

Waiting area
-Limit use as much as possible-Remove all unnecessary items-Limits sits, spaced by 1m-Disinfect room twice daily-Air room 3 times a day for atleast 15 min

All staff-Forearm not covered-Short nail without polish-No jewellery-Clean shaven-Wear hair up-Dedicated working uniform-Working uniform should notleave practice (washed at least
30min 60degrees c)

Clinical room
-If multiple dental units insame room: respect social
distancing measures; only
one patient in the clinicalroom if AGP required-During AGPs clinic door must
be closed and team mustwear appropriate PPE-If possible swap between 2
rooms between patients-Clinical waste container
directly available-Disinfection container withcover directly available-All working surfaces
susceptible to be soiled byprojection (1.5m aroundsource) should be empty or
covered with plastic covers toease cleaning anddisinfection-Cover and disinfect IT andphone equipment regularly-Ban use of spittoon on dentalunits- Dedicated scrubs fortreatment room.

Reception-Hand sanitiser available-Surgical masks available forpatients who don’t have one-Display of poster regarding social
distancing and preventive
measures-Ban use of water fountains-Ban access of toilets except
emergencies-If possible protective screen at
reception desk
Patients’ triage- Group A: “Healthy patients” alltreatments available- Group B: Shielded patients (over65yo, cardiac or respiratory
disease, immunosuppressed),case by case discussion for nonurgent treatment (dedicatedslots)-Group C: High risk COVID-19,
patients who had close contact
with confirmed COVID-19.
Emergency treatment on
dedicated slots only, delay of
non-urgent work (review 14days
incubation)-Group D: Confirmed COVID-19
patients, emergency treatment
on dedicated slots only. Delay

Support staff- Surgical masks at all time
-If no protective screen at
reception desk, eye protections
or full-face visor-Surgical masks should bechanged every 4 hours
Clinical team-Dedicated working uniform
during clinical procedures(short sleeves, trousers, closed
shoes) should be changed
every half-day or if soiled-Single use gloves-Surgical hat or equivalent(maximum half day if notsoiled)-Protective glasses/goggles andfull-face visor (protective ofmasks)-FFP2 masks for AGPs and biocleaning/disinfection/airing-FFP2 worn up to 4 hours (canbe reused if not soiled)-If clinical team not wearing
FFP2, wear surgical masks- Plastic apron during low risk
AGPs

Air quality-Prime goal is to limit AGPs
-After each AGP, air renewal
before next patient-After AGPs, ventilate clinicalroom for at least 15mins withwindow wide opened anddoor closed-Clinical room with window:
continuous minimal
ventilation; air clinical room atleast 15mins post AGPs

Dental procedures
AGPs include-Ultra-sonic scaling-Use of dental handpiece-Dental air polishing-Use of air-water (3-in-1)
syringeIf possible favour use ofcontra-angle rather thandental air turbine
Clinical procedures protocol-Patients should wear a facemask until the starting of theprocedure and wear it again
at the end-Antiseptic mouthwash isadvised despite no clinicalevidence-Intra-oral radiograph should
be carefully considered due
to risk of cough and saliva
flow stimulation-Consider panoramic and
CBCT if possible andindicated-Use of rubber dam wheneverpossible-Use of high flow suction, 2 atsame time when possible-Favour 4-handed dentistry-Air dental polishing is notrecommended-if use of dental handpiece isnecessary, prefer blue contra
angle rather than red; set
hand piece setting to minimal
water flow; proceed tosterilisation after each AGP-Use resorbable sutures if
possible

Post-operative
cleaning/disinfection/waste
management
Cleaning and disinfection
procedures
Between patients-Due to shortage FFP2 masks
should be kept if not soiled-PPE should be discarded ordisinfected-Clinical waste and soiled
PPE should be discarded via
clinical waste pathway-Non-soiled PPE should bediscarded using main waste
pathway but with dedicatedbin bags-Perform hand hygiene-Disinfect all surfaces withdetergent disinfectant (NF
EN 14476) or classic
detergent and use of sodium
hypochlorite 0.1%
-Be mindful of 1.5m perimeterfor projection from sources-All medical devices
disinfected with detergent(NF EN 14476)-Impressions should be rinsed
with cold water anddisinfected with disinfectedwith NF EN 14476 norm orwith sodium hypochlorite
0.5% (inform dental
technician of disinfection
method)-Purge suction cable withwater
-Disinfect suction cable caps
-Adequate PPE after AGP for
disinfection and bio-cleaningRecommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Management of theclinical room

non-urgent treatment (15 days
following start of symptoms or 24days if immunosuppressed)-Single use surgical gown orequivalent during high risk
AGPs (high risk of biologicalfluid projection)-Clinical room without window:
if no window needs for fresh
air handling unit (FAHU)
without recirculated air
system-Air conditioning is not subject
to consensus: if usedrecommended to change
filters weekly-Air purifier: No evidence, only
use as complement withother ventilation systems-Ventilation system must use
HEPA filter system (level 13
minimum)

No serology test or diagnostic test
in dental practice recommended
Patients’ pathway-Patients should be informed of
new pathway prior toappointment-Temperature check notrecommended-Patients should wait outsidepractice as long as possible-If possible, admit patients
straight into clinical room
-Avoid physical contacts-Patients should come alone orwith only one accompanying
person if necessary (e.g.
child/non-autonomous person)-Patients’ belongings container
made available and disinfected
between patients (optional)-Hand hygiene after manipulated
patients’ belongings-Favour card payments-Disinfect card terminal regularly
Staff- Professional presenting
symptoms: Stop activity
immediately and liaise with GP or
Occupational Health for testing-Professional in close contact withconfirmed COVID-19: If
asymptomatic, continue activity
wearing mask continuously for
14 days; if symptomatic, stop
activity immediately and liaise
with GP/OH for testing
Page 13 of 45

6 May 2020

- Administrative andreception staff should neverenter clinical room

Dental procedures-Avoid prescribing NSAID for
covid-19 patients
Prescription of steroids should
be carefully considered, if
COIVD-19 symptoms, theyshould be stop immediately
and prescriber contacted

Post-operative
cleaning/disinfection/waste
management
Half-day and at the end of
the day-Same as between patients-Disinfection of suctions-Disinfection of suction filters-Disinfection of all surfaces in
waiting area if used
-Seal waste bags with gloves
and perform hand hygiene
At the end of the day-Floor cleaning with NF EN
14476 detergent or sodium
hypochlorite 0.5%
-No use of vacuum cleaner
Laundry
Dental scrubs should be
washed on site and neverleave the practice.
Clinical waste disposal
Immediate access to
disinfection tray with cover andclinical waste container in thetreatment room.
Single use items should betrashed after use.
All clinical waste and PPE
should be eliminated using theinfectious waste pathway.
Do not transfer waste from one
bag to another; double bagwith second one; seal bag andstore for 24h prior toevacuation.

Recommendations for the re-opening of dental services: a rapid review of international sources

6 May 2020

Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Management of theclinical room

Country:
Spain
Source:Council of
Dentists andCollegial
Organization of
Dentists

Reopening surgery- Clinical staff health status needs
to be checked and staff toreceive appropriate training on
protocols, procedures, andmaterials.
- If possible, do a simulation prior
to the arrival of patients.

All staff
Reception staff should wear asurgical mask and, if possible,
glasses.

Date ofpublication:
13.04.2020
Latest update:
01.05.2020

Reception area
- Cleaning of shoes.
- Methacrylate screen in thepatient reception area.
- Visible line to indicate a security
distance of approximately 1.5
meters from reception desk.
- Person at the reception shouldwear a surgical mask and, if
possible, glasses.

Minimise equipment
Before the patient enters:
Organise the strictly necessary
material and instruments, andPPE. Avoid viral crosscontamination by placing
unnecessary material or
instruments out of sight. The
placement of plastic or
aluminium film in certain areas(those considered to be at
greater risk of splashing or
aerosols) can be useful. All
common contact areas of theequipment (e.g. chair lamp
handle, etc.) should becovered with plastic film (oraluminium foil) between
patients visits.

https://www.con
sejodentistas.es/comunicacion/a
ctualidadconsejo/notasde-prensaconsejo/item/17
83-planestrategico-deaccion-paraclinicasdentalesdurante-elperiodo-dedesescalada.html

Waiting room
- Remove all unnecessary items
such as decorations, coffee
makers, magazines, books, etc.
- Chairs placed in a way torespect social distancing and at
least 2 metres apart.
Toilets- Remove bathroom towels or
hand dryers and replace withpaper.
- Provide instructions on proper
hand washing.
Patient advice
With the exception of children andpersons in need, patients shouldcome alone.
- Avoid wearing jewellery oraccessories.
- Mobile phones must be stored
and not used in the dental
practice.

Page 14 of 45

Non-AGPs- Single use of FFP2 masks
without valve for up to 4
hours. Possible to re-use themask after sterilization if notdamaged (2 or 3 sterilizations
permitted).
- Dealing with a symptomaticpatient: no need of a mask if
2 meters away; use ofsurgical mask if 1 to 2 meters
away; use of FFP2 mask if <1meter away.
- Double pair of nitrile or latex
gloves.
- Eye protection- Waterproof disposable gown,
cap, and shoe covers- Avoid wearing rings,
bracelets, pendants, watches,or other accessories
AGPs- Shoe cover- Hand hygiene (for at least 40
seconds)- Protective gown, disposablecap, and gloves, mask, andeye protection- Avoid touching your face andsurrounding surfaces while
wearing PPE.

Closed clinic rooms
Door of the clinic must be
closed to prevent viral spreadthat may occur during
treatments.
Patient preparation
Before starting any procedure,
patients should disinfect theirhands, wear a disposable
gown and for thoseinterventions that generate
aerosols eye protection. Use
only disposable cups.
Air quality
During aeration, no drafts
should occur (close door).

Dental procedures
Tiered procedure levels
Level of severe restrictions(A) corresponding to the
lockdown period
Urgent Care. Assess severityof the patient. Address severe
pain, inflammation and/or
infection, severe trauma, major
postoperative bleeding.
Professional criterion: Any
activity that in the dentist's
opinion should not be delayed.
Level of important
restrictions (B) the firstdeescalating phase
Minimally invasive
restorations, restorations that
do not require high-speed use
using absolute isolation andspecific indications. Do not
generate aerosols or, if
necessary (emergencies),
minimise them, always with arubber dam. Extractions(preferably non-surgical).
Manual scaling (not ultrasonicor sonic), manual periodontal
procedures, prosthodontic
procedures without carving.
Professional assessment ofurgent endodontic procedures(with absolute isolation, priordisinfection of the consumer,
preferably with sodium
hypochlorite). Professional
assessment of some
implantology procedures
without high speed.
Assess relevance of sealants
in all medical or preventive
procedures and orthodontic

Post-operative
cleaning/disinfection/waste
management
Cleaning and disinfection
procedures
Use thick gloves for cleaningand disinfection. The use of adouble pair of gloves isrecommended. Once thetreatment is finished, remove
the external pair keeping theinternal pair until completion of
the collection, transport,
cleaning and disinfection ofmaterial and instruments.
Doffing procedures after
treatment and general
hygieneGlove hygiene (for at least 20
seconds), remove the gown
trying not to touch the clothes,
remove the external pair ofgloves, then remove theglasses, disposable caps,
masks, and the internal pair ofgloves. Then wash yourhands.
Cleaning and disinfection
protocol:Surfaces must be disinfected
after patient contact and all
instruments should besterilised. The floor of theclinical area must be cleaned
at least 3 times: at the
beginning of the morning, atnoon and at the end of theworking day. Protective
glasses and screens must be
disinfected between patients.
Cleaning and disinfection of
the clinic at the end of thedayRecommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations- A distance of at least 2 metersmush be observed if another
patient is present in the dental
practice.
- Payment should be arranged
preferably by cards.
Patient scheduling- Patient temperature should betaken at arrival and invited towash hands at arrival.
- Patients should be offered asurgical mask and a disposablecap.
- If children and adults need to
be seen it is advisable todifferentiate schedule.
- Ensure that patients waitingtime does not exceed 15
minutes.
- Use an appropriate booking
system to minimise the numberof patients in the waiting room.
- Patients should not wanderaround.
Postoperative instructions topatient- Explain to the patients thatelective procedures may bedeferred or reassessed.
- Avoid shaking hands.

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures
treatments (care with polishingafter removal of brackets).
Level of moderate
restrictions (C)Progressively normalise highspeed use, extreme caution in
relation to PPE, incorporate
restorative dentistry andapplication of sealants.
Ultrasonic scaling in selectedpatients.
Incorporate the rest of thetreatments, adopting all the
updated protocols.
Level of minimal orunrestricted restrictions (D)Standardised care, but
continued PPE use isrecommended for the longterm.
Avoid aerosols
Avoid using the air-watersyringe to generate aerosols.
High volume suction
Use high flow aspiration to
decrease the viral load
generated by aerosols. Coverthe vacuum cleaner hose witha disposable cover.
Rubber dam
The use of the rubber dam isessential in any operative
manoeuvre. Use of disposable
covers is highly convenient, in
addition to the necessary
sterilization.
Mouthwash

Page 15 of 45

Post-operative
cleaning/disinfection/waste
management
Common zones and reception
area: Cleaning and disinfectionof all common areas including
window knobs, handrails,
tables, armrests for chairs andarmchairs, switches,
telephones, etc.
Bathing area: Cleaning anddisinfection of all areas (e.g.
sink, toilet, tiles,switches).
Floor scrubbing with bleach.
Disinfection and sterilization
area: Autoclave andthermostable cleaning anddisinfection.
Clinical areas must be cleaned
at least 3 times a day (at the
beginning, at the end of themorning and at the end of theday).
Clinical waste disposal
PPE and other disposable
contaminated material shouldbe placed in a plastic bag in apedal-operated, hard-lid
container.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
Portugal
Source:Direcao Geralda Saude(DGS)(DirectorateGeneral of
Health)Date ofpublication:
01.05.2020
https://www.dgs.pt/directrizesdadgs/orientacoes-e-circularesinformativas/ori
entacao-n0222020-de01052020.aspx

Practice preparation andpatient considerations

Practice reopening generaladvice- Ensure that all professionals
are informed about this plan.
- Ensure patients have access to
information related torespiratory good practice, handhygiene and mask use.
Reception area
- Remove all unnecessary items
such as decorations, coffee
makers, magazines, books, etc.
- Promote the circulation of air in
the waiting room, preferablewith windows and doors
opened.
- Protect surfaces that might be
exposed to hand contact withplastic barriers or aluminium foilthat is disposable (e.g. lamp
handle, rotating instrumentsetc.).
- Ensure surgical masks areavailable and an alcoholic
solution at the entrance of theclinical practice. The mask
should be used in the reception
and waiting room and should
only be removed once thepatient is in surgery.
Patient triage- Triage prior to the appointment.
- Prior to the appointment, aremote triage should be done toassess whether the patient has
symptoms compatible withhaving COVID-19: new coughor worsening of a previous

Page 16 of 45

PPE for dental practicepersonnel

All staff
The receptionist should have asurgical mask, safety
spectacles, face shields, clinicaluniform, and shoes.
Non-COVID-19 patients
Oral health professionals should
use PPE according to the risk ofthe procedures undertaken
during the appointment.
Oral health professionals
involved in seeing patientsshould use PPE according to theNorm 007/2020 from the DGS.
COVID-19 patients
For high risk procedures(aerosol generating) or forpatients with suspected orconfirmed COVID-19 inemergency situations:- Surgical Apron – open in theback, disposable, waterproof
with long sleeves and thatsits below the knee
- Mask FFP2 (N95) or FFP3;- Safety spectacles or faceshields (with inferior opening)- Gloves – disposable and nonsterilized- Hairnet- Safety shoes
For high risk procedures, theuse of a double pair of gloves(long sleeve) or a full protection
suit.
For low risk procedures (that do
not generate aerosols):

6 May 2020
Management of theclinical room

Before the appointment
Promote air circulation,
preferably by opening
windows.
Disinfect surfaces, particularly
those that are touchedfrequently, according to
Guidance 014/2020 from the
Chief Medical Office.
Minimise equipment
Prepare in advance all thematerial you expect to use to
avoid the circulation of people
and the opening of drawers.
Clear works surfaces
Remove all jewellery andaccessories to see patients.
Staff general hygiene
Keep nails clean and short.
The use of acrylic nails,
shellac, nail varnish or any
other nail products is not
permitted
After treatment/room
decontamination
Clean and disinfectimmediately all surfaces andwork environment.
Renovate the air at the end ofeach appointment.
Assure effective disinfection ofmodels and moulds.
Follow all universal principles
of sterilization and disinfection

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Patients should mouthwash for
30 seconds to decrease theviral load when proceedingwith intraoral examination.
AGPs
Risk of dental procedures to
COVID-19 transmission.
All procedures that generate
aerosols are considered highrisk, including root canaltreatments and all activities
using rotating instruments(polishing included) or an airwater syringe.

Cleaning and disinfection
procedures
Cleaning and disinfecting all
surfaces outside the surgery
must be undertaken with 1 to
2-hour breaks.

During the appointment:- Avoid, whenever possible,
aerosol generatingprocedures.
- Instruct the patients, before
any procedure, to mouth
wash for 30 seconds with ahydrogen peroxide solution
1% or iodopovidone 0.2%.
- Use surgical suction to
decrease aerosol
generation.
- Use rubber dam whenappropriate.
- Use rotation instrumentswith non-return valve 3 anddisposable protections.
- Prioritise extraoral
radiographs compared withintraoral.
- Prioritise re-absorbablesutures after extractions.

Cleaning and disinfection of all
surfaces in the surgery must
be done after every
appointment.
Reusable material
Reusable spectacles orgoogles must be disposed in adisposable board and sprayedwith alcohol 70 degrees or
immersed in a chlorine
solution as indicated by
Guidance 014/2020 from the
DGS.
Face shields must be sprayedwith alcohol 70 degrees in adisposable board.
Laundry
Garment parts of PPE that are
washable must be removed
carefully, without shaking
them, from inwards to
outwards, and put into awaterproof bag. They must be
washed at the highest
temperature possible.
If the garment cannot be
washed with hot water, it must
be washed in washingmachine, at 30 to 40 degrees

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

cough or fever or breathingdifficulty in the last 14 days.
- If in contact with a suspected orconfirmed case of COVID-19 orif patient has been diagnosed
with COVID-19. If the answer isyes, ask if the patient is still in
self-isolation (14 days).

- Disposable apron on top of
the clinical garment- Mask FFP2 (N95)- Safety spectacles or faceshields (with inferior opening)

If the patient has symptoms
compatible with COVID-19, thepatient should contact the National
Health Services telephone line andan appointment should not bescheduled until the patient has
recovered respecting the selfisolation period.
If the patients has symptoms or
has COVID-19, and the problem isurgent, consider booking theappointment at the end of amorning or afternoon, in prespecified times.
Patient scheduling:
Book appointments in advanceand remotely to avoid having
patients in the waiting room.
Before the appointment patientsshould receive this information:
Patients should come alone. If thatis not possible, the accompanying
person should wait outside of thepractice or in the waiting room witha mask on. If the accompanying
person needs to be in surgery,they should sit over 2 meters awayfrom dental equipment.
- Patients need to wash theirhands with an alcoholic solution
provided, avoid touching surfaces,
and there should be a preference
for card payment.
Page 17 of 45

For cleaning, disinfecting andsterilization procedures, thedental assistant should wear
PPE as indicated in the point x
with surgical mask type IIR
In addition, they should use awaterproof apron and thickgloves.
If reusable, the safety
spectacles or face shields must
be disinfected before and after
each appointment.
When removing PPE, the firstpair of gloves must be removed
before removing the remaining
PPE, and leave the second pairof gloves until the end (Appendix
IV)
The clinical and assistance staff
should have all the PPE on
before they go into surgery.

6 May 2020
Management of theclinical room

During cleaning anddisinfection procedures, after
treatment and when moving
used material into thesterilization room, the dental
assistant should remove only
the first pair of gloves, store allmaterial, and then remove theremaining PPE.
Air quality
If air conditioning is available,
it should be used only inextraction mode, never inrecirculation mode. The
equipment should be checkedand certified.

Dental procedures

Post-operative
cleaning/disinfection/waste
managementwith an appropriate
disinfectant.
In the absence of a washingmachine, pack the garment
and put it into a waterproofbag, safely enclosing it until itreaches the washing place.
Put the garment directly into
the washing machine,
following the points above.
Clinical waste disposal
Dispose all PPE anddisposable materials in thecontaminated material bins
(type III or IV).

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management

During the appointment:
Ensure personal objects are notvisible during the appointment andthat they are disinfected regularly
and keep the door of the surgery
closed.
Country:
Germany
Source:Institut der
Deutschen
Zahnärzte(GermanDentists
Association)
Date ofpublication:
24.04.2020(version 3)
https://www.idz.i
nstitute/publikati
onen/sonstiges/
system-vonstandardvorgeh
ensweisen-fuerzahnarztpraxenwaehrend-dercoronaviruspandemie.html

Patients’ triage
If patient has a planned
appointment:- Clarify with dentist urgent
treatment need
- Check if patient has been
recently tested or not- Confirm with patient whether
suspected/ confirmed COVID19- Confirm whether symptomatic
If patient does not require urgent
treatment, postpone and prescribe
if required
If patient requires urgent treatment
has no symptoms and is not asuspected COVID-19 case, treat
with basic hygiene guidelines
If patient is suspect/confirmed
COVID-19 and requires urgent
treatment, refer to dedicateddental treatment centre (or see
patient with adequate PPE if
available)
If patient calls practice without
appointment:- Check if patient has been
recently tested or not- Confirm with patient whether
suspected/ confirmed COVID19- Confirm whether symptomatic

Page 18 of 45

PPE for “healthy” patients-Observe basic hygiene
instruction:- Work uniform- Safety glasses with sideshields- Surgical mask
- Hand hygiene- Disposable gloves
PPE for suspected/confirmed
patients- Goggles with side shields orvisor- At least FFP2 masks- Surgical hat and shoes
protections/boots- Long sleeves waterproof
gowns with cuffs and backclosure- Disposable gloves
PPE for disposal of waste anddisinfection:
Disposable gloves with longer‘sleeves’

For suspected/confirmed
patients- A specific treatment room
becomes “isolation room”
as is identified as such
- A team (dentist + assistant)in the room with adequate
PPE- Supporting staff outside theroom if extra
instruments/materials
required- Remove all unnecessary
objects- If required, cover ofcounters, stands and otherworking surfaces withwaterproof cover
Disposal of all wastes
Wipe of all surfaces following
treatment
Air quality
Ventilation of clinical room for
30min

Treatment of “healthy
patients”- Antiseptic mouthwash
before treatment (H2O2(1.5%) or equivalent) 30ml
for 1 minute- If using air-water syringe,
only water or only air (notboth together)- Avoid AGPs if possible (noultra-sonic or turbines, use
slow speed)- Use rubber dam whenpossible
Treatment ofsuspected/confirmed
patients
Non-surgical treatment or
simple surgical treatment only
Before treatment:- Antiseptic mouthwash
before treatment (H2O2(1.5%) or equivalent) 30ml
for 1 minute- Cover patients’ clothes
During treatment:- Use of rubber dam if
possible- High suction- Avoid AGPs when possible

Cleaning and disinfection
procedures
Disinfection of all items
potentially touched by patient(i.e. doorbell, door handles,
chairs)Clinical waste disposal
After treatment ofsuspected/confirmed cases
use dedicated, properly
marked special waste
container (impermeablecontainer easy to disinfect)

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management

If patient does not require urgent
treatment, postpone and prescribe
if required
If patient requires urgent treatment
has no symptoms and is not asuspected COVID-19 case, treat
with basic hygiene guidelines
If patient is suspect/confirmed
COVID-19 and requires urgent
treatment, refer to dedicateddental treatment centre (if notpossible and urgent treatment
required, see patient withadequate PPE if possible)
If unclear need for urgent
treatment and patientsuspected/confirmed COVID-19,
telemedicine then referral tourgent treatment centre ortreatment at the practice if
adequate PPE available or delay
treatment if non-urgent
Suspected/confirmed COVID-19
patients: Patients should wear aface-mask in practice and should
go straight into “isolation room”
Country:
Austria
Source:Austrian Dental
Chamber
Date ofpublication:
03.04.2020
Latest update
04.05.20

Waiting area
-At least 1 meter between
patients-Appropriate safety measures(plexiglas, removal of chairs)-Provide area for hand hygiene-Face-masks available forpatients who do not wear one-Ventilate room regularly-Remove unnecessary items
Reception

Page 19 of 45

All staff-Face-mask-Increased regular handhygiene
Asymptomatic patients-Surgical mask
-Single use gloves-Eye protection
Symptomatic patients-FFP2 with valve

Clinical room
Increased regular wipe
disinfection

Asymptomatic patients
Limit AGPs as much as
possible

Air quality
Regular ventilation of clinicalrooms

1% H2O2 solution mouthwash
recommended as mouthwash

Cleaning and disinfection
procedures
Increased regular surfaces
disinfection (e.g. door handles,
switch, chairs)
Disinfection/sterilisation of
medical equipment
immediately after use
Clinical waste disposal

Recommendations for the re-opening of dental services: a rapid review of international sources
Referencehttps://stmk.zah
naerztekammer.
at/zahnaerztinn
en/informatione
n-corona-virus/

Practice preparation andpatient considerations-Protective screen at reception
deskPatients’ triage-Dedicated ‘infection opening
hours’-Always telephone/email
agreement prior to appointment-Patients checked via phone
regarding COVID-19 symptoms
in the past 2 weeks-Symptomatic patients should bepostponed unless dental
emergency; refer them to ensure
diagnosis-Any risk groups : dental
treatments reduced to minimum

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures-Gloves-Safety glasses-Surgical hat-Surgical gown
-Protective face shield

Post-operative
cleaning/disinfection/waste
management
Disposal of potentially
infectious material without
intermediate storage in closed
container

Patients arrival-All patient should wear facemask-Encourage people to wait inpublic places/outside and contact
them by phone when ready-Patients should touch as few
things as possible
Staff of dental practice-Observe social distancing-Regular team meetings to ensure
clarityCountry:
Switzerland
Source:SSO (Dental
Swiss Society)
Date ofpublication:
Published
17.04.20
Page 20 of 45

Staff advice/screening- Minimize number of staff incontact with patients.
- Staff must adopt social
distancing at all time
- If a member of staff is showing
symptoms. Self-isolation for 10
days tested or not and return towork 48 hours after the end of

All staff
All staff must wear a mask allday.
Non-COVID-19 patients- Surgical mask
- Disposable gloves- Eye protection- FFP2 mask for AGPs

Staff general hygiene- Hair must be tied high anduse of a hat if possible- Nail short and no nail polish- Hand hygiene with cold
water and soap
- Hand hygiene with handsanitizer

Asymptomatic patients
Possibility to provide treatment
with the following precautions:- Wear of surgical mask
during the whole workingday- Before treatment, ask
patient to use viricide
mouthwash (1.5% H2O2

Cleaning and disinfection
procedures
Wear of mask, gloves and eye
protection during
cleaning/disinfection
procedures.
Follow hygiene guidelines
implemented by the SSO.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Effective from:27.04.20

symptoms following the 10 daysof self-isolation.

https://www.sso.
ch/home/corona
virus.html

Reception area
- If possible, use protection
screens at the reception desk.
- Disinfect phone after each use
if used by different people.
- Remove all unnecessary items
from the waiting area.
- Minimize the number of staff
touching drawers handles,
folders, patients’ notes,
keyboards and disinfect them
regularly.

COVID-19 patients- Disposable gloves- Eye protection- Surgical gown
- FFP2 masks for at least 30
min following AGP and for thewhole time the patient ispresent in the treatment room

Patient scheduling- Allow longer appointment thanusual.
- Only one patient at a time per
dental chair in the practice.
- Vulnerable patients (shieldedpatients) and possible
treatment following COVID-19
symptomatic/asymptomaticpatients:- Patient scheduled at specificslots in order to avoid any
contact with other patients.
- Professional discussion andopinion regarding pros andcons for treatment or delay.
- If any risks, elective proceduresshould be delayed.
Patient triage- Patients triage over the phonewith discussion regarding
symptoms and close contact
with potential COVID-19 cases.
- If deemed necessary, staff canprovide surgical mask topatients to wear while in thepractice.
Page 21 of 45

6 May 2020
Management of theclinical room
- No treatment if thesemeasures can’t be
respected

Air quality
It is forbidden to provide
treatment in a room without awindow or adequate
ventilation.
After each patient, the roommust be ventilated for at least
15 minutes and disinfected(disinfectant solution
instruction for estimated timeof action must be strictly
followed).

Dental procedures
solution or povidone-iodine
solution for 30 seconds)- Treatment with rubber dam
when possible. Do notforget to disinfect rubberdam.
- Use both high and low
speed suctions- Limit as much as possible
AGPs. If it is necessary,dental team should wear
FFP2 masks.
- Scaling only with handscalers
Patient suspected orconfirmed COVID-19
Only emergency treatment thatcannot be postponed.
Treatment must take place in a
‘COVID-19 treatment room’apart.
No contact with other patientsin the practice should happen.
- Patient must wear asurgical mask when hearrives.
- Dental team must wear
FFP2 30 minutes after theend of AGP and as long as
the patient is in thetreatment room.
- This patient group can bereferred to hospital setting
or dedicated emergency
centre for COVID-19.
General rules applying to all
patients- Avoid as much as possible
AGPs (if necessary, userubber dam if possible).

Post-operative
cleaning/disinfection/waste
management
Regular disinfection of all
surfaces (following disinfectant
solution instructions).
Disinfection of keyboard andcomputer screen after eachpatient.
Clean with soapy water anddisinfectant all that patients or
staff are susceptible to havetouched. Every hour:- Waiting area seats- Door handles

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
Belgium
Source:Conseil de l’Art
Dentaire on
behalf of theService Public
Fédéral deSanté Publique”
Date ofpublication:
19.04.2020
Latest update30.04.2020
https://organesd
econcertation.s
ante.belgique.b
e/fr/documents/t
ableau-dereprise-desactivites-de-lartdentaire

Practice preparation andpatient considerations- Highly recommended to screen
patient’s temperature. If>37.5oC, send patient backhome and delay treatment.
- Patients should directly go to
the treatment room.
- Exceptionally, they can wait in
the waiting area for up to 15
minutes with 2m social
distancing measures.
- Patients should wash theirhands before start of treatment.
Staff advice- Any member of the team withsymptoms should self-isolate.
- If diagnosed positive for
COVID-19, self-isolate for 7
days following symptoms and at
least 3 days without a fever.
- If you think you are a potential
risk without symptoms, same
rules apply.
- Enhanced hand hygiene.
- Working uniform replaced
regularly.
- Working shoes or shoes withshow protection within thedental practice.
- Try and limit the number ofsurfaces you touch.
- Respect social distancing (1.5
to 2 meters).
- Limit the number of staff to thestrict minimum.
- Regular disinfection of common
areas.
Waiting area
- Remove any unnecessary
items (toys, reading materialetc.).
- Seats placed in a way torespect social distancing.

Page 22 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management- Generalise use of rubberdam.
- Low and high-speed suction
simultaneously.
- No treatment can beprovided without adequate
PPE.

All staff
All staff should wear at least asurgical mask at all time.
Non-AGPs
For treatment:- Surgical mask
- Single use gloves- Protection apron with long
sleeves (or change scrubs
between each patient)- Eye protection (visors
recommended)
AGPs- Surgical gowns with long
sleeves- Eye protection + visor- Gloves
For patients B1 and B2, use of
FFP2 masks.
Supporting staff should limit
presence in treatment room but
if needed should wear eye
protection, gloves, surgicalmask.

Treatment room
- Turn off air conditioning.
- Make sure the room is wellventilated (open windows).
- Remove or cover all
unnecessary items on
working surfaces.
- Prepare in advance all
required equipment ormaterials for treatment.
From waiting area totreatment room
- Keep social distance at least
1.5m.
- Open the doors yourself.
- If possible switch between
different treatment rooms
especially following AGPs.
Ban of dental unit spittoon
Supporting staff brings in clean
instruments and anynecessary material.
Dental nurse assists by trying
to limit cross infection as muchas possible (suction).
After treatment

Treatment types
Urgent treatment (treatment
required within 24h):- Oral infection with facialswelling and general
symptoms- Oral bleeding- Dental trauma- Severe pain not controlledwith analgesia
Required treatment- Oral infection not controlled
following antibiotics course- Oral pain difficult to control
with analgesia- Treatment following dental
trauma (RCT, removal of
splint)- Completion of RCT- Follow up of implant caseor transplantation- Dental fracture or loose
filling- Fit of prosthesis- Denture ease
- Orthodontic maintenance(e.g. debonded bracket,
broken arch wire)- Follow up of patients withsevere periodontal disease

Cleaning and disinfection
procedures- Wear a mask, apron andcleaning glove.
- Remove all visible stains
first with soapy water- Dry and then disinfect all
surfaces with disposable
wipes- Floors should be- cleaned every half day.
Disinfection products- Alcohol 60% to 70% ethanol- Chloroxylenol 0.12-0.24%(Dettol)- Bleach 0.1-0.5%
Instruments- Clean instruments from any
visible stain.
- Use autoclave andthermodisinfection prior toreuse instruments.
Laundry
Working uniform washed daily
at 60 degrees minimum.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations- Only one patient in waiting area
at a time with eventual
accompanying person if
necessary.
Toilets- Close toilet room.
- Possible to use they by asking
staff.
- After each use, the room should
be disinfected.
Reception desk
- Respect social distancing.
- Remove all unnecessary items.
- All documents should be sent
electronically if possible.
- Contactless payment should be
favoured. Protective screen on
payment machine or disinfectafter each use.
Patient triage based on thefollowing patient groups:
Group A1: COVID-19 positive.
Postpone any treatment andrefer to hospital setting. No
treatment unless absolute
emergency
Group A2: Suspected COVID19 positive. Symptomaticpatient or patient who has been
in close contact with aconfirmed case.
Group B1: Asymptomaticpatient with high risk conditions(shielded patients). Only urgent
or required dental treatment(FFP2). If further treatment,case by case discussion andprofessional advice. Patientsshould be scheduled at the
beginning of the day.

Page 23 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room
- Patient should perform
hand hygiene and leavetreatment room as soon as
possible.
- Dental team should remove
surgical gown and apron
and place them in a plastic
bag then sealed.
- Removal of gloves andhand hygiene.
- Leave treatment room andthen remove visor, eyeprotection and eventual
FFP2.
- Hand hygiene.
- Wear a surgical mask
again.

Air quality
Ventilate the treatment room
according to the amount of
AGPs

Dental procedures

Routine treatment- All other dental treatments- Patients should use
mouthwash 1%H2O2
solution or Povidone Iodine
1% solution for one minute
before spitting in adisposable cup- Limit use of intra oral
radiographs- Limit use of 3-in-1 syringe- Use of rubber dam whenpossible including any toothpreparation. Placed prior tostart AGP
- Use large suction tip

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
Group B2: Asymptomaticpatient with special need(patients having moredifficulties with social
distancing). Prioritise urgent
treatment, then required
treatment and then routine
treatment. Scheduled at theend of the day. (use of FFP2)Group C: Asymptomaticpatients. Dental treatment canbe provided prioritising urgent
treatment, then required
treatment and then routine
treatment.
For patients- Treatment is provided only withappointment- If patient shows symptoms
following appointment booking,they should contact the practiceby phone- Patient should not present early
to the practice- If necessary they should waitoutside the practice- Patients should come wearing amask- Favour electronic payment
When patient arrives topractice- Hand hygiene- Ask about household and close
relatives’ status in relation with
COVID-19- Ask or screen patient for
temperature (if >37.3oC refer toGP)- Patient should then seat in
waiting area without touchingdoor handles if possible

Page 24 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference
Country:
Netherlands
Source:Commissie
LeidraadMondzorg
Corona (CLMC)(Committee forthe preparationof Oral Care
Guidelines
during theCoronaoutbreak The Committee
includes various
national
dentistry
associations)
Date ofpublication:
21/04/2020
https://www.kn
mt.nl/sites/defau
lt/files/2020-0421leidraad_mondz
org_corona_def.
pdf

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Management of theclinical room

General considerations
Patient should attend alone asmuch as possible

All staff
Patient contact less than 1.5m
must wear:• Surgical mouth and nose
mask type II / R, or• Surgical mouth nose mask
type II + face shield (faceshield)• Replace nasal mask after
every patient

GeneralPermit only one patient tosurgery at any one time

All individuals who enter practice(patients and staff) should clean
their hands with soap and water or
alcohol hand rub
Prevent patients from touchingdoor handles, surfaces etc.
Reception
Digital provision of paperwork e.g.
receipts, referrals, invoice
Indicate 1.5m distancing with floor
markings
Remove unnecessary items suchas folders, samples
Contactless payment (clean card
terminal after each use)
Waiting area
Maintain 1.5m distance between
chairsChairs should be easily cleansable
Active door policy
Minimise time spent in waiting
room
Offer hand disinfection facility(preferably hands free) after entry
Provide tissues and foot operated
waste bins
Decommission coffee
machine/water stations

Page 25 of 45

6 May 2020

Masks can be worn until
breathing becomes difficult ormask is too wet
FFP2 masks are reserved forthe treatment of patients withsymptoms of COVID-19 orproven COVID-19

Dental procedures
Information on
Emergency Care
Necessary non-regular oral
care

Equipment
Remove unnecessary items

Emergency and Necessary
non-regular oral care only

Easy to clean surface

Emergency care in adesignated Corona centre for
Acute Oral Care.

Air quality
Ventilate the room as much as
possible
Patient Preparation
Mouthwash use pre-op:
1% hydrogen peroxide for 1
minute If AGP

Treatment aids
Use rubber dam where
possible
Large mist vacuum (highvolume suction)

Post-operative
cleaning/disinfection/waste
management
Cleaning and disinfection
procedures
Disinfect tables, chairs andsurfaces regularly
Consistently clean surfaces intreatment room and disinfectwith 80% alcohol
If surfaces are visibly
contaminated, wipe withdisposable cloth and water orwater and soap
Use disposable cleaningmaterials where possible
Make sure surfaces/objects
are dry before disinfecting
Instruments not suitable forthermodisinfection, disinfectwith 80% alcohol after
cleaning with soap and waterRecommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

6 May 2020

PPE for dental practicepersonnel

Management of theclinical room

Laundry
Washed daily at 85 degrees atlaundry or dental clinic. It should
not be taken home.

Minimise equipment- Clean surfaces including
desks and shelves- When AGP, only one
patient present in the room
- All doors, drawers andcabinets closed before startof treatment

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Remove toys, magazines etc
Patient triage
Determine which procedures
patients may receive.
Those with symptoms of COVID19 or are confirmed COVID-19
positive receive only Emergency
care in designated CAM facility.
Staff
Space 1.5m if not possible stage
breaksThose without symptoms or who
have been free of symptoms for 24hours can work
Employee with 24 hours ofsymptoms can be tested and mustremain at home
Country:
NorwaySource:Directorate for
Health; Dental
Health Service
Date ofpublication:
19.04.2020
Latest update30.04.2020
www.helsedirekt
oratet.no
This guideline ispart of acomprehensive
document,
Page 26 of 45

Staff advice/ personal hygieneand physical contact- Avoid any unnecessary
physical contact- Hand hygiene arranged for staff
and patients on arrival and after
treatment completion- Avoid use of rings, watches andsimilar jewellery- Assess common touched areas
and whether contact can be
reduced- Equipment used is cleaned
between each patient
Waiting room
- Posters for patients’ information- Minimize number of patients atthe same time. Consider adding

Non-COVID-19 patients- Disposable gloves andadequate hand hygiene
before and after use- FFP2 or FFP2R, change
between patients- Eye protection (visors
recommended)- Cover clinical tools withplastic cover disinfected
between patients- Hat or hood covering all hair
if available

Patient/staff flow
Suspected/Confirmed COVID19 patients should not wait in
waiting area but should bedirected into a treatment roomwith closed door. Dental teamshould enter the room only
after wearing full PPE.

Non-COVID-19 patients- Hand hygiene whenentering clinical room
- Mouthwash with 1% H2O2
for at least 1min prior todental treatment- AGP with turbine and contra
angle should be minimized- Ultrasounds and airflow
should not be used
- AGP preferably done at theend of the day- Short ventilation oftreatment room between
patients following AGP- Dentists should work withthe assistance of dental
nurse

Cleaning and disinfection
procedures
All surfaces that the patient
has touched (e.g. chair, door
handles, toilets) are
disinfected according tonormal routine
decontamination
Disinfection products
SARS-CoV2 is sensitive todisinfectants such as Virkon®,
Perasafe® and alcohol withconcentration of 70%.
Household chlorine can beused at a concentration of atleast 1000 ppm.
Clinical waste disposal

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference
which details all
aspects of theNorwegianhealth andsocial careduring the
COVID-19
pandemic.
Section 5.5 ofthe document
relates to Dental
Health.
www.helsedirekt
oratet.no

Practice preparation andpatient considerations

PPE for dental practicepersonnel

breaks between each patient todo so.
- Social distancing if several
patients. Use of tape on thefloor and re-furnish ifnecessary.
- Avoid unnecessary objects in
waiting areas (reading material- Avoid food and drinks

AGP with non-COVID-19
patients- Long sleeved disposable orreusable gown, changed
between patients

Patient triage- All patients should clarify theirstatus over the phone prior toattend (forms to be used)- No patient should attend thedental clinic without
appointment- Consider whether physicalconsultation is necessary- Prior to treatment/examination,
patient’s infection status must
be considered
Treatment of patients suspected
or confirmed COVID-19- Treatment should be postponed- Prescription should be used
when justified as an alternative
to operative dentistry- Emergency treatment should bereferred to establishedemergency clinics- Emergency clinics for COVID19 should only treat this groupof patients- Patient should wear surgicalmask on arrival unless nottolerated for medical reasons- Hand hygiene on arrival andwhen they change rooms- Surgical mask removed only fordental examination andtreatment and after dental teamwear all PPE

Page 27 of 45

Suspected/confirmed COVID19 patients- Disposable gloves andadequate hand hygiene
before and after use- FFP3 (alternative FFP2)- Eye protection (visors
recommended)- Cover clinical tools withplastic cover disinfected orchanged between patients- Long sleeved disposable orreusable gown, changed
between patients
Hat or hood covering all hair

6 May 2020
Management of theclinical room

Dental procedures- Any conversation withpatient should take place inthe treatment room
Suspected or confirmed
COVID-19- AGP should be avoided asmuch as possible.
- If necessary, use of vacuum
suction and rubber dam isused is possible. (placed
prior to start AGP)
- Extra oral X-ray should beconsidered instead of intra
oral X-ray- Resorbable sutures should
be used to reduce need ofreviews
Treatment types
Prioritization of treatment in
non-suspected COVID-19
patients (in order of priority):- Emergencies (acuteinfections, trauma, pain…)- Condition potentially leading
to infection- Loosecrowns/bridges/fillings- Deep caries or otherconditions potentiallyleading to pain or infection if
untreated- Delivery of prosthetic
devices- Orthodontic treatment
needing adjustment- Sedation treatment
Treatments which should beprioritized down:- Regular recalls- Aesthetic treatments

Post-operative
cleaning/disinfection/waste
management
Waste management as per
local waste management
procedures based on theRegulations on infectious
waste from health services.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

- Patient wears surgical mask
when treatment is finished- Mouthwash with 1% H2O2 for atleast 1 min prior to dental
treatment

Country:
Denmark
Source:Danish Health
Board
Date ofpublication:
Unclear
Latest update22.04.2020

Page 28 of 45

Dental care must always take into
account the risk of spreading of
infection; follow generalrecommendation of good handhygiene and 1-2 meters distanceto others

Post-operative
cleaning/disinfection/waste
management- Treatment of minor caries
lesions and mild forms of
periodontitis- Starting comprehensive
treatment plans that can
wait (prosthetic andorthodontics)

Infection at the dental clinic- If patient diagnosed 24 hours
post treatment: conduct
infection detection + close
contacts should isolate for 14
days- Disinfection of the clinic shouldtake place asap (anybody who
was not in close contact canwork again after disinfection of
the practice was performed)
Patients with special needs
should be identified andfollow up should be clarified
with GP- Children and adolescent withspecial needs or diseases- Drug users, mental ill patients,
prison inmates- Shielded patient with high riskof developing severe form of
COVID-19 or becoming
seriously ill as a result of oral
infection
Re-opening practice
To minimize the risk of infection
with Legionella, attention shouldbe paid to flushing of water
systems/dental units, whenreopening dental clinics

Dental procedures- Case by case professional
judgment must be madeand deviations from therecommendations should
be recorded

General hygiene
National Infection Hygiene
Guidelines (NIR) for dental
clinics must be adhered to andthe focus should be on theproper use of PPE. All membersof the dental team use the same
protective equipment:
Clothing during AGP
For aerosol-generatingprocedures, as an additional
precautionary measure,Home visits
Focus must be on infectionreducing measures: upon
arrival at home, it isrecommended that all citizens
be asked about symptoms of
COVID-19; keep 1-2 meters
away; encourage handwashing or hand disinfection.

Suspected/confirmed
COVID-19 patients
Dental workers must use
protective equipment with any
AGP and the room aired briefly
afterwards.

Proper hand hygiene is
performed before and after
contact with all citizens. Use of

AGPs in patients not tested
for COVID-19

Effective saliva suction should
be used.

Cleaning and disinfection
procedures
National Infection Hygiene
Guidelines (NIR) for dental
clinics must be adhered to andthe focus should be on
cleaning and disinfection.

Recommendations for the re-opening of dental services: a rapid review of international sources
Referencehttps://www.sst.
dk/da/udgivelser/2020/haandteri
ng-af-covid-19_kritiskfunktioner-itandplejen

Practice preparation andpatient considerations
Information on COVID-19
symptoms should be posted on
entrance to clinic
Waiting room
- minimum of one meter distance
between seating- remove newspapers,
magazines, toys, beverages
from common jugs, etc.,- focus on frequent and thoroughcleaning- poster with information onprotective measures against
coronavirus on the clinic door in
waiting room.
Personal hygiene- access to hand spirit in waiting
room if possible and request
patients adhere to good handhygieneStaff screening
Dental staff should pay special
attention to their own symptoms
and stay home or be sent home
immediately with symptoms of
COVID-19 (fever, cough, sorethroat, headache and muscle
soreness, which may be
accompanied by nasal symptoms).
Dental care personnel can return
to work 48 hours after symptom
relief. Personnel with mild
respiratory symptoms may betested by their own physician or
medical officer.
Patient triage
Patients with respiratory
symptoms where COVID-19 may
be suspected or patients with

Page 29 of 45

6 May 2020

PPE for dental practicepersonnel

Management of theclinical room

disposable long-sleevedisposable coat and long-sleevecuff / disposable apron should
be used. In case of supply
difficulties, disposable plastic
aprons covering the neck can beused. If disposable plastic apron
is not available, it can bechanged to clean clinicalclothing after each patient. The
clinical clothes should be
washed as specified in NIR for
dental clinics, if applicable.
Instructions can be prepared
locally for the removal of clinic
clothes, if applicable using ashort video.

protective equipment as
specified in the section “Reg.
dental protective equipment ".

Mask and eye protection
Visor or goggles can be multipleuse, cleaned and disinfected(according to the manufacturer's
instructions) between eachpatient. In case of supply
difficulties, full-face visors canbe used alone (except for
surgical procedures). Ordinary
glasses and magnifying glasses
can be used if they are designed
for protection.
Mask should be tight-fitting andcover nose and mouth. The
mask must retain at least 98% of
microorganisms (type II), butdoes not have to be R type. As
masks become leaky whenmoistened, they must bechanged regularly and always
after each patient.

Contact surfaces (e.g.
countertop) in the patient’s
home should be cleaned
before leaving the home.
Contact surfaces in thedentist’s car, including steering
wheel, gear lever andhandbrake (for bicycle
handlebar and saddle) issanitised after each visit.

Dental procedures
For patients who have notbeen tested for SARS-CoV-2
prior to aerosol-generatingprocedures, the National
Board of Health’s principle ofprecaution should be taken.
The use of a 3-in-1
syringe/handpiece should be
limited and drying must be
effected by effective suction
and the use of cotton wool etc.
Dental treatment such as
fillings and root canaltreatment that necessitate theuse of an air rotor, turbine,
handpiece and angle pieceshould not be undertaken
unless it is an emergency thatcannot be postponed until after
test results for SARS-CoV-2.
For emergency treatment,
effective saliva suction should
be used with assistance [fourhanded dentistry] and rubber
dam used when it istechnically feasible. At the endof treatment, the treatment
room must be briefly ventilated
before the next patient.
Dental cleaning (scale andpolish/scale and root planning)
and the treatment of
periodontitis must be donewith the use of hand
instruments.
Prescribing
Prescribing antibiotics andpainkillers after conducting an
individual telephoneassessment of the patient:

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
proven COVID-19 should not betreated in [primary dental clinics]
but should be referred to hospital
Patients should not be referred fortreatment which is usually
performed in the primary sector
which is not acute/critical. For
Dental, Oral and Oral Surgery thatis acute/critical, the patient can beseen once symptom free for 48
hours.
Asymptomatic patients requiring
AGPs or other procedures that areconsidered to pose a special risk
in dental care, may be prescribeda test for SARS-CoV-2. The test
can be prescribed by the dentist or
dental hygienist. The test
responses should be available
prior to scheduling.
If the test is positive for SARSCoV-2 prior to scheduled
procedure, the procedure is
postponed. The patient should be
informed to self-isolate for 7 days
according to recommendations
and if symptoms appear within the
7 days, the patient must selfisolate for 48 hours after symptom
cessation.
Patient scheduling- telephone and video
consultations should be used
where possible- It is essential that there is easy
access to telephone contact
with the dentist; there may be aneed to extend telephone time.
Electronic scheduling must not
be possible.

Page 30 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures
1. Painkillers for short-term
treatment (up to a couple ofweeks in minimum packs),
where milder preparations
prior to prescription have notproved sufficiently successful.
2. Prescription antibiotics
where it is obvious that
infection is not due to any
other disease that falls within
the medical field
Dental treatment of children
and adolescentsMidazolam - children andadolescents who have no
symptoms of infection or are
infected with COVID-19,
Midazolam use should follow
existing guidelines followed.
Nitrous oxide can be usedprovided that the hoses arealways be retreated properlywith cleaning and disinfection.
Disinfection with heat ispreferred. Alternatively, if
possible, disposable hoses
may be used.

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
Malta
Source:Ministry for
HealthDate ofpublication:
18.03.2020

Practice preparation andpatient considerations- Plan fewer appointment times
so that there is a lower daily
patient flow in the clinic andfewer patients in the waitingroom.
- Assessments should focus onwhether dental work can bepostponed without affecting
morbidity, taking into account:seriousness and severity of thedisease / condition; risk of
exacerbating the disease if nottreated, including increase drug
consumption; risk of thedisease / condition becoming
chronic if not treated; impact on
quality of life; influence onfunction and / or ability to work
- When booking consultations
advice should be given to notshow up with symptoms of
COVID-19 (fever, cough, sorethroat, headache and muscle
soreness, which in some may
be accompanied by symptoms
from the nose).
- Vulnerable patients (those atrisk of greater COVID-19
severity) should not bescheduled for examination ortreatment in clinics whereaerosol-generating procedures
have just been performed.
Staff screening
Staff should be screened for
symptoms prior to entry into thedental practicePatient triage
Patient walk-in should be
discouraged.
Patients should be contacted by
telephone and questioned

Page 31 of 45

PPE for dental practicepersonnel

Non-COVID-19 patients
Clinicians should wear
disposable surgical masks,
protective eyewear/face-shields
and disposable gloves
Suspected/confirmed COVID19 patients
Patients who have tested
positive or are suspected
positive for COVID-19 should

6 May 2020
Management of theclinical room

Dental procedures

Four handed dentistry shouldbe performed.
Anti-retraction hand pieces
should be used and only if
absolutely necessary.
The patient should be given a
1% hydrogen peroxide or 0.2%
povidone rinse prior to thetreatment.

Post-operative
cleaning/disinfection/waste
management

Cleaning and disinfection
procedures
Surfaces must be disinfected
before and after eachprocedure or patient contact.
All instruments should besterilised according tostandard protocol.

Recommendations for the re-opening of dental services: a rapid review of international sources
Referencehttps://deputyprimeminister.gov.
mt/en/healthpromotion/Documents/Guidance%20for%20Dent
al%20Practices%20in%20Malta%20%20Covid1
9.pdf

Country:
USA
Source:Centers for
Disease Control
and Prevention(CDC)
Date ofpublication:
Unclear
Latest update
27.04.2020
https://www.cdc.
gov/coronavirus/2019ncov/hcp/dental-settings.html

Practice preparation andpatient considerations
regarding signs, symptoms andrisk factors of COVID-19.
Patients should be screened on
arrival through a questionnaire,
forehead thermometer andinstructed to use alcohol hand rub.

Management of theclinical room

have treatment postponed until
recovery. If they need to beseen, staff need to wear full PPE
including FFP3 masks, gowns,
gloves and cap and visor.

Staff screening
Screen all staff at the beginning of
their shift for symptoms of COVID19 and actively measure theirtemperature
Patient triage
Telephone screen all patients forsigns or symptoms of respiratory
illness and systematically assess
the patient at time of check-in at
the dental clinic
If a patient arrives with suspected
or confirmed COVID-19, defer
dental treatment, provide thepatient a mask and refer thepatient home or if acutely unwell toa medical facility

Dental procedures

Treatment should be
conducted under rubber dam
and high-volume suction.
Hand-instruments should be
used whenever possible todecrease airborne droplets.

Patient scheduling
Patient appointments should bespread out (20-30mins) to allow
effective disinfection of all areas
and avoid cross infection between
patients in waiting rooms.

Patients with COVID-19 canreceive dental care:- (non-test based): At least 72
hours since recovery and 7
days since first symptoms
appeared.
- (test-based) Following
resolution of fever andPage 32 of 45

PPE for dental practicepersonnel

6 May 2020

Extra-oral radiography isrecommended in preference tointra-oral radiography.

All staff
Staff should wear a facemask at
all times
Cloth face coverings can beused by staff that do not require
PPE (such as clerical staff) andby all staff not engaged in direct
patient care activities
Non-AGPs
The following PPE should beworn before entering a patientroom or care area:- A N95 respirator or surgicalmask with full-face shield- Eye protection (goggles orfull-face shield)- An isolation gown
- Gloves
AGPs
During aerosol generatingprocedures a N95 respirator or
equivalent is required

Suspected/confirmed
COVID-19 patients
Treatment on a patient withsuspected or confirmed
COVID-19 should beundertaken in an isolation
room with negative pressure
and use of an N95 mask

Non-AGPs
Avoid aerosol generatingprocedures (including dental
hand pieces, air-water syringe
and ultrasonic scaler)
Priority for minimallyinvasive/atraumatic restorativetechniques
AGPs
If aerosol generatingprocedures are necessary
clinician should use:
- Four handed dentistry- High evacuation suction- Dental dams
Only essential staff should bepresent. There should be no
visitors for the procedure

Post-operative
cleaning/disinfection/waste
management
Clinical areas need to bedisinfected with Sodium
Hypochlorite (this process cantake up to two hours) for
patients who have tested
positive or are suspected
positive for COVID-19 andreceived treatment in thedental practice.
Clinical waste disposal
Medical waste should be
disposed of as appropriate.

Cleaning and disinfection
procedures
Hand washing with alcohol(60-95%) based hand rub orsoap and water for at least 20
seconds
Routine cleaning anddisinfection of room surfaces(e.g. cleaners and water toclean surfaces before applying
an EPA-registered hospital
grade disinfectant)
Clean and disinfect all
reusable dental equipment
according to manufacturer’s
instructions
Clinical waste disposal
Manage laundry and medical
waste in accordance withroutine procedures

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
USA
Source:AmericanDentalAssociation
Date ofpublication:
24.04.2020
Latest update
07.05.2020
https://success.
ada.org/~/media/CPS/Files/Ope
n%20Files/ADA_Return_to_Wo
rk_Toolkit.pdf
Patient
screeningquestionnaire
available.
Staff screening
questionnaire
and logavailable.

Practice preparation andpatient considerations
improvement of respiratory
symptoms and negative resultsof FDA approved COVID-19
tests from two swabs ≥24 hours
apart.
- (test-based) 7 days since alaboratory positive COVID-19
test with no symptoms
Reopening practice- Distribute patient letter aspractice opens reassuring
patients of infection control
measures and updated process
in place.
- Shock unit water lines after
prolonged closure (consult
manufacturer instructions)- Consider supplies.
- Consider soft launch –introducing new strategies andreasons for them. Practice
before welcoming patients.
- Emphasise hand hygiene andcough etiquette for everyone- Consider patient flow into andthrough practice, timing surgery
utilisation and sterilisation, staff
routines (don and doffing of
PPE), appointment
scheduling/timing.
Patient/staff flow
- Limit access to surgery (onlypatient if possible) & provide
also a mask and shield to any
accompanying person- Keep staff entry to a minimumin surgery.
- Don mask prior to entry tosurgery.
- No handshaking or contact.
- Wash hands and don gloves insurgery

PPE for dental practicepersonnel

Management of theclinical room

All staff- Front desk staff can wear
masks and googles, or faceshields, or a clear barrier
should be installed.
- Wear mask prior to entry tosurgery

Clinical room
Limit paperwork as much as
possible. If using paper
charting, cover with clear
barrier to allow reading.

Clinical staff
Professional judgement should
be exercised with regards todisposable foot/head covers.
Use highest level of PPE
available. Assume all patients
can transmit disease.
N95, KN95, or surgical mask(based on risk assessment) withface shield or goggles
For clinical staff, if available
gowns should be used. Change
gowns if soiled. Dispose gowns
or launder after each use.
Long sleeved garments should
be worn.
Remove mask outside ofoperating room
Replace mask if it is soiled,damaged or hard to breathethrough
Strict hand hygiene measures:

Page 33 of 45

6 May 2020

Place new chart notes into
document away from patient
contact area when possible
Cover keyboard of computerwith disposable, flexible, clear
barrier (e.g. plastic wrap) andchange it between patients.
Limit access only to patientwhere possible
Minimise staff numbers in theclinical room
No hand shaking or physicalcontact
No evidence exists for use of
pre-operative oral rinses
Shock dental waterlines if
returning from extended breakin practice. Consult
manufacturers’ instructions

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Pre-treatment
Check with indemnity
regarding any requiredchanges to consent forms

Cleaning and disinfection
procedures
Strict attention to staff handhygiene procedures

Decide on treatment based onclinical judgement and known
facts: combining patient
health/risks factors/geographic
incidence and availability of
PPE

Clean surfaces with soap anddetergent prior to disinfection

Consider clinical risks: aerosol
production, ability to employ
rubber dam and inducement ofpatient cough

Replace surface barriers

Between patients
Clean surgery while wearing
gloves, mask and face shield

Employ lowest aerosol
producing technique available(e.g. hand scaling)

Waiting areas
To disinfect, use products thatmeet EPA’s criteria for use
against SARS-CoV2, thecause of COVID-19, and areappropriate for the surface

AGPs
Use high velocity evacuation
where possible

On a regular schedule, wipe all
touchable surface areas with
an approved surface cleaner.

Post-operative instructions
They should include areminder to report any signs or
symptoms of COVID-19 within
next 14 days.

Remember to include tables,
chair arms, doorknobs, lightswitches, hangers, andanything else with whichpeople come in contact. If
surfaces are dirty, they should
be cleaned using a detergent
or soap and water prior todisinfection.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations- Confirm patient screening
questionsStaff screening- Pregnant staff should follow
available guidance. Limit
exposure to AGPs
- Consider screening checkpoint
and log for all staff.
Reception and waiting area
- Use should be minimised:patients can wait in their own
car or outside. If not possible
consider alternative entrance
arrangements- Wipes should be provided toclean surfaces that patients
may touch.
- A hand sanitation station should
be available upon entry into
facility with a notice for people
to use this before entry- Tissues, alcohol-based handrubs, soaps at sinks and trashcans should be provided- Toys, reading materials, remotecontrols or communal objects
should be removed or cleaned
regularly- On a regular schedule, wipe all
touchable surface areas with anapproved cleaner.
- Consider individual phoneheadsets for each front desk
staffer to reduce virus spread
Patient triage- Pre-appointment patient
screening.
- Patient questionnaire repeated
and temperature taken on
arrival at the dental clinic. If thisPage 34 of 45

PPE for dental practicepersonnel- Upon entry- Before and after contact withpatients- After contact withcontaminated surfaces or
equipment- After removal of PPE
PPE for companions
Provide mask for anyone who
accompanies patient

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management
To disinfect, use products thatmeet EPA’s criteria for use
against SARS-CoV, the causeof COVID-19, and areappropriate for the surface.
Laundry
Cloth gowns should belaundered after use
Scrubs should be laundered in
office or by contracted service

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
CanadaSource:The College ofDentalSurgeons of
Saskatchewan(CDSS) Alert –COVID-19
Pandemic: IPC
interim protocol
updateDate ofpublication:
27.04.2020
Effective from:04.05.2020
https://media.or
alhealthgroup.c
om/uploads/202
0/04/20200427_
CDSS_IPC_Inte
Page 35 of 45

Practice preparation andpatient considerations
is elevated, supply patient witha mask and alert the dentist.
- Reminder forpatients/guardians to limit the
number of companions to
reduce people in reception area
- If suitable, patients can wait intheir car and can then be calledor messaged to enter thepractice.
- Patients should be asked tobring their own pens to use- If patients cancel due to illness,practices may consider waiving
cancellation fees
- Postoperative instructions
should include a reminder tonotify practice if develops signs
or symptoms of COVID-19 innext 14 days.
Reception and waiting area
Following AGPs the patient isdischarged and guided to thereception area for post-op
instructions, processing and exit
Patient advice- Escorts can only accompany
minor patients only (children)- Pandemic informed consent- Patient hand hygiene
Patient scheduling
Vulnerable patient appointment
times on specific days or early inthe day- Fewer appointment times- Stagger appointment times
Patient triage- Patient risk assessment
screening (SHA COVID-19
Screening Tool – 27th March
2020)

6 May 2020

PPE for dental practicepersonnel

Management of theclinical room

All staff including thosedisinfecting treatment room
- Level 1 mask as a minimum- Eye protection- Gloves- Scrubs- Maintain social distancing
Non-AGPs- Level 2 or 3 surgical mask
- Eye protection (glasses,
goggles or face shield)- Scrubs- Gloves- Lab coat or gown if patient
contact

Non-AGP rooms- Enhanced cleaning,
including twice dailycleaning of high touch
surfaces- Patient should perform
ABHR prior to exiting theoperatory room
- Clean operatory room andclinical contact andhousekeeping surfaces as
per normal SOHP Infection
Prevention Control
Standard for Oral HealthCare Facilities (04-01 to 0405)

Intermediate risk AGPs withdental dam- N95 or K95 respirator (fitted)- Face shield or goggles- Cap/bouffant- Gown/lab coat (with cuff)- Gloves

AGP rooms- AGP operatory rooms mustbe isolated rooms from floor
to ceiling with an entry or
entries that must be closed
and secured during the
AGP (temporary isolation

Dental procedures

Non-AGPs- Extraoral radiographs
recommended (minimise
use of intraoral radiographs)- Utilise hand instruments
only- Utilise four-handed dentistry- Do not use air watersyringes- Do not use ultrasonicinstruments- Do not use high-speed
rotary hand pieces orelectric low-speed handpieces with air and water
All patientspatients to perform preprocedural 1% hydrogen
peroxide mouth rinse for 60
seconds and expectorated
into the same dispensing cup
Treatment types

Post-operative
cleaning/disinfection/waste
management

Cleaning and disinfection
procedures
AGP rooms- The operatory door androom must remain closed
and air to settle for 120
minutes after AGPs before
cleaning. If the number of
air changes per hour in theroom permits, the settle
time can be decreased- Following appropriate
settling time, clean clinicalcontact and housekeeping
surfaces as per normal
SOHP Infection Prevention
Control Standard for Oral
Health Care Facilities (0401 to 04-05)
Donning and doffing
procedures and clinicalwaste disposal

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference
rim_Protocol_U
pdate.pdf

Page 36 of 45

Practice preparation andpatient considerations- Thermometer temperature vital
sign screening (<38°C)- All urgent dental treatment forpatients who have been
identified as moderate or highrisk for COVID-19 or have been
confirmed as COVID-19
positive must be provided by a
SHA Level 3 provider in theappropriate facility

PPE for dental practicepersonnel
High risk AGPs withoutrubber dam- N95 or K95 respirator (fitted)- Face shield- Cap/bouffant- Gown/lab coat (with cuff)- Gloves

6 May 2020
Management of theclinical room
rooms can be designed –hoarding with plastic and aframed or zippered door)- Enhanced cleaning,
including frequent cleaningof high touch surfaces- Remove all unnecessarycabinets, fixtures and nonessential supplies or
products, including pictures
or artwork- AGP signage should beplaced at the entrance tothe room- AGP rooms must have a
Donning (clean side orarea) and Doffing(decontamination side orarea) anteroom or hallway
area- PPE must be donned in theclean side of the anteroom
immediately before entering
the AGP operating room (donot go anywhere else once
PPE is donned)- Operating room door toremain closed during theprocedure. Only the dentist,
dental assistant and patient
will be permitted access.
The door should only be
opened once when
discharging the patient andfor clinical staff to exit.

Dental procedures
Dental procedures included inPhase1:- any emergency NAGP or
emergency AGP- Examinations andconsultations- Simple extractions (NAGP)- Hygiene – hand scaling
only and no ultrasonicinstrumentation- Preventive procedures
such as the application of
topical agents (fluoride,silver diamine fluoride, etc.)- Oral & maxillofacial
radiology procedures- Orthodontic procedures(NAGP)- Removable prosthodontic
procedures- Cementation of previously
fabricated fixed
prosthodontics- Temporomandibular
dysfunction management
and procedures- Medical management ofsoft tissue presentations- Oral pathology and oral
medicine procedures- Periodontal procedures(NAGP)- Urgent endodontic
procedures- Urgent restorative
procedures- Urgent paediatricrestorative procedures- Urgent complex extractions- Dental public healthinitiatives including
community programing andpreventive measures.

Post-operative
cleaning/disinfection/waste
management- PPE must be doffed in thedecontamination side of theanteroom- Doffing station includes:
laundry receptacle with lid,
garbage receptacle with lid,
eye protection disinfection
receptacle with lid- Leaving the room: withgloved hands, remove thegown or lab coat and gloves
with gloved hands only
touch the outside of thegown, grasp the gown andpull away from the bodywithout rapid movements,
roll gown/coat inside out
into a bundle,
simultaneously remove
gloves inside out. Discard
gown and gloves
immediately. Lab coats
should be transferred to thelaundry receptacle avoiding
contact with “clean”
surfaces. Perform handhygiene- Remove eye protection atsides with the hands without
touching facial skin andplace in the disinfection or
garbage receptacle- Remove cap or bonnet bygrasping at the rear andpulling forward off the headand place in the laundry or
garbage receptacle- Remove N95 respirator withtouching the front of themask and discard garbage
receptacle or stored in asealed labelled receptacle
for possible futuredecontamination

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Country:
Australia
Source:Australian
DentalAssociation
Date ofpublication:
23.04.2020
https://www.ada.org.au/Covid19Portal/Cards/De
ntalProfesionals/Gu
idelines-andRiskFactors/Practica
l-Advice-forstepping-backto-Level-2-Rest

Page 37 of 45

Practice preparation andpatient considerations

Reopening practice- What additional surgery recommissioning or maintenanceprocedures need to beundertaken before commencing
more routine care (for example,
has any validation andmaintenance that was deferredduring closures now been
completed)?
- What water management
processes need to beundertaken following the nonuse of dental unit waterlines foran extended period?
- Has stock, including
medications been checked to
avoid the use of out of datematerials?
- What staffing and PPE
requirements are anticipated?
- What patient screening and risk
mitigation protocols will bemaintained while ensuring thatall staff are up to date withthese protocols?
- What refresher training isrequired for team members who
have not been working?
- How will patients be prioritised
according to their treatment
needs (e.g. periodontallycompromised, high caries risk)

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Airborne precautions include theneed for the patient to be treatedin a negative pressure room,with dental staff wearing P2/N95
respirators which have beenpreviously fit-tested, and then fit
checked at time of use

Dental procedures notincluded in Phase 1:- All elective and non-urgent
AGP- Hygiene ultrasonicinstrumentation- Selective polishing /prophy- Laser instrumentation- Dental implant placement
Nitrous oxide sedation
Non-AGPs
Provision of dental treatmentsthat are unlikely to generate
aerosols or where aerosols
generated have the presenceof minimal saliva/blood due tothe use of rubber dam. This
includes:- Examinations- Simple non-invasive fillings
without use of high-speed
handpieces- Restorative procedures
using high speed
handpieces only provided
with the use of rubber dam- Non-surgical extractions- Hand scaling (no use ofultrasonic scalers)- Medical management ofsoft tissue presentations(such as ulcers)- Temporomandibular
dysfunction management- Denture procedures- Preventative procedures
such as the application of
topical remineralising
agents e.g. fluoride- Orthodontic treatment

All confirmed coronavirus cases
will only have dental treatment
as in-patient or within a hospital

Use a pre-procedural
mouthwash, use a
dental dam for any

Moderate risk of COVID-19
Surgical masks and eye
protection protect the wearerfrom droplet contamination of
the nasal or oral mucosa, or
conjunctivae.
Use of appropriate PPE (thisincludes disposable gowns,
gloves and eye protection
Minimising patient transfer or get
the patient to wear a surgicalmask while they are beingtransferred and to follow coughetiquette
Patients confirmed with COVID19 may either be treated as
hospital in-patient or managed
by hospital care workers in theirhome

Post-operative
cleaning/disinfection/waste
management- Perform hand hygiene- Put on a clean surgicalmask

Cleaning and disinfection
procedures
For those at risk of COVID19 previous publication
recommended: applying twocomplete cycles of cleaning of
all environmental surfaces
using detergent anddisinfectant (as per contact
transmission-based
guidelines)

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Page 38 of 45

Practice preparation andpatient considerations

PPE for dental practicepersonnel

when restrictions are lifted
further?
- How will patients be managed
who may have missed theirregular care cycle? Checklist
for practice start up: Water- Turn on the mains water supply
as the first action of the start-up
process. Listen and look for any
water leaks.
Detail chair- Check the dental unit
manufacturer’s instructions forthe correct protocol forwaterline treatment for chair
start-up.
- Check that any external waterbottle attached to the dental
chair is free of visible biofilm
growth. Fill the bottle with waterand add any required chemicaltreatment agents to the waterthat will feed into the chair.
- Flush out each waterline for atleast 2 minutes, holding themover the intake of the highvelocity evacuator one
waterline at a time.
- After this has been done, flush
all the suction lines using therecommended agent, and thenrun several cups of tap water
down the suction hoses.
- Other equipment containing
water reservoirs- Fill the water storage bottles inoperatory or laboratory
equipment, including benchtop
ultrasonic scalers with separate
water bottles, CAD-CAM milling
workstations (coolant for cuttingburs), hard tissue lasers (waterfor cooling during cavity
preparation), and the like, withsetting by appropriately trained
dental personnel.

6 May 2020
Management of theclinical room

Dental procedures
procedures generating
aerosols.
Under level 2 restrictions, it isacceptable to complete
courses of care that areunderway such as
cementation of a crown. A
dental dam must be used tominimise the potential forsaliva to become aerosolised
inadvertently.
Necessary treatment such as
crown and bridge preparationthat can be completed using
dental dam isolation ispermitted under Level 2
restrictions.
AGPs:
Defer all treatments that arelikely to generate aerosols
which may include the use of- high-speed handpieces
without the use of rubberdam- ultrasonic scalers- surgical handpieces
All surgical extractions should
be referred to specialist oral
surgeons/oral and maxillofacial
surgeons who will undertakethese procedures usingtransmission based
precautions.
Elective implant dental
treatment should be delayed.
Urgent dental treatment forpeople who DO meet
epidemiological or clinicalPost-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
the appropriate type of water,
and include any required
additives.
Suction system andcompressor- Check whether any specificactions are needed for thecompressor (e.g. closing off thedrain of the compressed air
reservoir, then restart thecompressor. Check thatcompressed air pressure rises
and there is no obvious leaking
or malfunction.
- Turn on the power to thesuction system.
Ultrasonic cleaner- Turn on the unit at the mains
power outlet.
- Rinse the chamber thoroughlywith tap water, and drain thisout, before refilling with tap
water. Add the required
additive, then degas andperform the aluminium foil
performance check. Ensure that
there are perforations acrossthe foil sheet(s). Then discard
the chamber contents, rinse thechamber with water, refill thechamber, add fresh additive,then degas once more. The
ultrasonic cleaner is now readyfor use.
Washer disinfector- Ensure the chemical supply
tanks are connected and havesufficient levels of chemicals,
and that the water supply taps
are turned back on. Then turnon the power. When the unit isused, include a soil test in every
load and record the results (asPage 39 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures
symptom criteria for COVID-19
risk or confirmed as a COVID19 case, provided as per ADA
Managing COVID-19
Guidelines.
Confirmed COVID-19 cases
For provision of urgent or
emergency treatment use
airborne precautions which
includes treatment in anegative pressure room using
a fit-tested P2 respirator that is
fit-checked at time of use. Thisis typically provided in a public
hospital by appropriately
trained personnel.
For probable COVID-19
cases
For provision ofurgent/emergency treatment
use droplet precautions inaddition to standard
precautions and additional
appropriate PPE including fluid
impervious disposable gowns
and fit-checked P2 respirators.
Only provide treatment that
does not generate aerosols or
where aerosols are controlled
by using dental dam. Seepatient as the last patient of
the day, avoid patient being in
the waiting room, use preprocedural mouthwash, place
all disposable items in a
separate bag before disposal
in general waste; apply twocycles of environmental
cleaning of all environmental
surfaces potentiallycontaminated using detergent
and disinfectant as per

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
part of normal performance
testing procedures).
Steam sterilizer- Make sure the unit has the datacard (if appropriate) replaced.
- Ensure that any deionizedwater reservoirs are filled with
deionized water. Close off thedrain control for thewastewater.
- Turn the power on. Watch as
the sterilizer goes through its
start-up procedure. If there is adate/time shown on the display,check that this is correct, andadjust as needed.
- Check that the chamber is
empty (other than for racks),
and run a warm-up cycle. For apre-vacuum sterilizer, now run
the air leakage test, to checkthe integrity of the door seals.
- Then run a suitable air removal
test, e.g. a Bowie-Dick test, andrecord the results for this.
Electrical equipment- Check the status of therefrigerator (which should berunning), and then the contents
for medicines or supplies thatare nearing or have passed
their expiry date.
- Turn on minor appliances in thestaff area (e.g. electric jug,microwave oven).
- Ensure arrangements havebeen made for re-setting phone
diversion, mail collection, parcel
delivery and the like.
- Check that remote access toservers is working properly.
Scheduled medicines- Ensure that sufficient suppliesof all required scheduled

Page 40 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedurestransmission based
precautions.
For suspected COVID-19
cases
For provision ofurgent/emergency treatment
use droplet precautions inaddition to standard
precautions. Only provide
treatment that does not
generate aerosols or whereaerosols are controlled byusing dental dam. See patientas the last patient of the day,avoid patient being in thewaiting room, use preprocedural mouthwash, place
all disposable items in a
separate bag before disposal
in general waste, apply twocycles of environmental
cleaning of all environmental
surfaces potentiallycontaminated using detergent
and disinfectant as pertransmission based guidelines

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
medicines (including local
anaesthetic) are available,
within the use-by date, and are
kept securely away frompatient/public access.
Waiting room
- Remove unnecessary items in
the waiting room including toysand magazines.
- Adjust seating in waiting roomto ensure social distancing of atleast 1.5 m between seats if
possible.
- Regularly wipe down surfaces
with >60% alcohol-based wipes
or 0.1% sodium hypochlorite
solution, including door
handles, reception desks,
phones.
- Any hospital-grade, TGA-listed
disinfectant that is usedcommonly against norovirus isalso suitable and use as per
manufacturer’s instructions.
Patient scheduling- Prioritising patients who require
timely treatment that was
excluded under Level 3
restrictions, such as extractionof asymptomatic teeth that havean associated infection (ifsurgical extraction can be
avoided);- Re-scheduling examinations,while avoiding aerosol
generation, including the use of
the air/water spray from a
triplex;- Resuming ongoing courses oftreatment that do not generate
aerosols, such as denturefabrication stages and repairs,

Page 41 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations
orthodontic reviews, mandibularadvancement splints and night
guards;- Providing necessary restorative
treatment using dental dam
isolation- Re-instigating preventative
treatments and some hygiene
services by using hand
instrumentation only.
- If your practice has on-siteparking, consider placing a signon the practice door asking
patients to wait in their car in
the car park and call thepractice upon arrival.
- Provide entry to the practice
only immediately prior to their
appointment or to use thebathroom. This allows patients
to avoid waiting in the waitingroom.
- If patients are waiting in theircars, pre-appointment
questionnaires can be done
over the phone.
Patient triage- returned from overseas orinterstate travel in the past 14
days- felt unwell, including but notlimited to symptoms of COVID19 such as fever, cough, sorethroat or shortness of breath- had any contact with aconfirmed or suspected case of
COVID-19 in the past 14days- If the patient answers YES to
any of these questions, advise
them that you cannot provide
routine dental care andreschedule the dental
appointment for 14 days after

Page 42 of 45

PPE for dental practicepersonnel

6 May 2020
Management of theclinical room

Dental procedures

Post-operative
cleaning/disinfection/waste
management

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

6 May 2020

PPE for dental practicepersonnel

Management of theclinical room

Low risk patients
Surgical mask (level 2 or above)
Eye protection
GlovesOuter protective clothing as per
IPC practice standard

For low risk patients: dental
surgery, standards precautions
apply

Dental procedures

Post-operative
cleaning/disinfection/waste
management

their return from overseas,interstate or contact with a
COVID-19 case, or when their
symptoms have resolved andthey are no longer considered arisk.
Country: New
Zealand,
Source: Dental
Council,
Date ofpublication:
11.05.2020
https://www.dcn
z.org.nz/assets/
Uploads/COVID/Guidelines-atAlert-Level-2final.pdf

Minimisation of risk
• use telehealth when possible• encourage patient respiratory
hygiene using alternatives tofacemasks• isolate symptomatic patients assoon as possible. Place patientswith suspected or confirmed
COVID-19 in private rooms withdoor closed and private bathroom(where possible)• protect healthcare personnel• emphasise hand hygiene• limit the number of staff providing
their care.
-Aim to schedule and manage
patients to limit their contact withothers and the time they spend in
a common area.
-Ask patients to arrive as close as
possible to their appointment time.
Risk assessment
For all patients ask COVID-19
symptom related questions before
scheduling an appointment, andrecord the patient’s responses intheir record about COVID-19 andsuspected symptoms
If the patient doesn’t have COVID19 or symptoms, manage thepatient as a ‘low risk patient’.
When the patient arrives for their
appointment, confirm their
responses to the questions asked
when scheduling, and record thePage 43 of 45

High risk patients and nonAGPs
Surgical mask (level 2 or above)
Eye protection
GlovesOuter protective clothing as per
the IPC practice standard. In
addition, an impervious singleuser layer, e.g. apron, must beworn with resuable outer
protective clothing
High risk patients and AGPs
N95 or FFP2 mask (single use)
Eye protection
GlovesLong sleeved impervious gowns
General recommendations
Any reusable PPE must be
properly cleaned,decontaminated, and maintained
after use and between patients.
Oral health care practitioners
must have received appropriate
training in the use of PPE

AGP procedures: close thedoor whenever possible; use
measures aimed at reducing
the extent and contaminationof aerosol and splatterwhenever possible; highvolume evacuations systems,
use of dental dam, and preprocedural mouthrinses.
For high risk patients and nonaerosol generatingprocedures: single room, door
closedFor high risk patients &aerosol generatingprocedures: negative
pressure, single room, door
closed stand room down for 20
min after treatment before
cleaning

High risk patients
Avoid aerosol-generatingprocedures where possible. All
rotary handpieces generate
aerosols, regardless ofwhether the motor is electric or
air-driven (with or withoutwater). Other aerosol
generating instruments
commonly used in oral healthcare include ultrasonic andsonic scalers, triplex syringe,
air-abrasion and air-polishing
etc.

Cleaning and disinfection
procedures
Appropriate PPE should beworn for cleaning down theroom. At minimum wear agown, gloves, surgical mask
and protective eyewear.

Use measures aimed at
reducing the extent andcontamination of aerosol andsplatter as appropriate, forexample, high volume
evacuation systems, use of
rubber dam, andpreprocedural mouth rinse.

After treating a suspected or
COVID-positive patient whenaerosol generating procedures
have occurred, the roomshould remain closed for astand-down period of 20
minutes prior to cleaning.

Preferably use a slow speed
handpiece that operates at ≤40000 rpm, and where
possible turn the chip air off, tominimise the aerosol
generated during theprocedure.

Wipe down hard surfaces
using a two-step process: firstwith detergent and water, thenhospital grade disinfectant withactivity against respiratory
virus, including COVID-19.

Laundry
Remove any linen that has
been used into linen bags for
hot washing.
Clinical waste disposal
Remove and discard PPE as
clinical waste (remove in thefollowing order: gloves, handhygiene, gown, hand hygiene,
protective eyewear (if separate
from mask), hand hygiene,mask, hand hygiene).

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference

Practice preparation andpatient considerations

6 May 2020

PPE for dental practicepersonnel

Management of theclinical room

All staff-Train staff on how to follow
established protocols.
-Avoid face touching andcarefully remove PPE after eachprocedure.
- Staff members should change
from personal clothing to scrubsand vice versa before entering

Clinical room
- Limit paperwork in theoperatory as much as
possible.
- Minimise staff in operatory.

Dental procedures

patient’s responses in their record.
Someone who has recovered fromCOVID-19 infection is classified asa low risk patient. If the patient has
COVID-19 or symptoms of
COVID-19, manage the patient asa ‘high risk patient’. You canprovide only urgent or emergency
care for these patients, defer allother care.

Post-operative
cleaning/disinfection/waste
management
Perform hand hygiene
thoroughly up to elbow level.

High risk patient:• Schedule and manage thepatient in a way that minimises
face-to-face interaction with others(e.g. at the end of day or session).
Waiting areas• All unnecessary items should be
removed from the waiting room
• Separate waiting room chairs by
at least 2 metres.
• Clean surfaces and high-touch
surfaces regularly with a detergent
or ready detergent wipes.
• Areas of known contamination
should be cleaned and disinfected
as described in the Dental
Council’s Transmission Based
Precautions – Cleaning section
contained in the Infection
Prevention and Control PracticeStandard.

Country:
India
Source:Dental Councilof India
Date ofpublication:
07.05.2020
Page 44 of 45

Reception/waiting area
- Hand wash at arrival.
- Patients and any companion
should wear masks to attend
practice and avoid wearing
jewellery or accessories. Masks
and shields should be provided
when possible.

Equipment- Ban use of spittoon on
dental units.

Procedures triage should
focus on the provision ofadvice, analgesia, andantimicrobials.
Non-emergent or cosmetic
treatment should bepostponed.

Cleaning and disinfection
procedures- Clean and disinfect publicareas frequently, includingcommon and working areas.
- All instruments need to bedisinfected, cleaned, andsterilised as per standard
protocols.

Recommendations for the re-opening of dental services: a rapid review of international sources
Reference
http://www.dciin
dia.gov.in/Admin/NewsArchives/Dental%20Clini
cs%20Protocols%20Final.pdf

Page 45 of 45

6 May 2020

Practice preparation andpatient considerations

PPE for dental practicepersonnel

Management of theclinical room

- Patients’ temperature should betaken at arrival and they should
be checked for any COVID
symptoms. If any, they should bereferred to a government hospitalor designated hospital.
- COVID-19 patients should beseen after viral clearance isconfirmed by primary caredoctors.
- Physical/Social distancing should
be maintained in clinical areas.
- Avoid receiving cash payments.
- Protective screens for reception
desks.
- Limit use of waiting area.
- Tissues, hand sanitizer and soap
should be available.
- Display health awarenessposters regarding COVID-19

the dental practice and before
returning home.

- Usage of saliva ejectors is
recommended, since canreduce the production ofdroplets and aerosols.

Patients triage in groups- Emergency (increased patient’s
death risk)- Urgency (requires priority carebut do not increase the patient’s
death risk)- Non-emergency (patients which
treatment can be postponed).

AGPs- Goggles and face shield (fitted
goggles with a soft tissue seal)- Triple layer surgical mask
- N95 respirator during routine
dental procedures- FFP3 – standard mask should
be used during treatment of
COVID19 positive patients.
- Surgical gloves- Disposable and waterproof
gown (gown maybe improvised
but needs to be changed after
each patient).
- Shoe covers

Observe frequent hand hygiene.
PPE protocol should be followed(including instructions forremoval of PPE)
Non-AGPs- Goggles and face shield (fitted
goggles with a soft tissue seal)- Triple layer surgical mask
- N95 respirator during routine
dental procedures- Disposable gowns- Shoe covers- Head cap- Surgical gloves

Air quality- Adequate ventilation isadvised. If dental offices areequipped with the capability,
local exhaust ventilation
should be used to capture
and remove mists or aerosols
generated during procedures.
- Use directional airflow, (e.g.
fans), to ensure that air
moves through staff working
areas before patient
treatment areas.

Dental procedures
Pre-operative and postoperative infection control
protocols should be followed.
AGPs- Avoid or minimise
operations that can produce
droplets or aerosols.
- If patient needs aerosolbased treatment, detailed
medical history andcontact history should berecorded.
- Patients should be
scrubbed with Iso Propyl
alcohol extra orally prior to
any dental procedure.
- Pre-procedure rinses like
1% hydrogen peroxideshould take place when thepatient is conscious.
- Four-handed techniquerecommended.
After the patient leaves thetreatment room, all hand
instruments should becleaned immediately.

Post-operative
cleaning/disinfection/waste
management- Perform as many tasks as
possible in areas away frompatients.
- Ensure dental unit waterlines
are flushed, disinfected using
appropriate organic- disinfectant and drained- Remove visible pollutants
completely before
disinfection.
- Equipment (e.g. keyboards)
should be covered with adisposable, flexible, clear
barrier (e.g. plastic wrap),
which needs to be changed
between patients.
- Fumigation of clinics
periodically is advised.
- Sterilise and oil hand pieces,store upright in a clean dry
environment.
- Remove couplings and air
motors from tubing.
- Suction pumps should beflushed with chemicalcleaning solution.
Clinical waste disposal- PPE should be judiciously
used and appropriately
disposed as per cleaning
protocols.
- Change the surgical mask
after every dental procedure.
- All waste pertaining to patientcare should be carefully
disposed as per the Bio
Medical Waste (Managementand Handling) Rules.