ODA Pandemic Recovery Toolkit - ADAPTING THE DENTAL OFFICE IN POST-COVID-19 TIMES - Ontario Dental Association
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ODA
Pandemic Recovery
Toolkit
ADAPTING THE DENTAL OFFICE
IN POST-COVID-19 TIMES
V 6.0 | FEBRUARY 2021
DISCLAIMER
This toolkit was developed by the Ontario Dental Association as a resource for its members.
No recipient of this toolkit shall copy, alter, in any way reproduce it, or provide it to a third
party, either in whole or in part, without the express written permission of the Ontario
Dental Association.
This toolkit provides general information on dentists’ return to practice and throughout
the recovery of the COVID-19 pandemic. It is not intended to constitute legal advice or as a
substitute to any guidance or direction provided by the Royal College of Dental Surgeons of
Ontario, Public Health Ontario, Ontario’s Ministry of Health and Ministry of Labour, Training
and Skills Development.
The Ontario Dental Association acknowledges the assistance of the Canadian Dental
Association and Ontario Dental Association’s Pandemic Recovery Working Group and Health
Policy & Government Relations Advisory Committee in the development of the Pandemic
Recovery Toolkit.
ODA Pandemic Recovery Toolkit (V6.0) 2
DEAR ODA MEMBER
Eight months after returning to practice after the shutdown in the spring, the focus of the
toolkit must now turn to a long-term vision for our profession. Our goal has always been to
help Ontario dentists go beyond simply returning to practice. This revised toolkit is designed
to provide ODA members with the knowledge and tools to sustain their practices throughout
the pandemic recovery and adapt to the new normal with the same confidence in our protocols
we had when we reopened.
Confidence will be maintained by understanding what the new normal will look like in our
communities, as well as what it will look like in our practices. The provincial government’s
COVID-19 response framework: keeping Ontario safe and open has provided all Ontarians
with a template for our communities. Of key importance in establishing a new normal in our
practices is doing our best to demonstrate our willingness and capacity to practise safely
under any pandemic conditions — even future ones. This toolkit, as along with guidance from
the Royal College of Dental Surgeons of Ontario, will provide you with a template for the new
normal for our practices.
Many of the changes we have made to our practices will remain long after the COVID-19
pandemic is behind us, because they make sense. Dentistry is a surgical profession and aerosols
present a risk of respiratory-based infections. Science not only continuously provides dentists
with the knowledge of this risk, it also builds expectations in our patients and staff that we do
all we can to minimize that risk. At the time of this writing, the entire province is considered
grey within the response framework, in a second State of Emergency, and subject to a stay-
at-home order. Dentists are expected to enhance infection prevention and control protocols
for all patients. Will this always be required? Likely no, but we will need to be able to go
there when we must. When the current province-wide restrictions are relaxed, we anticipate
returning the more regional approach outlined in the COVID-19 response framework: keeping
Ontario safe and open.
I would, again, like to thank the members of the Practice Recovery Working Group, as well as
ODA volunteers and staff, in helping to produce a toolkit that is such a valuable resource to
our entire profession. A special thank you goes to you, ODA members, for your vigilance and
caring throughout the pandemic. You have helped us in producing not just a better toolkit, but
a better profession.
Stay safe,
David M. Stevenson,
Chair, ODA Return-to-Practice Working Group
ODA Pandemic Recovery Toolkit (V6.0) 3
INTRODUCTION
In March 2020, dental offices across Ontario stopped providing oral health treatments and
services except for emergency care with the arrival of the novel coronavirus SARS-CoV-2 and
the illness it causes, COVID-19. As the pandemic became contained dental offices were allowed
to re-open in a staged manner. Since that time dentists have demonstrated that our protocols
have been effective in keeping our offices and communities safe from the transmission of
COVID-19 while we treat the oral health-care needs of our patients. Now the second wave
is upon us and while dental offices remain able to provide complete care for our patients
through the various stages of community transmission measures must continue to be taken to
protect patients, dental office staff, dentists and the community at large from the transmission
of COVID-19.
Kudos to our profession for demonstrating a willingness and diligence to return to practice
at a more comprehensive level and safely care for our patients. This has required tremendous
adaptation and there are still significant requirements and restrictions in place. Member dentists
must take care to ensure they are compliant with all new requirements. This toolkit is designed
for use by dentists and their dental teams and should be read in conjunction with relevant
provincial, territorial and local legislation, regulations and policies to ensure compliance.
Included in this toolkit are posters, signs, and other materials that you can download, and
checklists, templated letters and forms you can modify to suit your individual practice.
This toolkit continues with interim recommendations from the Ontario Dental Association’s
(ODA’s) Practice Recovery Working Group. Since these are interim recommendations, they
focus on the latest guidance from the Royal College of Dental Surgeons of Ontario (RCDSO)
— COVID-19: Managing Infection Risks During In- Person Dental Care — as of January 14, 2021.
As of Thursday, January 15, 2021, the Provincial Government has declared a province-wide
state of emergency which includes a stay-at-home order, now in effect. The order requires
Ontarians to remain at home, except for essential purposes, to help limit the community
spread of COVID-19. The RCDSO has stated that the state of emergency and stay-at-home
order do not alter the scope of care that dentists can provide, including in-person emergency,
urgent, and non-essential care. In response to the provincial shutdown, dentists are required
to undertake enhanced precautions when providing in-person care and should exercise
professional judgment when deciding how to triage and manage patient care in order to
support reduced mobility within the community.
During the State of Emergency, the COVID-19 response framework: keeping Ontario safe and
open has been paused. The entire province is considered grey at this time. However, it continues
to be imperative we remain cognizant of the risks of COVID-19 transmission, especially as it
exists within our own individual communities. The practices of respiratory hygiene, physical
distancing, decreased staff levels, decreased patient flow, treatment decisions, protocol
practices and preparedness remain vital to ensure the protection of ourselves, our staff, our
patients, and our communities. The dental office has always been a safe place to be. Helping
to protect our communities will ultimately protect our practices.
The toolkit is informed by the best available scientific evidence and expert opinion available
at this time and is subject to revision as additional information, data and new evidence
becomes available. Because of the evolving knowledge of COVID-19, it is expected that more
recommendations will be brought forward that might impact how dentists deliver care. Further
information and recommendations will be provided to our members as it becomes available.
In this version, the following sections have been added or significantly updated:
• New Introduction Letter (page 4)
• COVID-19 Framework (page 4)
• COVID-19 Safety Plan (page 7)
• Employee Absenteeism (page 7)
ODA Pandemic Recovery Toolkit (V6.0) 4
• Stay-at-Home Order (page 8)
• Updated Algorithm (page 9)
• A Note about Office Capacity (page 11)
• “Welcome Back” Communications (page 15)
• Aerosol Generating Procedures (page 19)
• Updated PPE chart (page 23)
• A Note about Face Shields (page 24)
• Special Protocols for Regions of High Disease Transmission (page 26)
• Template Letter for Staff (page 37)
• Template Letter for Patients (page 37)
Of note, since the release of the toolkit Version 4.0 the ODA has been made aware of a
limited, small number of inspections of dental practices with respect to infection prevention
and control during COVID-19. We anticipate inspections and enforcement of restrictions to
continue throughout all stages of the pandemic, and especially during the current State of
Emergency, as the government introduces new measures, and reinforces existing ones. The
ODA has developed resources to help members understand and comply with inspections
from the RCDSO, College of Dental Hygienists of Ontario, Public Health Units, and Ministry of
Labour, Training and Skills Development. Each of these organizations has different mandates
and authorities, and it is important that all members be prepared. You can access these
resources at www.oda.ca/member.
It is also important to note that inspectors often look to the suite of protocols that have been
put in place as opposed to following a simple checklist. Being able to justify the measures
and procedures in place through a risk assessment — including consideration of the level of
community spread or individual considerations through a point-of-care risk assessment, is
advised.
The toolkit is not a substitute for guidance from regulators or government but can be an
important tool in demonstrating due diligence in the adoption of leading best practices for
your office.
SECTION 1: PREPARING YOUR STAFF
How to bring your staff back to work (with guidance for employers) and develop strategies
to protect you and your staff, including staff screenings, hand hygiene, personal protective
equipment, physical distancing and health and wellness.
SECTION 2: PREPARING YOUR OFFICE
Start with these basic recommendations for office cleaning and modifications to your common
staff areas, reception and waiting room to reduce the risk of transmission between patients.
SECTION 3: PREPARING YOUR PATIENTS
Welcome back communications to reinsure your office’s commitment to infection prevention
and control procedures and guidance on preparing your patients before the appointment and
handling in-office patient registration.
SECTION 4: PREPARING TO PRACTISE
Clinical practices and protocols, physical build considerations, chairside protocols and personal
protective equipment use.
ODA Pandemic Recovery Toolkit (V6.0) 5
TABLE OF CONTENTS
Section 1: Preparing Your Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Handling the Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
COVID-19 Safety Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Guidance on Recalling Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Stay-at-Home Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Strategies to Protect You and Your Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Daily Staff Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Dental Staff COVID-19 Management Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Respiratory Hygiene/Etiquette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Physical Distancing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A Note about Office Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Clothing and Office Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Health and Wellbeing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 2: Preparing Your Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
General Office Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Reception and Waiting Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Clinical Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Common Staff Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Receiving Deliveries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Section 3: Preparing Your Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Welcome Back Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Before the Appointment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Determining Patient COVID-19 Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
During the Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
COVID-19 in the Dental Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Section 4: Preparing to Practise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Aerosol- Generating Procedures (AGPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Point-of-Care Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
A Note About Face Shields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Clarity on Alternatives And Reuse of PPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
General Chairside Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Clinical Practices and Protocols for Patients Who Screened
Negative for COVID-19 with enhanced precautions requirement . .. . . . . . . . . . . 25
Additional Clinical Practices and Protocols for Patients Who
Screened Positive for COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Special Protocols For Regions of High Disease Transmission . . . . . . . . . . . . . . . . 26
Donning and Doffing PPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Fallow Times and Air Filtration After Treating Patients When Enhanced
Precautions are Required in Accordance With RCDSO Guidance . . . . . . . . . . . . 27
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendices: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
ODA Pandemic Recovery Toolkit (V6.0) 6SECTION 1: PREPARING YOUR STAFF
Under the Occupational Health and Safety Act, as an employer you must take precautions to
keep workers safe. That means ensuring your practice adheres to the interim guidelines set
out by the Royal College of Dental Surgeons of Ontario (RCDSO). It also means addressing
the concerns your staff may have about returning or continuing to work and treating patients
during uncertain circumstances.
Staff need to understand the risk of infection and disease and feel that they are working in
an environment that is safe. Until the pandemic recedes, effective therapy is available, or a
vaccine is developed and administered to most of the population, COVID-19 remains a risk
for everyone, especially vulnerable populations and dental professionals. Not just before you
reopened your practice, but throughout all stages of the pandemic, it is important to let them
know what to expect and reassure them that you are working to ensure the safety of everyone
at your practice. Take the time to review this toolkit, and any information particular to your
communities as can be found in Ontario’s Response Framework, with them. This confidence
gained from knowing the details of one’s circumstances can then be effectively relayed to
our patients.
HANDLING THE RETURN TO WORK
COVID-19 Safety Plan
The Government of Ontario has required that any business that is open during the COVID-19
pandemic should prepare and make available a COVID-19 Safety Plan which describes the
measures and procedures which have been implemented or will be implemented in the
business to reduce the transmission risk of COVID-19.
You can develop your COVID-19 Safety Plan using the Government of Ontario template found
on this webpage.
This RCDSO COVID-19 Self-Audit Review Form is a helpful resource in completing the COVID-19
Safety Plan as well as a nice checklist to keep in the office.
Guidance on Recalling Staff
Currently many practices are not operating at full capacity. Employers continue to be permitted
to bring back some staff only and need not recall all employees at once if it is not operationally
feasible to do so. However, employers should have a strategy and rationale for how they decide
which employees to recall and when. For guidance, we encourage you to obtain legal advice
when making such decisions. Resources relating to these matters can be found on the ODA
member website.
Message to dental staff
Use the following screening form for both dentists and staff in the office as they initially return
to work and daily throughout the COVID-19 pandemic. The COVID-19 pandemic has created
many challenging circumstances for staff outside of the office environment such as child care and
virtual schooling from home. We know that managing your human resource needs can be difficult
and flexibility is often required. This form can also be used for new hires or temporary staff.
Dental Office Return-to-Work Screening Form
Staff members who are pregnant or potentially immunocompromised should seek and follow
medical guidance from their physician regarding returning to work.
For resources on government COVID-19 financial programs, visit the ODA member website.
Employee Absenteeism: Child/Elder Care Quarantine Requirements During COVID-19
ODA Pandemic Recovery Toolkit (V6.0) 7Stay-at-Home Order
As of Thursday, January 15, 2021, the Provincial Government has declared a province-wide
state of emergency which includes a stay-at-home order, now in effect. The order requires
Ontarians to remain at home, except for essential purposes, to help limit the community
spread of COVID-19. While dentistry is considered an essential service under this state of
emergency, some staff and patients may express concerns regarding travelling to and from
the dental clinic. We have developed a letter that you can provide staff and patients if they are
concerned. This letter is not mandatory and does not need to be used, but may be helpful to
reassure staff and patients.
Template Letter for Staff
Template Letter for Patients
STRATEGIES TO PROTECT YOU AND YOUR STAFF
Help protect office staff as you reopen the practice by utilizing the following strategies on an
ongoing basis. Discuss with your staff new processes that may need to be implemented and the
reasons behind them. This should include, among other things, consideration of patient flow into
and through the practice, timing for operatory usage and sterilization, staff routines as they don
and doff new and unfamiliar personal protective equipment (PPE), and how to time the daily
schedules when returning to patient care.
Health and Safety Guidance During COVID for Dental Offices (PSHSA)
Daily Staff Screening
The health of all dental office staff is paramount and must be monitored for the continued health
and safety of the dental team. Daily staff screening and self-monitoring focuses on this principle
and includes a daily log confirming that they are not experiencing any symptoms of COVID-19.
This could include each staff member having their temperature taken twice per day if community
levels of COVID-19 warrant such consideration.
The screening questions for staff are based on screening questions from the Ministry of Health.
As the COVID-19 pandemic continues and restrictions are modified on a regional basis, the
opportunity for exposure increases due to travel, social interaction, and multiple employment
locations. How one conducts themselves outside of the dental practice can impact one’s
capacity to come to work and treat patients. It is important that all staff understand and
comply with the restrictions in place within their communities according to the COVID-19
Response Framework. Daily screening of staff is a vital component of protecting our practices
and communities as circumstances can easily change from one day to the next.
Dental Office Return-to-Work Screening Form
The following algorithm could be considered to determine the next steps as a result of the
staff screening process or a self-assessment done prior to entering the clinic, particularly in
regions where community spread of COVID-19 is high.
ODA Pandemic Recovery Toolkit (V6.0) 8DENTAL STAFF COVID-19 MANAGEMENT ALGORITHM
Was there CLOSE CONTACT with Dental staff can work with
this probable or confirmed case? use of procedure mask and
START HERE RETURN Consider close contact if YES to self-monitor for symptoms
TO WORK any one of the following examples: and self-isolate when not at
3 options
• Less than 2 metres from work, until the probable case
probable AND test is NEGATIVE
• Contact of more than 5 If probable case tests
minutes
NEGATIVE, mask and self-
YES
• Provided physical care to a isolation no longer required.
patient without appropriate
PPE? If probable case test is
1. Has asymptomatic
Were they NO
• Was person coughing/ POSITIVE, continue to work
dental staff had sneezing? with procedure mask for 14
YES wearing
contact with a
appropriate PPE?
• Sharing of equipment (e.g., days. Self -monitor and self-
probable or confirmed phone, computer)? isolate for the full 14 days
COVID-19 staff or • Social distancing was not from exposure.
patient up to 48 practised?
hours prior to their • Strict hand hygiene was not
symptoms starting? practised? If dental staff has a NEGATIVE
test result, they can return to
Dentist TO: work when symptom-free for
If Symptoms* Develop? 24 hours. Procedure mask is no
• Send staff
longer for direct contacts.
member home
2. Does dental YES
staff member • Direct staff
have symptoms*? member to call Contact your primary care provider
assessment centre or Telehealth Ontario at 1-866-797- If dental staff tests POSITIVE,
for screening 0000 to determine next steps, they must self-isolate for 14
days after symptom onset and
• Direct staff or visit an assessment center.
can RTW after 14 days if:
member to
contact dentist Contact Local Public Health Unit • they are symptom-free for
with confirmation to self-report. 24 hours, AND
of testing. • If hospitalized, they have
2 negative tests, taken 24
hours apart, at day 14 or
If Symptoms* Develop? beyond.
3. Has
asymptomatic Dental staff to notify If dental staff is symptomatic and NOT tested by the assessment
dental staff Dentist: centre, they are treated as though they are POSITIVE. Dental staff
member had YES must self-isolate for 14 days after symptom onset and RTW after 14
contact with Self-monitor and self-isolate days if:
a household or 14 days. If HM receives • they are symptom-free for 24 hours, AND
member (HM) NEGATIVE test results then
that has staff member can return to • If hospitalized, they have 2 negative tests, taken 24 hours apart, at
symptoms and work. day 14 or beyond.
has been tested?
If HM is POSITIVE, must
continue to self-monitor *Symptoms: Self-isolate: Stay at home
and self-isolate for 14 days, maintaining distance from
Fever
and if asymptomatic after 14 household members
days, can RTW. New/worsening cough
https://www.
Difficulty breathing publichealthontario.ca/-/
If deemed critical to
essential patient care, RTW Other symptoms possible. Testing media/documents/ncov/
wearing a procedure mask. centre will determine whether factsheet-covid-19-how-
testing is recommended to-self-isolate.pdf?la=en
https://www.phsd.ca/health-topics-
programs/diseases-infections/
coronavirus
ODA Pandemic Recovery Toolkit (V6.0) 9RESPIRATORY HYGIENE/ETIQUETTE
The COVID-19 virus typically spreads through coughing and sneezing, personal contact with
an infected person, or touching an infected surface and then face (mouth, nose or eyes).
Remember to cover your nose/mouth with tissue when coughing or sneezing, or use a mask
when sneezing or coughing, use disposable tissues and discard after use, and wash hands or
use hand sanitizer after having contact with respiratory secretions.
Cough Etiquette Sign (Public Health Ontario)
Hand Hygiene
Strict attention to staff hand hygiene is critical and staff must clean hands thoroughly:
• upon entry into the dental office;
• before and after any contact with patients;
• after contact with contaminated surfaces or equipment; and
• between procedures and after removing PPE depending on the procedure, following
established PPE protocols.
How to Use Hand Sanitizer Sign (Public Health Ontario)
How to Wash Your Hands Sign (Public Health Ontario)
Physical Distancing
It will be challenging to practice physical distancing in your office. Work with your team
to develop a process for patient flow into and through the practice to encourage physical
distancing and minimize interaction with other staff or patients. Protocols should also be
developed which should include:
• Limiting the total number of people at the workplace and where they are assigned to work.
• Staggered start times, breaks and lunches.
• Suspending all group activities and gatherings.
• Alter the workplace layout of the floor by moving furniture or using visual cues such as
tape on the floor to enhance physical distancing.
• Lunchrooms and break rooms must be arranged to follow physical distancing practices. .
Please do not gather in the lunchroom. When more than one staff member must be in the
lunchroom, staff must continue to social distance and wear PPE (when possible).
• Staff should bring their own dishes and utensils from home and take home for washing or
use disposable utensils.
• Meals should minimize use of appliances. Any appliances used with high-touch surfaces
such as microwaves or refrigerators should be disinfected after use.
Vigilance in this regard cannot be stressed enough. While there has been to date no known
transmission of COVID-19 directly related to treatment in a dental office, there have been cases
of transmission between staff members. The ability for COVID-19 to be contracted through
airborne transmission is becoming more apparent the more we learn. All staff and dentists
must always wear a mask throughout the office. Only when appropriate physical distance
requirements can be met, can masks be removed for eating, and meal duration should be kept
to a minimum.
Ways to Stay Safe at Work (Poster)
Physical Distancing Fact Sheet (Public Health Ontario)
ODA Pandemic Recovery Toolkit (V6.0) 10A Note About Office Capacity
As of January, 15, 2021, dental offices are subject to a provincial order requiring certain
businesses within the “Grey Zone” of the areas listed in Schedule 1 to Ontario Regulation
363/20 (which is currently all areas in the province) to operate at 50 percent capacity. This
does not mean necessarily that dentists must cut their staff to 50 percent, as the capacity limit
reflects the total number of people in the office at any one time, including patients, staff and
visitors. For most offices, simply limiting the occupancy of waiting rooms and requiring that
patients wait in their cars up until the time of their appointments should effectively fulfill this
requirement. The provincial order provides that the maximum number of persons permitted in
a business or facility operating at 50 percent capacity is determined by:
Taking the total square metres of floor area accessible to the public in the business or facility,
not including shelving and store fixtures, dividing that number by 8 and rounding the result
down to the nearest whole number. (Ontario Regulation 82/20) .
For example, a dental office with a total area of 130 square metres accessible to patients and
staff has a 50 percent capacity limit of 16 people; combined staff, patients and visitors.
Clothing and Office Environment
In the highly infective COVID-19 environment, all dental office staff should consider wearing
scrubs at work. Scrubs and shoes should be only worn in the office and should be put on
when entering the office at the start of the day and removed at the office at the end of the
day. If a workplace-supplied uniform and laundry are not an option, it is best to bag your work
scrubs and set up a decontamination station at home that you can use immediately upon
arrival. Although daily scrubs may be laundered at home or at work, surgical gowns must
be laundered through a commercial service or on-site, subject to specific criteria as per the
RCDSO FAQ, including:
• there must be a dedicated space, physically separate from other areas of the laundering
facility; and
• the space must contain a sorting area for soiled items that is kept under negative pressure,
generated and maintained by a ventilation system that removes more air from the room
than air is allowed into the room.
Frontline Worker Safety Chart (Poster)
Health and Well-Being
Many people find it difficult to cope with the COVID-19 pandemic because of the number
of drastic and rapid changes happening in everyday life. In these uncertain times, dentists,
their staff, and families are invited to contact the CDSPI Members’ Assistance Plan (MAP) for
no-cost support. MAP is a confidential service that helps you manage issues affecting your
physical and mental well-being.
Members’ Assistance Program
ODA Pandemic Recovery Toolkit (V6.0) 11SECTION 2: PREPARING YOUR OFFICE
We realize that most dentists at this point have already prepared their offices and returned
to treating patients. However, the Provincial Response Framework, and other restrictions
deemed necessary throughout the pandemic recovery, will inevitably result in changes to how
we manage and prepare our practices. It is important dentists and staff remain familiar with
the principles and protocols recommended from the outset of the COVID-19 Pandemic.
We recommend the following changes and protocols to enhance the existing infection
prevention and control procedures currently in place. These will vary based on your practice
layout. As the COVID-19 pandemic continues, continued vigilance with administration and
common area protocols, as well as clinical, is extremely important, especially in regions with
higher levels of community spread.
Return to Practice Checklist
GENERAL OFFICE CLEANING
• Clean surfaces with detergent or soap and water prior to initial disinfection. Disinfect touch
surfaces at least twice daily, including chairs, tables, door handles, light switches, clothes
hangers, bathroom countertops and fixtures, staffroom surfaces, lab areas, etc.
• Enhanced cleaning should be done if there has been potential exposure to a patient or
staff member tested or screened positive for COVID-19.
• Keep surfaces clear of items as much as possible and wipe down common areas frequently
according to usage.
Cleaning and Disinfection for Public Settings (Public Health Ontario)
RECEPTION AND WAITING AREA
• Minimize contact at reception.
• Consider adding a plexiglass screen for reception or enforcing physical distancing
with furniture, etc.
• Use disposable pens when required or choose a specific type of pen that are only
dispensed to patients so that you know not to use them again.
• Place markers on ground to encourage physical distancing from reception and other
patients.
• Avoid using paper forms where possible.
• Avoid accepting cash or cheques and encourage electronic payment.
• Ensure patients’ ability to maintain physical distancing at reception desk. Focus
patient activity at the front desk to a limited area. Disinfect the area after patient
contact. Wipe down any tablets, card machines, or electronic devices after each use.
• Consider limiting the number of patients who are in the waiting room at one time.
• Only children and infirm patients may be accompanied. Accompanying persons should
also be screened for COVID-19 symptoms.
• Create an area for patient registration, screening and hand sanitizing.
• While we all wish to maintain a welcoming and friendly environment, socializing should
be avoided, and patients should leave once all treatment and administration matters
are complete.
ODA Pandemic Recovery Toolkit (V6.0) 12• Discourage staff sharing.
• Do not share pens, phone headsets, staplers, etc.
• Consider individual phone headsets for each front desk staffer to reduce virus
spread through the phone.
• Provide a hand sanitation station upon entry into facility, with a notice to people to use it
before entry into the rest of the office.
• Provide masks for those patients who do not have their own.
• Remove fabric surfaces and choose items that can be wiped down/disinfected.
• Promote physical distancing. Reduce the number of chairs in the waiting area, ideally chairs
are two metres apart. or post signs on chairs to “Do not sit” to achieve this distancing.
• Remove unnecessary items. Remove magazines, brochures, toys, etc.
• Remove or shut down coffee, drink or snack stations.
• Consider posting notices. Promote hand hygiene, physical distancing and cough etiquette.
• Update contacts. Know how to contact the local public health unit.
• Prepare washrooms. Post hand-washing instructions. Ensure there is an adequate supply
of soap (antibacterial, if possible) and dispenser for disposable towels for drying hands.
Make a trash can with no lid available or one with a foot pedal.
• Clean and disinfect. Clean surfaces with detergent or soap and water prior to initial
disinfection. Disinfect touch surfaces at least twice daily, including chairs, tables, door
handles, light switches, clothes hangers, bathroom countertops and fixtures, staff-room
surfaces, lab areas, etc. Use only Health Canada-approved disinfectants for use against
COVID-19.
How to Wash Your Hands Sign (Public Health Ontario)
How to Use Hand Sanitizer Sign (Public Health Ontario)
Physical Distancing Fact Sheet (Public Health Ontario)
Cough Etiquette Sign (Public Health Ontario)
CLINICAL AREAS
• Sterilization room and patient-care areas to be cleaned regularly, particularly those patient-
care areas in which aerosol-generating procedures (AGPs) are performed. Terminal cleaning
should be carried out after AGPs on patients who have tested or screened positive for
COVID-19, or in Public Health Regions where enhanced aerosol precautions are required.
This ideally should be assigned to a staff member not in direct contact with patients and
must be done after the appropriate fallow time. See Appendix A for terminal cleaning
for dental operatories after an AGP on patients who have tested or screened positive for
COVID-19.
• Shock your dental unit water lines if you are returning from an extended break in practice.
Consult the manufacturer’s instructions for proper product recommendations.
• Test sterilizers using a biological indicator with a matching control after a period of non-
use prior to reopening per manufacturer’s instructions.
• Air compressor, vacuum and suction lines, radiography equipment, high-tech equipment,
amalgam separators, and other dental equipment: Follow protocol for recommended
maintenance as per manufacturer’s instructions.
• Only patients and necessary attendants are allowed in clinical areas.
• Patients and staff should always wear masks. Patients should only remove their masks
when treatment is to begin.
ODA Pandemic Recovery Toolkit (V6.0) 13COMMON STAFF AREAS
• Encourage physical distancing, even when wearing a mask.
• Disinfect high-touch surfaces often.
• Hand-washing signage in staff washrooms.
RECEIVING DELIVERIES
• Wear gloves when collecting and/or accepting mail or packages.
• Wipe entirely the exterior of every box delivered with a paper towel and soap and water
solution or sanitizing wipe depending on your supplies.
• Boxes should remain untouched for 15 minutes prior to being opened.
• Clean all surfaces that were touched by the mail with soap and water mix or sanitizing
wipes.
• Contractors and dental supply repair should be screened the same as patients and enter
through the staff entrance, if possible.
• Consider a log recording all delivery and repair personnel and others for entry into your
building for contact tracing.
Stop and Read Before Entering (Poster)
ODA Pandemic Recovery Toolkit (V6.0) 14SECTION 3: PREPARING YOUR PATIENTS
WELCOME BACK COMMUNICATIONS
Notify your patients that your office is open and reassure them of your commitment to
maintaining up-to-date infection prevention and control procedures. The goal is to help your
patients understand what they can expect when they come back to your office, and while there
will still be risks, reassure them that their safety is your team’s utmost priority. While many
patients have returned to our practices at this point, there are some who have not and these
communications remain important. Establishing proper expectations is equally important for
patients who may be new to our practices.
While dentists have done so much to demonstrate the effectiveness of our safety protocols
and this is understood by most in our communities, it is important to understand that during
the province-wide stay-at-home order, many patients may simply choose to stay at home.
Everyone has a different comfort level and this is best respected.
Some patients may not necessarily reach out to you directly about their safety concerns and
may simply choose not to see their dentist at this time. To help reach this group, be proactive
in sharing information about your safety protocols in your electronic communications (e.g.
website, email, social media). The ODA’s recent advertising campaign reminded the public
that dentists are infection prevention and control experts and are doing everything possible
to keep patients safe. Our advertising materials can be used by ODA members in your own
communications to your patients.
Welcome Back Letter (Template)
Template Letter for Patients
Reassuring your patients is not just a one-time event. As our communities move from one
level to the next in the provincial COVID-19 Response Framework, take every opportunity to
remind them of the protocols your office is using to ensure that their safety and the quality of
their care remains a top priority. Dental care remains an essential component of health care
through all levels of Public Health measures within the framework.
BEFORE THE APPOINTMENT
Before an appointment, the patient must be contacted, and a pre-appointment screening
completed. The purpose of the screening is to get as much information from the patient to
allow staff to prep accordingly and reduce the amount of time the patient must be in the
office. Any forms that can be sent and completed digitally prior to the appointment should be
considered (contact your software provider). Please note, according to the RCDSO, dentists
must have a patient’s consent to send text and/or emails. The texts and/or emails must be
encrypted and secure as they contain personal health information. Fillable PDFs of the ODA’s
Patient Acknowledgement and Patient Screening forms have been developed and can be sent
to the patient prior to the appointment. They can also be printed for in-office use.
• Determine the patient’s risk level for being infected with COVID-19.
• If you are seeing a high-risk patient, make every effort to schedule them at the first
appointment time to maximize the social distancing factor. “High-risk” includes, but is not
limited to: over the age of 65; immunocompromised (e.g. diabetes, active cancer therapy,
renal dialysis, lung disease, transplant patient, presence of cardiovascular disease); and/or
infirm patients.
• Explain the changed office protocols to the patient.
• Collect new patient medical histories over the phone by an appropriate team member.
• Ensure patient is aware to bring their own mask or cloth covering their nose and mouth to
the appointment to conserve your medical mask supply.
ODA Pandemic Recovery Toolkit (V6.0) 15Patient Screening Form (Fillable PDF)
Patient Acknowledgement: COVID-19 Pandemic Dental Risk (Fillable PDF)
Determining Patient COVID-19 Risk
Pre-appointment screening or triage is critically important in assessing the risk the patient may
have COVID-19 . The importance of this process cannot be overemphasized and at this time all
“walk-in” patients should be discouraged. All patients should be screened before they enter your
practice, and no patient should be in the facility without a scheduled appointment.
Below are current screening questions to ask the patient the day before the appointment and
again upon arrival, as developed by the Ontario Ministry of Health:
1. Did the person travel outside of Canada in the past 14 days?
2. Has the person tested positive to COVID-19 or had close contact with a confirmed case of
COVID-19 without wearing appropriate PPE?
3. Does the person have any of the following symptoms?
• Fever • Headaches
• New onset of cough • Decrease or loss of sense of taste or smell
• Worsening chronic cough • Unexplained fatigue/malaise/muscle aches
• Shortness of breath (myalgias)
• Difficulty breathing • Nausea/vomiting, diarrhea, abdominal pain
• Sore throat • Pink eye (conjunctivitis)
• Difficulty swallowing • Runny nose/nasal congestion without other
known cause
• Chills
4. If the person is 70 years of age or older, are they experiencing any of the following
symptoms: delirium; unexplained or increased number of falls; acute functional decline; or
worsening of chronic conditions?
If the response to ALL of the screening questions is NO: COVID-19 Screen Negative.
Patients who are screened negative for COVID-19 can be treated, including non-essential care,
using strict adherence to Routine Practices as well as Contact and Droplet Precautions, unless
your practice is currently within a Public Health Region requiring enhanced precautions in
accordance with the RCDSO guidance. During the province-wide shut down, state of emergency
and stay-at-home order this includes all Public Health Units and enhanced precautions are
required throughout the entire province.
If the response to ANY of the screening questions is YES: COVID-19 Screen Positive.
Patients who have screened positive must be treated with enhanced precautions in accordance
with Royal College of Dental Surgeons of Ontario (RCDSO) guidance and treatment limited to
emergency and urgent care only that cannot be delayed.
For the general population, fever is measured as a temperature ≥ 38°C. Fever may be
subjective or confirmed by thermometer, if possible. If one suspects the patient may have a
fever associated with a dental diagnosis (e.g. pulpal and periapical dental pain and intraoral
swelling is present), but no other symptoms consistent with COVID-19 are present, clinical
judgement must be used to determine screening status. When in doubt, it is best to err on the
side of caution.
The current approach to treatment protocols and guidance from the RCDSO reflect the
importance of the screening process in preventing the spread of COVID-19 and determining
what scope of treatment is permitted. The current status of COVID-19 within your community
ODA Pandemic Recovery Toolkit (V6.0) 16should be considered when assessing the risk of treating asymptomatic or vulnerable patients.
It is for this reason the province has developed the COVID-19 Response Framework as a means
for you to know the current status of your community. In response to the provincial shutdown,
dentists are required to undertake enhanced precautions when providing in-person care to all
patients. For communities on provincial borders who have cross-border patients, contact your
local Public Health Unit (PHU) for information, as travel restrictions may be in place.
No matter what the transmission rates of your community are, it is recommended that you
discuss all protocols with your staff as a team and understand that everyone has a different
comfort level. Do not hesitate to take precautions and enhance protocols to a level above
and beyond what is required if that is what it takes to make everyone feel comfortable and
confident. Dentists are also advised to contact their local PHU for information about the
prevalence of community transmission of COVID-19 in their particular area as local outbreaks
can occur. Also, if patients present with an employment, travel or medical history that may
warrant additional screening considerations, contact your local PHU for clarification and
guidance. This is also important if your community borders a region with higher incidence
to which patients must travel for personal or work-related regions. For up-to-date screening
questions refer to the Ministry of Health’s COVID-19 Patient Screening Guidance.
Ensure that all responses are well documented.
Patient Screening Form
DURING THE APPOINTMENT
In-Office Patient Registration
When patients arrive:
• Have patient wait in car until they are called to come in.
• Ensure patient is wearing a mask before they enter the office. Dentists must ensure that
patients do not remove their mask, except as required for treatment, and do not leave
their mask in waiting areas or anywhere else inside the office. Patients must be advised
to secure their mask when not in use. If the patient is exempt from wearing a mask it is
recommended that all staff who deal directly with this patient (within two metres) wear a
full-face shield as the minimum eye protection in addition to a surgical mask.
• Have patient disinfect hands with hand sanitizer on entry and inform of cough etiquette.
• Complete patient arrival screening:
• Patient Screening Form (this fillable form can be emailed to the patient before the
appointment).
• If patient’s temperature is taken, record result.
• If patient screening indicates positive to COVID-19, isolate patient and consult with
dentist to determine appropriate treatment protocol; report to your local PHU or
contact Public Health Ontario.
• Have patient complete and sign the Patient Acknowledgement of COVID-19 Risk
Form. (This fillable form can also be emailed to the patient before the appointment).
This document is to be used as a template and we have modified the form as a result
of member feedback and expansion of eligible care. However, based on legal advice,
further significant modification to the patient acknowledgement of the risk of contracting
COVID-19 in the dental office would render the document essentially ineffective. Careful
consideration should be given to any use of alternate wording. Patient consent is not
simply a form, it is a process. Whether you choose to use this template or not, a thorough
discussion with your patients and documentation of such is required to ensure their
understanding of the risks of COVID-19.
ODA Pandemic Recovery Toolkit (V6.0) 17• Ask patient to respect physical distancing with all staff and patients.
• Limit patient time in waiting room. Ideally, take the patient to the operatory immediately.
• Inform patient to notify a staff member if the bathroom is required at any time.
Before Seeing Reception (Poster)
Cough Etiquette Sign (Public Health Ontario)
Stop! Read Before Entering Clinic (Poster)
Stop! Read Before Entering Clinic (Sign)
Patients in the Operatory
• No hand-shaking or physical contact.
• Review overall health history, confirming that the screening questions were asked during the
check-in procedure, and review if necessary.
• Limit movement out of operatory as much as possible.
• Ask patients to wear their masks before and directly after procedure.
When the Patient Leaves
• Try to have paperwork completed before patient arrives at reception.
• Choose a touchless payment method, if possible.
• Ensure that all surfaces touched by a patient are properly wiped down after exiting (handles,
doors, clipboards, counter, phone, light switches, surfaces, etc.)
• Establish follow-up procedures.
• Post-op instructions should include a reminder to report any signs or symptoms of
COVID-19 within the next 14 days to your office and the PHU.
• For those patients who screened positive for COVID-19 and only emergency treatment was
provided, a care call should be made 7 to 10 days after clinic visit to ensure any symptoms of
the emergency have resolved.
COVID-19 IN THE DENTAL OFFICE
The dental office should be prepared for the situation of learning that either a patient who has
visited the office has been diagnosed with COVID-19, or a dental office staff member has been
diagnosed with COVID-19.
There are provincial regulations and guidelines to manage each of these situations. Please contact
your local PHU to determine the protocol in your area.
Some general considerations are outlined below.
When the dental office learns that a patient who has recently visited the office, or a staff member,
has been diagnosed with COVID-19, the office must:
• Determine which staff members and other patients may be at risk through either direct or
indirect contact with the infected person.
• For staff members, assess the risk of disease transmission based on the facts of the contact.
• Either inform all persons who were in contact with the infected person, or work with contact-
tracing personnel assigned by the PHU to assist in contacting the affected people.
ODA Pandemic Recovery Toolkit (V6.0) 18SECTION 4: PREPARING TO PRACTISE
Preparing to practise will be different for each office, depending on their existing protocols,
clinical set up and engineering settings. At this stage of the pandemic recovery, this is particularly
important with regards to treating patients who screen or test positive to COVID-19, as all
patients require enhanced precautions.
This Preparing to Practise Section will change as restrictions and guidance evolves and will be
updated as required. It reflects the COVID-19 Operational Requirements Health Sector Restart
document issued by the Chief Medical Officer of Ontario and must be considered an adjunct
to the RCDSO guidance, COVID-19: Managing Infection Risks During In-Person Dental Care.
For additional guidance on reopening practices, refer to the resources below.
COVID-19 Operational Requirements Health Sector Restart (Ministry of Health)
Guidance for Reopening Buildings After Prolonged Shutdown or Reduced Operation
(Centers for Disease Control and Prevention)
AEROSOL-GENERATING PROCEDURES (AGPS)
The capacity for SARS-CoV-2 to be spread via airborne transmission is increasingly supported
through research as more information becomes available. Dental aerosols are generated with
many procedures, as shown in Table 1. Aerosols that may contain SARS-Cov-2 from an infected
patient occur when saliva is aerosolized along with products of the procedure. This occurs
with ultrasonic scaling and other aerosol procedures where the saliva cannot be prevented
from entering the procedure area and becoming aerosolized.
Table 1: Dental devices and procedures known to produce airborne contamination
Device and/or Procedure Contamination
Ultrasonic and Sonic Scalers Considered the greatest source of aerosol
contamination; use of a high-volume evacuator will
reduce the airborne contamination by more than 95
per cent
Air Polishing Bacterial counts indicate that airborne contamination
is nearly equal to that of ultrasonic scalers; available
suction devices will reduce airborne contamination by
more than 95 per cent
Air-Water Syringe Bacterial counts indicate that airborne contamination
is nearly equal to that of ultrasonic scalers; high-
volume evacuator will reduce airborne bacteria by
nearly 99 per cent
Tooth Preparation with Air Turbine Minimal airborne contamination if a rubber dam is
Handpiece used
Tooth Preparation with Air Bacterial contamination is unknown; extensive
Abrasion contamination with abrasive particles has been shown
From: Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control
implications. J Am Dent Assoc. 2004;135:429–437. https://pubmed.ncbi.nlm.nih.gov/15127864/
It should be noted that a cough or sneeze is not considered an aerosol-generating medical
procedure and thus procedures that may cause a cough or sneeze would not be classified as such.
ODA Pandemic Recovery Toolkit (V6.0) 19While we do know that aerosols generated within the operatory have the capacity to contain
the SARS-Cov-2 virus, we do not know the exact quantity of the virus required to spread the
COVID-19 infection. For this reason, we must weigh all of the options available to us to reduce
this risk, and adapt as necessary.
Throughout the COVID-19 pandemic dentists have demonstrated a willingness and capacity
to practise safely in providing our patients with essentially a full range of treatment. Our
practices have not only helped provide vital health care to our communities or prevent the
spread of COVID-19, we have helped ensure our patients’ problems don’t become the problem
of our local hospitals. When patients need to see a dentist, we are there for them.
Dentists have adapted all protocols, not just infection prevention and control protocols, as
necessary and we must continue to do so. As is reinforced through the Provincial COVID-19
Response Framework, this is not a one-way journey. During the province-wide shutdown
and stay-at-home order, all regions are required to utilize enhanced precautions. We have
also seen a change in demographic of those most likely to test positive for COVID-19 to a
younger population with a greater chance of experiencing fewer symptoms. The screening
questionnaire remains a vital component to risk assessment and determining appropriate
treatment and protocols. However, regardless of the current status of where you practise, it is
recommended you go beyond just the screening process and consider the type of treatment
on an individual appointment basis when determining appropriate protocols. This is known as
a Point-of-Care Risk Assessment.
POINT-OF-CARE RISK ASSESSMENT
A Point-of-Care Risk Assessment (PCRA) is a specific assessment of risk during treatment for
an individual patient in a particular environment. It does not reflect an all-or-nothing approach
to safety but demonstrates consideration of multiple controls in reducing the transmission risk
of COVID-19 while treating a patient, regardless of whether they screen positive or negative
for COVID-19. The following table represents a hierarchy of these controls, and as a hierarchy,
it is important to note that controls are listed in order of priority.
ODA Pandemic Recovery Toolkit (V6.0) 20Table 2: Hierarchy of controls for reducing COVID-19 transmission risk in dental settings
Control Description Examples
Elimination/ Strategies that remove Avoiding performing AGPs when possible,
Substitution the hazard completely prioritize use of manual instruments
Designated/closed room, physical barriers,
Remove/block the hazard
high volume evacuation, dental dam,
Engineering at source before it can
ventilation optimization, portable HEPA
reach the worker
filtration units.
Patient and worker pre-visit screening or
testing, physical distancing, AGP earlier in
visit if possible, delay visit or schedule visit
Optimizing processes and
at end of day for known COVID-19 patients,
workflows to minimize
Administrative cleaning and disinfection, sick leave policy
potential contact with the
for staff who screen positive, strict limitation
hazard
on visitor policy, minimize number of staff
in operatory, use and length of a “fallow
period” after AGPs
Actions or behaviours
Personal
that may potentially Cough/sneeze etiquette, hand hygiene
Hygiene
reduce hazard exposure
The “last line of defense” Droplet/contact precautions for general
Personal
when other controls are practice; plus use of N95 respirator or Health
Protective
infeasible, inadequate or Canada approved equivalent instead of
Equipment
exhausted surgical mask when performing AGPs
Adapted from: Public Health Ontario, “Focus on COVID-19 in Dental Care Settings” (2020).
Not all of these controls must be in place for every situation, but they can be used to consider
the appropriate level of PPE and protocols required for a particular procedure. The health
and safety requirements that may be necessary at a specific workplace may depend on any
number of factors including the type of procedures that are performed, the controls that are
already in place at the workplace and of course, the risk of transmission based on the patients
presenting at the clinic.
Conducting a PCRA involves asking a series of questions before every patient procedure
to determine whether you are at risk of being exposed to a respiratory infection such as
COVID-19. Questions include:
1. Is the hazard present or suspected in the situation?
Consider the level of COVID-19 community spread through local conditions or the provincial
COVID-19 Response Framework.
2. What is the health status of the patient?
Did they screen positive or negative to COVID-19 or are they immunocompromised in
regions with actively high transmission rates, the screening process may not capture the
asymptomatic patient. If there are doubts or unknowns with the health status of the patient,
use the precautionary principle and approach treatment as high risk.
ODA Pandemic Recovery Toolkit (V6.0) 21You can also read
