COVID-19: new guidance and support for the ‘delay’ phase

News Published: 
20 March 2020

***PLEASE NOTE THE INFORMATION IN THIS ARTICLE HAS NOW BEEN SUPERSEDED***

The latest nation-by-nation advice, as at 1700 on Wednesday 25 March 2020, is summarised here.

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After a week in which most general dental practices have been left in the dark, the Chief Dental Officers (CDOs) have now issued updated advice for the 'delay' phase of the coronavirus pandemic, which will bring a halt to much routine dentistry throughout the UK.

The key new points, effective immediately, are:

  • Cease all care of anyone who should be self-isolating (whether or not they are symptomatic)
  • Cease non-urgent care for patients who are 70 or older, pregnant or have a serious underlying health condition
  • Cease all aerosol generating procedures for all patients receiving non-urgent care
  • Where aerosol generating procedures are necessary, the dental team should all wear a full face shield or goggles/visor in addition to a surgical face mask

Practices are also advised:

  • To establish which patients are or should be self-isolating prior to appointments (travel history is now irrelevant; anyone who has a new and continuous cough, or a temperature of at least 37.8 degrees, should stay at home for 7 days; and anyone sharing a household with someone with one of those symptoms should stay at home for 14 days, and if they become symptomatic themselves, 7 days from that point in time)
  • To postpone routine care for patients who are or should be self-isolating
  • Not to provide urgent or emergency care for patients who are or should be self-isolating; they should be seen in dedicated centres which are being established, not in general practice
  • To identify patients in high risk groups (‘social distancers’) and postpone their routine appointments
  • To offer cancellation to anyone who wishes to avoid travel
  • To review all open courses of treatment for all patients, and identify those requiring care that cannot be postponed
  • To ask patients to travel unaccompanied where appropriate
  • To wipe down door handles and other surfaces between patients with extra vigilance
  • To remove all unnecessary items from waiting rooms and work surfaces
  • To provide handwashing facilities for patients and carers
  • To cancel domiciliary visits for routine care
  • To establish business continuity plans
  • To ensure practices are registered to receive email updates from the NHS

Practices in Scotland have also been advised that the requirement for a patient or guardian to sign a GP17PR or GP17(O)PR has been suspended to avoid multiple patients using the same pen or tablet within the practice.

Definitions of routine, urgent and emergency care are provided in the NHS England commissioning standard for urgent dental care.

Routine care includes treatment for:

  • 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

Urgent care includes treatment for:

  • 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

Dental emergencies 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) 

Nation-by-nation advice is below:

England

Scotland

Wales

Northern Ireland

 

Aerosol Generating Procedures

Recent 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 have decided on a precautionary basis to advise dentists to cease all aerosol generating procedures for all patients except where it is required for urgent care.

To help clarify this new advice, the CDO for Scotland has provided the following non-exhaustive list of 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”)

The same letter also provides a non-exhaustive list of non-AGPs, which may continue for appropriate patients:

  • Examinations
  • 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

An exception is made for opening teeth for drainage, “where a high speed handpiece would be required. The advice would be to use rubber dam, which considerably reduces aerosol production, along with high volume suction. The operators should wear a full-face visor and fluid-resistant mask”.

 

Business support

To ensure the continued viability of practices, the NHS in Scotland, Wales and Northern Ireland have given some reassurance of continued remuneration during the coronavirus pandemic.

NHS practices in Scotland will receive 90% of their usual Item of Service income in return for making themselves available to assist the wider NHS if asked.

NHS practices in Wales will continue to receive monthly income, but should continue to submit FP17Ws for patients they see, and monitoring and UDA targets will be relaxed or suspended.

NHS practices in Northern Ireland will receive 80% of their expected Item of Service income, though this may be recovered in future years.

No financial support measures have yet been announced for dental practices in England.

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.

 

The CDO for England has also advised that further stocks of masks were released to Henry Schein, Wrights and Dental Directory this week. Order quantity restrictions are in force, and practices should quote ‘DHSC – face mask request’ by phone or email.

 

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 your NHS regional team