A Summary of Updated Interim IPAC Recommendations from Public Health Ontario

Update: December 28th, 2021


Ontario’s Chief Medical Officer of Health (CMOH) has revised Directive #1 that was first announced December. 17th. The updated directive sets out new requirements for all health care providers. These updated directives have been made in response to increasing community transmission of the new Omicron variant of concern, and in compliance with the CMOH’s revised Directive.

What this means for dentists? Effective immediately, dentists must adhere to the following new requirements:

  • Dentists must don a fit-tested, seal-checked N95 respirator (or the equivalent, as approved by Health Canada) for all in-person patient interactions and for the provision of all direct clinical care.
  • Dentists must ensure that all staff don a fit-tested, seal-checked N95 respirator (or the equivalent, as approved by Health Canada) for all in-person patient interactions except where there is a physical partition or barrier between office staff and patients.
  • Dentists and staff who are not yet fit-tested for an N95 respirator must don a well-fitted surgical/procedure mask, a KN95 respirator, or a non-fit-tested N95 respirator (or the equivalent, as approved by Health Canada). Dentists must make reasonable efforts to ensure that all staff who are not yet fit-tested for an N95 respirator obtain fit testing at the earliest opportunity.

These changes are effective immediately and are in place until further notice.

Dentists must continue to adhere to all additional precautions as set out in RCDSO’s COVID-19: Managing Infection Risks During In-Person Dental Care guidance document which is outlined below with a link to the full document at the bottom.

Here at maxill, we want to keep your practice at ‘best practice’ to help you keep yourself, your staff, and your patients as safe as possible. This is why we have infection control experts on staff and sales representatives that are ready to go above and beyond to answer your questions and provide you with quality products priced competitively. We also have a convenient online shopping option for quick and easy ordering of:

As new information evolves around the new Omicron B.1.1.529 variant, best practice around reducing transmission in healthcare settings also evolves. As a large majority of dental professional’s work in environments that include performing high levels of aerosol-generating procedures and similar high-risk procedures, it is especially important to always be reevaluating infection control best practices.

The latest interim IPAC recommendations incorporates evidence to date on modes of transmission, effectiveness of personal protective equipment in healthcare workers and the undetermined impact of the emergence of the Omicron (B.1.1529) variant of concern. It is important to note that these are interim recommendations and will continue to be evaluated and updated as more information surrounding Omicron becomes available.

Read The Entire IPAC Recommendations Report

Summarized IPAC Guidance from Different Jurisdictions:

General recommendations from a review of guidance on infection prevention and control and personal protection from Public Health Ontario, CDC, WHO, Alberta, British Columbia (BC), PHAC, and multiple United Kingdom (UK) jurisdictions include the following:

  • All jurisdictions emphasize the use of a Hierarchy of Controls. This approach employs multiple levels of assessment to identify appropriate interventions to prevent transmission.
  • For standard care of patients with suspect or confirmed COVID-19, WHO, Alberta, BC, PHAC and multiple UK jurisdictions recommend surgical/procedure (medical) masks. CDC preferentially recommends the use of N95 respirators, with medical masks as an alternative minimum standard.
  • In all jurisdictions, an N95 respirator (or equivalent or greater protection) is recommended when aerosol generating procedures are being performed.
  • All jurisdictions recommend that N95 respirators be considered when the organizational and/or personal assessments determines there is a significant risk of transmission when all elements of hierarchy of controls have been addressed as best as possible. However, detailed guidance on risk assessment is generally not provided outside of aerosol generating medical procedures (AGMPs).

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Expanded guidance on ORA, PCRA and HOC to include more details on risk assessment of control measures:

ORA: An Organizational Risk Assessment (ORA) is a systematic approach to identifying areas of infection risk and assessing the efficacy of control measures that are in place to mitigate the transmission of infections in the health care setting. Organizational risk assessment of the efficacy of the most important control measure, elimination, would center on vaccination status of HCWs in the organization. Engineering control measures include care and maintenance of HVAC systems, physical barriers for screening and access to point of care alcohol-based hand rub (ABHR); administrative controls, such as policies and procedures regarding screening, monitoring the local epidemiology (including implications of new emerging variants) and appropriate selection and use of PPE.

PCRA: The Point of Care Risk Assessment (PCRA) empowers the Health Care Worker to decide what additional steps need to be taken to protect themselves, the patients they care for, and others in the environment. An individual’s personal risk assessment and PCRA are dynamic and should therefore be completed by the HCW before every patient interaction or task to determine whether there is risk of being exposed to an infection and selection of the correct PPE required to protect the health worker and other staff in their interaction with the patient and patient environment.

HOC: The fundamental framework for protecting workers is through the application of the Hierarchy of Controls (HOC). The hierarchy is arranged beginning with the most effective controls and proceeds to the least effective.

The five rungs of the HOC with examples:

  1. Elimination – Not seeing patients in person.
  2. Substitution – Vaccination of all parties, including booster.
  3. Engineering Controls – Ventilation, optimizing airflow and fresh air changes in the HVAC system, transparent barriers, point of care sharps containers, easily assessable alcohol-based sanitizer, antechambers for donning and doffing PPE (must include reinforced training to eliminate contamination).
  4. Administrative Controls – HCW vaccine policy, active screening (patient screening), passive screening (signage), restricted visitor policies, restricting entrances policies, cohorting of staff and patient, designated screening area, and regular audits of practice.
  5. Personal Protective Equipment – PPE is the last tier in the hierarchy and should not be relied on as a stand-alone primary prevention program. The PPE tier refers to the availability, support, and appropriate use of protective gear to minimize exposure and prevent transmission. Examples of PPE include gloves, gowns, facial protection, including medical or surgical/procedure masks (ASTM level 1-3) and N95 respirators and eye protection (including some types of safety glasses, face shields, goggles).

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Expanded Risk Assessment of Procedures with Increased Risk of Transmission:

Procedures that are listed as aerosol-generating medical procedures (AGMPs or AGPs) are those procedures/encounters that have epidemiological data that indicate they may significantly increase risk of infection to health care workers within close range of the procedure and thus N95 respirators and eye protection are required as a minimum level of respiratory protective equipment.

It is acknowledged that other procedures may have high-risk features similar to an AGP, including close, prolonged contact with the airway. The risk associated with these other procedures will depend on various other factors such the likelihood of infectious SARS-CoV-2 virus, community infection rates, duration of procedure, and the distance from the patient. These types of procedures currently lack clear evidence on increased risk and HCWs may choose to wear an N95 respirator based on this uncertainty and their PCRA.

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Interim Recommended PPE for Treating Patients with Suspect or Confirmed COVID-19:

In light of emerging evidence of substantial increased transmissibility of the Omicron (B.1.1.529) variant, unclear mechanism for this increased transmissibility, and reduced vaccine effectiveness, the recommended PPE for direct care of patients with suspect or confirmed COVID-19, includes a fit-tested, seal-checked N95 respirator (or equivalent, or greater protection), eye protection, gown and gloves.

Other appropriate PPE (based on individual risk assessment) includes a well-fitted medical mask or non-fit tested N95 respirator (or equivalent), eye protection, isolation gowns and gloves for direct care of patients with suspect or confirmed COVID-19.

Fit-tested N95 respirators (or equivalent or greater protection) should be used when aerosol-generating medical procedures (AGMPs) are performed or anticipated to be performed on patients with suspect or confirmed COVID‑19. N95 respirators should be fit-tested prior to use to optimize any expected benefit.

Sources:
Ontario Agency for Health Protection and Promotion (Public health Ontario). Interim IPAC recommendations for use of personal protective equipment for care of individuals with suspect or confirmed COVID‑19. Toronto, ON: Queens’s Printer for Ontario; 2021. Available at: https://www.publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en#:~:text=529)%20variant%2C%20the%20interim%20recommended,protection%2C%20gown%2C%20and%20gloves.
https://buyandsell.gc.ca/specifications-for-COVID-19-products#100
https://www.rcdso.org/en-ca/rcdso-members/dispatch-magazine/articles/6683
https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/health_care_providers_HPPA.pdf