***PLEASE NOTE THE INFORMATION IN THIS ARTICLE HAS NOW BEEN SUPERSEDED***
The latest guidance and resources are summarised here.
This week's updates
NHS England says that 50 Urgent Dental Care centres are now able to treat patients, with a further 110 expected by the end of next week. Centres are also open across Scotland, 15 have been set up in Wales and five are up and running in Northern Ireland. However the gap in provision, particularly in England, for patients with urgent dental needs that may not be adequately met by remote delivery of the '3As', is concerning. While some of this gap will be closed once all Urgent Dental Care centres are up and running, GDPs report a shortage of capacity even in those centres which are open. In particular, there is the distinct possibility that some patients who do not meet local criteria for referral (based on their initial remotely-delivered assessment) may develop more serious and potentially life-threatening symptoms, and the Faculty is pushing for criteria and procedures which minimise this risk. We have amended our advice on referral for treatment following remote assessment and prescribing of antimicrobials to reflect the shortage of urgent care provision.
NHS England has published plans for deploying the clinical dental workforce to support the NHS clinical delivery plan for COVID-19. This follows the online form for volunteering published last week, and we have also added links to the NHS Volunteer Responder website, and the GDC’s position on supporting redeployment, in a new section on redeployment.
Northern Ireland’s Department of Health has published further details of the financial support it is offering NHS dental practices, and an FAQ. A letter to practices confirmed that the support will cover patient contributions and capitation payments as well as Items of Service, but all are subject to a 20% abatement.
UNW has updated its advice on the financial impact of COVID-19 for dentists and dental practices.
The BDA has published a briefing on the financial support available for dentists and practices in Scotland.
A link has also been added to the BDA’s coronavirus financial impact page.
The Chief Dental Officer for England hosted a webinar on dental services during Covid-19.
Ian Mills, Dean of FGDP(UK), also took part in a webinar on Covid-19, together with the Deans of the UK’s other dental faculties.
We still await a revised Standard Operating Procedure for dentistry in England, as well as further advice on PPE in dentistry.
The key instructions from government agencies, which effectively apply in both private and NHS practice, remain:
- Cease ALL routine dental care (including orthodontics) (UK-wide)
- Cease ALL aerosol generating procedures (UK-wide)
- Offer patients with urgent needs appropriate advice and prescriptions over the phone (UK-wide)
Further details are below, alongside information on:
- Telephone triage and assessment
- Remote prescribing and advice
- Urgent care arrangements
- FGDP's position
- Nation-by-nation updates
- Routine vs urgent care
- Aerosol Generating Procedures
- Personal Protective Equipment
- Record Keeping
- Financial and employment support
Telephone triage and assessment
NHS practices throughout the UK are expected to make arrangements for patients with urgent dental needs to be triaged and assessed over the phone by a dentist during normal business hours.
Dentists may wish to consult the Scottish Dental Clinical Effectiveness Programme's guidance on the Management of Acute Dental Problems during the COVID-19 Pandemic. They should also familiarise themselves with the GDC’s principles for good practice in remote consultations and prescribing, the key element of which in the current context is risk assessment. The British Dental Association has published advice on risk assessments during the COVID-19 pandemic (this is only available to its members).
The official advice to practices in Wales and Northern Ireland allows for face to face assessments if strictly necessary (and subject to the clinical discretion of the dentist), so long as practice teams use ‘robust standard’ PPE procedures, and only see patients who are asymptomatic and who have a pre-agreed appointment following an initial assessment by phone. COVID-19 symptoms remain a new and continuous cough or a temperature of at least 37.8 degrees.
The advice given by the CDO for Scotland initially allowed for face to face assessments if strictly necessary and subject to the conditions described above. However we understand that subsequent advice issued by Health Boards, that no clinical care whatsoever should now take place in general dental practice, has superseded this.
The advice to practices in England does not mention face-to-face assessments, and it has been understood since the ban on routine care that these are not to take place for urgent care either. In the CDO for England's recent webinar, it was briefly suggested that face-to-face care within general dental practice was appropriate in certain circumstances given the delays in establishing Urgent Dental Care centres, however it was then clarified that this should not take place regardless.
Remote prescribing and advice
Following triage and assessment, patients should be offered self-care advice by the dentist as necessary.
Appropriate prescriptions for analgesics and/or antimicrobials can be made by phone under the emergency supply provisions of the Human Medicines Regulations 2012, through which pharmacists can supply a medicine provided the dentist undertakes to provide a physical prescription within 72 hours. Photos of prescriptions do not fall within the definition of a legally valid prescription, but may be accepted pending provision of the hard copy. Dental prescribers experiencing difficulty in obtaining emergency supply of medicines from local pharmacies should contact their NHS Local Area Team and LDC as a matter of urgency.
As above, prescribing by phone should comply with the GDC’s principles for good practice in remote consultations and prescribing.
Antimicrobials should continue to be prescribed in a responsible manner and only where clinically indicated, and dentists should consult FGDP(UK)’s Antimicrobial Prescribing for General Dental Practitioners guidance.
This states that the prescribing of antibiotics for toothache, including acute pulpitis, is inappropriate as they are of no clinical benefit in managing dental pain. Analgesics can provide pain relief prior to provision of definitive treatment, and recommended drug regimens for dental pain relief in adults and children can be found here.
While non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can be prescribed, paracetamol is as effective for dental pain in most cases, and the government has advised on a precautionary basis that patients with suspected or confirmed COVID-19 take paracetamol in preference.
The guidance notes that antimicrobials may be appropriate where patients present with an acute dental infection for which definitive treatment has to be delayed because of a need to refer for specialist services due to an inability to establish drainage. It may therefore be appropriate to prescribe antimicrobials based on a provisional diagnosis, conducted remotely, of a swelling associated with an acute dental infection.
Ideally, any patient prescribed antimicrobials should be referred for definitive treatment in an urgent care setting to avoid repeat prescribing of antimicrobials. However, where Urgent Dental Care arrangements are up and running there may be insufficient capacity at present to treat all dental patients who have been prescribed antimicrobials. In these circumstances, dentists may wish to follow the SDCEP guidance on the Management of Acute Dental Problems during the COVID-19 Pandemic, which provides case definitions and recommendations in the context of remote assessment for self-care advice, prescribing, urgent care and emergency care for common dental presentations. In parts of England where no local Urgent Dental Care arrangements have yet been put in place, the SDCEP guidance can still be consulted, and when referral to an Urgent Dental Care centre is deemed necessary, the local NHS Area Team should ideally be in a position to arrange referral to an out-of-area centre.
Urgent care arrangements
In England, patients with urgent needs which cannot be provided remotely should be referred to new Local Urgent Dental Care arrangements which are being established. NHS England says 50 of these are now up and running, and that another 110 will be operational by the end of next week.
In Scotland, patients with urgent needs which cannot be provided remotely should be referred to the designated local Public Dental Service or Hospital Dental Service urgent dental care centre. Centres are now up and running in every Health Board region, and practices should have been advised of local arrangements by their local Board.
In Wales, 15 urgent dental care centres are open. Those with urgent needs which require an aerosol generating procedure must have an appointment booked with the centre designated by their local Health Board, which should have advised practices of booking arrangements. The implication is that urgent care delivery can continue in general dental practices if it does not involve an aerosol generating procedure, though the communications do not say as much.
In Northern Ireland, general dental practices are expected to continue delivering urgent care, following triage/assessment by phone and an examination, if it does not involve an aerosol generating procedure and the patient is asymptomatic for COVID-19. Out-of-hours centres are operating under the same restrictions as general dental practices, but for those requiring an aerosol generating procedure as amatter of urgency, five urgent dental care facilities have now been established.
The British Orthodontic Society has published a guide to orthodontic emergency centres.
General dental practitioners throughout the UK are being asked to volunteer to be redeployed to support the NHS COVID-19 response. While an increasing number are staffing Urgent Dental Care centres, others will be asked to support other types of healthcare in hospitals and other facilities.
NHS England’s publication, Deploying the clinical dental workforce to support the NHS clinical delivery plan for COVID-19, maps the skills of different members of the dental team to roles in which they might be redeployed, indicating what training, if any, would be necessary to fulfil them.
Those in England willing to be redeployed, whether for face-to-face or telephone-based work, should complete this online form.
The GDC supports the redeployment of dentists, including to undertake task beyond their usual scope of practice, but still requires them to ensure they are trained, competent and indemnified for the tasks they undertake. Under the Coronavirus Act 2020, the NHS provides indemnity for work undertaken while redeployed, but dental professionals are advised nonetheless to notify their usual indemnity provider of the roles they will be performing.
For those who cannot, or prefer not to, redeploy, another option is to sign up as an NHS Volunteer Responder to help with tasks such as transport and community support. There are also telephone-based roles for those deemed at higher risk.
The CDOs' latest advice came only three working days after the issue of the previous guidance, which ended all care of those who should be self-isolating, routine care of those who should be ‘social distancing’, and the use of aerosol generating procedures in remaining routine care.
However, the earlier advice stopped short of recommending the end of routine care for all other patients, and suggested that remaining aerosol generating procedures could be safely carried out while wearing a surgical mask.
FGDP(UK) was concerned that this did not go far enough, and made the case for the guidance to rapidly become more robust, and for:
- Cessation of all routine care within general dental practices
- Provision and supply of appropriate PPE for any dental professional providing oral healthcare for patients
- Details about the financial entitlement for dental practices with an existing NHS contract
In view of the increasing incidence of COVID-19, the low levels of testing and its long incubation period, the Faculty takes the view that every dental patient now represents a potential infection risk to dental teams, even if asymptomatic, just by being in the practice.
For non-urgent care, this is a disproportionate risk, and for urgent care where an aerosol generating procedure is necessary, this means wearing a class three filtering face piece (FFP3) in line with Public Health England’s guidance on infection prevention and control for COVID-19. These are in extremely short supply within general dental practice, and it was not appropriate in the Faculty's view for dentists to be asked, long after the government had announced the move to the 'delay' phase of the coronavirus response, to carry these out wearing a standard or surgical mask.
The Faculty therefore welcomed the updated communications from the CDOs, which did much to address the three areas on which it has been asking for swift action.
However, some details remain to be worked out, and FGDP will continue to press for outcomes which reduce the risks to dental professionals, provide safe care for patients where treatment remains necessary, and ensure the continued viability of general dental practices.
The gap in provision, particularly in England, for patients with urgent dental needs that may not be adequately met by remote delivery of the '3As', is concerning. While some of this gap will be closed once all Urgent Dental Care centres are up and running, GDPs report a shortage of capacity even in those centres which are open. In particular, there is the distinct possibility that some patients who do not meet local criteria for referral (based on their initial remotely-delivered assessment) may develop more serious and potentially life-threatening symptoms, and the Faculty is pushing for criteria and procedures which minimise this risk.
Ian Mills, Dean of FGDP, is a member of NHS England’s national dental stakeholder group on COVID-19, and you can read his thoughts on the challenges facing primary care dentistry due to coronavirus at www.fgdp.org.uk/deans-blog. Ian also recently took part in a webinar and Q&A on Covid-19.
Faculty representatives are also bringing the voice of general dental practice to the development of clinical guidance on the delivery of paediatric dentistry, restorative dentistry and oral surgery during the pandemic.
The latest letters of advice in the four nations are in full below:
The above link directs to the latest advice from Health Boards (as issued to practices in the Greater Glasgow area). The preceding letter from the CDO for Scotland is here, and the latest details on financial arrangements are here.
The Northern Ireland advice is accompanied by a financial support document, FAQ, and patient pathway flowchart. (Please note the flowchart is only relevant to the new patient pathway in Northern Ireland, not elsewhere in the UK.)
Routine vs urgent care
Definitions of routine, urgent and emergency care are provided in the SDCEP guidance on emergency dental care and NHS England commissioning standard for urgent dental care:
Routine dental problems are those for which self-help advice and/or access to treatment within seven days would normally be required, and include:
- Mild or moderate pain: that is, pain not associated with an urgent care condition and that responds to pain-relief measures
- Minor dental trauma
- Post-extraction bleeding that the patient is able to control using self-help measures
- Loose or displaced crowns, bridges or veneers
- Fractured or loose-fitting dentures and other appliances
- Fractured posts
- Fractured, loose or displaced fillings
- Treatments normally associated with routine dental care
- Bleeding gums
The SDCEP guidance suggests that approximately 25% of ‘emergency’ phone calls are likely to fall into its ‘advice, self-help and routine care’ category.
Urgent dental problems are those for which self-help and access to treatment within 24 hours would normally be required, and include:
- Dental and soft-tissue infections without a systemic effect
- Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
- Fractured teeth or tooth with pulpal exposure
The SDCEP guidance suggests that approximately 75% of ‘emergency’ phone calls are likely to fall into the ‘urgent care’ category.
Dental emergencies are those conditions that require contact with a dentist within an hour, and include:
- Trauma including facial/oral laceration and/or dentoalveolar injuries, for example avulsion of a permanent tooth
- Oro-facial swelling that is significant and worsening
- Post-extraction bleeding that the patient is not able to control with local measures
- Dental conditions that have resulted in acute systemic illness or raised temperature as a result of dental infection
- Severe trismus
- Oro-dental conditions that are likely to exacerbate systemic medical conditions such as diabetes (that is lead to acute decompensation of medical conditions such as diabetes)
The SDCEP guidance suggests that approximately 1% of ‘emergency’ phone calls are likely to fall into the ‘emergency care’ category.
Aerosol Generating Procedures
Public Health England’s COVID-19 guidance for infection prevention and control in healthcare settings states that ‘human coronaviruses can survive on inanimate objects and can remain viable for up to 5 days at temperatures of 22-25°C and relative humidity of 40-50% (which is typical of air-conditioned indoor environments)’, and highlights the risk of ‘extensive environmental contamination’ from the use of ‘potentially infectious Aerosol Generating Procedures’ including ‘some dental procedures’.
The CDOs previously advised a reduction in aerosol generating procedures, and have now – to the extent that dental practice is continuing - advised the cessation of all aerosol generating procedures. The non-exhaustive lists of procedures falling and not falling into this category, as previously advised by the CDO for Scotland, remain relevant:
Aerosol Generating Procedures (AGPs):
- Use of high speed handpieces for routine restorative procedures
- Use of Cavitron, Piezosonic or other mechanised scalers
- Polishing teeth
- High pressure 3:1 air syringe (“NB Risk of aerosols could be reduced when using a 3:1 if only the irrigation function is used, followed by low pressure air flow from the 3:1 and all performed with directed high volume suction. Dry guards, cotton wool or gauze can also help with drying and moisture control”)
Opening teeth for drainage has since been added to this list.
- Hand scaling with suction
- Non-surgical extractions (“NB If this became a surgical extraction, a slow speed reducing handpiece could be used for bone removal, with cooling provided using saline dispensed via a syringe along with high speed suction. If this is not a suitable option, temporisation or referral would need to be considered”)
- Removable denture stages
- Removal of caries using hand excavation or slow speed handpiece if necessary
However dental professionals providing face-to-face urgent care may wish to take note of guidance from the British Association of Oral Surgeons and British Association of Oral and Maxillofacial Surgeons which advises that all urgent dental procedures, including oral examination, are treated as aerosol-generating.
We understand that an official review of which dental procedures are classified as aerosol-generating, and their safety in the current context in view of the close proximity of dentists to their patients, is imminent, and that this will include consideration of the use of suction and 3-in-1.
Personal Protective Equipment
Dental professionals providing urgent care may wish to note the guidance on PPE for patients with emergency oral and dental problems of unknown COVID status published by the British Association of Oral Surgeons and British Association of Oral and Maxillofacial Surgeons, which recommends that:
- all urgent dental procedures, including oral examination, are treated as aerosol-generating in terms of PPE
- an FFP3 mask is covered by either a surgical mask or visor
- an FFP3 mask can be worn for an entire day or session in the interests of conserving finite resources
The official NHS England advice is:
PPE for healthcare workers delivering or assisting with an aerosol generating procedure:
• FFP3 (filtering face protector, class 3) respirator
• long sleeved disposable gown
• eye protection (disposable goggles or full-face visor)
PPE for all other procedures - even for patients with possible or confirmed COVID-19:
• fluid repellent facemask
• eye protection if there is a risk of splashing or exposure to respiratory droplets
We are expecting further advice on PPE in dentistry in the near future.
The Chief Dental Officers have instructed that all routine orthodontic care cease throughout the UK in both NHS and private practice.
The British Orthodontic Society has issued a Covid-19 guide to the management of orthondontic emergencies and advice for patients undergoing orthodontic treatment during the COVID-19 pandemic. Providers may also wish to consult its guidance on virtual consultations for emergency triage and advice and guide to orthodontic emergency centres.
The Chief Dental Officers have instructed that all routine endodontic care cease throughout the UK in both NHS and private practice.
The British Endodontic Society has published guidance for primary dental care on the triage and management of dental pain likely to be of endodontic origin and on the diagnosis and management of endodontic emergencies during COVID-19.
NHS dental practices are advised to maintain good audit trails tracking the effect of the pandemic on their service delivery, and the NHS in Greater Manchester suggests:
- Maintaining records of staff and dentist absence, both for illness and caring for dependants. Week by week records will help to demonstrate the varying impact of the pandemic
- Identifying days when the practice is unable to open as a result of insufficient staff
- Recording the number of patients attending the practice and, if possible, identify the types of treatments provided. This information can then be compared with a typical working day, if necessary
- Maintaining records of other work carried out within the practice as a result of patients not being seen (updating policies and undertaking audits, for example) to demonstrate that time spent not seeing patients was used constructively and contributed to the improvement of patient services
- Maintaining records of any other work undertaken at the request of the NHS
The DDU recommends that:
- practitioners keep a log of when they checked the COVID-19 advice so they can demonstrate what they have done to stay up to date
- each practice or department appoints a lead person with responsibility for checking the relevant advice regularly and disseminating it
- practitioners make sure to view documents from a website rather than relying on a saved copy, to make sure you are working from the most up-to-date guidance.
The BDA has published advice on record keeping during the COVID-19 pandemic, though this is only available to its members.
Financial and employment support
To ensure the continued viability of practices, the NHS has given some reassurance of continued remuneration during the coronavirus pandemic, and practices may be able to access wider government support for small businesses.
Practices in England may continue to receive monthly NHS income, less a deduction for variable costs. However practices receiving continued NHS income must continue to pay 100% of the salaries of staff and associates, and will not be eligible to apply for wider coronavirus-related assistance for the NHS proportion of their revenue.
Practices in Scotland have been told that they will receive 80% of their usual NHS Item of Service and patient contribution income. The BDA has published a briefing on the financial support available for dentists and practices in Scotland.
Practices in Wales will continue to receive monthly NHS income, and should continue to submit FP17Ws for any patients with urgent care needs that they see. Earlier advice pledged that monitoring and UDA targets would be ‘relaxed or suspended’, however to date only a 4% relaxation, representing two weeks’ lost practice, has been offered. Significant concerns remain over the position of mixed NHS-and-private practices.
NHS practices in Northern Ireland can apply to receive 80% of their expected NHS income, though this may be recovered in future years.
Accountancy firm UNW has published advice on the financial impact of COVID-19 for dentists and dental practices, and further details of the support available to dental practices are available on the BDA’s coronavirus financial impact page.
The Care Quality Commission has said that dental providers do not need to inform it if they are closing temporarily, or only managing emergency cases, as a result of COVID-19.
The CQC has also said that providers can apply for a fast, free DBS check for staff or volunteers they need to start work urgently as a result of the pandemic.
The GDC has said that it will be sympathetic to those registrants who are unable to maintain their CPD responsibilities in present circumstances.
All healthcare staff, including NHS dentists and dental care professionals, are classified as key workers for the purposes of the pandemic. This means that otherwise-closed schools and nurseries should continue to provide education and childcare to their children so they can continue working.
Members of the Medical and Dental Defence Union of Scotland will have their subscriptions markedly reduced from April - by around 75% for full time dentists.
The Dental Defence Union is offering its members 'reduced subscriptions and prompt refunds tailored to individual circumstances' on application.
BDA Indemnity is reducing subscriptions by around 70-80% for Associate Dentists and 65-70% for practice owners.
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