***PLEASE NOTE THE INFORMATION IN THIS ARTICLE HAS NOW BEEN SUPERSEDED***
The latest guidance and resources are summarised here.
This week the Chief Dental Officers (CDOs) have issued further COVID-19 letters which effectively ends all routine care, and most or all urgent care, in general dental practices throughout the UK. A financial support package for NHS practices in England has also been announced.
The key new points, effective immediately, are:
- 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)
- Cease ALL face-to-face urgent care (England, Scotland)
Other new advice includes:
- Dental team members who are pregnant or immunosuppressed should not provide or assist in the direct care of patients
- Update practices’ messaging and websites
- Stop all community outreach activities
- Practices in England should inform their regional commissioner of any change in practice availability hours or cover arrangements
Telephone triage and assessment
NHS practices throughout the UK are now 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 advice on triage in Section 2.2 of the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance on emergency dental care, and should familiarise themselves with the GDC’s principles for good practice in remote consultations and prescribing.
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 earlier this week also 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advice issued by Health Boards, that no clinical care whatsoever should now take place in general dental practice, has superseded this.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 is understood that these are not to take place.
Remote prescribing and advice
Following triage and assessment, patients should be offered self-care advice by the dentist as necessary. Practitioners may wish to consult Section 2.3 of the SDCEP guidance on emergency dental care, which covers the provision of self-care advice.
Dentists can also offer appropriate prescriptions for analgesics and/or antimicrobials by phone, and are reminded that under the emergency supply provisions of the Human Medicines Regulations 2012, pharmacists can supply a medicine on this basis provided the dentist undertakes to provide a physical prescription within 72 hours. Prescribing by phone should comply with the GDC’s principles for good practice in remote consultations and prescribing.
Antimicrobials should however 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.
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.
Any patient prescribed antimicrobials should be rapidly referred for definitive treatment in an urgent care setting to avoid repeat prescribing of antimicrobials.
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 (and may be provided in some general dental practices). Practices may wish to seek local guidance on what to do with patients with urgent needs prior to the establishment of the new centres, but if in doubt any scheduled treatment should be cancelled.
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. Practices will be advised of local arrangements by their NHS Board, and practice staff may be asked to assist in care delivery at these centres, which we understand anecdotally to already be under strain.
In Wales those with urgent needs who absolutely require an aerosol generating procedure must have an appointment booked with the urgent dental care centre designated by their local Health Board, which will advise 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 letter does not say as much. Practice staff may be sought to join urgent care centre rotas.
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. In practice, the only treatment that can now carry on, if these provisos are met, is non-surgical extraction. However out-of-hours centres are operating under the same restrictions as general dental practices, therefore treatment options requiring an aerosol generating procedure will not be available until five new urgent dental care facilities (to be staffed by GDPs) are established. In the meantime, alternative treatment options should be explored.
Reducing the risk to dental professionals and patients
The new advice comes 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, last week’s 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 face mask.
FGDP(UK) has been concerned that this did not go far enough, and has been making 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 for dentists to be asked to carry these out wearing a standard surgical mask.
This week’s announcements also include financial support for NHS practices in England, meaning that some sort of cover is now in place throughout the UK.
The Faculty therefore welcomes the updated communications from the CDOs, which do much to address the three areas on which it has been asking for swift action.
However, much detail remains 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 necessary and ensure the continued viability of general dental practices.
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. Faculty representatives will also bring 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.
The Northern Ireland advice is accompanied by a patient pathway flowchart. (Please note this 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 now 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
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
However, given the government’s instruction to minimise travel to work, this should be carried out remotely where possible.
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, in return for making themselves available to assist the wider NHS if asked. 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 assistance such as the Coronavirus Job Retention Scheme (under which the government will cover 80% of the salaries of furloughed workers). FGDP(UK) is urgently seeking clarification of how this will work for mixed NHS-and-private practices, whose NHS income may be insufficient to meet overheads without further government support.
Practices in Scotland have been told that they will receive 90% of their usual NHS Item of Service income in return for making themselves available to assist the wider NHS if asked. However practices whose patients are disproportionately non-exempt from patient charges may be harder hit, and in theory could receive as little as a fifth of their usual NHS income.
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 will receive 80% of their expected Item of Service income, though this may be recovered in future years.
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.
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