E-BOOK

GUIDELINES FOR
BEST PRACTICE IN
BIOSAFETY AT THE
DENTAL CLINIC

2020
Dr. Geninho Thomé
Dr. Sérgio Bernardes
Dr. Sérgio Guandalini
Dr. Maria Claudia Vieira Guimarães

Scientific support:

Institutional support:
togetherstrong

#TogetherStrong
We, who work in Dentistry, know the importance of following safety
procedures regarding prevention, protection and care.

The world has changed. For this reason, we started the #TogetherStrong
movement: together with dentists working in health care to reinforce
biosafety protocols and prepare ourselves for this new era.

In order to promote the safety of patients and dental workers, we created

this manual of good biosafety practices in dental environments. The
aim is to provide guidance to prepare the 4 essential counterparts in
dentistry: CLINICS, DENTISTS, AUXILIARY STAFF and PATIENTS.

Count on us and together we will spread this message.

Please note that by publishing these texts, Straumann merely supports clinics who wish to share their best practice guidelines.
Straumann as a manufacturer of medical devices is not in a position to create or publish guidelines for clinics or dentists.
Therefore, the content does not originate from Straumann and Straumann cannot accept any responsibility or liability in
respect to this content. Neither Institut Straumann AG nor any of its affiliates accept any responsibility for completeness,
accuracy, appropriateness and/or correctness of the information provided by third parties. Any content published here shall
not be construed as any kind of recommendation or guarantee. Institut Straumann AG and all its affiliated companies explicitly
disclaim any and all liability for any damages, claims etc. that may arise related to any information provided hereinafter.
 INTRODUCTION
Dentists are responsible for adopting prevention and infection control
measures to avoid or reduce as much as possible the transmission of
microorganisms during any procedure in their practice. In this manual
you will find basic orientations that must be followed. Nevertheless,
dental care workers or providers may enforce even more stringent
prevention and control measures, taking into account their individual
and specific realities.

In 2009, after 36 thousand cases in 75 countries, the World Health

Organization (WHO) declared H1N1 a pandemic. This is a diseased
called by a new strain of the H1N1 Influenza A, which we already
know, and mutated from animals (pigs) to start infecting humans
(swine flu).

WHO has recently declared another pandemic, this one caused by

the SARS-CoV-2 virus. Compared to H1N1, there are similarities and
differences in its transmission, how to fight the disease, and how
to treat it. Just like the new coronavirus disease (also known as
COVID-19), Influenza A was a respiratory disease transmitted by
coughing and sneezing, by direct contact with an infected person, or
by contact with respiratory secretions of infected persons. However,
according to research, that virus was less contagious than that of
COVID-19. The WHO claims that someone infected with H1N1 could
infect between 1,2 and 1,6 other people, while a study published by
the American Center for Disease Control claims that this rate is of
2,79 for the coronavirus disease (1).
INTRODUCTION The last pandemic served as a warning to the world about the
dissemination of a disease like SARS-CoV-2 (severe acute respiratory
syndrome of coronavirus) which quickly infected communities in
several countries due to sneezing, coughing, droplet inhalation or
indirect contact with nasal, oral, and eye mucosa. Dental workers
play a crucial role in the prevention of this viral infection, because
aerosol and droplets are the main transmission vectors (2). For this
reason, dental clinics must be an environment of great control and
prevention of microbiological infections in general.

https://commons.wikimedia.org/wiki/File:3D_medical_animation_coronavirus_structure.jpg

Dental workers and patients may be exposed to pathological

microorganisms, including viruses and bacteria that infect the oral
cavity and the respiratory tract. Dental practices are at risk of
infection due to face-to-face procedures and frequent exposition
to saliva, blood, and other body fluids, and due to the use of
cutting and piercing tools. Pathogens may be transmitted in dental
environments through the inhalation of microorganisms that remain
suspended in air for a long time, direct contact with blood, oral
fluids, or other patient materials. It may also be transmitted when
the conjunctival, nasal, or oral mucosa is in contact with droplets or
aerosols containing microorganisms from an infected person, which
travel short distances due to coughing or speaking without wearing
a face mask. Moreover, it may be transmitted by indirect contact with
contaminated tools or surfaces (2).
 INTRODUCTION
Possible transmission routes in a dental practice

Airborne transmission

Droplets Vulnerable individuals

Dro
plet
s an
da Direct contact
ero
sol
Dental practice

ct
Contaminated surfaces nta
Infected t co
irec Dental care workers
patient Ind Clinic
Dental Assistants
Dental Hygienists

Many dental procedures produce aerosols and droplets (high speed

hand pieces, triple syringes, ultrasound, etc) that may be contaminated
with the virus. Therefore, droplets and aerosols are a cause for great
concern in dental clinics and hospitals, because it is difficult to avoid
the production of great amounts of aerosol and droplets mixed with
patient saliva or even blood during the clinical practice of dentistry.
Besides coughing and breathing from infected patients, dental tools
such as handpieces use high-speed air to operate their turbines, and
operate with water. When these devices are used in the patient’s
mouth, a great amount of aerosol and droplets mixed with patient
saliva or blood are generated. These droplets and aerosols are small
enough to remain suspended in air for a long period of time before
falling into environment surfaces or entering the respiratory tract of
other individuals.

High speed rotation pen generatingaerosol sprays

INTRODUCTION Moreover, droplets and aerosols containing microorganisms from an
infected person may have contact with the conjunctival, nasal or oral
mucosa of dental care workers and other patients. Working at a short
distance from the patient’s face, as well as coughing and engaging
in mask-less conversation are reasons to apply efficient strategies
to control infection and prevent the dissemination of diseases such
as COVID-19.

Some viruses are controlled and prevented through vaccination,

especially of health care workers, such as viral Hepatitis B. However,
no vaccine for SARS-CoV-2 has been found yet. This virus has an
average incubation period of 5 to 6 days, but there is evidence of
incubation periods of up to 14 days. For this reason, quarantining
people exposed to it for 14 days, even if they are asymptomatic,
has been encouraged(3). This virus may remain in the saliva of a
contaminated individual for up to 24 days. After that, it is difficult to
determine whether the person is infected or not (2). For this reason,
it is recommended that health care workers work as if all patients
were infected. It should be noted that dental care workers are more
exposed to the virus than patients, because during dental procedures
patients are the ones who keep their mouth open, propelling aerosols.
The best way to prevent any disease is to adopt practices that stymie
the virus’ propagation. This is why controlling environments that carry
biological risk is part of the routine of all dental care workers.
 SUMMARY
This manual of good biosafe ty practices in dental environments
has been prepared with 4 essential counterparts in mind:

Click on the icons to access the content:

CLINIC

Precautions to be adopted
in clinical environments
 CLINIC
1.1 Standard precautions

Your clinic should have the following basic elements available in order
to follow standard precautions. These should be implemented with all
patients, regardless of whether they are believed to be infected or not:

• Have surgical masks available, to cover

mouth and nose. The masks should be easily
accessible for patients and they should be
offered instructions on how to use them.

• Have alcohol based sanitizer easily available

for patients in several places within the clinic,
from the reception to the consultation room.

• Have disposable wipes for nasal hygiene in

case you or the patients needs it. After using
them, dispose of them immediately and then
wash your hands.

• A sink and liquid soap in the reception, to

wash hands and face: wash your hand with
water and soap, or apply 70% alcohol based
sanitizer to them before and after having
contact with any patient, after removing the
gloves, and after having had contact with
blood or secretions (4). Wash your face with
water and soap when you arrive at the clinic
and between appointments.

• Gloves: wear gloves when there is risk

of having contact with blood or mucus.
Wear them immediately before having contact
with the patient and remove them immediately
afterwards, then wash your hands (4).
CLINIC • Goggles, face mask, and apron: wear goggles
and face masks or aprons when there is risk
of having contact with blood or secretions in
order to protect eye, mouth and nose mucosa,
as well as clothes and body surface (4).

• Disposable needles and syringes box: dispose

of needles and syringes in appropriate places
without disconnecting them or covering them
again(4).

• If possible, clinics should have a comfortable

private room to isolate patients who may be
infected, while they wait for their appointment
or recover after treatment, if needed. If this
room is not available, there should be a chair at
a distance of 1 to 2 meters of all other chairs.
The number of people waiting should be
limited as far as possible that they can keep
a reasonable distance. The clinic should be
re organized to be maintained in such a way
that patients can maintain a safe distance
when entering or leaving the practice. Signs
on the practice door should indicate this.
Accompanying adults of adult patients should
be asked to leave the practice.

1.2 Visual alerts

Visual alerts such as posters and signs may be placed at

the entrance of dental clinics and other strategic locations
(such as waiting rooms, parking lots and elevators) to offer
patients and visitors instructions on the correct procedures.
 CLINIC
When you cough or
sneeze, cover your nose
and mouth with your
elbow or a tissue.

You should wash your hands whenever

they seem dirty, as well as before
and after:

• Having contact with any person;

• Going to the rest room
• Touching any surface;
• Wash your hands for at least
20 seconds.

1) Wet your hands 2) Use soap 3) Rub your palms 4) Rub your fingers
with water

5) Rub your nails 6) Rub the back of 7) Rub your thumb 8) Rub your wrist
your hands

9) Wash your hands 10) Dry your hands 11) Close the tap 12) Clean hands
with water
CLINIC
Wash your face with
water and soap for
20 seconds after
washing your hands
and before your
dental appointment

Download printable posters at:

www.dentistaspelasaude.com.br/posters

TIP:
Health care workers should wash their hands before examining
patients, before dental procedures, after touching patients,
after touching surfaces and tools that haven’t been sanitized, and
after touching oral mucosa, damaged or injured skin, body fluids,
secretions, or excretions.
 CLINIC
1.3 Precautions in the waiting room:

• Install a antibacterial disinfectant rug in the entrance of the

waiting room;

• The waiting room for patients and visitors should have

1,2m2 per person;

• Chairs should be at a distance of 1 meter from each other;

• Face masks and disposable tissues should be available in the

waiting room;

• There should always be a pedal-activated trash bin;

• There should be dispensers to distribute alcohol based sanitizer

or alcohol at 70% to encourage people in the waiting rooms to
clean their hands;

• There should be simple tools to allow people to wash their hands

and faces: a sink with a liquid soap dispenser, paper tissue
holders, and trash bins with lids that can be opened without using
one’s hands;

• All environments should be well-ventilated;

• Eliminate, restrict or control the sharing of objects that patients

might use, such as pens, sheets, telephones, and magazines;

• Nowadays, there are devices like tablets that may be sanitized

with alcohol and thus be made available in waiting rooms

• The surfaces of all environments used by patients should be

cleaned and sanitized daily, once or more as per requirement;

• Health care tools and equipments that may have been used to
treat patients should be cleaned and sanitized;

• If a patient needs to be sent to another health care service, always

inform that provider how to care for that patient.
CLINIC 1.4 Precautions in the consulting room:

Surfaces in the consulting room and other environments used by the

patient should be cleaned and sanitized before clinical activities and
between appointments.

1.4.1 Dental disinfection agents for inanimate surfaces:

• 1% Sodium hypochlorite;
• 7-9% Quaternary ammonium;
• 70% alcohol.

70% alcohol and sodium hypochlorite require the prior cleaning of

dirty surfaces with paper tissues, water, and detergent. Afterwards,
that surface may be sanitized. Alcohol should be applied at least
3 times. These compounds are not recommended for use in acrylic,
rubber, or plastic surfaces, because they make these surfaces harder
and yellow. Quaternary ammonium, biguanide, and glucoprotamine
should be applied at the same time as a surface is cleaned. They
clean and sanitize simultaneously.

1.4.2 Precautions for chairs and desks in the

consulting room:

The room should be closed and have at least 9m2. Shared consulting
rooms should follow a distance of at least 0,8 meters for desks and
1m to the side of each chair, and there should be a minimum distance
of 2 meters between 2 chairs, as well as a physical barrier between
the chairs if they are at the minimum distance (5). Sprays caused by
high speed rotation pens are propelled by up to 2 meters. For this
reason, surfaces exposed to these aerosols must always be sanitized.
Indeed, there is evidence that the coronavirus may be infectious in
inanimate, ambient-temperature surfaces for up to 9 days (6,7).
 CLINIC
MINIMIZING THE PRODUCTION OF AEROSOL:
• Saliva must be constantly suctioned with a high volume
vacuum pump and 4 hand dentistry.

• Intra-oral X-rays that may stimulate salivation and coughing

should be used with precaution. Remember that panoramic
x-rays or computerized tomographies avoid the problem.

• Avoid using the spray function of the triple syringe by

pressing two triggers simultaneously.

• Preferrably, use cotton or gauze to dry.

1.4.3 Cleaning clinical environments:

The sanitizing of surfaces in clinical environments should follow

these guidelines:

1º. start at the least contaminated area and proceed to the most
contaminated one;
2º. s tart at the top and move downwards;
3º. s tart inside and move outwards.

Don’t forget the air and water pipes, and the air conditioning filter.
To clean the biofilm of the air and water pipes, use peracetic acid for
the best sanitizing (it is effective even if there is organic material).
CLINIC

5.
Equipment
4.
1. 3. (high and
2. Surface of
Spotlight Dentist’s low rotation,
Chair the auxiliary
handles chair triple syringe,
stroller
and suction
units)

1.4.4 Places that should have mechanical barriers

(PVC films or plastic bags):

• Manual triggers;
• Spotlight handles;
• Headrests;
• Dental chair arms;
• Dental chair rest;
• High speed handpieces;
• Triple syringe body;
• Tip of suction units.

Surfaces like benches and auxiliary strollers should be covered by

disposable and impermeable barriers. Triple syringes should have
disposable tips.
 CLINIC
1.4.5 Sanitizing equipment and tools:

• Hand pieces without anti-reflux valves should be avoided in order

not to contaminate the equipment’s air and water system;

• All hand pieces (high and low rotation) should be decontaminated

with enzymatic detergent, cleaned and sterilized(7);

• Tools need to be washed, and cleaned with enzymatic detergent,

preferably in ultrasonic bowl (check the manufacturer’s
instructions), not conventional detergents, and finally sterilized,
prior to being used.

1.5 Centrals to manipulate materials with two environments:

• Materials used for coating walls, floors, and ceilings of critical

and semicritical environments should be resistant to washing
and to sanitizers, and they should not have any visible cracks or
scratches even after frequent use and cleaning.

• Dirty environments: Washing and decontamination room with a

bench, a sink, and a counter in the clean area (material sterilization
room), with a minimum area of 4,8 m2. Receiving, cleaning, washing,
and separating materials are considered “dirty” activities and,
therefore, must take place in the proper, exclusive environment,
according to adequate parameters, and with the use of the following
PPE: plastic aprons, face mask, cap, closed shoes, goggles, and
thick rubber gloves (not surgical ones). However, these materials
should be allowed to be directly transferred between these
environments and the remaining “clean” environments through a
counter or similar object;

• Clean environment: Material preparation/sterilization/storage

room, with a bench for sterilization equipment, cabinets to store
material, and a counter to distribute material, with a minimum area
of 4,8 m2.
 CLINIC
1.6 Cleaning clinical environments(5):

Product Concentration How to apply Level Spectrum Advantages Disadvantages

Volatile,
deactivated by organic
Rubbing in material, inflamable,
Tuberculicide, Easy to apply, quick
Great Germicide 3 different stages, makes acrylics opaque,
bactericide, fungicide, effect, compatible with
Alcohol spaced by the natural Medium and virucide; metal objects, surfaces
parches plastics and
at 70% drying time, for a total of
is not sporecide. and anesthetic tubes.
may damage the
10 minutes. cement in optical tools;
must be stored in
ventilated areas

Irritates skin and

Is not corrosive, mucosa, it’s lifespan
has quick effect, is is reduced when
Bactericide, fungicide,
Glutaraldehyde 2% Dipping for 30 minutes High virucide and sporecide.
a bactericide even effectively diluted
in the presence of for 14 to 28 days,
organic matter. depending on
the formula.

Dipping instrument Quick effect,

for 30 minutes. recommended for
Sodium Unstable, corrosive,
Surfaces with Bactericide, fungicide, surfaces and
1% organic matter. Apply Medium virucide and sporecide. non-metallic
deactivated by
hypochlorite; for 2 to 5 minutes objects, as well as
organic matter.
then clean. thermosensible objects.

Does not produce toxic

Unstable when diluted.
residues, is effective
Corrodes some types
Dipping instruments Bactericide, fungicide, even with organic
Peracetic Acid 0.2% for 10 minutes High virucide and sporecide. matter, produces
of metal. This effect
may be reduced by
quick effects in
modifying the pH.
low temperatures.

1.7 Personal Protection Equipment (PPE):

Impermeable lab coats and aprons, gowns, gloves,
surgical masks, and surface protections: must
be used during appointments and disposed after
each appointment in a disinfectant bin. Must be
used during direct contact with patients (physical
exams) and removed during administrative
moments of the appointment (e.g., writing and
typing on a keyboard). Aprons should be closed in
the back. Surface protectors should cover critical
areas for the protection of patients, areas were
tools are stored, and areas that would be difficult
to clean if directly contaminated.
 CLINIC
Goggles and face shields: must be used during
appointments with patients with Influenza-like
symptoms. Must be used during direct contact
with patients (physical exams) and removed
during administrative moments of the appointment
(e.g., writing and typing on a keyboard). May be
Goggles and face shields
sanitized after each appointment and then reused.

Clothes and surgical scrubs: should be dipped in

a sodium hypochlorite solution (white clothes) or
Lysoform® or similar disinfecting agent (colorful
clothes), then washed separately with water and
soap. Should be worn by dental workers who have
direct contact with patients and patients who go
Clothes and surgical scrubs through invasive procedures.

Facial Respirators (N95): should be worn by health

care workers whose tasks generate aerosols
(manipulating airways or invasive exams), and may
be swapped after each appointment.

What mask should I wear?

SURGICAL MASK
Used routinely and used by patients suspected or infected
with COVID-19, as long as no procedures that generate
aerosols are carried out. Used alongside the face shield;

N95 MASK
Used during procedures that generate aerosols with
patients who have or are believed to have COVID-19.
Used alongside the face shield. Only reuse in exceptional
circumstances (maximum 4-5 times). Store for 4 days in a
well-ventilated location before reusing. Do not touch the
outer part of the mask when reusing it. Use new gloves to
touch the side bands.

CLOTH MASKS
Their use is not recommended by the WHO under any
circumstances. The same applies to homemade masks.
CLINIC 1.8 Architectural Structure (5):

Coating materials, ceramic or not, must have a water absorption

rate of 4% or lower when used in critical areas. Grouting pieces,
when needed, must use material with the same absorption rate.
Using cement without any antiabsorbent additives to grout ceramic
pieces or similar objects is not recommended nor for the walls, not for
the floors of critical areas.

Epoxy, PVC, polyurethane or other coatings intended for wet areas

may be used in critical areas, floors, walls, and ceilings, as long as
they are resistant to washing and to the use of sanitizers and they
are not applied with brushes.. When applied to the floor, they must
also be resistant to abrasion and to impacts.

The use of removable dividers is not recommended in critical areas.

However, pre-fabricated walls may be used as long as they have a
monolithic finishing after installation. Dividers may only be used in
semicritical areas if they are also resistant to washing with water and
soap, and to sanitizing. There should be no visible piping on the walls
and ceilings of the critical and semicritical areas. When these are not
built-in, they must be protected throughout their entire extension by
materials that are resistant to impacts, washing, and sanitizers.

The junction between the skirting and the floor must be made in
such a way that corners can be completely cleaned. Round-shaped
skirting are difficult to build and to clean. Extra attention should
be paid to the junction of the skirting and the wall, so that both
are aligned, in order to avoid the common skirting ledges where
dust accumulates.

Ceilings in critical areas must be continuous and the use of false

removable ceiling plasters, which interfere with the cleaning,
is prohibited. In other areas, these ceiling plasters may be used,
including for maintenance reasons, as long as they are resistant
to the cleaning and sanitizing processes when used in semicritical
areas. The use of protective film on the glasses or brise soleils on the
facade is recommended to protect against the sun and reduce the
amount of dust gathered. The use of blinds is allowed in dental care
services, but its cleaning must be extra rigorous.
 DENTIST
Precautions to be adopted
by the Dentist
DENTIST 2.1 Personal protection care

HEALTH CARE WORKERS

(ONE WHO ASSIST PATIENTS AT A DISTANCE OF 1 METER OR FEWER)

• Wash your hands with water and liquid soap OR a 70% alcohol;
• Wear goggles or a face shield;
• Wear a surgical mask;
• Wear an apron;
• Wear surgical gloves;
• Wear a gown.

2.2 Routine

1 Sanitize shoes with the antibacterial disinfectant rug at the

entrance upon arriving every day.
2 Check body temperature and if it is above 37.8 degrees Celsius,
check if a flu vaccine was taken at least 10 days ago, and go
back home;
3 Remove rings, necklaces, earrings and other accessories.
Wash hands and face with water and soap. Sanitize your
mobile phone with disposable tissues using 70% alcohol.
Disinfect bags that go inside the clinic using a 70 alcohol spray.
All other bags should be stored in a locker. Whenever you need
to handle those bags, don't forget to wash your hands with
water and soap appropriately;
4 Wear shoe covers comprised of 30 grams of polypropylene;

5 Wear adequate-sized gowns comprised of 30 grams of

polypropylene, ensuring that your hair and ears are completely
covered. Wear long-sleeved lab coats/aprons comprised of
30 grams of polypropylene with elastic cuffs and collar.
3/4 length, until the middle of the shin, closed behind, and with
shoulder straps;.
6 Wear N95 face masks and face shields for appointments that
result in a lot of aerosol. To increase the shelf life of N95 masks,
you may cover them with a surgical mask. For appointments
that do not result in aerosols, wear a surgical mask with 3
filters(8). Don’t forget that viruses remain suspended in aerosol,
so for your own safety you should not remove the mask inside
the clinic.
 DENTIST
SURGICAL MASK
Must be worn by all workers involved
in clinical appointments, be replaced
after each appointment or after every
3 to 4 hours in the clinic.

Patients with flu-like symptoms

should wear a mask as soon as they
are identified.

7 Wear goggles with plastic straps or that may be closed from

the side.

8 During appointments in the clinic, wear latex or vinyl gloves,

and whenever you remove the gloves, wash your hands again
and dry them with disposable tissues.

9 During surgeries, hands should be surgically degermed with 2%

chlorhexidine, then dried with a sterile towel. During surgeries,
surgical scrubs should be worn with an impermeable lab coat/
surgical apron on top and sterilized surgical gloves;

CLINICAL RECOMMENDATIONS

Alcohol Based Thermometer Shoe covers

Sanitizer
DENTIST 2.3 Removing personal protection (9) (removing PPE):

• This procedure is extremely important to avoid possible

contamination of health care workers;
1. Remove the gloves;

2. Afterwards, remove the face shield. Start by removing it from behind;

3. Remove the lab coat/apron by pulling it from your shoulders;

 DENTIST
4. Remove the gown first, in a single frontward movement, and the
mask, by the lateral strips, avoiding contact with the contaminated area;

5. To disinfect the face shield, use new gloves;

• Always wash your hands and face at the end of the process, and
wash your hands after each step (or alcohol based sanitizer).
DENTIST
URGENT APPOINTMENTS OF PATIENTS WITH COVID-19
• In cases of irreversible pulpitis in patients with COVID-19, the pulp
should be exposed under absolute isolation with manual chemical-
mechanical methods if possible;
• In case of injury to the soft tissue of patients with COVID-19, sutures
should preferably be made with absorbent strings;
• Any lesion should be slowly watered to avoid pulverization.

2.4 Precautions when leaving the clinic or arriving home

Leave bags, keys, and other When going back home, do not Take off your shoes.
personal objects in a box at the touch anything without washing
entrance of your house. your hands first.

Sanitize your mobile phone and your Remove your clothes and put them Shower and wash the most exposed
goggles with 70% alcohol. in a bag inside the dirty clothes areas, like hands, fists, neck,
basket. Bleach. It is recommended and face, really well.
to use at least 60°.

Rinse your mouth for 01 minute

with Hydrogen Peroxide 1% ,
followed by gargle.
 AUXILIARY STAFF

Precautions to be adopted by
the auxiliary staff
AUXILIARY STAFF 3.1 General precautions of the dental staff

3.1.1 Auxiliary staff (those who assist patients at a distance of

1 meter or fewer):
• Wash your hands with water and soap OR a 70% alcohol based
sanitizer;
• Wear goggles or a face shield;
• Wear a surgical mask;
• Wear an apron;
• Wear surgical gloves;
• Wear a gown.

3.1.2 SUPPORT staff: RECEPTION AND SECURITY (those who need

to be within at least 1 meter from other people):
• Wash your hands with water and liquid soap OR a 70% alcohol
based sanitizer;
• Practice social distancing (at least 1-2 meters from patients);
• Wear a surgical mask.

Observation: replace the mask if it is wet or dirty.

3.1.3 SUPPORT STAFF: HYGIENE AND CLEANING THE

ENVIRONMENT (when cleaning the isolation room/area)
• Frequently wash your hands with water and soap OR a 70% alcohol
based sanitizer;
• Wear a gown;
• Wear goggles or a face shield;
• Wear a surgical mask;
• Wear an apron;
• Wear long rubber gloves;
• Wear long impermeable boots.
 AUXILIARY STAFF
3.2 Precautions for auxiliary staff:

• When booking an appointment, instruct patients and those

accompanying them to inform the reception whether they have
had any flu-like symptoms (such as coughing, a running nose,
fever, or difficult breathing), and to take appropriate preventive
measures like wearing a surgical mask when they enter the clinic,
if possible.

• Keep a distance of at least 1-2 meter from patients who are visibly
infected and wear a disposable mask only when near patients.

• Avoid contact with patient secretions. When disposing of the

patient’s garbage, wear disposable gloves.

• Workers should frequently wash their hands with water and

soap, or clean them with alcohol based sanitizer, especially after
touching objects or other people, or after using the rest room.

• If the patient is accompanied, their company should be instructed

to not enter clinical environments unless needed.

• Workers who are directly involved in clinical appointments in

closed spaces, and who touch and examine patients, must wear
PPE (gowns, masks, aprons, gloves, and goggles). These PPE must
be changed after every appointment, except for the goggles.

3.3 Clinic auxiliary staff routine:

1 Sanitize shoes with the antibacterial disinfectant rug at the

entrance upon arriving every day.

2 Check body temperature and if it is above 37.8 degrees Celsius,

check if a flu vaccine was taken at least 10 days ago, and go
back home;
AUXILIARY STAFF
3 Before entering the clinic, remove rings, necklaces, earrings
and other accessories, store personal belongings in your
locker, wash your hands with water and soap in the rest room,
sanitize your mobile phone with tissues and 70% alcohol.
Sanitize any bags that go inside the clinic using a 70% alcohol
spray. Whenever you need to handle those bags, don't forget
to wash your hands with water and soap appropriately;

4 Wear shoe covers comprised of 30 grams of polypropylene

when entering clinical environments;

5 Wear adequate-sized gowns comprised of 30 grams of

polypropylene, ensuring that your hair and ears are completely
covered. Wear long-sleeved lab coats/aprons comprised of
30 grams of polypropylene with elastic cuffs and collar.
3/4 length, until the middle of the shin, closed behind, and with
shoulder straps;.

6 Wear N95 face masks and face shields during appointments

that result in a lot of aerosol. For appointments that do not
result in aerosols, wear a surgical mask with 3 filters(8). Don’t
forget that viruses remain suspended in aerosol, so for your
own safety you should not remove the mask inside the clinic.

7 Wear goggles with plastic straps or that may be closed from

the side.

8 During appointments in the clinic, wear latex or vinyl gloves, and

whenever you remove the gloves, wash your hands again and
dry them with disposable tissues. If necessary, wear disposable
plastic gloves.

9 During surgeries, hands should be surgically degermed with

2% chlorhexidine, then dried with a sterilized surgical swabs.
During surgeries, surgical scrubs should be worn with an
impermeable lab coat/surgical apron on top and sterilized
surgical gloves;

10 When washing tools, wear thick domestic red cloves.

When boxing them, wear blue ones, and when sanitizing, yellow
ones;
 AUXILIARY STAFF
11 After each appointment, wear thick gloves to remove the tools
from the surgical desk, then place them inside the tapware to
be transported to the sterilization central;

12 If the clothing has been contaminated by organic material, it must

be immediately replaced and disposed of at the hospital waste.

13 After work, remove shoe covers, gloves (without touching

their external side), aprons, gowns, and masks, and dispose
of them at the hospital waste. Protection goggles must be
placed inside a recipient with sanitizing solutions. N95 masks
should be disposed at the hospital waste if they are dirty or
wet. Otherwise, they may be placed at a previously disinfected
location to be reused. Remember not to touch the external
surface of the mask.

14 Wash your hands with water and soap correctly, dry them with
sterilized paper tissues, sanitize with 70% alcohol based sanitizer,
let them dry, collect your belongings at the locker, and go back
home. If your locker is shared with another worker, sanitize it
before leaving.

15 If a patient needs to be sent to another health care service,

always inform that provider how to care for that patient.

CLINICAL RECOMMENDATIONS

Alcohol Based Thermometer Shoe covers

Sanitizer
AUXILIARY STAFF
3.4 Removing personal protection (9) (removing PPE):

• This procedure is extremely important to avoid possible

contamination of health care workers;
1. Remove the gloves;

2. Afterwards, remove the face shield. Start by removing it from behind;

3. Remove the lab coat/apron by pulling it from your shoulders;

 AUXILIARY STAFF
4. Remove the gown first, in a single frontward movement, and the
mask, by the lateral strips, avoiding contact with the contamined area;

5. To disinfect the face shield, use new gloves;

• Always wash your hands and face at the end of the process, and
wash your hands after each step.
AUXILIARY STAFF 3.5 Precautions when leaving the clinic or arriving home:

Leave bags, keys, and other When going back home, do not Take off your shoes.
personal objects in a box at the touch anything without washing
entrance of your house. your hands first.

Remove your clothes and put them

Sanitize your mobile phone and your Shower and wash the most exposed
in a bag inside the dirty clothes
goggles with 70% alcohol. areas, like hands, fists, neck,
basket. Bleach. It is recommended
and face, really well.
to use at least 60°.

Rinse your mouth for 01 minute with

Hydrogen Peroxide 1%, followed by
gargle
 PATIENTS
You play a crucial role as a health care worker in orienting and explaining
to patients on how to prevent virus propagations and contagious
diseases. Explain and calm your patients by telling them that dentists are
trained to work in high biological risk environment.
We have compiled recommendations you can share with patients so that
the appointment is safe for them and you.
PATIENTS 4.1 General precautions patients should take when arriving
at a dental clinic:

• Instruct patients that if they have flu-like

symptoms or a cough, they should wear a face
mask before leaving their homes and follow the
following breathing etiquette:
- Whenever you cough or sneeze, cover your
nose and mouth with your elbow or a tissue;
- Use a disposable tissue to clean your nose
(dispose of it immediately after using, then
wash your hands);
- Avoid touching their eyes, nose, and oral
mucosa;
- Wash their hands.
• Washing your hands and face: hands and face
should be washed with water and soap for
20 seconds.

• If necessary, sanitize the hands with alcohol

based sanitizer.

• Do not touch your face.

• Thermometer: request someone to check your

body temperature.

• Tie your hair and avoid wearing earrings, rings,

and wristbands.
 PATIENTS
• Bags: check if the clinic offers safe storage in
the waiting room, or leave them with someone.
If you decide to enter the clinic with your bag,
it is recommended that you sanitize it with 70%
alcohol spray.

• Wear shoe covers , which are provided by the

clinic (heels make it difficult to use this cover)

4.2. General precautions for patients and those

accompanying them when arriving at a dental clinic

1 Patients and those accompanying them should be instructed

to immediately inform the reception whether they have had
any flu-like symptoms (such as coughing, a running nose, fever,
difficult breathing), and should take appropriate preventive
measures like wearing surgical masks as soon as they enter
the clinic (surgical masks should be available at the entrance,
otherwise, a patient with flu must request them). Practice
social distancing;

2 It is recommended that the patient sanitize their shoes at the

clinic entrance using the antibacterial disinfectant rug;

3 Wash your hands with water and soap for 20 seconds,

dry them with disposable tissues, and sanitize the hands
with 70% alcohol based sanitizer. Let them dry naturally. After
sanitizing, do not touch anything else, including your mobile,
which should remain off.

4 As soon as the patient enters the clinic, an attendant

should check their body temperature with a digital infrared
thermometer and update their medical history (even if it is
a return patient, always ask about viral symptoms or if any
relative, friend, or acquaintance has had any symptoms).
If the patient’s temperature is above 37.8 degrees Celsius,
they should be provided with a face mask and instructed
about possible symptoms, then they should return home, rest,
and seek medical care.
PATIENTS
5 When entering the clinic, remove rings, wristbands, and other
accessories. Turn off mobile phones and place them away,
sanitize bags with 70% alcohol spray.

6 Wear shoe covers comprised of 30 grams of polypropylene;

7 As the virus is sensitive to oxidation, it is recommended to

do a pre-surgery antisepsis (2) 1% hydrogen peroxide in order
to reduce viral loads. Chlorhexidine does not seem to be
effective. This procedure should take place after the consistent
reduction of residual saliva through continuous pumping. It is
recommended that oxidizing compounds be used exclusively
prior to procedures. It is not recommended that they be used
continuously by patients. Pre-procedure rinses (15mL of the
solution for 30 seconds) should take place when the patient is
conscious. Do not use a spittoon. Use the same sink that had
been used for washing the hands and face.

8 Give the patient a 30 gram polypropylene cap and instruct

them to fully cover their hair and ears.

9 Give the patient a 20 gram polypropylene apron with long

elastic sleeves, waist-high shoulder straps that is closed in
the back;

10 Instruct patients to remove the shoe cover when leaving the

clinic, taking care not to touch the sole or the shoe, remove
the gown without touching its external surface, and remove
the apron, then place all of them in the hospital waste.

11 Then, they should return to the restroom to wash their hands

with water and liquid soap, dry them with disposable tissues
and sanitize the hands with 70% alcohol based sanitizer. They
should wait for their hands to dry before going home safely.
 PATIENTS
4.3. General precautions when arriving home

Instruct patients to follow these procedures when arriving home:

Leave bags, keys, and other When going back home, do not Take off you shoes.
personal objects in a box at the touch anything without washing
entrance of your office. your hands first.

Remove your clothes and put them

Sanitize your mobile phone and your Shower and wash the most
in a bag inside the dirty clothes
goggles with 70% alcohol. exposed areas, like hands, fists,
basket. Bleach. It is recommended
neck, and face, really well.
to use at least 60°.

4.4. Dental care to patients with acute viral symptoms

There is high risk of virus transmission in dental care, due to the high
viral load present in high airways and due to likelihood of exposure to
biological material in aerosols generated by procedures.

Especially during the COVID-19 outbreaks, it is recommended that

dental procedures be restricted to urgent cases, which include:
uncontrolled bleeding; facial celulitis or bacteria diffused in soft
tissue, intra-oral or extra-oral infection with swelling that may
compromise the patient’s airways; and trauma involving facial bones
that may compromise the patient’s airways. Urgent cases are those
of extreme pain or risk of systemic deterioration of the patient’s
condition in a short amount of time, and should also be treated.

Please find below guidelines to help decision making and identifying

these cases:
PATIENTS

EMERGENCY
(Situations which increase the patient’s death risk)

• Uncontrolled bleeding.
• Cellulitis or diffuse bacterial infections leading to intra-oral or
extra-oral edemas, and potential risk of damage to airways;
• Facial bones trauma, which may damage the patient’s airways.

URGENT
(situations which require priority care but do not increase the
patient’s death risk)

• Acute dental pain (Pulpitis).

• Pericoronitis.
• Alveolitis.
• Dental or periodental abscesses.
• Dental fractures that lead to pain or trauma in soft oral tissue.
• Dental care needed for another critical medical procedure.
• Cementation fixed prosthodontics or crowns.
• Biopsies.
• Adjustments of orthesis and prosthesis that cause pain and
compromise chewing function.
• Finalizing the treatment or changing intracanal medication.
• Removal of extensive dental caries or restorations that
cause pain.
• Treatment of tissue necrosis.
• Mucositis.
• Dental trauma with avulsion or luxation.
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implications for control of severe acute respiratory syndrome coronavirus
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and controls in dental practice. Int J Oral Sci. 2020 Mar 3;12(1):9.

3.Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus

(2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020.
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anvisa nº 04/2020 orientações para serviços de saúde: medidas de prevenção
e controle que devem ser adotadas durante a assistência aos casos suspeitos
ou confirmados de infecção pelo novo coronavírus (sars-cov-2). (updated
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8dcf5820-fe26-49dd-adf9-1cee4e6d3096. Access on: April 05, 2020.

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inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect.
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https://www20.anvisa.gov.br/segurancadopaciente/index.php/legislacao/item/
rdc-15-de-15-de-marco-de-2012. Access on: April, 06, 2020.

8.Agência Nacional de Vigilância Sanitária. Nota técnica nº 08/2020. Available

at: http://portal.anvisa.gov.br/documents/219201/4340788/NOTA+TÉCNICA+8+-
+CORONAVÍRUS+2.pdf/75797abb-1bf5-4eb6-99e1-a1238269e30a. Access on:
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gov/hai/pdfs/ppe/ppe-sequence.pdf Access on: April, 14, 2020.

Attention!
This manual does not replace the World Health Organization’s guidelines nor those
of other related organs. Likewise, it does not replace specific instructions for use
of the mentioned products. It is the dental care worker’s exclusive responsibility to
evaluate each clinical case before using products or applying techniques presented
in this manual.

The guidelines in this manual were based on the evidence available at this moment
(April/2020). They do not guarantee that contamination will be prevented, and they
may be changed in face of new evidence.

© 2020 – JJGC Indústria e Comércio de Materiais Dentários S.A. All rights reserved.
Neodent is a registered trademark of JJGC Indústria e Comércio de Materiais Dentários
S.A. Yller is a registered trademark of YLLER BIOMATERIAIS LTDA. Straumann and
ClearCorrect are registered trademark of STRAUMANN HOLDING AG.
togetherstrong

Scientific support:

Institutional support:

490.621/en/A/00 04/20