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Philippine Academy of Dental Public Health. August 16, 2021

 Dental Clinical Protocol Recommendations
During the COVID-19 Pandemic
(as of August 16, 2021)

Introduction

The Philippine Academy of Dental Public Health (PADPH), in the interest of

public health, presents these recommendations to Philippine Dental Health Care
Providers (DHCPs) to navigate through this COVID-19 pandemic as they start,
resume, or continue with their clinical practice.

The dental profession is facing the most challenging era in the history of the
world. These challenges brought about by the COVID-19 pandemic began in
December 2019. In May 2020, the Philippine Dental Association (PDA) released the
Interim Guidelines on Infection Prevention for COVID-19 Pandemic to help its
members traverse and manage their practices in a safe environment for both patients
and DHCP. More studies have been done since then. Yet, there is still some
confusion on how to go forward.

Our objective is to provide updated, safe, minimal clinical practice guidelines

for the effective management and control of the spread of the disease in the dental
setting. These recommendations are made based on recent available evidence from
scientific literature and guidelines from health organizations and agencies (WHO, CDC
ADA, DOH, etc.) and other dental profession stakeholders.

Some dental practice guidelines in other countries may not be feasible or

practical in the Philippines because of the differences in COVID-19 response by the
government and organizations in different parts of the world (including different
vaccines and vaccination rates). Therefore, these recommendations are made for the
Philippine context.

Updates on return to work, quarantine, testing, and other COVID-19 guidelines

are not detailed in this document. You may refer to issuances by the Inter-Agency
Task Force for the Management of Emerging Infectious Diseases (IATF-EID),

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Philippine Academy of Dental Public Health. August 16, 2021
Department of Health, Philippine Food and Drug Administration (FDA), other official
government sources and your local government units for further details. You may also
refer to recommendations from infectious disease experts such as the Philippine
Society of Microbiology and Infectious Diseases (PSMID) or the Infection Control Unit
of your health facility.

The 2020 PDA Interim Guidelines and the PADPH recommendations presented
here are not meant to restrict the DHCPs in using sound clinical judgment as they
deem best and necessary for themselves and their patients. Moving forward, it is
PADPH’s aim that this will be updated when new findings necessitate changes to the
recommendations.

DISCLOSURE: The contributors declare no conflict of interest and did not receive any
funding and are not endorsing any product that may be mentioned in this document.

PADPH contributors:
Arlene Cecilia A. Alfaro, DDM
Ma Aurora G. Dellosa, DDM, MHA, FPBDPH
Mariano T. Maglutac Jr., DDM, MHA, FPDBPH
Angelica A. Niñal, DMD
Liel Ma.Theresa L Plantig, DDM, MPH
Rose Anne Q. Rosanes, DDM, MPH, FPBDPH
Edbert P. Solano, DMD, DDPH

For comments, feedback, and suggested updates, contact PADPH at

padphsecretariat@gmail.com.

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Philippine Academy of Dental Public Health. August 16, 2021
Background

The World Health Organization (WHO) in April 2021 stated that COVID-19 virus
particles which can “spread from an infected person’s mouth or nose in small liquid
particles when the person coughs, sneezes, sings, breathes or talks, by inhalation or
inoculation through the mouth, nose or eyes.”2 The virus ranges from larger respiratory
droplets to smaller aerosols and transmission can occur in settings of less than 1 meter
but in poorly ventilated and/or crowded indoor settings, where people tend to spend
longer periods of time, the virus can also spread rapidly because aerosols remain
suspended in the air or travel farther than 1 meter. Variants of the virus (ex. Delta
variant) has been found to be more infectious than the original, with increased
transmissibility3-5 even with vaccinated persons, and therefore infection control
measures in the dental clinic should be reinforced.

Infection prevention and control (IPC) guidelines against the threat of COVID-
19 continue to be released and updated by agencies such as the WHO, OSHA, and
United States’ Centers for Disease Control and Prevention (CDC) which serves as
basis for recommendations for IPC in the dental settings.1,6-12,15 These
recommendations include the hierarchy of controls developed by National Institute for
Occupational Safety and Health (NIOSH) of the CDC. Dental clinic protocols should
be developed according to IPC measures which follow this hierarchy where elimination
of the exposure to the virus is the most effective while using personal protective
equipment (PPE) is least effective. Layering of controls provides the best protection
against infectious agents. Figure 1 presents the hierarchy of controls with dental
examples12-14 adapted from the Organization for Safety, Asepsis and Prevention11.

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Philippine Academy of Dental Public Health. August 16, 2021
 Most Effective
Physically remove the hazard
● Symptom screening prior to appointment
and arrival; isolate and eliminate (discharge,
refer) all symptomatic patients and workers
ELIMINATION ● Preprocedural viral testing16-17
● Remove items and surfaces that might
cross-contaminate and replace with non-
touch options
● Reduction of microbes in dental unit water
lines

Replace the hazard

● Remotely assist patients through
Teledentistry
● Alter or postpone treatment plan if this does
SUBSTITUTION not harm the patient
● Prioritize at-risk population in most need of
dental care
● Limit close contact of patients throughout the
practice
● Re-assign roles of high-risk personnel to
low-exposure work or locations

Isolate people from the hazard

● Facility space organization into infection
control zones; isolate and separate space
with physical barriers
ENGINEERING ● Use directional airflow such as exhaust fans
CONTROLS ● Use of rubber dam isolation
● High-volume evacuation in conjunction with
isolation
● Preprocedural mouth rinse to reduce
microorganisms load
● Hand instrumentation for hygiene, non-
surgical periodontal treatment, minimal
restorative treatment

Change the way people work

● Respiratory hygiene/cough etiquette/hand
ADMINISTRATIVE hygiene stations
CONTROLS ● Sick leave policies
● Manage visitors; limit points of entry
● Adjustments in appointments scheduling
● Universal Source Control - all people wear
appropriate level face coverings in facility
● Create, train new staff on updated protocols
and roles
● Respiratory Protection Program

Protect the worker from the hazard

● Gowns
PPE ● Gloves
● Mask/ N95 respirator
● Face shield
● Goggles / eyewear

Least Effective
Figure 1. Hierarchy of controls with dental examples

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Philippine Academy of Dental Public Health. August 16, 2021
 The California Dental Association identified four zones of clinical infection
control in the dental clinic9 (Figure 2). Specific measures are then put in place for each
zone.

Figure 2. Zones of clinical infection control in the dental clinic

Implementation of IPC measures in the lower zones, especially with aerosol-

generating procedures (AGPs), is the most effective way of preventing transmission
of the virus in the dental clinic. The hierarchy of controls and layering of IPC measures
in the different zones create a safer environment for DHCPs and the patient.

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Philippine Academy of Dental Public Health. August 16, 2021
 Zone 1: Recommendations for Intraoral Aerosol Management

Limit aerosol-generating procedures1,2,6-9,14-15,18-19

● Limit use of ultrasonic scaler, high- or low-speed handpieces, 3-way
syringe
● When possible, perform hand instrumentation such as manual scaling
and minimally invasive/atraumatic restorative techniques over AGPs

Preprocedural mouth rinse (PPMR)1,6-7,9,11-13,15,19,21-30

● Moderately Recommended
● Limited evidence of preventing COVID-19 transmission and reduction of
viral load by antiseptic solutions containing polyvinylpyrrolidone iodine
(PVP-I), cetylpyridinium chloride (CPC), chlorhexidine gluconate (CHX)
and hydrogen peroxide (H202) and essential oils with ethanol though
they have been recommended as PPMR
● Gently gargle (undiluted) for 30 seconds in the oral cavity and held at the
back of the throat for another 30 seconds.
○ Povidone-iodine (PVP-I) 1% (10ml)
○ Cetylpyridinium chloride (CPC) 0.05% (15ml)
○ Chlorhexidine gluconate (CHX) 0.12% (15ml)
○ Hydrogen peroxide (H2O2) 1%-1.5% (15 ml)

Rubber dam isolation1,6,11,14,19

● Highly Recommended
● Use with high volume evacuator (HVE)

HVE1,6,9,11,13-14,18-20,31-32
● Highly Recommended
● Shown to remove up to 97%31 of aerosols within the surrounding area.
● Effective evacuation volume 1 liter/minute.
● Use HVE instead of saliva ejector because of its low volume of evacuation
and risk of backflow

Practical tip:
• Follow manufacturer’s instructions on use and maintenance

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Philippine Academy of Dental Public Health. August 16, 2021
 Zone 2: Recommendations for Aerosol Management Within Three Feet of
the Oral Cavity

Extraoral vacuum (EOV) or extraoral suction unit (ESU)1,9,32-35

● Moderately Recommended
● 4-12 inches distance from the patient’s mouth at 5 o’clock position
● Effective in reducing droplet splatter during treatment

Practical tip:
• Follow manufacturer’s instructions on use and maintenance

Micropore / masking tape as an alternative for bib holders

• Moderately Recommended
• Risk of introducing cross infection with bib holders with metal clips because
these are readily contaminated by bacterial attachment and may still carry
microbial contaminants after disinfection36
o Clean before disinfection and sterilize bib holders in between patients

Practical tip:
● Use a tape dispenser
● Dispose tape after each patient

Practical tip for when patient removes her/his face mask:

● Provide the patient with a brown paper bag for temporary storage and
dispose bag after each patient

Hand Hygiene1-2,6-7,11,15,18,37-40
● Highly Recommended
● Follow the WHO 5 Moments of Hand Hygiene (Figure3) and proper
handrub and handwashing steps
● Wash hands with soap and water if visibly soiled and/or use alcohol-based
rub or sanitizers
● Use ethyl or isopropyl alcohol at 60% – 80% concentration
● Practice proper hand hygiene in all areas of the dental clinic

Practical tip:
• Use products in the Philippine FDA list of registered notified hand
sanitizers and registered topical antiseptics and antibacterials

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Philippine Academy of Dental Public Health. August 16, 2021
 Figure 3. Your Five Moments for Hand Hygiene

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Philippine Academy of Dental Public Health. August 16, 2021
 Zone 3: Recommendations for Aerosol Management in the
Operatory

“Efficient management in Zones 1 and 2 may significantly reduce additional

management requirements in Zones 3 and 4”9

Air Exchange / Ventilation1-2,4,5,6,7,9,11-14,18-19,21,31-33

● Highly Recommended
● Aerosol accumulation occurs in rooms with poor ventilation
● Maintain adequate ventilation in all parts of the clinic (including waiting area
and staff lounge)
● Achieve at least 6 to 12 air changes per hour either through natural (open
windows) or mechanical ventilation (exhaust fan).
● Allow for enough time in between patients for adequate air exchange
● Limit the number of people in the room to allow good air exchange

In the Absence of Windows:

● Air movement from a clean-to-less clean flow direction reduces the
distribution of contaminants and creates a safer place for DHCP and
patients.
o Consider heating ventilation and air conditioner (HVAC)
o Use portable air purifier and exhaust fans that is adequate for the area
o Follow manufacturer’s instructions on proper placement and
maintenance of the purifier

Physical Barriers/ Dividers (between treatment areas)2,6-7,9,11,14

● Ideally, dental treatment should be provided in individual rooms, whenever
possible
● For clinics with open floor plans:
o Place dental chairs at least 6 feet apart
o Install easy to clean floor-to-ceiling barriers if the treatment area lacks
complete walls to seal the room.
o Disinfect barriers after each patient

Negative Pressure Room1,2,6-7,11-13,31-32

● Highly Recommended
● For patients suspected or positive for having COVID-19, treatment should be
performed in an isolation room with negative pressure with high-level PPEs

Exhaust Fan2,6-7,9,11,13-14
● Highly Recommended
● To draw out air from the operatory area to the external environment
● Position opposite from the intake of clean air or ventilation

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Philippine Academy of Dental Public Health. August 16, 2021
 High-efficiency particulate air (HEPA) filter1,2,6-7,9,11-14,18,21,31,42
● Highly Recommended
● Designed to filter air; improves air quality in spaces where there is inadequate
ventilation.
● Ensure the manufacturer’s operating protocols are followed (configuration,
maintenance and replacement of the HEPA filters within the unit)

Surface disinfection1,2,6-7,9,11,14-15,18,21,31,41-42
● Highly Recommended
● Limited evidence on COVID-19 transmission through environmental
surfaces
● Follow WHO Cleaning and Disinfection Interim Guidance for COVID-19
o Clean surfaces before disinfecting
o Use:
 Ethanol 70-90%
 Chlorine-based products (e.g., hypochlorite) at 0.1% (1000 ppm)
for general environmental disinfection or 0.5% (5000 ppm) for
blood and body fluids large spills
 Hydrogen peroxide >0.5%

Portable ultraviolet-C (UVC) lamp1-2,6-7,9,11,13,18,21,42

● Limited evidence on effectiveness of UVGI
● “Decontamination occurs only for surfaces that are directly exposed to UV-C
light and that the amount of radiation received by contaminated surfaces
depends upon the distance from UV emitting device and the presence of
opaque objects in the line of emission”13
● Should be done at the end of clinic operations in the absence of patients and
staff

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Philippine Academy of Dental Public Health. August 16, 2021
 Zone 4: Recommendations for Aerosol Management in
Common Areas in the Dental Clinic

“Efficient management in Zones 1, 2 and 3 may significantly reduce

additional management requirements in Zones 4. Evaluation of Zone 4
options is best accomplished by evaluating the air flow patterns in your
office or clinic space.”9

Maintain good air ventilation in the all areas of the dental clinic

Physical barrier 2,6,9,15,18,21,42

● Moderately Recommended
● Glass, acrylic or plastic
● Used at the reception desk area, office or staff tables, etc. when physical
distancing cannot be done
● Regularly clean and disinfect barriers

Reception area protocols

● Highly Recommended
● Post visual alerts or infection control instructions for patients and staff
● Limit the number of people in the clinic
● Maintain a record of everyone entering the clinic
● Practice physical distancing
● Provide adequate access to supplies or facilities for hand hygiene
(alcohol-based hand rub or soap and water)

Health screening1-2,6-7,10-15,18,21,31,42-43
● Highly Recommended
● Screen and triage everyone entering the clinic for symptoms.
“Although screening for symptoms will not identify asymptomatic
or pre-symptomatic individuals with SARS-CoV-2 infection, symptom
screening remains an important strategy to identify those who could
have COVID-19, so appropriate precautions can be implemented.”7
● Use patient screening forms to include vaccination status and new
symptoms (if any) of COVID-19 variants
● Advise the patient to inform the clinic if they develop symptoms or are
diagnosed with COVID-19 within 48 hours of dental visit

Practical tip:
● Use online contact tracing apps or forms but provide paper-based forms for
those who may not have online access

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Philippine Academy of Dental Public Health. August 16, 2021
 Non-contact infrared thermal scanner7,15,44-46
● Highly Recommended
● Use noncontact infrared thermometers or thermal scanners place of digital
or mercury thermometers to conduct temperature checks
● Use scanners on the temporal artery in the forehead8

Practical tip:
● Purchase and use a thermometer or scanner with FDA Certificate of
Product Registration

Nonclinical area protocols

● Highly Recommended
● Maintain physical distancing and PPE protocols in nonclinical areas such
as the staff lounge.
● Schedule staggered break times for staff and proper ventilation measures
in these areas.
● Train dental clinic staff on IPC protocols

Online/cashless payment method

● Moderately Recommended
● Limited evidence of cash (bank notes and coins) as possible source of
COVID-19 transmission
● Mode of payment options
○ Cashless/online cash transfer (Credit card, bank transfer, cash payment
apps like GCash, PayMaya, PayPal, etc.)
○ Cash

Practical Tips:
● If cashless, print out bank details (including QR code) and internet/wifi
information to share data when needed
● If using electronic terminals or card readers, move terminal away from
cashier, have the patient swipe their card
● If cash
○ Wash hands diligently with soap and water after handling cash.
○ Avoid touching your face and eyes.

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Philippine Academy of Dental Public Health. August 16, 2021
 Recommendations for IPC Outside of the Four Zones of the Dental Clinic

COVID-19 Vaccination 2-5,11,20,42,47-49

● Highly Recommended
● DHCP and patients have complete COVID-19 vaccination
● Vaccines in the WHO Emergency Use Listing are effective to prevent both
symptomatic and asymptomatic infection as well as to reduce severe
COVID-19 cases, hospital admission rates and deaths
● ‘Vaccination of dentists and dental teams is important to contribute to
continued access to oral healthcare”49

Teledentistry1-2,6-7,10-12,15,18,31,51-55
● Highly Recommended
● Purposes:
o Initial health screening for COVID-19 symptoms and consultation
prior to coming to the clinic to shorten clinic time;
o Consultation for patients unable to come to the clinic
o Home-based oral health promotion

Practical tip:
o Follow the DOH Guidelines for Telemedicine or the Telemedicine:
Guidance for Physicians in The Philippines

COVID Testing2,5-7,10,11,13,15-17,21
● Facilities may choose to require patients or clinic personnel to be tested
given the limitations on cost, access and possible false negative results
based on timing of testing.
● SARS COV-2 RT-PCR of nasopharyngeal swabs remains the diagnostic
test of choice to confirm the diagnosis of COVID-19 among suspected
individuals.22
○ Testing should be done within 48-72 hours prior to dental
appointment.

Practical tip:
● Follow latest Philippine FDA advisories on approved COVID-19 test kits

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Philippine Academy of Dental Public Health. August 16, 2021
 Personal protective equipment (PPE) recommendations

PPEs are the least effective method of IPC measure according to the
hierarchy of controls. The CDC guidance states that recommendations for fully
vaccinated individuals are continuously being updated but the recommendations for
use of PPE by HCP, including dentists, remain unchanged.9 The following
recommendations are for specific areas and procedures.

PPE Recommendations for DHCPs

Low Risk Moderate Risk High Risk

Item Reception or Clean Area Non-AGP AGP

Triage

Gloves2,6-7, Not Not Highly Highly

11,14-15,18,21
recommended recommended; recommended recommended
non sterile Use thick utility Single gloves Single gloves
- single use gloves

Highly Highly Highly Highly

recommended recommended recommended recommended
Surgical mask Surgical mask Surgical mask FFP2 (N95 or
● changed daily ● changed with face shield KN95) to be
Masks2,6-7, ● changed daily ● discard face changed per
9-11,14-15,18,20-21
when visibly ● changed mask and patient OR half-
soiled or when visibly disinfect face facepiece
damaged soiled or shield after respirator
damaged every patient

Not Recommended Highly Highly

recommended alternatively recommended recommended
with wearing a ● Protective Sealed
Protective face shield eyewear with goggles
eyewear/ side panels and/or face
goggles2, ● If using shield
6-7,11,14-15,21
prescription
glasses wear
together with
face shield

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Philippine Academy of Dental Public Health. August 16, 2021
 PPE Recommendations for DHCPs

Low Risk Moderate Risk High Risk

Item Reception or Clean Area Non-AGP AGP

Triage

At a minimum, it should be full face length with outer edges of the face
shield reaching at least to the point of the ear, including chin and
forehead protectors, and cover the forehead. No specific material is
Face recommended but it should be cleaned after each patient and replaced
Shield2,6,11,14- if there is an obvious dent or scratches.
15,18,20-21,51

Recommended Recommended Recommended Recommended

Optional, if Sealed goggles
acrylic barrier is and/or face
present shield

Not Not Not Recommended

Head recommended recommended, recommended, Change per
covering Optional Optional patient, covers
15,21
ears

Long-sleeved, ankle-length fluid-resistant gown with elastic cuffs that

should cover the legs to below the knees and be tied in the back
Protective
gown
2,6,7,9,11,14,15,18,21 Not Not Recommended Recommended
recommended recommended;
Use scrub suit Use fluid-
OR clinic wear repellent apron

Should be tear resistant, waterproof, and anti-slip.

Closed shoes Closed shoes Closed shoes Recommended

Shoes / Closed shoes
Shoe OR
covering Dedicated/clinic
15,18,21
al closed
footwear OR
shoe cover

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Philippine Academy of Dental Public Health. August 16, 2021
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