October 1, 2020 Page 1 of 18

COVID-19: Standards for Managing Infection Risks when providing In-Person Dental Care in the Northwest Territories

During the Public Health Emergency

EFFECTIVE October 1, 2020

These Standards apply to all dental health professionals providing dental services in NWT including

dentists, dental hygienists, dental therapists, orthodontists, dental technicians, denturists, and oral

maxillofacial dentists.

Introduction

The COVID-19 pandemic is producing major health and societal impacts in the NWT, Canada and

globally. As of September 29, 2020, the incidence of infections in many Canadian provinces is

rising, with increasing risk for further peaks during Canada’s winter viral respiratory infection

season. Northern regions of Saskatchewan and Alberta, NWT’s closest neighbours, had significant

outbreaks in the recent months.

Although there have been no cases of COVID-19 attributed to NWT since April 2020, the territory

presently receives close to 1000 travelers (returning residents, out-of-territory workers) per week.

The risk of importation and transmission within NWT persists and can change quickly.

The Office of the Chief Public Health Officer of NWT (OCPHO) still believes that guidance which

considers a longer time horizon, to establish long-term protective measures for dental care in NWT,

is efficient and safe for the profession, and maximizes public safety.

OCPHO Consultations to Develop This Standard

The OCPHO consulted with public health officials in Nunavut, Yukon, Alberta, and with professional

dental Colleges in Alberta, Saskatchewan and Ontario, including requests for scientific briefings to

support risk management decisions in other jurisdictions in the development of this standard. The

OCPHO and the NWT Office of Professional Licensing (OPL) have been participating in Canadian

Dental Regulatory Authorities Federation (CDRAF) meetings since May 2020.

With permission, OCPHO adapted the Royal College of Dental Surgeons of Ontario (RCDSO) May 25,

2020 Standard and the College of Dental Surgeons of Saskatchewan’s Standard. Both Ontario and

Saskatchewan have updated their standards since their original publication. OCPHO also reviewed

World Health Organizations’s Considerations for the provision of essential oral health services in the

context of COVID-19, published on August 3, 2020.

October 1, 2020 Page 2 of 18

From the available evidence, and especially out of concern for further COVID-19 morbidity and

mortality in Canada and NWT, this Standard uses a principle of precaution to minimize risk to

dental care providers and the public.

Transmission of COVID-19

The World Health Organization and researchers continue to review the modes of transmission of

COVID-19. There is evidence of transmission occurring up to 48 hours before symptom onset, or

from individuals who are asymptomatic. Transmission occurs via respiratory droplets. Airborne

transmission can occur during aerosol generating procedures (AGPs), with ongoing investigation

into whether airborne transmission occurs outside of AGPs. There is also strong evidence showing

that COVID-19 persists on surfaces and it is highly plausible that indirect transmission from

contaminated surfaces occurs.

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-

professionals/assumptions.html

https://www.who.int/publications/i/item/modes-of-transmission-of-virus-causing-covid-19-

implications-for-ipc-precaution-recommendations

Dental Aerosols

Dental aerosols, although different from aerosols produced during coughing or from interventions

of the lower respiratory tract, contain saliva and remain suspended in air following aerosol

generating procedures (AGPs) in dentistry. Saliva contains viable COVID-19.

Available engineering and administrative controls in dental offices can significantly reduce the

burden of dental aerosols. Reviews estimate that consistent use of rubber dams and high volume

evacuation (HVE) reduces aerosols by 90%123.

Transmission in Dental Settings

To date, there are no reports of clusters of COVID-19 resulting from dental care transmission in

North America. With the capacity of dental procedures to produce droplets or aerosols which

contain saliva and considering the frequency of these procedures during dental care, however,

NWT’s OCPHO assumes that dental offices are a high risk for transmission of COVID-19 to workers

or clients receiving care. Other organizations, including RCDSO and multiple publications

characterize the risk for transmission in dental offices as high. NWT is also unique in that it relies

frequently on visiting oral health specialists who travel from higher incidence areas.As they are

1 Bennett AM et al. Microbial aerosols in general dental practice. British Dental Journal (189); 12 December 23 2000.

2 To k et al. Consistent Detection of 2019 Novel Coronavirus in Salilva. Clinical Infectious Diseases. Brief Report

(2020) Published online February 12 2020, and referenced in the review by Xu J et al. Salivary Glands: Potential reservoirs for

COVID-19 Asymptomatic Infection. Journal of Dental Research. Letter. April 9, 2020.

3 Harrel, SK, Molinary J. Aerosols and splatter in dentistry. A brief review of the literature and infection control implications.

JADA; 2004; (135); 429-37

October 1, 2020 Page 3 of 18

exempted essential workers, they are not able to immediately self-isolate and the nature of their

work also does not allow physical distancing.

Dental providers returning to any degree of in-person care must comply with the direction of this

Standard, and pertinent legislation pertaining to workplace safety.

A Staged Approach to Return to Practice

An Order from the OCPHO on March 23, 2020 and related guidance from the OPL restricted dental

services to only urgent or emergent (also called “essential”) services. A subsequent letter from Dr.

Kandola on May 20, 2020 outlined the minimum criteria required for dental care providers to

resume non-urgent, non-emergent procedures. The May 20, 2020 letter provided an exception for

dental providers to resume non-urgent, non-emergent services before “Phase 2” of NWT’s

“Emerging Wisely” plan.

The guidance in these standards apply to the current COVID-19 situation in the NWT,

Canada, and globally. As the pandemic changes, and as new information emerges, OCPHO

will adapt its recommendations.

https://www.gov.nt.ca/covid-19/en/services/public-health-orders/emerging-wisely

Aligning With Other Dental Standards in NWT

This Standard provides guidance in conjunction with other accepted Standards of Practice.

Historically, NWT Standards for dental care align with those from the Alberta Dental Association

and College. During the COVID-19 pandemic, the NWT will rely on Alberta Dental Association

Standards for routine infection prevention and control and other professional guidance, and this

Standard for precautions related to COVID-19.

Principles

1. The OCPHO has produced this standard after multiple consultations and reviews of other

jurisdictions guidance.

2. Patient access to oral healthcare must be balanced with the risks of spreading COVID-19.

3. Guidance is based on the best available evidence and data. In the absence of clear evidence,

guidance will prioritize caution and safety.

4. Decisions to allow non-urgent, non-emergent services will occur in the context of intensity of

COVID-19 pandemic in Canada and NWT and consideration of benefits and harms of options.

5. Engineering controls which change the physical workspace of dental health professionals, and

administrative controls which change the way dental health professionals work, are the most

effective means of reducing exposures to COVID-19. Personal protective equipment (PPE) is

the lowest protection on the “hierarchy of controls”. Amplifying engineering or administrative

measures, including tele-dentistry services, will maximize protection.

October 1, 2020 Page 4 of 18

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/public-health-

measures-mitigate-covid-19.html

PREPARING THE OFFICE

Review of Personal Protective Equipment (PPE)

Prior to reopening the practice, dental providers should take an inventory of personal protective

equipment (PPE) and use this inventory to help inform the volume and scope of care that can be

provided.

Dental providers should use PPE appropriately to prevent unnecessary use of limited

supplies and other PPE resources (e.g., N95 respirators or the equivalent, as approved by

Health Canada).

N95 respirators (or the equivalent) should be reserved for situations where risks are

highest, especially AGPs.

General Staff Requirements

1. Dental providers must meet with staff and thoroughly review and explain the guidance

contained in this document as well as any new office policies and procedures.

2. Dental providers must require staff to wear PPE as appropriate to their role (see Table 1

below).

3. As clothing worn in the office can become contaminated with COVID-19, dental providers and

staff must change into office clothes (e.g. scrubs) and footwear immediately upon reporting to

work.

Clothes worn in the office must not be worn outside of the office (e.g., home), and should be

laundered after every shift.

Laundry bins/containers should be lined with a barrier (such as a garbage bag) to avoid

cross-contamination during the storage and transportation process.

4. Dental providers are advised to limit the number of staff in the practice at one time.

5. Dental providers are advised to stagger shifts and lunch/coffee breaks when possible to

support physical distancing.

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6. Dental providers must advise staff to conduct hand hygiene frequently by using soap and

running water (especially before and after any contact with patients, after contact with high-

touch surfaces or equipment, and after removing PPE) or an approved alcohol-based rub

(ABHR) if soap and running water are not available or accessible. ABHRs with an alcohol (i.e.

ethanol, isopropanol or n-propanol) concentration from 60% to 90% are appropriate for

clinical care.

http://publications.gc.ca/collections/collection_2012/aspc-phac/HP40-74-2012-eng.pdf.

7. Dental providers must require staff to maintain physical distancing of at least 2 meters, except

as required to provide patient care.

8. Dental providers must require staff to self-monitor for any symptoms of COVID-19. Staff

experiencing symptoms of COVID-19 must not return to work until after consulting with their

physician and/or after they are symptom-free following 14 days of self-isolation.

Office Setup

1. Dental providers should limit points of entry into the office (e.g., by designating a single

entrance door).

2. Dental providers must ensure that the office and operatories are clean and disinfected.

3. Dental providers must shock their dental unit water lines if returning from an extended break

in practice (contact the product manufacturer for product recommendations).

4. Dental providers must ensure magazines, toys, and any other non-essential items are removed

from office, reception area, and operatories.

5. Dental providers should post signage in common areas (e.g., at the main entrance and in the

waiting area) communicating relevant expectations for patients, including any requirements

for:

a. hand hygiene (e.g., a requirement to wash and/or sanitize hands upon entry to the

practice);

b. respiratory hygiene (e.g., a requirement to wear a mask within the practice); and

c. physical distancing (e.g., a requirement to maintain a minimum distance of 2 meters,

except as required for the provision of care).

6. Dental providers must ensure the availability of 60-90% ABHR at all entry points to the office.

7. Dental providers must ensure the availability of 60-90% ABHR at the reception area for use by

staff.

8. Dental providers are advised to consider installing physical barriers at key contact points to

reduce the spread of droplets, including reception (e.g., a plexiglass shield).

Scheduling Appointments

1. In order to schedule in-person appointment for assessment and/or treatment, dental providers

must ensure that they can meet the PPE and operatory requirements outlined in this document.

a. Since each office is arranged and functions differently, the OCPHO relies on the

professional judgement of dental providers and their staff to adjust their practice for the

enhanced protection of others.

October 1, 2020 Page 6 of 18

2. If a dental provider is unable to meet the applicable PPE and operatory requirements, and the

patient requires essential treatment, the patient must be referred to another available

practitioner.

3. Dental providers must ensure that appointments are scheduled and managed to avoid or limit

direct, face-to-face interaction with others, including staff and other patients (for example, by

staggering appointment times).

4. Dental providers must ensure that patients are triaged and appointments are scheduled by

phone (not in person or via walk-in).

5. Prior to scheduling an appointment, dental providers must ensure that patients are screened

for COVID-19 with an accepted screening questionnaire. The CPHO recommends that providers

use the questionnaire in Appendix B.

a. Patients who screen as higher risk of COVID-19 should contact their primary care

provider or call 811 to determine next steps.

b. In addition, COVID-19 is a designated disease of public health significance and as such,

under NWT’s Public Health Act, a dental provider must report to the OCPHO when they

suspect COVID-19 by calling (867) 920-8646. Dental providers should report a

confirmed case of COVID-19 immediately, or, if they suspect COVID-19, within 24 hours.

They could also complete a COVID-19 Report Form Case –Part B, located here

https://www.hss.gov.nt.ca/professionals/en/covid-19-report-form-confirmed-cases-

%E2%80%93-part-b, and send to the OCHPO via fax (fax: 867-873-0442) or send via

Secure File Transfer (SFT), after communicating with OCPHO delegate on call (867 920-

8646) within 24 hours. SFT interface is available at:

https://sft.gov.nt.ca/filedrop/~SXTSaO

6. Dental providers must record the results of the patient’s COVID-19 screening in the patient’s

record (a written notation summarizing the conversation and screening results is sufficient for

record keeping purposes).

Patient Arrival Protocol

1. Prior to permitting entry to the office, dental providers should ask patients about presence of

symptoms associated with COVID-19. A new Screening Survey (Appendix B) is attached to

identify clients with very low risk for COVID-19.

a. Dental providers should purchase a non-contact infrared thermometer and assess

patients’ temperature prior to permitting entry to the office.

b. If a patient reports or exhibits symptoms of COVID-19, dental providers must defer the

appointment until the patient has consulted with their physician and after they are not

required to self-isolate as per NWT guidelines to practitioners.

2. Dental providers must, at minimum, advise patients and visitors to wear their own mask at all

times if they cannot physically distance while in the office except during the provision of care

(e.g., a procedural/surgical mask, cloth covering, or other appropriate face covering). Children

under 12 and those who cannot tolerate a mask, however, should not wear one.

a. Dental providers should make non-medical masks available at the place of service in

case patients arrive without one.

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3. Dental providers should require individuals accompanying a patient to wait outside the practice

unless absolutely required (e.g., a parent accompanying a young child or a patient who requires

accommodation).

4. Dental providers must require patients (and guests) to perform hand hygiene with either 60-

90% ABHR or soap and running water upon initial entry to the office.

5. Dental providers should minimize patient contact with all surfaces.

6. Except as needed when providing care, dental offices should enable and enforce a physical

distance of at least 2 meters should between all people in the office.

Required PPE During Dental Care

Dental providers must ensure that all clinical staff wear PPE that is appropriate for the anticipated

procedure or activity (see Table 1). If providing emergent or urgent services for a person suspected

of having COVID-19, further precautions are necessary and should be reviewed with public health

((867) 920-8646)

Table 1: Required PPE

Setting Procedure/Activity Type of PPE

Operatory or other treatment area

Non-Aerosol generating procedures (NAGPs)

see below

Aerosol generating procedures (AGPs)

see below

Cleaning and disinfection of operatory or other treatment area

ASTM level 1 procedure/surgical mask

Gloves

Eye protection

Protective gown

Reprocessing area Reprocessing of reusable instruments

ASTM level 2 or 3 procedure/surgical mask

Heavy duty utility gloves

Eye protection or face shield

Protective gown

Reception area Reception duties ASTM level 1 procedure mask (if staff/clients cannot maintain 2 m physical distancing) AND/OR physical barrier, determined by WSCC risk assessment

Maintain physical distancing

Common and staff areas

Administrative and other tasks

ASTM level 1 procedure mask OR maintain physical distancing. Non-medical masks may be appropriate as per WSCC risk assessment)

1. Dental providers must ensure that clinical staff are trained in and use proper donning and

doffing procedures for PPE, see Donning and Doffing Video (Alberta Health Services).

2. While acknowledging the lack of documented evidence, dental providers should require

patients to rinse with 1% - 1.5% hydrogen peroxide or 1% providone-iodine for 60 seconds

prior to examination of the oral cavity, as this may help decrease oral pathogens.

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3. Dental providers should minimize the use of intra-oral radiographs and consider using extra-

oral radiographs, when possible.

4. Dental providers must ensure that operatories are cleaned and disinfected between each

patient appointment

Patient Departure Protocol

1. Dental providers should request that patients wash their hands with soap and water or use 60-

90% ABHR before leaving the dental practice.

2. Patients should seek medical care and report their dental procedure if they experience any

symptoms of COVID-19 within 14 days of their appointment. Patients should also inform dental

office staff of the same, and dental office should notify OCPHO as per above.

End of Day Sanitization

1. Dental providers must ensure the general office housekeeping, including cleaning and

disinfection of high-touch surfaces, occurs at least twice per day (e.g., door knobs, hand rails,

counters, and the arms of chairs).

As a reminder, operatories must be cleaned and disinfected between each patient

appointment.

Aerosol-Generating Procedures (AGP)

AGP is any dental procedure where aerosolised particles are expected to be generated by dental

instrumentation. This includes the use of ultrasonic scalers, high-speed handpieces, surgical

handpieces or air-water syringes at any point in the procedure. When assessing the quantifiable

risk of transmission of SARS CoV-2 (COVID-19) during an AGP, the dental provider must take into

account the duration of a procedure, patient factors (such as respiratory disease, diabetes,

hypertension and obesity), the ability to employ mitigation factors (pre-procedural rinse, dental

dam and HVE) and the probability of the success of these mitigating factors. Natural exposures,

which include contact transmission and both droplet and aerosol caused by coughing, sneezing and

exposure to respiratory droplets during expiration, must also be factored in. Consideration of

naturally generated aerosols is also very important in assessing the overall risk during a dental

visit. 4

1. Dental providers should avoid AGPs whenever possible and use the lowest aerosol-generating

options when necessary.

1. If possible, dental providers should use a rubber dam with high-volume suction to minimize

aerosols and possible exposure to infectious agents.

2. Dental providers must ensure that clinical staff are trained in and use proper donning and

doffing procedures for PPE, see Donning and Doffing Video (Alberta Health Services).

3. AGP can be divided into three categories:

Low Risk AGP

Moderate Risk AGP

4 Adapted from College of Dental Surgeons of Saskatchewan. CDSS Alert – COVID-19 Pandemic IPC Protocol

Update, June 15, 2020

October 1, 2020 Page 9 of 18

High Risk AGP

Low Risk AGP or Non-Aerosol Generating Procedure (NAGP) For procedures such as examinations, hand scaling, simple extractions, orthodontic procedures,

crown cementations, etc.

1. Mandatory routine precautions use for infection prevention control.

2. Mandatory PPE for Low Risk AGP and NAGP: Level 2 or Level 3 surgical mask, eye protection

or face shield, gloves, and gown.

3. Enhanced cleaning, including frequent cleaning of high touch surfaces.

4. A 1% hydrogen peroxide mouth rinse for 60 seconds must be performed by the patient and

expectorated into the same dispensing cup prior to examination and procedures within the oral

cavity.

5. Oral radiology will be provided using standard guidelines with clinical judgement.

6. Utilize hand instruments only.

7. Utilize four-handed dentistry.

8. With the use of HVE, an air water syringe could be used separately with caution, and the

combined use of air and water should be avoided.

9. Do not use ultrasonic instruments.

10. Do not use high-speed rotary handpieces or electric low-speed handpieces with air and water.

11. Patient should perform ABHR prior to exiting the operatory room.

12. Clean the operatory room clinical contact and housekeeping surfaces as per normal infection

control practices.

Moderate Risk AGP with Dental Dam and all Aerosol Protective Measures (including

High Volume Evacuation) used for entire procedure

1. Mandatory PPE for Moderate Risk AGP: lab coat, Level 2 or Level 3 surgical mask, face shield,

gloves (to cover gown or coat cuffs), and a barrier for patient.

2. A 1% hydrogen peroxide mouth rinse for 60 seconds must be performed by the patient and

expectorated into the same dispensing cup prior to examination and procedures within the oral

cavity.

3. Mandatory settling time for a Moderate Risk AGP is to be a minimum of 15 minutes.

4. Enhanced cleaning, including frequent cleaning of high touch surfaces.

5. AGP operatory rooms require the removal of all unnecessary cabinets, fixtures, and non-

essential supplies or products, including pictures or artwork.

6. AGP operatory rooms should have a Donning and Doffing anteroom or hallway area. Donning

Station (“Clean” side or area) Includes: Gowns or Lab Coats, Level 2 or Level 3 surgical masks,

Face Shields, Gloves, Alcohol Base Hand Rub (ABHR) Doffing Station (“Decontamination” side or

area) Includes: Laundry Receptacle with Lid, Garbage Receptacle with Lid, Eye Protection

Disinfection Receptacle.

7. PPE must be donned in the “Clean” side of the anteroom immediately before entering the AGP

operatory room - do not go anywhere else once the PPE is donned.

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Put on a gown or lab coat

Perform hand hygiene.

Put on a Level 2 or Level 3 surgical mask.

Perform hand hygiene.

Put on a face shield.

Perform hand hygiene.

Put on gloves to cover the gown or lab coat cuffs.

8. Aerosol Generating Procedure signage should be placed at the entrance to the room.

9. The patient is discharged and guided to the reception area for post-op instructions, processing,

and exit.

10. PPE must be doffed in the AGP operatory room or the “Decontamination Side” of the anteroom

or hallway area if utilized.

11. In the AGP operatory room or as you leave the room:

With gloved hands, remove the gown and gloves With gloved hands only touching the

outside of the gown, grasp the gown and pull away from the body without rapid

movements, roll gown inside out into a bundle, simultaneously remove gloves inside out,

and discard gown and gloves immediately. Perform hand hygiene.

With gloved hands, remove the lab coat and gloves With gloved hands only touching the

outside of the lab coat, open the lab coat and remove away from the body without rapid

movements, roll lab coat inside out into a bundle, simultaneously remove gloves inside out,

discard gloves immediately, and transfer the lab coat to the “Decontamination Side” of the

anteroom laundry receptacle careful to avoid contact with “clean” surfaces. Perform hand

hygiene.

12. Exit the AGP operatory room, close the AGP operatory room door if using an ACE, and in the

“decontamination side” of the anteroom or hallway area.

Perform hand hygiene.

Remove face shield at the sides careful not to touch facial skin with the hands and place in

disinfection receptacle or garbage receptacle.

Remove Level 2 or 3 surgical masks without touching the front of the mask and discard in

the garbage receptacle.

Perform hand hygiene.

13. Following the mandatory 15-minute settling time, clean the operatory room clinical contact and

housekeeping surfaces as per normal practice.

High Risk AGP High Risk AGP is without Dental Dam and All Aerosol Protective Measures for the duration of the

procedure, such as complex extractions, implant surgery, ultrasonic instrumentation, or any other

dental AGP done without a dental dam.

1. Mandatory PPE for High Risk AGP: cap or bonnet, gown or lab coat, properly fit N95 (or Health

Canada approved equivalent) respirator (fit test with documentation), goggles or face shield,

gloves (to cover gown or coat cuffs), and gown or barrier for patient.

October 1, 2020 Page 11 of 18

Given the shortage of N95 respirators many health care providers are wearing an N95

respirator and covering it with a face shield to prevent droplets and or splatter on the

N95 respirator. With this technique the N95 respirator may be used for multiple

patients during one operative day.

2. A 1% hydrogen peroxide mouth rinse for 60 seconds must be performed by the patient and

expectorated into the same dispensing cup prior to examination and procedures within the oral

cavity.

3. High risk AGP operatory rooms must be isolated rooms from floor to ceiling, with an Air

Controlled Environment (ACE), and an entry or entries that must be closed and secured during

the AGP.

4. Temporary isolation rooms can be designed – hoarding with plastic and a framed or zippered

door.

5. Clinical staff must limit their movement in/out of the treatment area during this time to

minimize airborne contamination of the adjacent spaces.

6. Enhanced cleaning, including frequent cleaning of high touch surfaces.

7. AGP operatory rooms require the removal of all unnecessary cabinets, fixtures, and non-

essential supplies or products, including pictures or artwork.

8. AGP operatory rooms must have a Donning and Doffing anteroom or hallway area. Donning

Station (“Clean” side or area) Includes: Caps or Bonnets, Gowns or Lab Coats, Masks, or N95

Respirator, Goggles or Face Shields, Gloves, Alcohol Base Hand Rub (ABHR). Doffing Station

(“Decontamination” side or area) Includes: Laundry Receptacle with Lid, Garbage Receptacle

with Lid, Eye Protection Disinfection Receptacle with Lid.

9. PPE must be donned in the “Clean” side of the anteroom immediately before entering the AGP

operatory room - do not go anywhere else once the PPE is donned.

Put on a gown and cap or bonnet.

Perform hand hygiene.

Properly fit N95 Respirator, or Health Canada approved equivalent (secure the straps,

mold the metal nose piece to the nose bridge, and perform a seal check).

Perform hand hygiene.

Put on appropriate eye protection – goggles or face shield.

Perform hand hygiene.

Put on gloves to cover the gown or lab coat cuffs.

10. The operatory door shall remain closed during the procedure. Only the dental provider, dental

assistant and patient should be permitted in the operatory during treatment. The operatory

door should only be opened once to discharge the patient and for clinical staff to exit.

11. Aerosol Generating Procedure signage should be placed at the entrance to the room

12. The patient is discharged and guided to the reception area for post-op instructions, processing,

and exit.

13. PPE must be doffed in the AGP operatory room as you leave the room or the “Decontamination

Side” of the anteroom.

14. In the AGP operatory room or as you leave the room:

With gloved hands, remove the gown and gloves. With gloved hands only touching the

outside of the gown, grasp the gown and pull away from the body without rapid

October 1, 2020 Page 12 of 18

movements, roll gown inside out into a bundle, simultaneously remove gloves inside

out, and discard gown and gloves immediately. Perform hand hygiene.

With gloved hands, remove the lab coat and gloves. With gloved hands only touching the

outside of the lab coat, open the lab coat and remove away from the body without rapid

movements, roll lab coat inside out into a bundle, simultaneously remove gloves inside

out, discard gloves immediately, and transfer the lab coat to the “Decontamination Side”

of the anteroom laundry receptacle careful to avoid contact with “clean” surfaces.

Perform hand hygiene.

15. Exit the AGP operatory room, close the AGP operatory room door, and in the “decontamination

side” of the anteroom or hallway area.

Perform hand hygiene.

Remove eye protection (goggles or face shield) at the sides careful not to touch facial

skin with the hands and place in disinfection receptacle or garbage receptacle.

Remove the cap or bonnet by grasping at the rear and pulling forward off the head and

place in the laundry receptacle or discard in the garbage receptacle.

Remove N95 Respirator without touching the front of the mask and discard in the

garbage receptacle or stored in a vented labeled receptacle for possible future

decontamination.

Perform hand hygiene.

Put on a clean surgical mask.

16. The operatory door and room must remain closed and settle for 120 minutes after AGPs before

cleaning. With respect to air management, if the number of Air Changes per Hour (ACH) of fresh

and or filtered air in the room permits, the settle time can be decreased. (Appendix A – Settle

Time after AGP)

17. *NEW

Client answers “no” to all questions in the enhanced screening survey, the oral health care

providers may reduce settle time to a minimum of 15 minutes from the time of the AGP.

Client answers “yes” to 1, 2, or 3 they should be self-isolating. If the dental procedure is

urgent or emergent, or cannot be safely rescheduled, oral health providers should follow

management under High Risk AGP recommendations.

Client answers “yes” to questions 4 or 5 there is possible COVID-19 exposure and oral

health providers should continue following the advice in this document for managing High

Risk AGPs, including allowing appropriate settle time after High Risk AGPs based on ACH.

Client answers “yes” to question 6 (has symptoms of COVID-19 in the previous 10 days),

oral health providers should follow guidance under “Scheduling Appointments” section 5 or

“patient arrival protocol” section 1b. Clients should contact ‘811’ or their health care

provider for advice and dental providers must defer the non-urgent/emergent appointment

In the absence of community transmission of COVID-19 in the NWT region where services

occur, oral health care providers may use an enhanced screening survey to identify clients

at very low risk of COVID-19 based on symptoms and potential exposures. See Appendix B

for the Enhanced Screening Survey.

October 1, 2020 Page 13 of 18

until the patient has consulted with their physician and after they are not required to self-

isolate as per NWT guidelines to practitioners. If providing emergent or urgent services for

a person suspected of having COVID-19, further precautions are necessary and should be

reviewed with public health on all (867) 920-8646.

If there is concern for community transmission, the enhanced screening survey will not

apply to the region of concern, or possibly to the whole NWT, based on risk assessment by

OCPHO.

18. An oral health care provider may apply more stringent standards, for example by maintaining

settle times for High Risk AGPs as outlined in this document, even for those who screen as very

low risk of COVID-19.

Clearing the Air of Aerosol (“settle time”)

1. Following an AGP, the operatory must be left empty (with the door closed) to permit the

clearance and/or settling of aerosols.

2. The length of time that the operatory must be left empty (settle time) is determined by the risk

of the AGP and the air changes per hour (ACH).

3. After a medium risk AGP, the settle time is 15 minutes.

4. After a high risk AGP, the aim is to achieve 99.9% removal of airborne contaminants.

5. If other engineering means are used to reduce aerosol burden, the validity and effectiveness of

that system must be reviewed by WSCC to guide settle time.

6. Dental providers must provide a validated estimate of the ACH of their operatory to guide settle

time. If a validated estimated of ACH is not provided as part of an exposure control plan to

WSCC, then the settle time remains 120 minutes (as above).

October 1, 2020 Page 14 of 18

Table 2: Air changes per hour (ACH) and time required for airborne-contaminant removal by efficiency5

ACH Minutes required for removal 99.9% efficiency

2 207

4 104

6 69

8 52

10 41

12 35

15 28

20 21

50 8

7. Dental providers should consult an HVAC professional to assess the existing HVAC system and

calculate the actual ACH for the dental practice. Dental providers may use the actual ACH to

calculate a settle time using Table 2.

Dental providers should retain copies of any documentation supporting the HVAC

assessment and any need for engineering controls.

8. Options to improve ACH (and reduce settle time) may be explored, including:

Consulting an HVAC professional to determine whether changes to the existing HVAC

system are possible to improve ACH for the dental practice.

If changes to the existing HVAC system are not possible or adequate, dental providers may

consider the use of an in-operatory air cleaner (e.g. HEPA filtration) to increase the effective

air changes per hour (eACH) for a specific operatory.

If an in-operatory air cleaner (e.g. HEPA filtration) will be used to increase the effective air

changes per hour (eACH) for a specific operatory, the HVAC professional must also take into

account several additional factors, including:

o any structural changes that may be necessary to contain the spread of aerosols (e.g.,

the addition of floor to ceiling walls or barriers),

o the type of unit being considered (e.g. fixed versus portable),

o the cubic feet of the operatory and airflow rate of the unit, and

o the optimal placement and operation of the unit.

Cleaning and Disinfection Following Aerosol-Generating Procedures

1. Following AGPs, cleaning and disinfection of the operatory must only be undertaken following

the necessary settle period.

2. Following the appropriate settle period, dental providers must ensure that operatories

(including all clinical contact surfaces and equipment) are cleaned and disinfected prior to

treating a new patient. Cleaning and disinfection must be undertaken using appropriate

disinfectant (i.e. has a DIN with virucidal claim from Health Canada).

5 Adapted from: Centers for Disease Control and Prevent, Guidelines for Environmental Infection Control in

Health-Care Facilities (2003): Table B.1. Air changes/hour (ACH) and time required for airborne-contaminant

removal by efficiency. Available at:

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

October 1, 2020 Page 15 of 18

COVID-19 Exposure in the practice 1. In the event of suspected exposure to COVID-19, staff must immediately self-isolate and contact

their primary care provider or local public health unit for further guidance.

October 1, 2020 Page 16 of 18

This Standard document was adapted from:

1. Royal College of Dental Surgeons of Ontario. COVID-19: Managing Infection Risks During In-

Person Dental Care, May 25, 2020. (with permission)

2. Canadian Dental Association. Return to Practice Office Manual. Adapting the Dental Office to

the COVID-19 Pandemic. Version 0.9 May 4, 2020

3. NWT and Nunavut Dental Association. Return to Practice Office Manual—Adapting the

Dental Office to the COVID-19 Pandemic (Version 1.0 May 10, 2020)

4. College of Dental Surgeons of Saskatchewan. CDSS Alert – COVID 19 Pandemic IPC Interim

Protocol Update (Effective June 15, 2020)

October 1, 2020 Page 17 of 18

APPENDIX A

SETTLE TIME AFTER AGP

What is “Settle Time”?

The “settle time” is the amount of time needed to remove infectious airborne organisms from room

air (e.g., TB, chicken pox) or infectious aerosols that may be created during an AGP. This begins

when the source of infectious aerosols ends. Examples of when the “settle time” starts include:

When a patient on continuous Airborne Precautions is moved out of the room.

Following an AGP when a pathogen or virus (e.g., COVID-19) has the potential to be

aerosolized during the procedure.

The “settle time” is used to guide if a N95 respirator needs to be worn while in the room or how

long the room must sit before cleaning can begin. The “settle time” should never impact patient care

needs and should not delay essential patient or staff movement in and out of the room.

How is the room “settle time” determined?

To determine a specific “settle time” for a specific room, the number of Air Changes per Hour

(ACH) must be evaluated as each room can be different (size, temperature, humidity, ventilation

capacity, etc.). The higher the ACH, the less time is required for settle time.

If the number of ACH for the patient room is known, a specific “settle time” can be calculated

using Table 2 (page 13) and posted (e.g., if the room has 12 ACH, the “settle time” is 35

minutes). Then staff will know how long they must wear an N95 respirator or how long before

anyone can enter the room to clean.

o Please note: the number of ACH does not reflect the direction of air flow (i.e., negative

pressure vs positive pressure).

If the number of ACH is unknown, the “settle time” for a patient room has been determined to

be 2 hours or 120 minutes.

IMPORTANT: Conditions that must be in place when using a specified “settle time”? Patient room door should remain completely closed, with the exception of essential

patient/staff movement.

NOTE: A specified “settle time” cannot be used if there is a power outage

PLEASE BE ADVISED, specified “settle time” information has been provided to your clinic due to

extraordinary circumstances and is only valid during the COVID-19 pandemic. Your clinic will be

notified of changes or when normal time procedures must be resumed.

October 1, 2020 Page 18 of 18

Appendix B

Enhanced Screening Survey to Identify Clients at Very Low Risk for COVID-19

This Screening Survey is to identify clients who are at the lowest risk for COVID-19. The

information collected will allow your oral health care provider to manage your dental procedure

appropriately.

Answering “yes” to some questions means your oral health care provider may defer your

appointment and recommend further assessment, while answering “yes” to other questions enables

your oral health care provider to make decisions on protective measures required for your

procedure.

Client’s name: _______________________________________________________________________________________________

Yes No Screening Questions 1. Have you traveled outside the NWT or Nunavut in the last 14 days?

2. In the last 14 days, have you visited any location or attended any gathering where there was a known COVID-19 infection (hospital with and outbreak or gathering linked to an outbreak)?

3. Has a health care provider or ProtectNWT asked you to self-isolate in the last 14 days for any reason?

4. Do you think you’ve been exposed to COVID-19 in the last 14 days (e.g. you spent more than 15 minutes physically close to a friend or family member with COVID-19 symptoms after travel or exposure, or you spent more 15 minutes to someone with COVID-19 symptoms in your workplace?)

5. Has anyone in your household (or any households where you lived in the last 14 days) traveled outside of NWT or Nunavut in the 14 days prior to you living with them?

6. In the last 10 days, have you had any of the following symptoms? Fever New or worsening cough Shortness of breath Unusual fatigue or tiredness Muscle aches Generally feeling unwell Sore throat Headache Runny nose Diarrhea/vomiting Loss of sense of taste/smell Loss of appetite