Risk management  principles for dentistry - During the COVID-19 pandemic

Document version: Version 1

Date: 22 October 2021

Preface

This document supplements the ADA COVID-19 Risk Management Guidance document published in August 
2020, and the Managing COVID-19 Guidelines published in March 2020. These Risk Management Principles for Dentistry replace the ADA Restrictions Levels framework.

Evidence continues to emerge that improves our understanding of the effectiveness of risk reduction strategies in the dental care setting. Most of these have already been adopted by the dental profession in Australia.

As the pandemic persists, the effects of delaying medical and dental care are evident. All health professions are faced with the challenge of facilitating access to care with an enhanced understanding of COVID-19 transmission and effective, sustainable strategies to reduce risks.

The following Risk Management Principles for Dentistry outline how to apply evidence-informed infection control measures within a broader risk-based approach. These Principles are based on the ‘hierarchy of 
controls’ framework summarised in Figure 1.

This document does not replace the need for clinical judgement based on the individual presentation and 
modifying factors, or the requirement to comply with your current state and federal health directives. The advice from public health regulators and State-based organisations may change rapidly, and it is critical that practices remain informed of current local requirements. 

This document describes the management of risks using terms consistent with the COVID-19 Communicable 
Disease Network Australia (CDNA) guidelines, however your jurisdiction may use different terms.

Risk Assessment and Management Assessment and management of risk remains a key responsibility of dental practitioners providing care during the current COVID-19 pandemic. Information on risk management in the context of COVID-19 is available from the Australian Commission on Safety and Quality in Health 
Care (ACSQHC).  
One of the key principles underpinning the Risk Management Principles for dentistry during the COVID-19 
pandemic is recognition that some strategies will be more effective in controlling risk. Wherever possible, a risk should be identified and eliminated. If it is not possible to eliminate the risk, the likelihood and consequences should be analysed, evaluated and managed by applying appropriate controls.

The 4 systems outlined by the Infection Control Expert Group that dental practitioners can control to mitigate 
COVID-19 transmission risks in practice are: 
• Screening (elimination)
• Preparation of facilities (engineering controls)
•  Planning, protocols and procedures  
(administrative controls)
• PPE

Appendices are provided to demonstrate key concepts within the Risk Management Principles.
Appendix 1.  Examples of risk management controls  
in dentistry
Appendix 2. Example of a screening protocol
Appendix 3.  Summary of risk-based infection  
control precautions
Appendix 4. Glossary of common terminology
A reference list for the Risk Management Principles for 
Dentistry during the COVID-19 pandemic is available  
as a separate document.
Vaccination
Vaccination is an essential community-wide measure for 
reducing the spread of disease to dental staff and patients 
and may influence the overall assessment of risk. 
It is important to note that breakthrough infections can 
occur among fully vaccinated persons. Since vaccinated 
individuals may have reduced symptoms, risk management 
controls beyond screening will remain important when 
there is COVID-19 transmission in the community.
Further information on workplace health and safety 
including information in relation to vaccination can be 
found on the ADA HR hub.
Screening
Screening typically involves the use of questions relating 
to epidemiological and clinical risk factors for COVID-19. 
It may also include temperature and/or COVID-19 testing. 
Screening is performed to determine that members of the 
workforce, patients and visitors do not meet the current 
Australian definition of a suspect, probable or confirmed 
COVID-19 case. Case definitions may change from time 
to time and are available from CDNA Series of National 
Guidelines (SONG) COVID-19 Guidelines. Case definitions 
available at the time of writing this document are provided 
in Appendix 4. Glossary of common terminology.
Assessment of COVID-19 risk should be determined 
by screening the workforce, patients, and visitors for 
epidemiological and clinical risk factors for COVID-19 
while considering current public health advice and state or 
territory regulations, local epidemiology, and community 
transmission of COVID-19.  
Screening protocols are adopted on presenting to the 
clinical setting but are also typically performed in advance 
to assess and manage the risks prior to attendance (e.g. 
phone call, SMS). An example of a screening protocol can 
be found in Appendix 2.

Where risk criteria are identified, systems should be in 
place to manage patients appropriately. This may include 
appointing a suitable person (e.g. a senior clinician) to 
assess whether treatment should be deferred or if it is 
appropriate to provide treatment, and if so, what additional 
patient management and infection control processes may 
be required. Consideration should be given as to how to 
manage patients who may be poor historians and/or may 
not have the capacity to answer COVID-19 screening or risk 
assessment questions accurately. 
If a patient requires a support person, this person should 
also be screened. Minimising the number of people in the 
facility by encouraging only one support person to attend 
will assist with social distancing and reduce the overall risk 
that a person with COVID-19 will enter the facility

When it is determined that a patient is known or 
suspected to have COVID-19, the risk of transmission 
should ideally be eliminated by deferring treatment. If 
care cannot be safely deferred, the practice will need to 
determine if they have the appropriate facilities, protocols, 
PPE and infection control to provide care. If the facility is 
retrospectively notified about the exposure of a worker, 
patients or visitor to COVID-19 contact should be made 
whith the state or territory health department and/or ADA 
Branch to assist with management.
Preparation of facilities
The preparation of a dental facility1 may include measures 
to ensure that physical distancing, patient flow, ventilation, 
single operatory and negative pressure room availability has 
been assessed and implemented in the management plan 
for the facility. 
It is critical to determine what transmission-based infection 
prevention control precautions can be provided in the 
facility. For instance, if facilities are not available for the safe 
management of a COVID-19 positive patient, a clinic will 
need to plan to refer these patients to another facility. 
Practical dental facility measures in the context of the 
COVID-19 pandemic include:
•  Use signage at the facility entrance asking patients not 
to enter if they are unwell or have COVID-19 symptoms, 
have been tested for COVID-19 and are awaiting test 
results, have been in contact with anyone diagnosed or 
suspected to have COVID-19, or have been in an area 
identified as high risk for community transmission 
•  Adopt ‘check in’ points and processes consistent with 
recommendations from the state or territory jurisdiction. 
•  Implement a process to safely screen patients for 
COVID-19 symptoms and epidemiological factors on 
entry to the facility. 
•  Remove all high touch, unnecessary items in communal 
areas e.g. toys and magazines.
•  Use appropriate measures to remind patients of the 
need for hand hygiene, cough etiquette and physical 
distancing. Household members who are normally in 
close contact can be permitted to sit together, and 
patients may also be given the option to wait in their 
vehicle if practical. 
•  Provide facilities to enable hand and respiratory hygiene 
such as alcohol-based hand rub (ABHR), hand washing 
facilities, tissues, and rubbish bins. Ensure all patients 
undertake hand hygiene prior to sitting in the  
waiting area.

Protocols
To help mitigate the risk of COVID-19 transmission, 
organisations should adopt the following protocols: 
•  Follow the requirements stated by local public health 
authorities, including those regarding limitations on the 
movements of people and the range of services that can 
be provided.
•  Maintain a current risk management plan in response  
to COVID-19. 
•  Use protocols to screen the workforce, patients and 
visitors for risks of COVID-19.
•  Comply with physical distancing requirements except 
when this is not possible such as when providing care. 
•  Ensure compliance with standard and transmission
based precautions in accordance with the current  
ADA Guidelines for Infection Prevention and Control.
•  Adopt PPE protocols (and ensure PPE availability) 
appropriate to care being provided.
•  Provide the opportunity for patients to perform hand 
hygiene prior to leaving the treatment area as patients 
may have contaminated their hands with saliva (such as 
when inserting and removing dental appliances).
•  Frequent cleaning of high-touch surfaces with detergent 
solution and then disinfection wipe/solution (or with a 
combined detergent/disinfectant product). The ADA’s 
Environmental Cleaning and Disinfection Guidance 
in the context of COVID-19 document outlines the 
recommended environmental cleaning and disinfection 
processes based on a risk assessment including 
individual patient risks as well as community risks of 
disease transmission. 
Staff training, rehearsing of protocols and compliance 
monitoring should be part of a current risk management 
plan. It is imperative to ensure that all staff have completed 
infection prevention and control training relevant to 
COVID-19 including the use of appropriate personal 
protective equipment. 
Dental Procedure Considerations
Guidance may be provided by state, territory or local health 
authorities and/or associations when there are specific 
requirements to defer certain types of treatments for  
local areas.
General principles that may assist in the management of 
procedural risks in dentistry are: 
•  The use of dental dam significantly reduces 
aerosolisation of saliva.
•  The routine use of high-volume evacuation significantly 
reduces the number of aerosols present in the 
environment.
•  It has been recommended by the National Health and 
Medical Research Council (NHMRC) that a 30-minute 
fallow time, is used where airborne precautions are 
required. Fallow times are not required for all AGPs 
in all patients. (See Appendix 3).
•  There is some evidence that the following commercially 
available mouth rinses when used before dental 
treatment reduce the viral load in saliva: - - - - - 
Hydrogen peroxide (0.5-1.0%).
Essential oils (Listerine™).
Cetylpyridinium chloride (0.07-0.1%).
Povidone iodine solutions (0.23%-1%). 
Chlorhexidine (0.12-0.2%).
Freshly generated ozonated water can also be used 
as a preprocedural mouth rinse provided the ozone 
concentration is at least 0.1ppm.
For supporting references, refer to the manufacturer’s 
instructions and the section on mouth rinses in the 
reference list.
If patients are unable to undertake a pre-procedural mouth 
rinse (e.g. young or special needs) consider providing 
topical mouth cleansing with gauze soaked in mouth rinse, 
focusing on wiping the buccal mucosa and dorsal  
tongue surface.

PPE and additional infection 
control considerations
PPE serves as the last line of defence against transmission 
of COVID-19. Transmission of COVID-19 can occur through 
direct, indirect, or close contact with infected people 
through saliva and respiratory secretions expelled through 
coughing, sneezing, talking, singing (‘aerosol generating 
behaviours’) or aerosol generating procedures. 
Standard precautions are required for all patients 
regardless of known COVID-19 status. Standard precautions 
consist of: 
1. 
2. 
3. 
4. 
5. 
6.  
7. 
8. 
Hand hygiene
PPE
Respiratory & cough etiquette
Aseptic technique
Routine environmental cleaning
Appropriate reprocessing of reusable  
medical devices
Safe handling of sharps
Linen and waste management
Since COVID-19 may be transmitted by contact, droplets or 
airborne particles, transmission-based precautions are 
adopted for patients with known or suspected COVID-19 
including the use of:-  - - 
Disposable single use long sleeved fluid  
resistant gown
P2/N95 respirator
Full face shield or visor
Dental team members using a P2/N95 respirator should 
be trained in their correct use. Fit testing is recommended 
as the gold-standard to ensure that the P2/N95 respirator 
is appropriate for the person wearing it. As a minimum, a 
well-fitting respirator that has been fit-checked to ensure at 
the time of each use that there is an airtight protective seal 
should be adopted.
If a suitable respirator cannot be found, or if facial hair 
impedes an adequate seal, an alternative respirator (e.g. 
powered air-purifying respirator) should be considered.
Follow the proper procedures for donning and doffing  
of PPE. 
See Appendix 3. A summary of risk-based infection control 
precautions   
All patient surrounds and frequently touched objects are to 
be cleaned with a Therapeutic Goods Administration (TGA) 
registered Hospital Grade Disinfectant using either a 2-step 
clean, which involves a physical clean using detergent 
solution followed by use of a chemical disinfectant; OR a 
2-in-1 clean in which a combined detergent/disinfectant 
wipe or solution is used and mechanical/manual cleaning 
action is involved.
Follow the manufacturer’s instructions for correct use of  
the product(s).
Patients with known or suspected COVID-19 should be 
asked to wear a surgical mask at all times when access to 
the mouth is not required (e.g. moving around the clinic or 
when taking a history). 
If AGPs are not being performed for suspected 
COVID-19 patient (e.g., assessment only):
Use negative pressure rooms where available. If a negative 
pressure room is not available, use a standard isolation 
room or single room with negative airflow. Avoid rooms 
with positive pressure airflow. 
If AGPs are being performed for suspected 
or any procedure for a confirmed COVID-19 
patient:
Patients must be placed in a negative pressure room.
Do not proceed with a procedure if the facility does 
not have the correct set up/PPE to manage any 
assessed risk.
Further information about adoption of standard and 
transmission-based precautions in a dental setting can  
be found in the ADA Guidelines for Infection Prevention 
and Control.

Appendix 4. Glossary of common terminology 
Aerosol generating procedure: (AGPs) in dentistry 
include procedures that use any of the following devices: 
high speed handpieces, low speed/prophy handpieces, 
surgical handpieces, ultrasonic and sonic devices, air 
polishing devices, and hard tissue lasers. The triplex when 
air and water are used together or when used with air on a 
wet surface is considered an AGP.
COVID-19: Coronavirus disease 2019. The name of the 
disease caused by the virus SARS-CoV-2, as agreed by the 
World Health Organization, the World Organisation for 
Animal Health and the Food and Agriculture Organization 
of the United Nations.
Close contact: a definition used to rapidly identify all 
persons who may be incubating the disease. These are 
generally defined as primary close contact, a casual contact 
and secondary close contact. These classifications are made 
at the discretion of the public health unit when contact 
tracing. (See CDNA Guidance for further details on different 
contact types).
Confirmed case: a patient with COVID-19 as confirmed 
by laboratory definitive evidence (see CDNA guidance for 
testing protocols).
Fallow time: a period in which the room is ‘rested’ before 
being used again to allow aerosols suspended in the air to 
settle. They can then be removed through environmental 
cleaning processes. There is variable evidence for the use 
of specific fallow times. It has been recommended by the 
National Health and Medical Research Council (NHMRC) 
that a 30-minute fallow time is used where airborne 
precautions are required.
Fit check: ensures the respirator fits the user's face snugley  
(ie. creates a seal) to minimise the number of particles that 
can then bypass the filter through gaps between the user's 
skin and the respirator seal.
Fit test: a validated method for matching P2/N95 
respirators with an individual's face shape (performed by an 
appropriately trained person)
Negative pressure room: a negative pressure room is 
a room in which air flows from hallways and corridors 
(cleaner areas) into the isolation room to prevent cross
contamination and spread of the virus. In Australia, facilities 
for the management of patients for which airborne 
precautions are indicated (including negative pressure 
rooms) should comply with the guidelines outlined by the 
Australasian Health Infrastructure Alliance.
SARS-CoV-2: Severe acute respiratory syndrome 
coronavirus 2. The formal name of the coronavirus that 
causes COVID-19, as determined by the International 
Committee on Taxonomy of Viruses.
Suspect case: those who may have an increased likelihood 
of current SARS-CoV-2 infection. A person who meets the 
below clinical and epidemiological criteria as defined in 
the CDNA COVID-19 SoNG:
Clinical evidence (in the past 14 days):
•  Fever (≥37.5 °C) or history of fever (e.g. night sweats, 
chills); or
•  Acute respiratory infection (e.g. cough, shortness of 
breath, sore throat); or
• Loss of smell or loss of taste.
Epidemiological evidence (in the past 14 days):
• Close contact with a confirmed case
•  International travel, with the exception of green zone 
countries 
•  Workers supporting designated COVID-19 quarantine 
and isolation services
• International border staff
• International air and maritime crew
•  Health, aged or residential care workers and staff with 
potential COVID-19 patient contact
•  People who have been in a setting where there is a 
COVID-19 case
•  People who have been in areas with recent local 
transmission of SARS-CoV-2.
9
Risk management principles for dentistry
Urgent treatment: Management of patients with urgent 
needs or where deferring care is likely to lead to adverse 
health outcome such as uncontrolled bleeding, infection 
or trauma. The ADA recommends deferring non-urgent 
care if a patient is known or suspected to have COVID-19. 
Dental practitioners are trained in the triage prioritisation 
of emergency and urgent care and some organisations 
(such as health departments) will produce their own triage 
documents. An example of such a document from the 
American Dental Association can be accessed here:

Key reference organisations 
ACSQHC: The Australian Commission on Safety and Quality 
in Health Care is a corporate Commonwealth entity and 
part of the Health portfolio of the Australian Government. 
It’s purpose is to contribute to better health outcomes and 
experiences for all patients and consumers, and improved 
value and sustainability in the health system by leading 
and coordinating national improvements in the safety and 
quality of health care. 
ADA Branches: Australian Dental Association Branches 
(States and Territories) assist members to access, interpret 
and apply local and regional guidance in relation to 
infection prevention and control requirements.  
ADA ICC: The Australian Dental Association Infection 
Control Committee synthesise national requirements, 
recommendations and research evidence to assist 
practitioners with implementing relevant infection control 
and prevention in a dental setting including through 
publication of the ADA Guidelines for Infection Prevention 
and Control. 
AHPPC: The Australian Health Protection Principal 
Committee is the key decision-making committee for 
health emergencies. It is comprised of all state and territory 
Chief Health Officers and is chaired by the Australian Chief 
Medical Officer. 
CDNA: Communicable Disease Network Australia provide 
nationally consistent advice and guidance to public health 
units in responding to a notifiable disease event. 
DBA: The Dental Board of Australia regulates dental 
practitioners in Australia under the National Registration 
and Accreditation Scheme (the National Scheme).
ICEG: The Infection Control Expert Group advises the 
Australian Health Protection Principal Committee (AHPPC) 
and its other standing committees on infection prevention 
and control issues. 
NHMRC: The National Health and Medical Research Council 
provides research funding, health guidelines and ethical 
standards for the health sector including the Australian 
Guidelines for the Prevention and Control of Infection in 
Healthcare (2019).
State and Territory Governments: provide directives, 
hotspot information and travel restriction information: 
• Australian Capital Territory COVID-19
• New South Wales COVID-19
• Northern Territory COVID-19
• Queensland COVID-19
• South Australia COVID-19
• Tasmania COVID-19
• Victoria COVID-19
• Western Australia COVID-19