Review information for your region (e.g., State, County, City/Metro, etc.) on the current level of COVID-19 community-transmission and recommendations and/or health orders in effect for your region.

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Monitor local case counts and death trends for your community.

• Trends of newly reported cases.
• Exposure settings of newly reported cases from communal settings (e.g., healthcare facilities, long-term care facilities, schools, workplaces, etc.)
• Trends of newly reported deaths, particularly in populations at higher risk for severe illness.
• CDC: Cases in the U.S.

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Based on your regions' community-transmission level and recommendations or health orders in effect, review the framework for providing Non-COVID-19 clinical care during the COVID-19 Pandemic to assist you with deciding how to expand and prioritize dental procedures.

• Deferral of in-person care highly likely to result in patient harm (dental emergencies).
• Deferral of in-person care may result in patient harm.
• Deferral of in-person care unlikely to result in patient harm.
• CDC: Framework for Healthcare Systems

*This review may need to be done frequently as region-specific information changes.

Implement a process to continually assess your office's supplies of personal protective equipment (PPE).

• Gloves.
• Gowns or other protective clothing that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or other potentially infectious materials.
• Eye protection (goggles, protective eyewear with solid side shields, or a full-face shield).
• Respirator (e.g., N95 or respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators, if available).
• Surgical masks.
• CDC: Personal Protective Equipment (PPE) Burn Rate Calculator
• Henry Schein Brand Products

*If respirator (N95) is not available, a combination of a surgical mask + full-face shield is minimally acceptable. If surgical mask + face shield is not available, CDC recommends that you refer the patient to another clinician who has the appropriate PPE.

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Assess your office's supplies of equipment that may be needed to implement COVID-19 precautions.

• Non-medical facemasks or cloth coverings (used for universal source control, not PPE).
• No-contact or skin-contact thermometer.
• Receptacles for PPE disposal or laundry.
• Hand hygiene supplies and stations (for patient and visitor use).
• Respirator fit-testing kit/supplies.
• CDC: Guidance on Dental Settings

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Determine what PPE is necessary and when PPE must be used based your assessment of OSHA guidance, CDC guidance, State and local guidance, and other risk factors, including, but not limited to the following.

• Level of community-based transmission.
• COVID-19 status of patient (e.g., symptom-based screening, testing-based strategy, suspected or confirmed case, home-isolation completed, etc.).
• Procedure's level of risk (e.g., aerosol-generating, etc.).
• OSHA guidance and hazard assessments for PPE.
• CDC: Guidance on Dental Settings
• OSHA: Dentistry Workers and Employers

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If respirators are to be used in your office, implement an OSHA Respiratory Protection Program.

• OSHA: Laws & Regulations
• CDC: Healthcare Respiratory Protection Resources

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Determine Contingency and Crisis PPE Optimization Strategies for each type of PPE.

• Identify PPE supply chain.
• Assess PPE inventory and understand utilization.
• Identify sequential engineering and administrative controls, including reducing patient volume (e.g., canceling elective and non-urgent procedures), to be implement before extended or reuse strategies are implemented.
• Train DHCP on the extended or reuse protocol, including doffing, storage, and re-donning of PPE that is to be reused.
• CDC: Guidance on Dental Settings
• CDC: Personal Protective Equipment (PPE) Burn Rate Calculator
• CDC: Strategies to Optimize the Supply of PPE and Equipment

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Verify that each team member is appropriately trained on donning and doffing PPE, is wearing the required PPE based on your PPE policy, and is adhering to procedure for changing PPE between uses (e.g., patients).

• CDC: Guidance on Dental Settings

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Ensure that all team members have received their seasonal flu vaccine and other immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) for healthcare workers.

• CDC: Recommended Vaccines for Healthcare Workers

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Monitor and manage DHCP.

• Ensure DHCP are self-monitoring for fever and symptoms consistent with COVID-19, and they stay home if they are ill.
• Screen DHCP for fever and symptoms consistent with a COVID-19 at the beginning of each shift.
• DHCP who have a fever or other symptoms at the beginning of their shift, or develop a fever or symptoms during their shift, should be provided a facemask and sent home.
• Instruct DHCP with COVID-19 symptoms to notify their primary healthcare provider to determine whether a medical evaluation is necessary.
• Follow the CDC's guidance for criteria for returning to work for healthcare personnel with confirmed or suspected COVID-19.
• CDC: Guidance on Dental Settings
• CDC: Criteria for Return to Work

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Verify all DHCP are adhering to strict, universal source control procedure and wear a facemask at all times while they are in the dental setting.

• When available, DHCP use surgical masks over cloth coverings.
• Cloth coverings are not worn in place of respirator or surgical mask if PPE is required (cloth coverings are not PPE).
• DHCP are provided training on when, how, and where cloth face coverings may be used.
• DHCP are trained to prevent self-contamination while using mask or cloth covering including, performing hand hygiene before and after touching their mask or cloth covering; changing mask or cloth coverings when they become soiled, damp, or hard to breathe through; and laundering cloth coverings daily or when they become soiled.
• CDC: Guidance on Dental Settings

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Verify all team members are trained on preventing transmission of infectious agents and are adhering to strict hand hygiene procedure.

• CDC: Guidance on Dental Settings
• CDC: Training: Basic Expectations for Safe Care
• CDC: Hand Hygiene Recommendations

Consider changing from scrubs to personal clothing before returning home. Upon arriving home, take off shoes, remove and wash clothing (separately from other household residents), and immediately shower.

• JAMA: Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Consult a heating, ventilation, and air conditioning (HVAC) professional to verify ventilation systems are properly maintained and configured for a healthcare setting.

• Configure ventilation systems to provide air movement from clean to less clean (contaminated) flow direction.
• Increase filtration efficiency to the highest level compatible with the HVAC system without significantly deviating from designed airflow.
• Where feasible with equipment capacity and environmental conditions, safely increase the percentage of outdoor air supplied through the HVAC system.
• Limit the use of demand-controlled ventilation (triggered by temperature setpoint and/or by occupancy controls) during occupied hours and when feasible, up to two hours post occupancy to assure that ventilation does not automatically change.
• Run exhaust fans in bathrooms continuously during business hours.
• Determine the air changes per hour (ACH) in each treatment room or treatment area.
• Determine the filter efficiencies and number of filter beds for central ventilation and air conditioning system, based on average dust spot efficiency per ASHRAE 52.1–1992.
• CDC: Guidance on Dental Settings
• CDC: Airborne Contaminant Removal

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Consider using a portable HEPA air filtration unit during and immediately following aerosol-generating procedures.

• HEPA units must be placed within the vicinity of the patient's chair but must not be behind DHCP.
• DHCP must not be between the HEPA unit and the patient's mouth.
• HEPA units must not pull air into or past the breathing zone of the DHCP.
• Determine air changes per hour (ACH) based on total room size (individual treatment rooms with doors vs. open floor plan treatment areas) to calculate turnover time for treatment room.
• CDC: Guidance on Dental Settings

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Consider the use of upper-room ultraviolet germicidal irradiation (UVGI) as an adjunct to higher ventilation and air cleaning rates.

• CDC: Guidance on Dental Settings
• CDC: Environmental Control for Tuberculosis

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Whenever possible, perform dental procedures in an individual treatment room (with the door closed).

• CDC: Guidance on Dental Settings

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For open floor plans, the following should be implemented to prevent the spread of pathogens.

• At least 6 feet of space between patient chairs.
• Easy-to-clean, floor-to-ceiling barriers between chairs, placed so that they do not interfere with sprinkler systems.
• Orient the operatories (and physical barriers) parallel to the direction of airflow, consulting with HVAC professional if necessary.
• Place the patient's head near the return air vents and away from pedestrian corridors where feasible.
• Ensure barriers are easy to move so that they do not interfere with emergency evacuation or exits.
• Comply with office leases, local building codes, permits, and other regulations based on the type of physical barriers installed.
• CDC: Guidance on Dental Settings

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Consider installing physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.

• CDC: Guidance on Dental Settings

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Determine the time necessary to leave treatment care areas vacant before cleaning and disinfecting the surfaces.

• At least 15 minutes is required to allow droplets time to sufficiently fall from the air after a dental procedure is performed; time allowed for droplets to fall may not be the same as the time required for airborne-contaminant removal by air ventilation and filtration system.
• If treatment care area must be vacant until airborne contaminants are removed, allow sufficient time based on the CDC's guidance for Airborne Contaminant Removal based on the treatment room's air changes per hour (ACH) rate, filter efficiency, and any other applicable air flow or filtration factor.
• CDC: Guidance on Dental Settings
• CDC: Airborne Contaminant Removal

Determine your patient triage and scheduling procedures, based on precautions implemented.

• Emergency care or expanded care priorities based on current regional assessment of COVID-19 information and available PPE.
• Maximum number of patients that can be seen at the same time based on office layout and the time needed to clear/clean air and complete the cleaning and disinfection process.
• Additional time required for modified clinical techniques.
• DHCP dedicated to one patient at a time.
• Extra time, time of day, sole patient in office, and other precautions taken for patients who are at higher risk for serious illness from COVID-19 or that have a suspected or confirmed cases of COVID-19.
• CDC: Framework for Healthcare Systems
• ADA: What Constitutes a Dental Emergency
• ADA: Interim Guidance for Management of Emergency and Urgent Dental Care

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When feasible, use teleconferencing/telehealth services to reduce in-office visits, triage patients, and prioritize care.

• CDC: Framework for Healthcare Systems

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Screen patients for COVID-19 symptoms before their appointment to prevent symptomatic patients from coming into the office.

• CDC: Symptoms of Coronavirus
• CDC: Guidance on Dental Settings

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Establish a procedure to provide emergency dental care, when care is medically necessary and cannot be deferred, for a patient who has, or is suspected of having, COVID-19, based on the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare. This may include, but is not limited to, the following.

• When possible, aerosol-generating procedures should be deferred until they can be performed in an airborne infection isolation room (AIIR).
• If available, procedure should be performed in an individual treatment room with a closed door.
• DHCP in the room should wear PPE recommended by OSHA and the CDC, including N95 or higher-level respirator, such as disposable filtering facepiece respirator, powered air-purifying respirator (PAPR), or elastomeric respirator, as well as eye protection (goggles or a full-face shield), gloves, and a gown.
• DHCP should be limited to the those essential for patient care and procedure support.
• Consider scheduling the patient for the end of the day.
• Do not schedule any other patients at that time.
• Report potential exposure to local health department if appropriate.
• CDC: Interim Infection Prevention and Control Recommendations
• CDC: Guidance on Dental Settings

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Screen patients for COVID-19 symptoms upon check-in. If they are suspected or confirmed to have COVID-19, defer dental treatment if possible and do the following.

• If the patient is not already wearing a facemask or cloth covering, give them a facemask to cover their mouth and nose.
• If not acutely sick, send them home and instruct them to call their physician or a medical provider for treatment.
• If the patient is acutely sick (e.g., trouble breathing, persistent pain or pressure in the chest, new confusion, inability to stay awake, bluish lips or face, or other serious symptom), refer them to a medical facility or call 911 and tell them that the patient may have COVID-19.
• If emergency dental care is medically necessary and cannot be deferred, follow your established procedure based on the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare.
• CDC: Symptoms of Coronavirus
• CDC: Guidance on Dental Settings
• CDC: Interim Infection Prevention and Control Recommendations

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Restrict visitors from the office, including family members or friends of patients, unless the patient is a minor or requires assistance. Any companions that do enter the office should also be screened for signs and symptoms of COVID-19.

• CDC: Guidance on Dental Settings

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Patients and visitors should be wearing cloth coverings when they come into the office, to preserve facemasks for DHCP, and wear them while in the office. Patients may remove cloth coverings while in the treatment room but must put them back on before leaving the treatment room.

• CDC: Guidance on Dental Settings

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Print and place signage in the dental office for instructing patients on standard recommendations for hand hygiene, respiratory hygiene/cough etiquette, and social distancing.

• CDC: Stop the Spread of Germs

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Ensure that there are supplies for hand hygiene and cough etiquette (e.g., alcohol-based hand rub with 60-95% alcohol, tissues, and no-touch receptacles for disposal) at entrances, waiting areas, and check-ins.

• CDC: Guidance on Dental Settings
• Henry Schein Brand Practice Reopening Products Guide

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Observe social distancing precautions in patient waiting areas.

• Place chairs six (6) feet apart.
• Consider asking patients to remain outside of the office (e.g. their vehicle) until their appointment and contact them on their mobile phone when the treatment room is ready.
• Minimize overlapping dental appointments.
• CDC: Guidance on Dental Settings

Adhere to standard and transmission-based precautions that may be necessary to prevent transmission of COVID-19 from pre-symptomatic or asymptomatic patients.

• CDC: Basic Expectations for Safe Care
• CDC: Guidelines for Infection Control in Dental Health-Care Settings—2003
• CDC: Transmission-Based Precautions
• CDC: Guidance on Dental Settings

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Review dental treatment procedures to identify clinical techniques that may be implemented to reduce risk from respiratory droplets and aerosols, such as, but not limited to, the following.*

• The use of preprocedural mouth rinses (PPMR), 1.5% hydrogen peroxide or 0.2% povidone. Although COVID-19 was not studied, PPMRs with an antimicrobial product may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures.
  CDC: Guidance on Dental Settings
  NCBI: Transmission Routes of 2019-nCoV and Controls in Dental Practice
• The use of extra-oral dental radiographs as alternatives to intraoral dental radiographs, as the latter can stimulate saliva secretion and coughing. ("Extra-oral dental radiographs, such as panoramic radiographs or cone beam CT, [and] are appropriate alternatives").
  NCBI: Emerging and Future Challenges for Dental and Oral Medicine
  NCBI: Severe Acute Respiratory Syndrome (SARS) and the GDP
• The use of hand instruments and minimally invasive/atraumatic restorative techniques.
  NCBI: Transmission Routes of 2019-nCoV and Controls in Dental Practice
• Alternatives to the use of air/water syringes (i.e., 3-in-1 syringes), as they may create droplets due to forcible ejection of air/water.
  NCBI: Severe Acute Respiratory Syndrome (SARS) and the GDP
• The use of rubber dams.
  NCBI: The Efficacy of Rubber Dam Isolation in Reducing Atmospheric Bacterial Contamination
  CDC: Guidelines for Infection Control in Dental Health-Care Settings—2003
• The use of resorbable sutures (i.e. sutures that last 3 to 5 days in the oral cavity) to eliminate the need for a follow up appointment.
  AAOMS: JOMS Guide to Suturing
• The use of high-volume evacuators.
  CDC: Guidelines for Infection Control in Dental Health-Care Settings—2003
• Additional techniques that may be appropriate, based on your clinical judgement.

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Place only the clean or sterile supplies and instruments needed for the dental procedure in the operatory; any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed.

*Information on treatment and techniques is provided for review purposes only and is not intended to replace the licensed healthcare professional's clinical judgement for patient-care decisions.

Review current cleaning and disinfecting procedures. Using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.

• CDC: Infection Prevention and Control Recommendations
• EPA: Disinfectants for Use Against SARS-CoV-2
• Clean and disinfect reusable eye protection and launder cloth (reusable) gowns or protective clothing after each use.
  CDC: Guidance on Dental Settings
• Wait at least 15 minutes after completion of clinical care and exit of a patient without suspected or confirmed COVID-19 to begin to clean and disinfect room surfaces.
  CDC: Guidance on Dental Settings
• Wait until sufficient time has elapsed for enough air changes to remove potentially infectious particles after completion of clinical care and exit of a patient, with suspected or confirmed COVID-19, before entering a room to clean and disinfect room surfaces.
  CDC: Guidance on Dental Settings
• Disinfect non-dedicated and non-disposable equipment (e.g., dental x-ray equipment, dental chair, and light) according to manufacturer's instructions after each patient.
  CDC: Guidelines for Infection Control in Dental Health-Care Settings—2003
• Hand pieces, if used, should be cleaned to remove debris, followed by heat-sterilization after each patient.
  CDC: Infection Prevention and Control Recommendations
  CDC: Dental Handpieces and Other Devices Attached to Air and Waterlines
  CDC: Sterilization: Cleaning
• High-touch surface, such as door handles, chairs, desks, elevators, and bathrooms should be cleaned and disinfected frequently.
  NCBI: Transmission Routes of 2019-nCoV and Controls in Dental Practice
• Henry Schein Brand Practice Reopening Products Guide

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Surfaces that may be difficult to disinfect, such as magazines, books, and toys, should be removed from patient waiting areas

• CDC: Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19)

Instruct patients to contact your office if they experience symptoms consistent with COVID-19, or are diagnosed with COVID-19, within 14 days following their dental appointment.

• CDC: Symptoms of Coronavirus
• CDC: Guidance on Dental Settings

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If a patient is confirmed to have, or is suspected of having, COVID-19 within 14 days of appointment, follow the CDC's Healthcare Personnel with Potential Exposure Guide.

• CDC: Interim U.S. Guidance for Risk Assessment and Work Restrictions

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If an employee tests positive for COVID-19, and illness may have been caused by occupational exposure, report to OSHA if the illness results in a hospitalization or fatality to OSHA.

• OSHA: Revised Enforcement Guidance for Recording Cases of Coronavirus Disease 2019 (COVID-19)

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If either an employee or a patient test positive for COVID-19, follow your local health department's instructions for reporting COVID-19 cases in healthcare settings and provide information to health agency as requested for contact tracing.

• CDC: Case Investigation and Contact Tracing