COVID-19 pandemic: multilevel dental technical guidelines based on new scientific evidence

Andrade, Sérgio Araújo; Lima, Raissa Emanuelle; Varotti, Fernando de Pilla; Abdelwahab, Omar; Lwaleed, Bashir Abdulgader

doi:10.31744/einstein_journal/2022AE6307

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Special Article • Einstein (São Paulo) 20 • 2022 • https://doi.org/10.31744/einstein_journal/2022AE6307 copy

COVID-19 pandemic: multilevel dental technical guidelines based on new scientific evidence

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The COVID-19 pandemic imposed restrictive measures on dentistry in different regions of the world, ranging from stoppage of care to only permission for urgent and emergency dental services. Thus, new biosafety guidelines for resuming activities, whether in single dental offices, large clinics or dental education activities, are urgently required. In this sense, herein, guidelines that incorporate common points of the main protocols found in the literature for the resumption of dental activities at their different levels, whether in the scope of care or education, are presented. Furthermore, we present the incorporation of measures that allow an increase in the level of biosafety, such as the control of the dental team, the inclusion in the history of conjunctivitis as a possible alert for COVID-19, and the use of the pulse oximeter to assess the risk of silent hypoxemia, which may indicate a complication of COVID-19. In addition, new perspectives for directing research and innovation for biosafety in dentistry are discussed.

Keywords:
Coronavirus infections; COVID-19; SARS-CoV-2; Pandemics; Betacoronavirus; Guideline; Dentistry; Dental care; Containment of biohazards; Telescreening, medical; Personal protective equipment

Advices	Description
Dental staff controls	Dental workers with comorbidities (hypertension, diabetes, cardiorespiratory and/or cerebrovascular diseases, and cancer) and/or elderly should be removed from the frontline of clinical care, undertaking only administrative activities or teletriage(⁴4 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... )
	Dental workers with suspected or confirmed case of COVID-19 should be removed from the clinical frontline and kept under medical care(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... )
	Asymptomatic dental workers should be monitored and tested for COVID-19(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
Engineering controls	Installation of physical barriers that maintain a minimum distance of 2m between people, whether they are patients and/or professionals(⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	Adequate ventilation with air flow directed from clean to less clean(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... )
	Allow 20 to 30 minutes between consultations to ensure sufficient time for cleaning, disinfection, sterilisation and renewal of ambient air. In the waiting room, social distancing should be observed and strictly adhered to, magazines should be removed, as well as ornaments and toys and, if possible, avoid the presence of escorts. Intelligent scheduling for the patient to arrive at the dental office and be cared for “just in time”(⁴4 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... –⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Preferably, use an individualised dental office. In the case of dental clinics with a large number of chairs, a spacing between chairs of at least 2m should be promoted, which must be positioned parallel to the air flow, with physical barriers between chairs. If available, consider the use of a portable HEPA air filtration unit in all types of dental offices(⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... )
	Use of plastic film in handle-able locations (e.g. door handles, equipment hand-pieces, handles of reflectors and keyboards)(⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Avoid the use of a spittoon, prioritising, if possible, the use of high volume suction to minimise aerosol(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)

Stage	Measures applied
Telephone or video conference triage	Perform anamnesis for assessment of the patient for the presence of signs and symptoms of COVID-19, with careful tracking of all professionals who were in contact with a COVID-19 positive individual.(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁵5 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.–⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.) In this context, attention should be drawn to the suspicious signs of COVID-19: fever >37.8°C, conjunctivitis, chill, cough, shortness of breath, fatigue, muscle or body pain, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, or vomiting, diarrhea, which appear 2 to 14 days after exposure to the virus. The presence of indicative signs of severity for COVID-19 should be assessed, including breathing difficulties, persistent pain or pressure in chest, confusion, difficulty keeping awake and bluish lips(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,²⁵25 Loffredo L, Pacella F, Pacella E, Tiscione G, Oliva A, Violi F. Conjunctivitis and COVID-19: a meta-analysis. J Med Virol. 2020;92(9):1413-14.,³¹31 Hu K, Patel J, Swiston C, Patel BC. Ophthalmic Manifestations Of Coronavirus (COVID-19). 2022 Jan 8. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.,³²32 Scalinci SZ, Trovato Battagliola E. Conjunctivitis can be the only presenting sign and symptom of COVID-19. IDCases. 2020;20:e00774.)
	Check the real need for a face-to-face consultation, through a history taking focused on the basic concepts of: – Emergency: situations involving the risk of death of the patient, such as airway obstruction and uncontrolled hemorrhage – Urgency: refers to cases of severe pain and/or infection – Elective procedure: refers to the scheduled consultation where there is no setting that requires emergency(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
	If available, use teledentistry, which includes remote patient assessment and medication prescription. This remote prescription includes analgesics, anti-inflammatory and/or antibiotics, according to the disease condition, patient preferences, possible complications, and the possibilities coming from the local public health departments(⁵5 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	Special attention should be given to elderly individuals and/or with comorbidities: if asymptomatic for COVID-19, only urgent or emergency care should be prioritised, and, if available, the possibility of home care should be considered. In turn, if infected with COVID-19, the elderly patient and/or with comorbidities should be referred to a hospital to assess the risk and benefit of urgent or emergency dental care(¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	History-taking should be repeated for each new patient consultation request(¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
Care in the face-to-face appointment	Patient must wear a face mask and perform hand hygiene with soap or alcohol 70°(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	Measure temperature, and, if >37.8°C, consider fever(⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Check oxygen saturation levels with pulse oximeter and, if <93%, refer to medical care due to the risk of silent hypoxemia(²⁷27 Tobin MJ, Laghi F, Jubran A. Why COVID-19 silent hypoxemia is baffling to physicians. Am J Respir Crit Care Med. 2020;202(3):356-60.–²⁹29 Dondorp AM, Hayat M, Aryal D, Beane A, Schultz MJ. Respiratory support in COVID-19 patients, with a focus on resource-limited settings. Am J Trop Med Hyg. 2020;102(6):1191-7. Review.)
	Repeat the triage history for COVID-19 before appointment(⁵5 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	Consider the use of a rapid test for COVID-19 since it has high specificity and sensitivity(⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... )
	Use of FFP2, N95 or FFP3 respirators for procedures with no generation of aerosols. However, in suspected or confirmed cases of COVID 19 and/or for any aerosol-generating procedure, it is ideal to use respirators, FFP3, N99 or N100 without exhalation valves(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.,³⁰30 Centers for Disease Control and Prevention (CDC). Healthcare Workers. Strategies for optimizing the supply of N95 respirators. CDC; 2020 Nov 23 [cited 2020 Aug 19]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html https://www.cdc.gov/coronavirus/2019-nco... )
	Priority should be given to emergency and urgent care, postponing elective procedures, avoiding adverse impacts on the patients’ conditions due to delayed care. If possible, carry out the entire treatment in a single consultation(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... ,⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Preferably, perform minimally invasive procedures, such as using excavators, chemical agents for tooth decay removal, and rubber dam to minimize the spread of microorganisms(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁵5 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.,⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Avoid procedures that produce aerosol (e.g. dental turbines, micro motor hand piece, ultrasonic scalers, air/water syringe and sodium bicarbonate powder jet), or procedures that lead to increased salivation, retching or coughing, such as an intraoral radiographic examination and impression. Otherwise, tomography or extra oral radiographic technique should be used(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁵5 Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19 pandemic. Saudi Dent J. 2020;32(4):181-6.–⁸8 Occupational Safety and Health Administration (OSHA). COVID-19 - control and prevention. Dentistry workers and employers. Occupational safety and health administration. Washington (DC): OSHA; 2020 [cited 2020 Aug 8]. Available from: https://www.osha.gov/SLTC/covid-19/dentistry.html https://www.osha.gov/SLTC/covid-19/denti... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.)
	Use PPE, such as goggles, face shields, gloves, apron, long-sleeved disposable fluid repellent coverall, surgical cap and, foot cover, in addition to adoption of work uniform (consider washing the uniform using the hospital services or specialised laundry facilities).(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,⁶6 Centers for Disease Control and Prevention (CDC). COVID-19 (Coronavirus disease). Healthcare Workers. Guidance for dental settings. Interim Infection prevention and control guidance for dental settings during the coronavirus disease 2019 (COVID-19) Pandemic. Atlanta: CDC; 2020 Dec 4 [cited 2020 May 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE https://www.cdc.gov/coronavirus/2019-nco... –⁹9 Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020;21(2):56-7.,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... ,¹⁹19 Clarkson J, Ramsay C, Aceves-Martins M, Brazzelli M, Colloc T, Dave M, et al. Recommendations for the re-opening of dental services: a rapid review of international sources (substantial update 16 May 2020). Cochrane Database Syst Rev. 2020. p. 6-45.) Change PPE at each appointment to avoid cross-contamination and spread of infection(⁷7 American Dental Association (ADA). As dental practices resume operations, ADA offers continued guidance: recommendations include changes before, during and after appointments to protect patients and dental team. Chicago: ADA; 2020 May 21[cited 2020 Aug 8]. Available from: https://www.ada.org/en/press-room/news-releases/2020-archives/may/as-dental-practices-resume-operations-ada-offers-continued-guidance?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-continuedguidance-statement&utm_campaign=covid-19# https://www.ada.org/en/press-room/news-r... ,¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )

Modality	Features
Theoretical classes	Maintaining remote on-line activities, preferably with live classes to promote students/lecturers interaction(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
Theoretical classes	Use of education tools, such as participation in on-line seminars, case-based discussions or problem-based learning, and clinical videos(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
Laboratory classes	Pre-clinical didactic videos(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
	Use of PPE suitable for staff and students. Maintaining social distance of 2m, imposing physical barriers and insuring appropriate levels of air flow(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
	Use of virtual reality tools, if available(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
General measures	Insuring that preventive and therapeutic psychological support are in place for students against psychological stress, anxiety and fear caused by the uncertainties arising from the COVID-19 pandemic(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
Clinical practices	It should be understood that the techniques of provision of the clinical care is the main component in the training of students in dentistry.(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.) Thus, these activities can be postponed, but preparations should be made to deliver sufficient clinical training in an optimal way when it is safe to do so
	It should be acknowledged that there is no way that virtual, on-line or remote tools can replace face-to-face clinical care activities(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
	Consider the recommendations of PPE, engineering controls, proper social distancing and patient flow for cases of clinics with multiple chairs
	Whenever possible, face-to-face urgent and emergency care should be considered. Special measures should be put in place in case of infected or suspected patients with COVID-19, ensuring strict social distancing and anti-infection measures are taken. Another technique worthy of implementing is to divide the patients into groups based on the presence or absence of aerosol generation. They then should be directed into different areas within the practice room. The separation of patients should minimise the risk of spread of COVID-19 as well as enable tracking in case of contamination(³3 Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99(5):481-7.,²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
	Similarly, the service teams should be separated to reduce the risk of infection and to facilitate contact tracking in the event of contamination. Thus, a lecturer should be kept in tutoring a specific and reduced number of students(¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	The temperature should be checked and history taken daily, regarding the signs and symptoms of COVID-19, maintaining confirmed and suspicious cases, as well as professors, students and patients from risk groups at home and, when necessary, under medical care(¹¹11 National Health Service (NHS). COVID-19 guidance and standard operating procedure. For the provision of urgent dental care in primary care dental settings and designated urgent dental care provider sites. Version 3 (updated 28 August 2008). United Kingdom: NHS; 2020 [cited 2020 Aug 8]. Available from: https://bda.org/advice/Coronavirus/Documents/covid-19-urgent-dental-care-sop.pdf https://bda.org/advice/Coronavirus/Docum... )
	Consider using rapid tests for COVID-19 on staff and patients(²⁶26 Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020;84(6):718-22. Review.)
Continued education	Strong migration trend from traditional conferences to webinars and on-line courses(⁴4 Views from around the world. Evid Based Dent. 2020;21(2):39-41.,⁴²42 Porpiglia F, Checcucci E, Autorino R, Amparore D, Cooperberg MR, Ficarra V, et al. Traditional and virtual congress meetings during the COVID-19 pandemic and the post-COVID-19 era: Is it time to change the paradigm? Eur Urol. 2020;78(3):301-3.)
Continued education	Use of on-line tools that allow audiovisual interaction in real time(⁴²42 Porpiglia F, Checcucci E, Autorino R, Amparore D, Cooperberg MR, Ficarra V, et al. Traditional and virtual congress meetings during the COVID-19 pandemic and the post-COVID-19 era: Is it time to change the paradigm? Eur Urol. 2020;78(3):301-3.)

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[1] Corresponding author: Sérgio Araújo Andrade Avenida Sebastião Gonçalves Coelho, 400 – Chanadour Zip code: 35501-296 – Divinópolis, MG, Brazil. Phone: (55 37) 3221-4657 E-mail: saandrade@ufsj.edu.br