CDSS Alert – COVID-19 Pandemic: IPC Interim Protocol Update
April 27th, 2020
All CDSS members are required to review this CDSS Alert as CDSS members transition to
Non-Emergency Dental Care
Some oral health care facilities may choose to remain closed due to shortage of PPE or recent
facility requirement changes. However, all CDSS members are required to maintain contact
information for patient dental emergencies.

Rationale for providing this interim protocol update:
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As COVID-19 community spread continues and the knowledge that COVID-19 infected
asymptomatic individuals could be spreading the COVID-19 virus to others in the population, the
Ministry of Health and CDSS feel it is prudent to phase the return back to practice.
Dental profession community support for the Re-Open Saskatchewan Plan.

CDSS Objective: Safe Transition to Non-Emergency Dental Care in Saskatchewan in
coordination with the Re-Open Saskatchewan Plan
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Safety for patients, families and communities.
Safety for dental providers, staff and their families.

CDSS members must:
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Update their IPC facility manual for this COVID-19 Pandemic and organize staff orientation and
training sessions for all clinical and non-clinical staff.
Make sure to have adequate PPE and facility requirements for the types of procedures being
provided in the facility.
Continue to take measures as outlined by the Chief Medical Health Officer (CMHO) to promote
physical distancing where possible, and where not, use appropriate personal protective
equipment (PPE).
Continue to operate under all current CDSS Standards, Bylaws and CDSS Alerts relating to this
COVID-19 pandemic.

“RE-OPEN SASKATCHEWAN” – A Summary for Dentists
A Methodical and Phased-In Approach to re-open Saskatchewan has been announced by the CMHO and
The Government of Saskatchewan to start on May 4th, 2020.
Re-Open Saskatchewan is a plan built on a methodical and phased-in approach to slowly and responsibly
lift restrictions on businesses and services. Flattening the curve and strengthening the system will
remain priorities, as will our ability to manage the current COVID-19 pressures by building capacity in

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 the coming weeks and months. Key elements will include increased testing and contact tracing, as well
as the preparation of additional space and critical equipment.
Restrictions will be lifted in stages, with consideration given to socioeconomic factors and the risk of
transmission. They will be implemented via public health orders and the timing will be dictated by
evidence of transmission.
As restrictions are gradually lifted, the Government of Saskatchewan and its Chief Medical Health
Officer, will carefully monitor the daily number of reported cases and other important indicators. They
will also monitor to ensure that:
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Transmission of the virus is controlled.
The provincial health system has enough capacity to test, isolate and treat every case, as well as
trace every contact.
Outbreak risks are minimized in special settings, such as health care facilities.
Preventive measures are established in workplaces, schools and other essential gathering
places.
The risks of importing the virus from outside the province can be managed.
Communities and businesses are educated, engaged and empowered to adjust to the new
realities brought about by COVID-19.
Individuals identified by a Medical Health Officer as having novel coronavirus disease (COVID-19)
must immediately go into mandatory self-isolation until it is determined they no longer pose a
public health threat.
Individuals identified by a Medical Health Officer as a close contact of a person or persons with
COVID- 19 must go into mandatory self-isolation for 14 days from the last date of exposure.

The following recommendations should remain in place through all five phases:
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Vulnerable individuals, such as seniors and those with underlying health conditions, should
continue to exercise caution and minimize high-risk exposures, such as public outings.
Protective measures for vulnerable populations.
Individuals should continue working from home if they can do so effectively.
Physical distancing must be maintained, wherever possible.
People must stay at home when they are sick.
Personal hygiene will continue to be a key prevention measure.
Enhanced cleaning and disinfection should take place in workplaces, public spaces and
recreational facilities.
Although the public health order regarding the size of gatherings does not apply to businesses
and workplaces, they are expected to follow the recommended public health measures,
including:
▪ physical distancing for staff and clients;
▪ regular cleaning and disinfection;
▪ frequent handwashing and sanitizing;
▪ use of PPE where required and appropriate; and
▪ keeping staff who demonstrate or report COVID-19 symptoms out of the workplace.

For a more in depth understanding of the Re-Open Saskatchewan plan please refer to the full document.
(Click HERE)

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 Preamble: CDSS COVID-19 Pandemic: IPC Protocol
The CDSS thanks the Dentists of Saskatchewan for the emergency dental care provided to the people of
Saskatchewan during the COVID-19 pandemic. This is a difficult time for all of Saskatchewan. You are
supporting your community and making a difference in the containment of COVID-19 in our province.
The Premier announced on April 23, 2020 that Saskatchewan will slowly re-open. This means that
Dentistry can slowly and methodically be re-introduced into Saskatchewan.
The CDSS recognizes that dental facilities and communities vary in size and complexity. This document
sets out protocols for dental care delivery. CDSS members will use clinical judgement implementing
these pandemic protocols.
This protocol will be updated as the pandemic evolves. Dental care providers MUST use appropriate PPE
(including fit tested N95 respirators) based on the type of dental care they are providing. Fit testing for
N95 respirators can be accessed through a ‘Qualified Fit Tester’ that members can contact.

Overview of Procedures
Similar to Re-Open Saskatchewan, the CDSS is implementing a plan to Re-Open Dentistry, again built on
a methodical and phased-in approach to slowly and responsibly restart dental care in Saskatchewan.
Dental care will be phased in. The following plan is based on published triage systems for dentistry
taking into account the following key objectives:
1. A controlled reintroduction of dental care to prevent COVID 19 transmission in Saskatchewan.
2. To support the medical system by keeping dental emergencies out of hospital emergency rooms.
All urgent dental treatment for patients who have been identified as moderate or high risk for COVID-19
or have been confirmed as COVID-19 positive MUST be provided by a SHA Level 3 provider in the
appropriate facility. In addition, SHA Level 3 Dental Emergency Facilities will continue to accept referrals
from providers for screened negative COVID-19 patients.

General Definitions:
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Aerosol-Generating Procedure (AGP): 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.

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Aerosol Controlled Environment (ACE): AGP operatory rooms must be isolated rooms from floor
to ceiling with an entry or entries that must be closed and secured during the AGP.

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Aerosol-Protective Measures: Actions aimed at mitigating the risk associated with aerosols.
These must include:
o patient Risk Assessment Screening (SHA COVID-19 Screening Tool – March 27, 2020);
o thermometer temperature vital sign screening (<38°C);
o a hydrogen peroxide pre-procedural mouth rinse;
o wearing PPE for high-risk situation (Cap or Bonnet, Gown or Lab Coat, properly fit KN95
or N95 Respirators (fit test with documentation of style and size within the last two years)
Goggles or Face Shield, Gloves (to cover gown or coat cuffs), and gown or barrier for
patient;
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 o
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the use of a rubber dam with a sealing material;
the use of high-volume evacuation/suction;
air management recommendations (aerosol settling time).

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COVID-19: The name of the infectious disease caused by a new coronavirus called SARS- CoV-2.
Although COVID-19 is not thought to be an airborne disease, such as measles or tuberculosis,
under certain circumstances the virus can be aerosolized into particles much smaller than
respiratory droplets (< 5 μm), allowing them to remain suspended in the air longer, to travel
farther, and to be inhaled by a person, thus acting like an airborne disease. Aerosol particles
bearing SARS-CoV-2 can be generated during medical and dental procedures when a patient’s
saliva is agitated by mechanical forces, such as an ultrasonic scaler, a high-speed handpiece, or
spray from an air-water syringe. Therefore, the risk of aerosol transmission can be reduced by
avoiding their generation in the first place, by utilizing appropriate PPE, and implementing
appropriate aerosol protective measures.

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Urgent Dental Care includes treatment for:
o dental or soft-tissue infections;
o severe pain that cannot be controlled by medication;
o fractured teeth or pulpal exposure;
o adjustment or repair of dental appliances where a patient’s health is significantly impacted.

PHASE 1 (May 4th, 2020)
Phase 1 will include the provision of Non-Aerosol Generating Procedures (NAGP) and Urgent Aerosol
Generating Procedures (AGP) in an Appropriate Aerosol Controlled Environment utilizing appropriate
Aerosol Protective Measures (APM), for patients who do not meet the criteria for COVID-19 based on
the SHA COVID-19 Screening Tool. (Click HERE)
The CDSS recommends dental professionals complete emergent and urgent care as a priority during this
phase of the COVID-19 pandemic.
The CDSS may update or modify this Phase as the COVID-19 Pandemic evolves depending on the
accumulation of evidence-based research.

Dental Procedures Acceptable in Phase 1 Include the Following:
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Any emergency NAGP or emergency AGP in Aerosol Controlled Environment utilizing Aerosol
Protective Measures and KN95 or N95 respirator
Examinations and consultations
Simple extractions (NAGP)
Hygiene – hand scaling only and no ultrasonic instrumentation
Preventive procedures such as the application of topical agents (fluoride, silver diamine fluoride, etc.)
Oral & maxillofacial radiology procedures
Orthodontic procedures (NAGP)
Removable prosthodontic procedures
Cementation of previously fabricated fixed prosthodontics
Temporomandibular dysfunction management and procedures

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 •
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Medical management of soft tissue presentations
Oral pathology and oral medicine procedures
Periodontal procedures (NAGP)
Urgent endodontic procedures – AGP with Dental Dam in Aerosol Controlled Environment
utilizing Aerosol Protective Measures and N95 respirator
Urgent restorative procedures - AGP with Dental Dam in Aerosol Controlled Environment
utilizing Aerosol Protective Measures and N95 respirator
Urgent pediatric restorative procedures - AGP with Dental Dam in Aerosol Controlled
Environment utilizing Aerosol Protective Measures and N95 respirator
Urgent complex extractions (AGP) without Dental Dam in Aerosol Controlled Environment
utilizing Aerosol Protective Measures and KN95 or N95 respirator
Dental public health initiatives including community programing and preventive measures.

Dental Procedures Not Included in Phase 1:
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All elective and non-urgent AGP
Hygiene ultrasonic instrumentation
Selective polishing /prophy
Laser instrumentation
Dental implant placement
Nitrous oxide sedation

Later phases will allow the provision of more dental treatment using an updated interim protocol as
directed by the CDSS after considering the accumulating evidence-based research.

Risk Mitigation Factors for Phase 1:
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Patient Risk Assessment Screening (SHA COVID-19 Screening Tool – March 27th, 2020)
Thermometer temperature vital sign screening (<38°C)
Patient hand hygiene
Pandemic informed consent
Preprocedural hydrogen peroxide rinse
Vulnerable patient appointment times – specific days or early in the day
Fewer appointment times
Stagger appointment times
Escort to accompany minor patients only

Personal Protective Equipment for Phase 1:
At this time, during the active spread of COVID-19, the standard should be to provide the highest level of PPE:
• For Non-Aerosol Generating Procedures (NAGP) (ie. examinations, hand scaling, simple
extractions, orthodontic procedures, crown cementations etc.) Table 1 Update
o ASTM Level 2 or Level 3 mask;
o Eye protection (glasses / goggles / face shield);
o Gloves;
o Mandatory routine precautions as per the SOHP Infection Prevention Control (IPC)
Standard for Oral Health Care Facilities (04-01 to 04-05).

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 •

For Aerosol Generating Procedures (AGP) with or without Dental Dam in AGP in Aerosol
Controlled Environment utilizing Aerosol Protective Measures (Complex extraction (AGP) Table
1 Update
o Proper Donning and Doffing techniques must be followed:
▪ NIOSH approved N95 or KN95 respirator;
▪ Must be fit tested for both dentist and dental assistant;
▪ Given the shortage of N95 respirators many health care providers are wearing
an N95 respirator and covering it with an ASTM Level 2 mask and 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;
▪ Face shield (goggles can replace face shield when using a dental dam);
▪ Gown / Lab coat;
▪ Surgical cap / bonnet;
▪ Gloves.

COVID-19 Pandemic: IPC Interim Protocol - Phase 1 Non-Aerosol Generating Procedure
(NAGP)
1. Mandatory routine precautions as per the SOHP Infection Prevention Control (IPC) Standard
for Oral Health Care Facilities (04-01 to 04-05).
2. Mandatory PPE for NAGP includes: Level 2 or Level 3 Mask, Glasses, Goggles or Face Shield,
Gloves. PPE for Front office staff is listed in Table 1.
3. Enhanced cleaning, including twice daily 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. Recommend extraoral radiographs. Minimize the use of intraoral radiographs to prevent the
possible formation of aerosols.
6. Utilize hand instruments only.
7. Utilize four-handed dentistry
8. Do not use air water syringes.
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 protocol SOHP
Infection Prevention Control (IPC) Standard for Oral Health Care Facilities (04-01 to 04-05).

COVID-19 Pandemic: IPC Interim Protocol - Phase 1 Aerosol Generating Procedure
(AGP)
1. Mandatory PPE for Dentists and Chairside assistants for AGP includes: cap or bonnet, gown or
lab coat, properly fit KN95 or N95 (with or without Dental Dam) Respirator (fit test with
documentation), goggles or face shield, gloves (to cover gown or coat cuffs), and gown or barrier
for patient.
2. COVID-19 Pandemic Emergency Treatment Consent should be obtained for both patient and staff.
3. 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.
4. AGP operatory rooms must be isolated rooms from floor to ceiling with an entry or entries that
must be closed and secured during the AGP.
5. Enhanced cleaning, including frequent cleaning of high touch surfaces.
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 6. AGP operatory rooms require the removal of all unnecessary cabinets, fixtures, and nonessential supplies or products, including pictures or artwork.
7. AGP operatory rooms must have a Donning and Doffing Anteroom or Hallway Area. (Donning
and Doffing Video --- Click HERE)
a. Donning Station – “Clean” Side or Area
Includes: Caps or Bonnets, Gowns or Lab Coats, Masks, N95 Respirator, Goggles
or Face Shields, Gloves, Alcohol Base Hand Rub (ABHR)
b. Doffing Station – “Decontamination” Side or Area
Includes: Laundry Receptacle with Lid, Garbage Receptacle with Lid, Eye Protection
Disinfection Receptacle with Lid.
8. 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.
a. Put on a gown and cap or bonnet.
b. Perform hand hygiene.
c. Properly fit a N95 Respirator (secure the straps, mold the metal nose piece to the nose
bridge, and perform a seal check).
d. Perform hand hygiene.
e. Put on gown or lab coat.
f. Perform hand hygiene.
g. Put on appropriate eye protection – goggles or face shield.
h. Perform hand hygiene.
i. Put on gloves to cover the gown or lab coat cuffs.
9. The operatory door shall remain closed during the procedure. Only the dentist, dental assistant
and patient will 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.
10. Aerosol Generating Procedure signage should be placed at the entrance to the room (Appendix A)
11. Implement Aerosol Protective and Minimization Procedures.
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 and the “Decontamination Side” of the Anteroom.
a. In the AGP Operatory Room or as you leave the room:
i. 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.
ii. 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.
b. Exit the AGP Operatory Room, close the AGP Operatory Room door, and in the
“Decontamination Side” of the Anteroom or Hallway Area.
i. Perform hand hygiene.
ii. 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.
iii. 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.

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 iv. Remove N95 Respirator without touching the front of the mask and discard in the
garbage receptacle or stored in a sealed labeled receptacle for possible future
decontamination.
v. Perform hand hygiene.
vi. Put on a clean surgical mask.
14. 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) in the
room permits, the settle time can be decreased. (Click HERE)
15. Following appropriate settling time - clean the operatory room clinical contact and
housekeeping surfaces as per normal protocol - SOHP Infection Prevention Control (IPC)
Standard for Oral Health Care Facilities (04-01 to 04-05).

Air Changes Per Hour (ACH) and Settle Times in Aerosol Generating Rooms
Aerosol generation during dental procedures will dictate the “how and where” these procedures are
completed. ACH will dictate how long the room must sit afterwards to allow the aerosol to settle before
it can be cleaned using normal SOHP IPC Standards for Oral Health Care Facilities. The AGP “settle time
guidelines” are based on ACH and will apply to both categories:
1. AGP with dental dam (restorative and endodontic procedures etc.)
2. AGP without dental dam (complex oral surgery procedures etc.)

AGP Environmental Controls
1. AGP operatory rooms must be isolated rooms from floor to ceiling with an entry or entries that
must be closed and secured during the AGP.
a. Temporary isolation rooms can be designed – hoarding with plastic and a framed or
zippered door.
2. Clinical staff must limit their movement in/out of the treatment area during this time to
minimize airborne contamination of the adjacent spaces.
3. All Donning/Doffing procedures must be followed.
4. If AGP must be performed, the following precautions should be taken:
a. Maintain physical separation of spaces between patients having AGP.
b. Assume air clearance time to be 120 mins unless otherwise confirmed.
c. IF YOU HAVE QUESTIONS ABOUT AIR CLEARANCE TIMES IN YOUR FACILITY, PLEASE
CONTACT AN HVAC CONSULTANT.

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 Table 1: Adapted from: World Health Organization. “Rational use of Personal Protective
Equipment for Coronavirus Disease 2019 (COVID-19).” February 27th, 2020: 1-7

Setting
Patient Room

Reception

Staff or patients
Dentists/RDA

Procedure Activity
Low Risk
Providing direct Care (Non-AGMP)

Type of PPE
- Level 2 or 3 mask
- Eye protection (glasses,
googles or face shield)
- Scrubs
- Gloves
- If contact with patient then
lab coat or gown

Intermediate
Aerosol Generating procedures
(AGP) with dental dam

- N95 or KN95 respirator
(Fitted)
- Face shield or goggles
- Cap/bouffant
- Gown/lab coat (with cuff)
- Gloves

High Risk
Aerosol Generating procedures
(AGP) without Rubber Dam

- N95 or KN95 respirator
(Fitted)
- Face shield
- Cap/bouffant
- Gown/lab coat (with cuff)
- Gloves

Disinfecting
treatment rooms
for non-AGPs

Can disinfect immediately

- Level 1 mask as a minimum
- Eye protection
- Gloves

Disinfection
treatment rooms
for AGPs

Wait to disinfect
(120 mins or amount of time
required to wait after completion
of AGP depending on room
ventilation specifications)

- Level 1 mask as a minimum
- Eye protection
- Gloves

Visitors

NO Visitors in room during AGP

Door/triage

Preliminary screening (vitals
including temp)

- Level 1 mask as a minimum
- Eye protection
- Gloves
- Scrubs
- Maintain social distancing

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 Aggendix A:

AEROSOL GENERATING
MEDICAL PROCEDURES
IN 

 

Saskatchewan
Health Authority saskatchewan.ca/COVIDI9



 

AGMP COMPLETED AT:

 

 

 

 

 

 

SETTLE TIME:

 

MINUTES

 

 

 

(IF SETTLE TIME NOT IDENTIFIED USE 120 MINUTES)

 

 

SAFE TO ENTER ROOM AT:

 

 

 

 

 

 

 

Saskatchewan
Health Authority saskatchewan.ca/COVI019

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