INFECTION CONTROL PROTOCOL DURING COVID-19 IN DENTISTRY

INFECTION CONTROL
PROTOCOLS DURING COVID-19
DR.JAMES

CONTENTS
Introduction
Infection control –goals , measures
Personal protective equipments (ppe) – donning , doffing
- components –facemasks , gloves , eyewear , faceshield,gown
Waste management
Instrument reprocessing
Recommendation for dental practise
Dental treatment consideration
Zones in dental clinic
Protocols – patient handling , patient discharge, clinic closure , HCW
QUEstionaire survey assessment

Guidelines – MOH, OSHA , ADA , IDA
Dental emergency
TRIAGE
Exposure prevention
Disinfection – types definition classification
Decontamination of water supply units
Immmunisation
Vaccination
Auditing
Facility design

PROTOCOLS OF PATIENT
HANDLING IN THE CLINIC AREA
1. For appointments that do not result in aerosols, and need examination only wear a triple
layer surgical mask and protective eyewear/face shield and gloves.
2. Wear N95 face masks, protective eyewear/face shields and gloves along with coverall for
High Risk and very high-risk procedures.
3. To increase the shelf life of N95 masks, you may cover them with a surgical mask and
discard only the surgical mask after use.
4. When examining patients with moderate risks the treating doctor will require all PPE as
high risk except that the coveralls can be substituted with surgical gowns.
5. Use of rubber dam is encouraged.
6. The 4-handed technique is beneficial for controlling the infection.

PATIENT DISCHARGE
PROTOCOL
The patient drape will be removed by the assistant, and the patient is asked to perform hand
wash and guided out of the clinic towards reception and handed back his foot wears and
belongings.
The procedures and prescription is recorded only after doffing the PPE.
Patient to perform hand hygiene and to be provided with review /follow up instructions.
After the patient leaves the treatment room, the Assistant will collect all hand instruments
immediately, rinse them in running water to remove organic matter and as per standard
sterilisation protocol.
All 3 in 1 syringe, water outlets, hand piece water pipelines, etc. should be flushed with the
disinfectant solution for 30-40 seconds. Remove water containers and wash them thoroughly
and disinfect with 1% sodium hypochlorite using clean cotton/ gauge piece and then fill with
fresh 0.01% sodium hypochlorite solution and attach back to the dental chair.

Then, disinfect the Dental Chair along with all the auxiliary parts within 3 feet of
distance using 1% sodium hypochlorite.
 The areas include: a. Patient sitting area and armrests b. Dental chair extensions
including water outlets, suction pipe, hand piece connector, 3 in 1 syringe, etc. c.
Dental light and handle d. Hand washing area – slab and tap nozzle e. Clinic walls
around the dental chair and switchboards f. Hand washing area – slab and tap nozzle
 Hand pieces should be cleaned using a hand piece cleaning solution to remove
debris, followed by packing in the autoclave pouches for autoclaving. Record to be
maintained for the same.
IMPRESSIONS will be thoroughly disinfected before pouring or sending to the
laboratory using an appropriate disinfectant.
Mop the floor with 1% sodium hypochlorite solution through separate mops for the
clinical area following unidirectional mopping technique from inner to outer area.
Wash and disinfect the mop with clean water and 1% sodium hypochlorite and leave
it for sun-drying.

PROTOCOL FOR CLINIC CLOSURE
1. Fogging: It is used as 'No-touch surface disinfection' after a large area has been
contaminated. The commercially available hydrogen peroxide is 11% (w/v) solution
which is stabilized by 0.01% of silver nitrate. A 20% working solution should be
prepared.
2. The volume of working solution required for fogging is approximately 1000ml per
1000 cubic feet.
3. After the procedure has been completed in the operatory ,exit the room and close the
operatory for half hour for the aerosols/droplets to settle down.
4. Perform the 2 Step surface cleaning followed by fogging. The fogging time is usually
45min followed by contact time/dwell time of one hour.
5. After that the room can be opened, fans can be switched on for aeration. Wet surfaces
can be dried/cleaned by using a sterile cloth or clean cloth (other surfaces).

WHAT IS INFECTION CONTROL?
The purpose of infection control in dental practice is to prevent the transmission of disease-
producing agents such as bacteria, viruses and fungi from one patient to another, from dental
practitioner and dental staff to patients, and from patients to dental practitioner or other dental
staff by limiting the spread of infectious agents
The goal of infection control is to break the chain of disease transmission !

Aims - Infection control focuses on limiting or controlling factors influencing the
transmission of infection or contribute to the spread of microorganisms.
The spread of microorganisms can be reduced by:
1. limiting surface contamination by microorganisms;
2. adhering to good personal hygiene practices, particularly efficient hand
hygiene;
3. using personal protective equipment;
4. using disposable products where appropriate (e.g. paper towels);
5. following risk minimisation techniques such as using rubber dam and pre-
procedural mouthrinsing.

INFECTION CONTROL IN PRACTISE
Hand Hygiene -is considered as one of the most critical measures in reducing the risk of transmitting
pathogens to patients and health care personnel. Handwashing reduces bacterial load on hands, which will
flourish under the warm and moist environment beneath gloves.
Care should be taken to ensure that all parts of the hands are washed.
Hand jewelry and wrist watches should be removed. Rings are preferred not to be worn.
For surgical procedures, an antimicrobial (surgical) handscrub, such as Hibiscrub which contains 4%
chlorhexidine gluconate w/v, should be used. Skin irritation can come about with frequent use of
chlorhexidine gluconate though true allergic reactions are uncommon. Alternative handwashing agents like
iodophors can be used for those who are sensitive to chlorhexidine.
At the beginning and the end of each clinical session, handwashing with rubbing action maintained for at
least 20 seconds before rinsing is recommended. For invasive surgical procedures, a 2 to 6 minute scrub of the
hands and forearms is necessary.
If the hands are not visibly soiled, an alcohol-based hand rub is considered adequate because of its rapid
action and accessibility (CDC, 2003a).
The drying effect of alcohol can be reduced or eliminated by adding glycerol (1% to 3%) or other skin-
conditioning agents (Rotter et al., 1991).
Alcohol-based gels containing emollients have been found to cause less skin irritation and dryness relative to soaps or
antimicrobial detergents(Boyce et al., 2000).

INFECTION PREVENTION AND CONTROL
PROTOCOL IN THE DENTAL CLINIC
1. Patient evaluation
2. In general, pre-screen all the patients for COVID-19, according to MOH Coronavirus
Disease 19 (COVID-19) Guidelines.
3. If the patient suspected, the dental practitioner should postpone the dental treatment
and report to the infection control department is recommended (follow guidelines).
4. Moreover, encourage family members, caregivers, and visitors with symptoms of
respiratory infection not to accompany patients during their visits to the facility

oTo help prevent the transmission, various infection control measures should be followed:
oPersonal protection equipment (PPE) is mandatory while treating such patients.
oAutoclave Handpieces after each use.
oPre-procedural mouth rinse with 0.2% povidone-iodine should be done.
oHigh-speed evacuation should be used for dental procedures producing an aerosol (for e.g. In
Endodontic procedures or ultrasonic scaling)
oPerform hand hygiene with soap and water for at least 20 seconds. 60% alcohol based
Sanitizers should be used. Face masks should be provided to patients who are coughing.
oPatients should be kept in isolation room to prevent transmission of disease to other patients
and personnel.
oRoutine cleaning and disinfection strategies should be followed in dental offices.
oProper Fumigation should be done in dental office
INFECTION CONTROL
MEASURES#

SELF PROTECTION:
Dental personnel should use disposable face masks, nonsterile gloves, head cap, gown and eye wear
while assessing patients with a flu-like or other respiratory illness. The personal protective barriers
should be worn once and discarded. According to recommendation of CDC all dental health care
professionals should receive flu vaccine.
POSTPONE ELECTIVE DENTAL PROCEDURES:
According to The CDC's Guidelines for Infection Control in Dental Healthcare Settings - 2003, Avoid
all elective dental procedures until the patient is no longer contagious with the airborne transmitted
disease.
Emergencies like Severe tooth pain, diffuse oral swelling, tooth fractures, 3rd molar pain/ pericoronitis
& uncontrolled bleeding should be treated.
PHARMACOLOGICAL MANAGEMENT:
Patients suspected or confirmed with COVID-19 infections, requiring emergency dental care in case of
tooth pain and/or swelling, antibiotics and/or analgesics should be given as an alternative to relief
symptoms. It will give dental personnel time to plan & deliver dental treatment with all appropriate &
preventive measures to avoid spreading infections.
On March 17, 2020, According to the British Medical Journal, use of Ibuprofen is prohibited due to its
interference with immune function. Acetaminophen is a drug of choice for analgesia in treating
COVID19 infected patients.

oWorld Health Organization (WHO) endorsed this recommendation on March 18,
2020. In certain emergency cases such as dentoalveolar trauma, fascial space infection
etc dentists should be aware of the following recommendations:
oRadiographs: Intraoral Radiographs should be avoided as it may produce gag reflex or
cough. Extraoral radiographs (e.g. panoramic radiograph or CBCT) should be done.
oRubber dam should be used to minimize splatter generation, of course, for
nonsurgical endodontic treatment. Dental procedures that generate higher aerosol
content for e.g.: ultrasonic instrument, high-speed Handpieces and three-way syringes
should be avoided.
oSuspected or confirmed cases of COVID-19 should only be treated in negative
pressure rooms or airborne infection isolation rooms (AIIRs) & not in routine dental
practice setting.
oOn Inanimate surfaces or objects survival time of Corona virus is up to 9 days at room
temperature, with a greater preference for humid conditions. So, Dry conditions
should be maintained to prevent the spread of SARS-CoV-2. Disinfection should be
done using chemicals recently approved for COVID-19

INFECTION CONTROL MEASURES FOR NON-
AUTOCLAVABLE PATIENT CARE ITEMS

Hydroxychloroquine Prophylaxis As per the advisory given by the MOH dated 22.03.2020, all
asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVID-19

STANDARD
PRECAUTIONS
undertaking regular hand hygiene before gloving and after glove removal
using personal protective barriers such as gloves, masks, eye protection and gowns
correctly handling contaminated waste appropriately handling sharps appropriately reprocessing
reusable instruments
effectively undertaking environmental cleaning ,respiratory hygiene and cough etiquette
Airborne precautions, such as wearing P2 (N95) surgical respirators, are designed to reduce the
likelihood of transmission of microorganisms that remain infectious over time and distance when
suspended in the air.
Infectious agents for which airborne precautions are indicated include measles, chickenpox (varicella)
and Mycobacterium tuberculosis.
A mask tightly sealed to the face has been shown to block entry of 95% of total influenza virus
particles, while a tightly sealed N95 surgical respirator can block over 99% of virus particles.
In contrast, a loosely fitted mask blocks 56% and a poorly fitted respirator only 66% of infectious
virus particles.In other words, a poorly fitted N95 surgical respirator performs no better than a loosely
fitting surgical mask.

1. Cleaning the environment Floors, walls and curtains pose
minimal risk of disease transmission in a dental practice;
nevertheless, these surfaces must be maintained in a clean
and hygienic condition.
2. Inanimate objects such as toys act as fomites and can spread
infections through indirect contact.
3. For this reason, it is prudent to wipe down the hard surfaces
of toys in reception and waiting areas on a periodic basis
using detergent impregnated wipes designed for use on
clinical hard surfaces, to reduce the levels of transient
microorganisms.
4. Environmental surfaces such as bench tops outside the
contaminated zone must be cleaned weekly using detergent
and water.
5. The practice should develop a schedule to ensure areas
including floors, window sills, door handles, and telephone
handsets are cleaned weekly.
6. Walls, blinds and window curtains in patient care areas must
be cleaned when they are visibly dusty or soiled

INFECTION CONTROL STRATEGIES
WITHIN THE CONTAMINATED ZONE
1. The goal during dental treatment is to contain contamination within this zone, both by determining what is
touched and where the spread of droplets, splash and splatter will occur.
2. Reducing the extent of contamination of the dental operatory can be achieved in part by use of rubber dam, pre-
procedural antiseptic mouthrinses, high volume evacuation and correct patient positioning.
3. All surfaces and items within the contaminated zone must be deemed contaminated by the treatment in progress.
These surfaces must be cleaned and the items in the zone disposed of, decontaminated, or cleaned and sterilised
before commencing treatment of the next patient.
4. Clinical contact surfaces in the contaminated zone must be cleaned after each patient.
Note: Instruments placed into the contaminated zone for a treatment session must not be used during the session and noted
as contaminated. For this reason all bulk supplies such as opened boxes of gloves, cotton rolls or gauze must be stored outside
the contaminated zone and protected from contamination from splashes and aerosols.

PERSONAL PROTECTIVE
EQUIPMENT (PPE)
Examples of PPE include: gloves, goggles, face shields, face masks
All types of PPE must be:
■ Selected based upon the hazard to the worker.
■ Properly fitted and periodically refitted, as applicable (e.g.,
respirators).
■ Consistently and properly worn when required.
■ Regularly inspected, maintained, and replaced, as necessary.
■ Properly removed, cleaned, and stored or disposed of, as
applicable, to avoid contamination of self, others, or the
environment

oWorkers, including those who work within 6 feet of patients known to be, or
suspected of being, infected with SARS-CoV-2 and those performing aerosol-
generating procedures, need to use respirators.
oGloving Hands should be properly dried with paper towels before donning gloves
because moisture trapped under gloves enhances bacterial growth and skin sensitivity.
oIt must be stressed that gloving does not replace handwashing.
oGloves serve as a barrier between the patient and operator. Its effectiveness is related to
its quality and the way it is used. Disposable (patient examination) gloves can be used for
routine operative procedures.
oSterile surgical gloves should be used when surgical asepsis is desirable,
oNon-latex or powder-free gloves should be used if either the operator or the patient is
sensitive to latex or glove powder respectively.
o A new pair of gloves must be worn for every patient

PERSONAL PROTECTIVE MEASURES
FOR DENTAL PROFESSIONALS
1. Since droplet transmission of infection is considered as the main route of spread of infection, particularly in dental
clinics,barrier protection types of equipment-protective eyewear, masks, gloves, caps, eye protection (face shields or
googles), and gown, are strongly recommended for all dental professionals, especially during the pandemic period of
COVID-19.
2. It is also recommended to wear respiratory protection (N95-or higher respirators for performing aerosol generating
procedures, If a respirator is not available, use a combination of a surgical mask and a full-face shield.
3. If essential PPE, including surgical facemasks, are not available, do not proceed with any dental procedure, regardless
of emergency/urgent patients. However, the use of disposable (single use) devices such as mouth mirrors, syringes,
and blood pressure cuff to prevent cross contamination is highly recommended.
4. Disposable respirators, disposable eye protection, disposable gown and surgical mask should be removed and
discarded before leaving the dental clinic/room. Reusable eye protection must be cleaned and disinfected according
to manufacturer’s reprocessing instructions prior to re-use.
5. Change the gown if it becomes soiled.
6. Remove and discard the gown in a dedicated container for waste or linen before leaving the dental clinic/ room.
Cloth gowns should be laundered after each use.
7. Change surgical masks during patient treatment if the mask becomes wet. Clean, disinfect, or discard the surface,
supplies, or equipment located within 2 meters of symptomatic patient

Mouth-rinse before dental procedures -Since COVID-19 is vulnerable to oxidation, pre-procedural
mouth rinse containing oxidative agents such as 0.2% povidone is recommended. That will be helpful
to reduce the salivary load of oral microbes, including potential COVID-19 carriage.
Dental Radiograph- Extra-oral imaging, such as a panoramic radiograph or CBCT, is recommended to
be used to avoid the gag reflex or cough that may occur with intraoral imaging. Intraoral periapical or
bite-wings radiographs should be limited, Occlusal radiographs may be considered as an alternative to
periapical radiographs. When intraoral imaging is mandated, sensors should be a double barrier to
prevent cross contamination.
Rubber dam isolation- The use of rubber dams can significantly minimize the production of saliva- and
blood-contaminated aerosol or spatter, particularly in cases when high-speed hand-pieces and dental
ultrasonic devices are used. When a rubber dam is applied, extra high-volume suction for aerosol and
spatter should be used during the procedures along with regular suction. If rubber dam isolation is not
possible in some cases, manual devices such as hand scalers, are recommended for caries removal and
periodontal scaling to minimize the generation of aerosol. All precautions should be taken for the
prevention of needle-stick or sharps injury. Anti-retraction hand-piece The use of dental hand-pieces
without anti-retraction function should be prohibited during the Pandemic period of COVID-19.
Antiretraction dental handpieces with specially designed anti-retraction valves or other anti-reflux
designs are strongly recommended to prevent cross-infection. The use of a 4-handed technique, high
volume saliva ejectors, and a rubber dam is necessary to decrease possible exposure to infectious agent

Aerosol producing dental procedures -Any dental procedure that has the potential to aerosolized saliva
will cause airborne contamination should be prevented. Those procedures might include ultrasonic
scaling, conventional restorative procedures, polishing, periodontal surgeries, and maxillofacial surgery
procedures.
Hence, the possible way for the spread of infection via an almost invisible aerosol must be recognized
and eliminated to the greatest extent.
This way of precaution can be done by using tertiary PPE, 4- handed technique and high- volume saliva
ejectors.
When an aerosol generating procedure performed in a patient with COVID-19, ensure that healthcare
workers are implementing, the use of the adequately ventilated single room (negative-pressure room
with a minimum of 12 air changes per hour or at least 160 liters/second/patient in facilities with natural
ventilation).
Disinfection of the clinic settings- Public areas and appliances should also be frequently cleaned and
disinfected, including door handles, chairs, and desks. The elevator should be disinfected regularly.
People taking elevators should wear masks correctly and avoid direct contact with buttons and other
objects.
It is worth noting that patients with suspected or confirmed COVID-19 infection should not be treated
in a routine dental practice setting. Instead, these patients should only be treated in negative pressure
rooms or negative pressure treatment room/Airborne infection isolation rooms (AIIRs)
Therefore, anticipatory knowledge of health care centers with provision for AIIRs would help dentists
to provide emergency dental care if the need arises. Of note, human coronavirus can survive on
inanimate surfaces up to 9 days at room temperature with a higher preference for humid conditions.
Therefore, clinic staff should make sure to disinfect inanimate surfaces using chemicals and maintain a
dry environment to curb the spread of COVID-19

GLOVES
1. Gloves are worn for all clinical procedures.
2. The type of gloves worn are selected according to the task: • Sterile gloves for
surgical procedures • Latex-free gloves for latex-allergic patients or staff, or staff
with sensitive skin • Hypo-allergenic gloves for staff with skin reactions
3. Non-sterile gloves for examinations and non-surgical dentistry
4. Utility gloves for instrument reprocessing, when washing contaminated
instruments by hand.

1. Begin to slide the ungloved fingers of the right hand into
the glove. keeping the ungloved right thumb facing
outwards.
2. Then bend the right thumb towards the centre of the right
palm and continue to slide the right hand into the right
glove, while at the same time pulling up with fingers of the
gloved left hand.
3. Last of all, complete donning the gloves by pulling up the
cuff of the left (first) glove with the gloved fingers of the
right hand.
4. Make sure the cuffs extend over the surgical gown.

EYE PROTECTION
1. In our practice, eye protection is worn to protect the mucous membranes of
the eyes from exposure to aerosols, splattering and penetration from
projectiles.
2. Protective eyewear provided by our practice complies with means to be
clear, anti-fog, distortion free, close fitting and shielded at the side.
3. Dental practitioners, staff and patients wear protective eyewear during all
clinical procedures.
4. Eye protection is also required when reprocessing instruments and working
in clinical and laboratory areas

Source: Zhang. W, Jiang. X. Front Oral Maxillofac Med 2020;2:4 |

WASTE MANAGEMENT
Clinical waste- Clinical waste including sharps box that contains used/contaminated
needles and blades, dressing dribbling or caked with blood or containing free-flowing
blood, etc. should not be kept for more than 3 months. All clinical waste must be disposed
of in red plastic bags conspicuously marked with 'Biohazard' symbol and labelled as
'Clinical Waste'
The bags filled with clinical waste should be tied up using the "swan neck" method of
sealing
Non-clinical waste All trash, other than clinical waste, could be disposed of as domestic
waste in black plastic bags. Liquid waste, except chemical waste, can be emptied into the
drain and flushed down with water

SEALING
AND
TAGGING
METHODS
FOR
CLINICAL
WASTE
BAGS

INSTRUMENT REPROCESSING
• Remove gross deposits of blood, cements and other contaminants from instruments by wiping
them at the chairside onto an adhesive-backed sponge. This will reduce the need for intensive
cleaning by hand and thus reduce the risk to dental chairside assistants.
• If instruments cannot be cleaned immediately once they have left the chairside, place them in a
holding solution (containing detergent) to prevent residues of dental materials or blood drying onto
instruments.
• Clean conventional hand instruments using ultrasonic cleaners or thermal disinfectors, rather than
by hand scrubbing.
• use instrument cassettes or trays to minimise the risk of sharps injuries to staff from handling
instruments.
• Develop a clear policy on which sizes and types of burs and endodontic files are discarded after
use.

Dentists should take strict personal protection measures and avoid or minimize operations that can
produce droplets or aerosols.
The 4-handed technique is better for controlling infection.
The use of saliva ejectors with low or high volume can lower the production of droplets and aerosols.
Patients screening
During the outbreak of COVID-19, dental clinics are recommended to measure and record the
temperature of every staff and patient as a routine procedure and ask patients questions about the
history of contact or travel.
Patients should wear medical masks and their temperature should be measured.
Patients with fever should be referred to hospital.
If a patient has been to epidemic regions within the past 14 d, quarantine for at least 14 d is suggested.
In areas where COVID-19 spreads, nonemergency dental practices should be postponed
Preoperative antimicrobial mouth rinse can be used to reduce infection.
Aerosol-generating procedures, such as the use of a 3-way syringe, should be minimized as much as
possible.
Extraoral dental radiographies, such as panoramic radiography and cone beam CT, are preferred over
intraoral radography
Recommendations for dental practice

DENTAL TREATMENT
CONSIDERATIONS:
1. Carry out only emergency dental treatments in a single treatment room. Preferably designate separate
clinical areas for Aerosol and Non-aerosol Control dental treatments.
2. Use 1.5% hydrogen peroxide or 0.2% povidine as a pre-procedural mouth rinse.
3. Wherever warranted, use extraoral dental radiographs such as panaromic radiographs as alternatives to
intra oral radiographs during the outbreak of COVID-19, as the latter can stimulate saliva secretion and
coughing.
4. Reduce aerosol production as much as possible, as the transmission of COVID-19 occurs via droplets or
aerosols, and dentists should prioritize the use of hand instrumentation.
5. Dental teams should use rubber dams if an aerosol-producing procedure is being performed to help
minimize aerosol or spatter.
6. Dentist may use a 4-handed technique for controlling infection.
7. Most of the Dental care should be performed with the use of high-volume suction or saliva ejectors
mainly aerosol based procedures.
8. Dental care teams should “minimize the use of a 3-in-1 syringe as this may create droplets due to
forcible ejection of water/air.”

9. Restrict the number of para-dental staff and patients who enter the clinical as
well as waiting area of the clinics.
10. Pre-operative and Post operative Infection Control protocols should be
followed and regular fumigation of clinics should be carried out
11.In the current COVID 19 pandemic, Dentists, auxiliaries as well as patients
undergoing dental procedures are at high risk of cross-infection. Most dental
procedures require close contact with the patient’s oral cavity, saliva.
12.Saliva is rich in COVID 19 viral load. Many patients who are asymptomatic
may be carriers. For this reason, it is suggested that all patients visiting a dental
office must be treated with due precautions.

MANAGEMENT OF GUTTA PERCHA
POINTS
1. On this basis, soaking GP points in 5.25% sodium hypochlorite for at least one minute
can be recommended as a clinical protocol.
2. Based on the principles of aseptic non-touch technique (ANTT), the disinfected cones
can be picked up with tweezers held in non-sterile gloves.
3. If the clinician feels compelled to touch the disinfected GP cones with their hands,
they should use sterile gloves.

ENDODONTIC FILES
The following recommended procedure is based on Effective Cleaning Protocols for Rotary
Nickel-Titanium Files
1. Insert files into a scouring sponge soaked in 0.2% chlorhexidine gluconate aqueous
solution immediately after use at the chairside
2. Clean the files using 10 vigorous in-and-out strokes in the sponge
3. Place the files in a wire mesh basket and immerse in an enzymatic cleaning solution
(Empower) for 30 minutes;
4. This is followed by a 15 minute ultra-sonification in the enzymatic cleaning solution.
5. Rinse in running tap water for 20 seconds

ZONES AND DENTAL CLINICS
1. The dental clinics will remain closed in the CONTAINMENT ZONE; however, they can continue
to provide tele triage. Patients in this zone can seek ambulance services to travel to the nearby
COVID Dental Facility.
2. In the RED ZONE, Emergency dental procedures can be performed.
3. The dental clinics in ORANGE AND GREEN ZONE will function to provide dental consults.
Dental operations should be restricted to Emergency and Urgent treatment procedures only.
4. All routine and elective dental procedures should be deferred for a later review until new
policy/guidelines are issued.
5. Due to the high risk associated with the examination of the oral cavity, oral cancer screening
under National Cancer Screening program should be deferred until new policy/guidelines are
issued.
6.The clinical conditions of dental origin, which require priority care but do not increase the
patient’s death risk are categorised as URGENT and which increase the patient’s death risk are
categorised as EMERGENCY

CLEAN ZONES
oClean areas include those surfaces and drawers where clean, disinfected or sterilised
instruments are stored and never come in contact with contaminated instruments or
equipment. All dental staff must understand the purpose of and requirements within
each zone, and adhere to the outlined protocols.
oA system of zoning aids and simplifies the decontamination process. Dental
practitioners and clinical support staff should not bring personal effects, changes of
clothing or bags into clinical (patient treatment) areas where cross-contamination is
likely to occur.
oIt is recommended, where possible, that materials such as cotton rolls, dental floss,
gingival retraction cord and restorative materials should be pre-dispensed from bulk
supplies that are kept in drawers or containers which keep these bulk supplies free of
contamination from splashes or aerosols.

oThe options include: • open drawers by elbow touch; retrieve instruments and
materials with a no-touch technique such as transfer tweezers; use over-gloves or
single-use barriers on drawer handles. If transfer tweezers are used, these must be
kept separate from other instruments; • gloves must be removed and hands
decontaminated with ABHR before dispensing additional materials.
oWhen moving from the contaminated zone to a clean zone to touch non-clinical
items without a barrier, gloves must be removed and hands washed or
decontaminated with ABHR before touching the item.
oThe individual must then perform hand hygiene and re-glove before re-entering
the contaminated zone.
oCartridges of local anaesthetic must be stored appropriately to prevent
environmental contamination by aerosols, splatter and droplets generated by
clinical patient care.
oCartridges should be kept in their individual bubble packs until use to protect them
from contamination by dust, aerosols, and droplets.

CURING LIGHT
1. Curing light tips are semi-critical pieces of equipment.
2. They should be heat sterilised or have an appropriate barrier placed over the
tip for each patient.
3. Another advantage of a barrier is that the sensitive light-conducting rods are
protected from accidental damage or material contamination.
4. Barrier protection is an appropriate level of infection control for all curing
light tips, as the equipment is not intended to contact mucosa.
5. The handle of the curing light and the tips must always be cleaned prior to
having the barriers placed and a new barrier used for each patient.

AIR ABRASION, ELECTROSURGERY
UNITS AND LASERS
1. High volume suction devices are essential when using electrosurgery units, dental lasers and air
abrasion/particle beam devices as they create particular bio-aerosol hazards.
2. Air abrasion devices create alumina dust, which can be a respiratory irritant for dental
practitioners, clinical support staff as well as patients.
3. Some pathogenic viruses such as human papillomavirus (HPV) are not inactivated by laser or
electrosurgery procedures and remain viable within the plume (smoke) created from soft tissue
vaporisation.
4. Most bacteria and viruses are rendered non-viable by laser or electrosurgery, even though
fragments may be present in the plume.
5. High filtration surgical masks combined with high volume suction can prevent inhalation of
particles in plume by dental practitioners, clinical support staff and patients. As well as particles of
tissue and fragments of microorganisms, plume also contains gases (e.g. hydrogen cyanide, benzene
and formaldehyde) which are irritant and noxious.
6. Evacuation systems which remove plume vapour and particles must be used when using
electrosurgery units, dental lasers and air abrasion/particle beam units.

DENTAL RADIOLOGY AND
PHOTOGRAPHY ITEMS
materials placed in a patient’s mouth and subsequently removed for processing must
be considered biologically contaminated and must be handled in a safe manner.
Gloves must be worn when taking radiographs and handling contaminated film
packets or sensors. Other personal protective equipment (e.g. masks, protective
eyewear) must be used in case of spattering of blood or other body fluids.
It is recommended to use heat-tolerant or disposable intraoral radiograph devices
(unless using digital radiography) wherever possible and semi-critical items (e.g. film-
holding and positioning devices) must be cleaned and either heat sterilised or barrier
protected before use on subsequent patients.
Exposed radiographs need to be transported and handled carefully to avoid
contamination of the developing equipment.

Following exposure of the radiograph, dry the film packet with a paper towel to remove
blood or excess saliva before placing in a container (such as a disposable cup) for transport
to the developing area.
Contaminated radiography equipment (e.g. radiograph tube head and control panel) must
be cleaned after each patient use. Alternatively, barrier protection can be applied and must
be changed after each patient use.
Digital radiography sensors come into contact with mucous membranes and are
considered semi-critical devices. They must be cleaned and covered with a barrier before
use on subsequent patients.
Most state regulations accept film packets and barrier envelopes contaminated with saliva
or blood as being able to be disposed of as general waste. However, some regional
authorities require these to be treated as contaminated medical waste. They must be placed
in yellow containers or plastic bags appropriately marked with the international biohazard
symbol and collected and disposed of by a licensed operator.

DENTAL CLINIC
Maintain air circulation with natural air through a frequent opening of windows
and using an independent exhaust blower to extract the room air into the
atmosphere.
Avoid the use of a ceiling fan while performing procedure.
Place a table fan behind the operator and permit airflow towards operating
procedure.
The window air condition system/ split AC should be frequently serviced, and
filters cleaned.
Use of indoor portable air cleaning system equipped with HEPA filter and UV
light may be used.

CLINIC ENTRANCE,
RECEPTION AND WAITING
1. Display visual alerts at the entrance of the facility and in strategic
areas (e.g., waiting areas or elevators) about respiratory hygiene,
cough etiquette, social distancing and disposal of contaminated
items in trash cans.
2. Install glass or plastic barrier at the reception desk, preferably
with a two-way speaker system.
3. Ensure availability of sufficient three-layer masks and sanitisers
and paper tissue at the registration desk, as well as nearby hand
hygiene stations.
4. Distant waiting chairs, preferably a meter apart.
5. Cashless/contactless payment methods are preferred.
6. A bin with lid should be available at triage where patients can
discard used paper tissues.
7. Changing room to be available for staff and all workers to wear
surgical top and clinic shoes

Equipment installation
1. Fumigation systems
2. High volume extra oral suction
3. The indoor air cleaning system
4. The dental chair water lines should be equipped with ant
retraction valves
5. Used hand pieces with anti-retraction valves only
6. Chemicals required for disinfection
7. Appropriate PPE and ensure it is accessible to HCW

Environment and Surface Disinfection:
1. Floors: 2 Step Cleaning Procedure (Detergent and freshly prepared 1% sodium hypochlorite with a
contact time of 10 minutes. Mop the floor starting at the far corner of the room and work towards
the door. Frequency: after any patient/ major splash or two hourly.
2. Electronic equipment Should be wiped with alcohol-based rub/spirit (60-90% alcohol) swab before
each patient contact.
Phase II Implementation Phase Tele-consult Tele-screening
1. Telephone screening is encouraged as the first point of contact between the patient and the dentist
or reception office is encouraged.
2. Current medical history and past history particularly pertaining to symptoms of Severe Acute
Respiratory Illness (fever AND cough and/or shortness of breath) or All symptomatic ILI (fever,
cough, sore throat, runny nose) must be analysed.
3. Any positive responses to either of the questions should raise concern, and care should be
postponed for 3weeks except in dental emergencies.
4. Encourage all to download the Arogya Setu App.
Disinfection of Dental Clinic

Comprehend dental treatment according to the urgency of the required treatment and the
risk and benefit associated with each treatment. Only pre-appointed patients should be
entertained in the clinic whose history, problems and procedures are already identified to
some extent through previous telephone and remote electronic or web-based systems.
What can patients do before arrival at a dental clinic?
1. Minimise or eliminate wearing a wrist watch, hand and body jewellery and carrying of
additional accessories bags etc.
2. Use their own wash rooms at home to avoid the need of using toilets at the dental
facility.
3. Have a mouth wash rinse with 10 ml of the 0.5% solution of PVP-I solution (standard
aqueous PVP-I antiseptic solution based mouthwash diluted 1:20 with water).
Distribute throughout the oral cavity for 30 seconds and then gently gargle at the back
of the throat for another 30 seconds before spitting out.
4. Wear a facemask during transport and before entering the premises.
5. Have the body temperature checked and use a sanitiser on the entrance.
6. Patients consent and declaration to be obtained in a physical print out or electronic
system.
7. Maintain social distance.

SURFACE DISINFECTION
oSurface disinfection is a two-step procedure. The first (pre-cleaning) step aims to
reduce the organic loads which interfere with the action of disinfectants. The second
step allows time for the disinfectant to take effect.
oWhen and what to disinfect If waterproof surface barriers are used properly, and
carefully removed and replaced, there is no need to disinfect protected surfaces in
between patients.
oIntermediate-level disinfection should be applied on unprotected clinical contact
surfaces, or housekeeping surfaces with obvious blood/saliva contamination.
oA low-level disinfection of the clinical contact surfaces is sufficient once daily. Door
handles should also be disinfected at least once a day.

HOW TO DISINFECT
oThe soak-wipe-soak technique can generally be adopted in most situations.
oThe first soak, and wipe, with disposable paper towels, is the pre-cleaning step that
lowers the bioburden. Disinfection per se is brought about by the second soak.
oThe “wetting” time of the second soak should follow the manufacturer's
recommendations.
oFor intermediate-level disinfection, 10 minutes are usually required.
oResidual disinfectant should then be removed with water (and paper towel).

CHOICE OF AGENTS
oHousehold bleach (5-6% sodium hypochlorite) is a generally accepted surface
disinfectant for intermediate-level disinfection.(Intermediate-level disinfectants
differ from low-level disinfectants in that they are tuberculocidal and virucidal.)
oTen-minute contact time is recommended.
oAlcohol is not accepted for intermediate-level surface disinfection because it
vaporises rapidly (and the contact time will thus be inadequate for effective surface
disinfection).

THE USE OF DISINFECTANTS & ANTISEPTICS
IN INFECTION CONTROL

WHAT SHOULD WE DO
ABOUT DENTAL
AEROSOLS?
Currently, we commonly see four basic approaches to aerosol control.
1. Physical clearance- This method involves (a) intake of contaminated air,
(b) air purified treatment , (c) release of the treated air within the
operatory or outside the operatory.
2. HEPA filtration consoles- uses HEPA filters built into the ceiling over the
treatment space, releasing purified air over the operating clinicians.
3. Chemical treatment -This method involves the release of aerosolized
chemicals that disinfect the air in the operatory by killing free microbes
and those attached to dust, liquids, small hairs, etc. The plasmas or fogging
chemicals generally used are highly oxidative and decompose potentially
into harmless substances such as oxygen and water.
4. Ultraviolet light treatment- This method involves light energy at specific
wavelengths (265 nm is considered optimum, but 254 nm is most
common) that can disrupt nucleic acids of microbes within aerosols to
inactivate them, if the organisms are susceptible and exposed long enough
to the energy

NO. 2: WHAT IS THE BEST
FACE MASK, AND CAN WE
STERILIZE AND REUSE
THEM?
1) There is a face mask called Critical Care PFL with a unique design that
gives it the following three characteristics necessary for protection:
(a) a soft wire all the way around its border allows the clinician to adapt a
secure fit to all facial contours, over the nose and cheeks and under the chin
(b) two stiff bands cause the mask to protrude enough to hold it away from
contacting the mucus membrane of the nostrils and lips at all times,
including during talking and inhalation
(c) very high filtration of greater than 99% of 0.1 µm particles.
2) An N95 face mask with a very similar design called the Isolator Plus
(Crosstex) is also available.

NO. 3: WHAT IS THE
BEST WAY TO DISINFECT
SURFACES?
oCurrently, our research has identified BioSURF Bagin-a-Box (Micrylium)
as having the best combination of the robust excellent kill , a dispensing
design that preserves kill potential of the chemicals, availability of a
companion noninterfering wipe material called LeCloth (Micrylium)
oFront desk and reception areas—BioSURF Bag-in-a-Box and barriers
would be appropriate for some of the most touched surfaces in these areas,
as well as in office bathrooms.
oPatient reception areas be used maximum as possible, by receiving
patients before they enter the office.
oFloors and window- Detergents with household bleach or other
reasonable additives could be used here. Floors should be wet-disinfected.

WHAT ARE THE STEPS AND
PRODUCTS FOR THE BEST HAND
DISINFECTION?
A. Massage vigorously and thoroughly, covering all hand surfaces plus wrists with a good-
quality 4% chlorhexidine hand antiseptic (Hibiclens, Mölnlycke) for 30 seconds, and then
rinse under very warm running water to remove visible debris, oils, and transient
microbes.
B. Use a new, clean paper towel to dry your hands thoroughly.
C. Dispense a 70% ethyl alcohol hand rub gel (Purell Advanced, GoJo) in sufficient
quantity to cover all surfaces of both hands liberally so they remain moist during 30
seconds of massaging the hands together.

IS THERE A PRODUCT AND
REGIMEN WE CAN USE AS A
PRETREATMENT RINSE?
Chlorhexidine rinses in various concentrations are frequently reported in the literature
for bacterial reduction, but chlorhexidine is notably less effective for inactivation of the
virus.
1.0%–1.5% hydrogen peroxide or 0.2% povidone iodine swished for one minute.

Q Is Cetylcide II an effective disinfectant against Human Coronavirus?
A: Cetylcide II is on EPA’s list of disinfectants that inactivate Human Coronavirus.
According to the manufacturer’s instructions for use, items must be wet for 10
minutes. CDC recommends that, where blood may be present, a high-level
disinfectant with a Tuberculocidal claim should be used. this product is a corrosive
material, so review the Safety Data Sheet for safety precautions.
Q: What or who will help control price gouging for PPE? And sterilization liquids?
A: The states are allowed to enact laws that protect the public from price gouging
during an emergency situation. Laws vary from state to state, so contact the state
attorney general’s office to find out the laws in your state.
Q: Is sodium hypochlorite (bleach) effective in treating impressions?
A: A sodium hypochlorite (bleach) solution is still one of the most reliable,
economical and effective disinfectant solutions. The solution must be 1 part sodium
hypochlorite to 10 parts water and the items or surfaces must remain wet for 10
minutes. The product is corrosive, so follow safety precautions for use from the
manufacturer.

Q: Does OSHA provide a laundry service for all of my employees PPE?
A: Employees are not allowed to self-launder any PPE. Any protective garments
must be either laundered onsite or laundered by an outside service.
Q: Will ultraviolet (UV) light kill this virus?
A: Because this virus is so new, there has not been much information on the use of
UV. UV light has been shown effective in inactivating other coronaviruses, so it is
likely that it would do so with SARSCov2 (COVID-19) since the structure is similar
to the other viruses. All areas of the item being disinfected must be exposed to the
light
Q: We talk about washing hands often, what about washing your face?
A: Hands are the primary surface contact and transmission source to the eyes, nose
and mouth, so should be washed often. Areas of the face may be subject to exposure,
so should be washed after potential exposure

Q: Can you please explain the reasoning for "double wipe down" of surfaces?
A: The first wipe is the cleaning wipe to remove any bioburden or other surface contaminates. Disinfectants only work on
the surface they touch. They cannot penetrate through any surface contaminate. The second wipe is laying down the
disinfectant.
Q: What are the "oils" that N95, NP95, etc. prevented?
A: . Particulate respirators are also known as “air-purifying respirators” because they protect by filtering particles out of
the air as you breathe. These respirators protect only against particles—not gases or vapors. Since airborne biological
agents such as bacteria or viruses are particles, they can be filtered by particulate respirators. Respirators are rated as N, R,
or P for protection against oils. This rating is important in industry because some industrial oils can degrade the filter
performance so it doesn’t filter properly.* Respirators are rated “N,” if they are Not resistant to oil, “R” if somewhat
Resistant to oil, and “P” if strongly resistant (oil Proof).” CDC & NIOSH Respirator Fact Sheet
Q: Should we be disinfecting the boxes we deliver the cases in?
A: It is not required. It is very difficult to disinfect cardboard and paper and retain their integrity. Practicing Standard
Precautions should eliminate the need to disinfect the delivery boxes.
Q: How long after a model is prepared from impression would it be considered 'safe'?
A: If the impression has been disinfected properly then the model should not be contaminated with coronavirus so it
should be safe to handle immediately. If the impression has not been disinfected then the model would need to be
disinfected.
Q: Can you address the need for lab coat protection that completely covers street
clothing for those in high risk area?
A: Any exposed uniform or street clothing that could be contaminated due to splash or spatter of body fluids or touched
by contaminated gloves might carry the virus wherever the employee goes in or out of the workplace.

Q.Is it better to use a full-face shield in conjunction with a mask / respirator when handling
possible infectious materials if you want to reuse masks in order to save on quantity of masks
used?
A: Yes.
Q: With such a highly contagious and widespread illness, with a 48-hour plus hour of being
asymptomatic, how on earth could that be tracked back to being contracted at the lab? What is
the reality of this connection being made?
A:. Follow the CDC guidelines for determining the risk assessment.
Q: What practice should we do with normal wear when coming back home?
A: The best practice during this pandemic is to immediately and carefully remove all clothing. Either
wash immediately or segregate from contact until washing.
Q: Instead of spraying them, I immerse models and impressions in a container of disinfection
liquid for a period of time while changing the liquid daily, is that a good practice?
A: If you have not had any problems with accuracy, then keep doing what you are doing.
Q: What do you recommend for disinfecting impressions before pour up? Before scan?
A: We do not promote any certain disinfecting product. Any EPA registered disinfectant that is
effective against the coronavirus and that you feel does not compromise the accuracy of the impression
or model would be best.

Q: I have seen that a pre-rinse in dental isn’t effective if it is Listerine for COVID, but a
hydrogen peroxide is recommended. What are your thoughts?
A: Only 1.5% hydrogen peroxide has been approved as a rinse by the American Dental Association (ADA) for
COVID-19 because of its viricidal activity, commercial availability, and taste. The Listerine website states
rinsing with Listerine does not kill COVID-19. “LISTERINE® Antiseptic is a daily mouthwash, which has been
proven to kill 99.9% of germs that cause bad breath, plaque and gingivitis. LISTERINE® mouthwash has not
been tested against the coronavirus and is not intended to prevent or treat COVID-19.”
Q.What resource are you using for the adaptation to PPE usage for endemic
methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus
(VRE), etc.?
A: CDC has released information about strategies to optimize the supply of isolation gowns. Healthcare facilities
should refer to that guidance and implement the recommended strategies to optimize their current supply of
gowns.
Q: When reusing gowns for COVID patients under investigation and in confirmed COVID-19
rooms with negative airflow vs negative pressure, is it appropriate to have the gown remain in
the room (clean side out)?
A: Disposable isolation gowns are not designed to be reused because the ties are usually broken when doffing
them. Cloth gowns can be reused after laundering. Donning a gown that has already been used can be tricky,
and a source of contamination to the user

WHAT CAN DENTISTS DO TO PROTECT
THEMSELVES AND PATIENTS?
hand hygiene has been considered the most critical measure for reducing the risk of transmitting microorganism to patients (larson et al.
2000). sars-cov-2 can persist on surfaces for a few hours or up to several days, depending on the type of surface, the temperature or the
humidity of the environment (who 2020c).
this reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within dental clinics. every
surface in the waiting room must be considered at risk; therefore, in addition to providing adequate periodic air exchange, all surfaces,
chairs, magazines and doors that come into contact with healthcare professionals and patients must be considered “potentially infected”.
 it may be useful to make alcoholic disinfectants and masks available to patients in waiting rooms. the entire air conditioning system must
be sanitized very frequently. the use of personal protective equipment (including masks, gloves, gowns and goggles or face shields) is
recommended to protect skin and mucosa from (potentially) infected blood or secretions.
as respiratory droplets are the main route of sars-cov-2 transmission, particulate respirators (e.g., n-95 masks authenticated by the national
institute for occupational safety and health or ffp2-standard masks set by the european union) are recommended for the routine dental
practice.

(MOH)
TYPES OF THE DENTAL
CARE IN EMERGENCY
SITUATIONS
1-Emergent dental care It includes uncontrolled bleeding, significant infection (e.g.
cellulitis), facial swelling and oral facial trauma potentially compromising the patient's
airway
2-Urgent (essential) dental care It focuses on the management of severe or uncontrolled
symptoms that cannot be managed by the patient and require the patient to see a
dentist in a designated urgent dental care center.
3-Non-urgent (non-essential) dental care It includes all routine and elective dental and
/or maxillofacial procedures.
4- Advice and self-care Mild or moderate symptoms managed remotely by the dentist
(by phone) providing advice and help, which may involve analgesics and
antimicrobials.

DENTAL TRIAGE PROTOCOL:
A- Remote dental triage:
1- All emergency/urgent cases should be triaged remotely (Call Center 937 or Dental Center
phone), to decrease the overflow in the emergency department. A history of the patient condition
and medical status should be assessed.
2- All patients should be screened for COVID-19 triage questions (travel history in the last 14
days, exposed to a person who is diagnosed or suspected to COVID-19 in the last 14 days, fever,
cough or shortness of breath).
3- Suspected cases of COVID-19 should follow the MOH guideline for handling of suspected
cases.
4- In a special needed situation, a photo of the site where the complaint comes from is sent to the
team by the route determined by the dental staff.
5- Use the recommended management of the most common presenting symptoms to the
emergency dental care as a simple guide for remote triage Remote dental triage should focus on
the provision of advice, analgesics and/or antibiotics (where appropriate).
6- Adequate staff training

7- Patients are advised that the dental care is severely restricted at this period and to call
back after 48-72 hours if the symptoms have not resolved.
8- If needed, referrals are done to the nearby medical emergency center or the designated
dental centers, who can provide the required care. The case will be registered under
National ID or Iqama number.
9- National ID or Iqama number and contact number should be used for registration during
the remote triage.
B- Urgent dental triage in the designated dental clinic:
1- All patients should be registered in the database with the National ID or Iqama number.
2- Body temperature should be measured in the triage room.
3- Patients should be asked for COVID-19 and fill the triage questionnaire.
4- Identify the suspected cases of COVID-19 and follow the MOH guideline for handling of
suspected cases.
5- Use the recommended management of the most common presenting symptoms to the
emergency dental care as a simple guide for clinical triage.
6- Adequate staff training and specifically appropriate human behavior

DENTAL CLINIC CONSIDERATIONS:
1. At this stage of the pandemic, all patients (adults/children) are potentially infective.
2. Restrict the presence of unnecessary individuals in the dental clinic.
3. Dentists should exercise professional judgment and carefully consider the risks of the disease
transmission and refer those risks against any possible benefit to the patient, the health care workers,
and the community.
4. Dentists should follow a strict infection control protocol guide with all emergency dental patients.
5. Decisions on undertaking treatment should be made with an appropriate patient or parents’
consent.
6. If the patient follows up needed, the dentist may contact the patient remotely to minimize patients
contact (as necessary).
7. The risk of dental practitioners being positive for COVID-19 and potentially infecting patients
attending emergency dental services should not be underestimated.
8. All dental staff who had unprotected high-risk exposure or have suggestive symptoms regardless of
exposure shall stop performing their duties immediately

STEPS ALL EMPLOYERS CAN TAKE TO
REDUCE WORKERS’ RISK OF EXPOSURE
TO SARS-COV-2
1) Develop an Infectious Disease Preparedness and Response Plan –
can help guide protective actions against COVID-19 consider how to incorporate those
recommendations and resources into workplace-specific plans.
should consider and address the level(s) of risk associated with various worksites and job
tasks workers perform at those sites. Such considerations may include:
■ Where, how, and to what sources of SARS-CoV-2 might workers be exposed including:
{ The general public, customers, and coworkers; and Sick individuals or those at
particularly high risk of infection (e.g., international travelers who have visited locations
with widespread sustained (ongoing) COVID-19 transmission, healthcare workers who
have had unprotected exposures to people known to have, or suspected of having, COVID-
19).

Implement Basic Infection Prevention Measures
 Promote frequent and thorough hand washing, by providing workers, customers, and
worksite visitors with a place to wash their hands. If soap and running water are not
immediately available, provide alcohol-based hand rubs containing at least 60% alcohol.
 Encourage workers to stay home if they are sick.
 Encourage respiratory etiquette, including covering coughs and sneezes.
 Maintain regular housekeeping practices, including routine cleaning and disinfecting of
surfaces, equipment, and other elements of the work environment. When choosing cleaning
chemicals, employers should consult information on Environmental Protection Agency
(EPA)-approved disinfectant labels with claims against emerging viral pathogens.
 Products with EPA-approved emerging viral pathogens claims are expected to be effective
against SARS-CoV-2 based on data for harder to kill viruses.
 Follow the manufacturer’s instructions for use of all cleaning and disinfection products (e.g.,
concentration, application method and contact time, PPE).

DEVELOP POLICIES AND PROCEDURES FOR
PROMPT IDENTIFICATION
Prompt identification and isolation of potentially infectious individuals is a critical
step in protecting workers, customers, visitors, and others at a worksite.
Employers should inform and encourage employees to self-monitor for signs and
symptoms of COVID-19 if they suspect possible exposure.
Employers should develop policies and procedures for employees to report when
they are sick or experiencing symptoms of COVID-19.
Move potentially infectious people to a location away from workers, customers,
and other visitors.
Although most worksites do not have specific isolation rooms, designated areas
with closable doors may serve as isolation rooms until potentially sick people can be
removed from the worksite.

■ Take steps to limit spread of the respiratory secretions of a person who may
have COVID-19.
Provide a face mask, if feasible and available, and ask the person to wear it.
■ Isolate people suspected of having COVID-19 separately from those with
confirmed cases of the virus to prevent further transmission—particularly in
worksites where medical screening, triage, or healthcare activities occur,
using either permanent (e.g., wall/different room) or temporary barrier (e.g.,
plastic sheeting).
■ Restrict the number of personnel entering isolation areas.
■ Protect workers in close contact with (i.e., within 6 feet of) a sick person or
who have prolonged/repeated contact with such persons by using additional
engineering and administrative controls, safe work practices, and PPE.
Workers whose activities involve close or prolonged/ repeated contact with
sick people are addressed further in later sections covering workplaces
classified at medium and very high or high exposure risk.

DEVELOP, IMPLEMENT, AND
COMMUNICATE ABOUT WORKPLACE
FLEXIBILITIES AND PROTECTIONS
Actively encourage sick employees to stay home.
Ensure that sick leave policies are flexible and consistent with public health guidance and that
employees are aware of these policies.
Maintain flexible policies that permit employees to stay home to care for a sick family member.
Employers should be aware that more employees may need to stay at home to care for sick children or
other sick family members than is usual.
Recognize that workers with ill family members may need to stay home to care for them
Be aware of workers’ concerns about pay, leave, safety, health, and other issues that may arise during
infectious disease outbreaks.
Provide adequate, usable, and appropriate training, education, and informational material about
business-essential job functions and worker health and safety, including proper hygiene practices and
the use of any workplace controls (including PPE).
Work with insurance companies (e.g., those providing employee health benefits) and state and local
health agencies to provide information to workers and customers about medical care in the event of a
COVID-19 outbreak.

ENGINEERING CONTROLS
1. Installing high-efficiency air filters.
2. Increasing ventilation rates in the work environment.
3. Specialized negative pressure ventilation in some settings, such as for aerosol
generating procedures (e.g., airborne infection isolation rooms in healthcare settings
and specialized autopsy suites in mortuary settings).

ADMINISTRATIVE CONTROLS
■ Encouraging sick workers to stay at home.
■ Minimizing contact among workers, clients, and customers by replacing face-to-face meetings with virtual
communications and implementing telework if feasible.
■ Establishing alternating days or extra shifts that reduce the total number of employees in a facility at a
given time, allowing them to maintain distance from one another while maintaining a full onsite work week.
■ Discontinuing nonessential travel to locations with ongoing COVID-19 outbreaks. Regularly check CDC
travel warning levels at: (www.cdc.gov/coronavirus/2019-ncov/travelers. )
■ Developing emergency communications plans, including a forum for answering workers’ concerns and
internet-based communications, if feasible.
■ Providing workers with up-to-date education and training on COVID-19 risk factors and protective
behaviors (e.g., cough etiquette and care of PPE).
■ Training workers who need to use protecting clothing and equipment how to put it on, use/wear it, and
take it off correctly, including in the context of their current and potential duties. Training material should be
easy to understand and available in the appropriate language and literacy level for all workers.

SAFE WORK PRACTICES
■ Providing resources and a work environment that promotes personal hygiene. For
example, provide tissues, no-touch trash cans, hand soap, alcohol-based hand rubs
containing at least 60 percent alcohol, disinfectants, and disposable towels for workers
to clean their work surfaces.
■ Requiring regular hand washing or using of alcohol-based hand rubs. Workers
should always wash hands when they are visibly soiled and after removing any PPE.
■ Post handwashing signs in restrooms.

CLASSIFYING WORKER EXPOSURE
TO SARS-COV-2

(IDA)
PREVENTIVE GUIDELINES FOR DENTAL
PROFESSIONALS ON THE CORONAVIRUS
THREAT
oIn the light of WHO declaring the COVID-19 virus to be a pandemic, the Indian Dental
Association (IDA) recommends preventative measures for dental professionals to minimize
transmission through contact and dental procedures.
Minimize Chance for Exposures-
oPost a sign at the entrance to the dental practice which instructs patients having symptoms of a
respiratory infection (e.g., cough, sore throat, fever, sneezing, or shortness of breath) to please
reschedule their dental appointment and call their physician,if they have had any of these
symptoms in the last 48 hours.
oReschedule appointments if your patients have traveled outside India in the last two weeks to an
area affected by the coronavirus disease. This includes China, Hong Kong, Iran, Italy, France,
Spain, Germany, Japan, Singapore, South Korea, Taiwan, Thailand, Vietnam or any other COVID19
affected country. Take a detailed travel and health history when confirming and scheduling
patients.
oDo not provide non-emergent or cosmetic treatment to the above patients and report them to the
health department immediately.
oScreen patients for travel and signs and symptoms of infection when they update their medical
histories.

oTake temperature readings as part of the routine assessment of patients before
performing dental procedures.
oTake the contact details and address of all patients treated. Install physical barriers
(e.g., glass or plastic windows) at reception areas to limit close contact with
potentially infectious patients. Make sure the personal protective equipment being
used is appropriate for the procedures being performed.
oUse a rubber dam when appropriate to decrease possible exposure to infectious
agents.
oUse high-speed evacuation for dental procedures producing an aerosol.
oAutoclave hand-pieces after each patient. Have patients rinse with a 1% hydrogen
peroxide solution before each appointment.
oClean and disinfect door handles, chairs and bathrooms. Post visual alerts icon (e.g.,
signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators,
cafeterias) to provide patients with instructions (in appropriate languages) about
hand hygiene, respiratory hygiene, and cough etiquette.

oInstructions should include how to use tissues to cover nose and mouth when coughing
or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how
and when to perform hand hygiene.
oProvide supplies for respiratory hygiene and cough etiquette, including alcohol-based
hand rub (ABHR) with 60-95% alcohol, tissues at entrances, waiting rooms, and patient
check-ins.
oRisk Assessment is Critical- Dental personnel should be alert and identify patients with
an acute respiratory illness when they arrive, give them a disposable surgical face mask to
wear and isolate them in a single-patient room.
oWear a surgical or procedure mask and eye protection (face shield, goggles) to protect
mucous membranes of the eyes, nose, and mouth during activities that are likely to
generate splashes or sprays of blood, body fluids, secretions, and excretions.
oGown Wear to protect skin and prevent soiling of clothing during activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
oRemove soiled gown as soon as possible, and perform hand hygiene. Linens Handle,
transport, and process used linen in a manner which: prevents skin and mucous
membrane exposures and contamination of clothing.
oAvoids transfer of pathogens to other patients and or the environment

SAFETY & PREVENTIVE MEASURES FOR
DENTAL HEALTH CARE PROFESSIONALS ON
COVID-19(JASMINE MARWAHA , KIANOR SHAH)
While treating patients keep following points in mind. These are:
o IDENTIFICATION: As Dental health care personnel are exposed to oral cavity which is a common route for
infection transmission, he/she should be alert. They will have to be careful while providing treatment to prevent
nosocomial spread of infection.
oIdentify patients with an acute respiratory illness. Unique feature of COVID-19 is it causes both Upper & lower
respiratory tract infection.
oTake proper medical history.
oPatient’s body temperature should be checked using a non-contact forehead thermometer or with cameras
having infrared thermal sensors.
oAsk every patient about their travel history in the last 14 days or being in contact with such person having
travel history.
oWhile confirming appointments or during the arrival of patients for treatment, appropriate questions should be
asked which includes whether patients have been in close contact with someone who has been diagnosed with
or is under investigation for COVID-19. Patients answering yes to these questions should be counseled or
encouraged to contact their physician as early as possible for COVID- 19 diagnosis.
oIf dentists or staff member comes in contact with a COVID-19 patient, he/she should get screening immediately.

TRANSMISSION ROUTES
oTransmission routes include:
1)Respiratory droplets a) Direct (i.e. person-to-person) and
b) indirect (i.e. person-to-surface-to-person) contact transmission
oThe SARS-CoV-2 virus can remain viable and transmit disease for variable lengths of
time but it is currently not known how long the virus remains viable
oIn airborne droplets 3-6 hours ,
oOn soft surfaces such as cardboard up to 48 hours ,On hard surfaces such as stainless
steel (consider dental instruments) up to 80 hours (3-4 days) ,On hard surfaces such as
plastic upto 96 hours (4-5 days)

IMMUNIZATION
oImmunizations substantially reduce the number of DHCPs susceptible to infectious diseases, as well as
the potential for disease transmission to other staff and patients. Therefore, immunizations are an
essential part of infection prevention and control programs.
oAll DHCPs should be adequately immunized against the following diseases: hepatitis B • influenza •
measles • diphtheria • mumps • pertussis • rubella • tetanus • varicella • polio
oIt is important that all DHCPs know their personal immunization status and ensure that it is up to date.
In this regard, DHCPs should consult with their family physician about the need for immunizations, as
well as baseline and annual tuberculosis skin testing.
oHepatitis B is the most important vaccine-preventable infectious disease for all workers engaged in
health care, immunization against HBV is strongly recommended for all DHCPs who may be exposed to
blood, body fluids or injury involving sharps.
oSerological testing for anti-HBs should be conducted 1 to 2 months after completion of the 3-dose
vaccination series to establish antibody response.
oDHCPs who fail to develop an adequate antibody response should complete a second vaccination
series, followed by retesting for anti-HBs.

•Dental practitioners and clinical support staff are at risk of exposure to many common vaccine-
preventable diseases (VPDs) through contact with patients and the general community.
• Immunisations substantially reduce the potential for acquisition of disease, thereby limiting further
transmission to other dental staff and patients
•Those working with remote Indigenous communities are advised to also receive immunisation for
hepatitis A, while those at high risk of exposure to drug-resistant cases of tuberculosis should also
undergo vaccination with Bacille Calmette-Guerin (BCG).
•All dental practitioners and clinical support staff should be vaccinated against HBV if they have no
documented evidence of pre-existing immunity (from natural infection or prior vaccination) and
ensure they are assessed for immunity post-vaccination.
• After a full course of HBV immunisation or rubella vaccination, testing for antibody levels should be
carried out
•Immunisation records-The practice must develop and maintain regularly updated .It is recommended
that dental staff also maintain their own immunisation and screening records.
•Staff should be asked to declare their vaccination status for hepatitis B, influenza and other infections
of relevance to the healthcare setting.
•The rationale for asking for vaccination status for hepatitis B is that successful vaccination confers
lifelong immunity

VACCINATION
1. HCW should be immune to hepatitis B and post-vaccination serological status should
be ascertained.
2. HCW should be immune to measles and rubella, by either vaccination or medical
evaluation.
3. HCW should be immune to varicella. HCW with negative or uncertain history of
receiving two doses of varicella vaccines or disease of varicella or herpes zoster should
be serologically tested. Vaccines should be offered to those without varicella zoster
antibody.
4. All HCW should receive seasonal influenza vaccination annually once the vaccine is
available

DECONTAMINATION OF DENTAL
UNIT WATERLINES IN
GOVERNMENT DENTAL SERVICE

WATER QUALITY
According to CDC recommendation, water quality for routine non-surgical dental treatment (such as
irrigants/coolant for cavity preparation and ultrasonic scaling) should be of no less than drinking water
standard (i.e., ≤500 Colony Forming Units per mL (CFU/mL) of heterotrophic water bacteria).
Bacterial levels should be tested according to the details stipulated in “Arrangement of Water Test for
Dental Unit Waterlines in Government Dental Service”. If the water test result indicates bacterial level
more than 500 CFU/mL (Action Level), the steps below should be followed:
1. Review the process of DUWL decontamination
2. Until re-shock treatment is started, all DUWL should be flushed at the beginning of each working
day
3. Perform the re-shock treatment as soon as feasible
4. Re-arrange water test for the dental unit
5. Inform ICSC for further investigation if bacterial level is still above the Action Level
WHO expert panel reached a consensus that the significance of heterotrophic water bacteria count on
human health should be treated with caution, heterotrophic bacteria count is used as a tool to indicate
the effectiveness of water treatment processes.

ARRANGE
MENT OF
WATER
TEST FOR
DENTAL
UNIT
WATERLIN
ES IN
GOVERNM
ENT

PROCEDURE FOR BASELINE
WATERLINE TESTING

SUCTION / EVACUATION SYSTEM
1. Intermittent flushing with water during treatment and in-
between patients can help to prevent the tubing from
clogging.
2. The use of suction cleaning devices such as “Oro-cup” helps to
create the necessary turbulence for more effective cleaning.
3. The detachable suction filters and hoses should be cleaned
with reference to the manufacturer's instructions.
4. Do not advise patients to close their lips tightly around the tip
of a saliva ejector to evacuate oral fluids, as this may lead to
suction backflow.

WATERLINES AND WATER QUALITY
Biofilm in dental unit waterlines may be a source of known pathogens (e.g. Pseudomonas aeruginosa, non-
tuberculous mycobacteria, and Legionella)
Waterlines -cleaned and disinfected in accordance with the manufacturer’s instructions. All waterlines must be
fitted with non-return (anti-retraction) valves to help prevent retrograde contamination of the lines by fluids
from the oral cavity. An independent water supply can help to reduce the accumulation of biofilm.
The manufacturer’s directions should be followed for appropriate methods to maintain the recommended
quality of dental water and for monitoring water quality.
Biofilm levels in dental equipment can be minimised by using a range of measures, including water treatments
using ozonation or electrochemical activation, chemical dosing of water (e.g. with hydrogen peroxide,
peroxygen compounds, silver ions, or nanoparticle silver), flushing lines (e.g. triple syringe and handpieces)
after each patient use, and flushing waterlines at the start of the day to reduce overnight or weekend biofilm
accumulation. This is particularly important after periods of non-use (such as vacations and long weekends)
Flushing each day has been shown to reduce levels of bacteria in dental unit waterlines.
Air and waterlines from any device connected to the dental water system that enter the patient’s mouth (e.g.
handpieces, ultrasonic scalers, and air/water syringes) should be flushed for a minimum of two minutes at the
start of the day and for 30 seconds between patients.

Water quality –
Sterile irrigants such as sterile water or sterile saline as a coolant are required
for surgical procedures such as dentoalveolar surgery, endodontic surgery, and
dental implant placements.
The number of bacteria in water used as a coolant/irrigant for non-surgical
dental procedures should be less than 500 CFU/mL, since this is a widely used
international limit for safe drinking water.
When treating immunocompromised patients, it is recommended that water
from dental unit waterlines contain less than 200 CFU/mL. Bacterial levels can be
tested using commercially available test strips or through commercial
microbiology laboratories.
Levels of microorganisms in dental unit waterlines can be assessed using
commercial test kits.

REFERENCES
World Health Organization : Report on the Burden of Endemic Health Care-Associated Infection Worldwide.
World Health Organization 2011
World Health Organization : Guidelines on core components of infection prevention and control programmes at
the national and acute health care facility level. World Health Organization 2016
Boyce JM, Pittet D : Guideline for hand hygiene in health-care settings: Recommendations of the healthcare
infection control practices advisory committee and the hipac/shea/apic/idsa hand hygiene task force. American
Journal of Infection Control 2002;30 S1-S46
Fendler EJ, Ali Y, Hammond BS, Lyons MK, Kelley MB, Vowell NA : The impact of alcohol hand sanitizer use on
infection rates in an extended care facility. American Journal of Infection Control 2002;30 226-233
Provincial Infectious Diseases Advisory Committee : Best Practices for Hand Hygiene in All Health Care Settings,
4th edition. Ontario Agency for Health Protection and Promotion (Public Health Ontario) 2014
Cheng VC, Wong LM, Tai JW, Chan JF, To KK, Li IW, Hung IF, Chan KH, Ho PL, Yuen KY : Prevention of
nosocomial transmission of norovirus by strategic infection control measures. Infection Control & Hospital
Epidemiology 2011;32 229-237 Journal Website
World Health Organization : Guide to Implementation: A Guide to the Implementation of the WHO Multimodal
Hand Hygiene Improvement Strategy.
World Health Organization 2009; Website 64. Allegranzi B, Pittet D : Role of hand hygiene in healthcare-
associated infection prevention. Journal of Hospital Infection 2009;73 305-315

Centers for Disease Control and Prevention : Guide to Infection Prevention for Outpatient Settings:
Minimum Expectations for Safe Care. Centers for Disease Control and Prevention 2016
Dixon AM : Environmental Monitoring for Cleanrooms and Controlled Environments. Drugs and the
Pharmaceutical Sciences 2016;
Garner JS, Favero MS : CDC Guideline for Handwashing and Hospital Environmental Control, 1985.
Infection Control 1986;7 231-243
Public Health Ontario : Routine practices and additional precautions in all health care settings, 3rd
ed: Routine Environmental Cleaning. Public Health Ontario 2012
Macdonald L : Transmission Based Precautions Literature Review: Environmental Decontamination
and Terminal Cleaning. Health Protection Scotland 2014; Website 108.
Macdonald L : Standard Infection Control Precautions - Literature Review: Routine cleaning of the
care environment . Health Protection Scotland 2017
Sehulster L, Chinn RY, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil
MM, Whitney C : Guidelines for Environmental Infection Control in Health-Care Facilities.
Sehulster L, Chinn RY, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil
MM, Whitney C : Guidelines for Environmental Infection Control in Health-Care Facilities. CDC and
the Healthcare Infection Control Practices Advisory Committee 2003

Mitchell BG, Dancer SJ, Shaban RZ, Graves N : Moving forward with hospital
cleaning. American Journal of Infection Control 2013;41(11):1138-1139
Marra AR; Schweizer ML; Edmond MB : No-Touch Disinfection Methods to
Decrease Multidrug-Resistant Organism Infections: A Systematic Review and
Meta-analysis. Infect Control Hosp Epidemiol 2018;39:20–31; Journal 129.
Public Health Ontario : Routine Environmental Cleaning . 2012;
Rutala WA, Weber DJ : Guideline for Disinfection and Sterilization in
Healthcare Facilities (2008). Centers for Disease Control and Prevention 2008
Therapeutic Goods Administration : Therapeutic Goods Order No 104 -
Standard for Disinfectants (TGO 104). Therapeutic Goods Administration 2019

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