The Chair of our International Affairs Committee looks at how other countries are preparing to increase dental activity as lockdown restrictions are eased.
The COVID-19 pandemic is far from over. However, the global focus has most certainly shifted towards the post-lockdown period. As governments start to map out how this will take effect within their own countries, we are working with administrations across the UK to explore how dental activity can increase in a safe and effective manner.
As part of this process we are exchanging information with the Council of European Dentists (CED) and numerous dental associations around the world to understand and review the approaches they are taking. In this blog we aim to summarise this information. It is a rapidly changing situation and our intention is to provide a snapshot look at other countries, using information that is publicly available (often in the original language). Many national efforts will be linked to a country’s ongoing restrictions, which may vary, and to the level of infections nationally as well as the availability of testing and tracing methods. We will update frequently however please also refer to the national dental associations guidance for the very latest changes.
Cochrane Oral Health have also published a detailed
rapid review on 8 May 2020. It looks into practice considerations, PPE for personnel, clinical room management and the approach towards dental procedures. It also includes some of the national guidance in detail.
The issues to consider for post-lockdown
The issues affecting dentistry in other countries are very similar to those in the UK. For example, while many governments are providing a degree of financial support, the profession has had to fight for that support and for further clarity. There are, of course, also differences in the way countries are approaching the next phase. The pace of relaxing restrictions varies, as does the outline for what is deemed to be appropriate personal protective equipment (PPE). The availability of PPE is however, highlighted as an issue across the globe.
PPE and AGPs
In most countries, it is advised that aerosol-generating procedures (AGPs) are avoided wherever possible as patients are considered to be potential carriers. If AGPs must take place, then enhanced protective equipment is essential. This equipment includes surgical masks, sometimes visors or FPP2/N95 respiratory masks, and long-sleeved gowns plus gloves and caps etc. There is some variation in this approach. Government protocols state that a patient’s COVID-19 status must be assessed first. Those who are likely to be infected, or are demonstrably ill, are expected to go to hospital.
Steps for patient management
Most countries have also provided guidance on patient management. This includes the following steps (with some variation):
- Telephone triage
- Patient completes questionnaire of COVID-19 history
- Appointments are arranged
- On arrival, patients are requested to wash/disinfect their hands. In some countries the patient will also have their temperature taken
- Waiting rooms are adjusted to adhere to social distancing policy
- Appointment timings are staggered to allow for social distancing and preparing of treatment room
- Disinfection / airing of treatment rooms takes place after every appointment
- Protective screens and masks for reception staff provided
- Before departing from the clinic patients are requested to wash/disinfect their hands.
Accompanying persons are asked not to enter the premises unless absolutely necessary – in which case they must also follow steps 4 and 9.
Special arrangements will be made for patients in high-risk categories (older people or those with underlying health conditions). This includes appointments at the quietest times of the day and avoiding all use of the waiting room.
The Australian Dental Association (ADA), in conjunction with the government, has developed a
framework corresponding to national restrictions.
After having been at level three for some time, Australia moved to level two at the end of April and progressed to level one in May. This means that dental treatments can be provided using standard precautions for people who do not meet the risk factors for COVID-19 infection transmission. However, for people who do meet the symptom criteria for COVID-19 risk, or are confirmed as a COVID-19 case, non-urgent treatment is to be deferred. Urgent treatment can be provided in line with ADA managing guidelines.
A decision tree and a checklist to assist practices in reopening were made available
to assist the return to level one.
The Australian Dental Association (ADA).
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In Canada lockdown measures are decided at province/territory level and there is variation in these approaches. The Canadian Dental Association (CDA) website has information on central government initiatives. It refers members to provincial/territory dental associations and regulators for detailed advice in the relevant area. Centrally, the CDA has developed a Return to Practice Manual with guidance and decision trees.
Official website: The Canadian Dental Association with links to provincial members and regulators.
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Danish dentists started to return to normal activity from 20 April. A new protocol was approved by the National Board of Health for this purpose. The new protocol foresees precautions and a severe reduction in the use of AGPs.
Official website: Danish Dental Association.
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The German Dental Chamber (Bundeszahnärztekammer- BZÄK) is regularly updating its COVID-19 advice.
In Germany, decisions about closing and reopening dental practices are made at state level. Generally speaking, practices were not officially closed except in a few specific areas where the decision was undertaken by state government decree.
Regional guidance incorporated heightened safety measures which included telephone triaging, social distancing, refraining from routine treatments, PPE and emergency provision of care. This information is being updated to reflect current advice for those returning to more routine provision.
BZÄK highlights the sector's routine intensive infection-control procedures as likely having contributed to the low rate of infection of dentists and their teams in the early days of the pandemic, when normal treatments were undertaken.
When addressing the current situation, BZÄK outlines the need to assess the level of risk that dentists face in regard to the corona infection. It refers to information from Wuhan (China), Italy and South Korea which suggests that there is no evidence of a heightened risk of infection in dental practices. It notes the high incidence of infection among professionals in medicine, especially ENT and ophthalmology. BZÄK concludes with the opinion, quoted from China, that the low rate of infection in dentistry is due to the strict infection-control measures. For this reason it does not see dental teams as the most 'at risk' professional group. Nevertheless, the additional safety measures are restrictive and in line with those in other countries.
Official website: German Dental Chamber (Bundeszahnärztekammer- BZÄK).
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There has been little government support for the profession in Ireland where the vast majority of practices are private. The Irish Dental Association fears the dental profession is approaching near collapse and has been urging the government for more support. This includes:
- help sourcing PPE
- easing of some tax payments
- an interest-free freeze on loan repayments for those whose earnings have stalled
- tax relief on private health insurance schemes for dentistry.
It has also conducted a member survey to illustrate the level of the crisis.
The Dental Council of Ireland has amended its infection control guidelines with interim guidance that states "aerosol-generating procedures should only be undertaken with an appropriate level of PPE, which includes a respirator mask to a minimum standard of FFP2".
The Irish government has published a long-term strategy for lifting restrictions on public life. There is nothing specific about dentistry in this document. Consequently, the IDA is in discussions with the government to clarify the approach.
Official website: Irish Dental Association.
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Information related to COVID-19 in Italy can be found on the dedicated blog of the Italian Dental Association - Associazione Italiana Odontoiatri (AIO).
More information from Italy is coming through and publicly available details will be linked to here.
Official website: Associazione Italiana Odontoiatri (AIO).
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New Zealand moved out of full lockdown to a restricted alert level on 27 April and to level two in the middle of May. This means that routine dental care can now be provided using both non-AGP and AGP procedures. The guidance explains this further.
You can download the
guidelines from the Ministry of Health and Dental Council of New Zealand.
The New Zealand Dental Association.
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Practices have been allowed to have face-to-face contact with patients since 20 April 2020. The Norwegian Directorate of Health has issued general guidelines for one-to-one health treatments. The Norwegian Directorate of Health has also issued special regulations for dental treatment. These
special regulations for dental treatments can be found here (in Norwegian).
Official website: Norwegian Directorate of Health and Norwegian Dental Association.
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The Spanish Dental Association has issued guidance (in Spanish) on emergency provision and an online course on the current situation. Clinical background information and protocols for practice are also include. It also has information on reopening of practices from early May.
The Spanish Dental Association and the Spanish Society Of Epidemiology And Oral Public Health (SESPO) conducted a survey among Spanish dentists regarding COVID-19. The results were published on 17 April as the "Work activity of Spanish dentists during the COVID-19 pandemic" and showed the high levels of concern around availability of PPE and infection amongst dentists.
Official website: The Spanish Dental Association.
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Dental practices in Switzerland were able to return to regular dental activities from 27 April. The Swiss Dental Association (SSO) and the Swiss association of cantonal chief dental officers have issued guidelines and recommendations. This includes patient handling, information about practice staff and additional practice and patient-specific measures. The guidance is available in French and German and generally mirrors the approach outlined in the introduction.
Official website: The Swiss Dental Association (SSO).
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In the US, lockdown measures are decided at state level. The American Dental Association (ADA) website has practical information and has recently put together a task force to look at the future of dentistry. Amongst other things it has advocated to the Government's Department of Health and Human Services that dentists should be able to carry out
patient testing for COVID-19.
The ADA taskforce has made a
toolkit available for dentists who are considering moving back to 'normal' practice. This contains checklists, model letters and protocols that can be downloaded for free. It will be updated regularly.
The ADA also has called for the cost of PPE to be addressed, requesting reimbursement packages to be offered to dentists.
American Dental Association.
The Centres for Disease Control and Prevention (US) have updated their dental guidance.
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Further reading on international responses to COVID-19
COVID-19 Resource Centre.
Ongoing research into antiviral therapies:
Remdesivir in adults with severe COVID19: a randomised, double-blind, placebo-controlled, multicentre trial.
European Centre for Disease Prevention and Control
The organisation has published a
Europe-wide rapid risk assessment for COVID-19. It is also expected to publish some dental guidance in due course.
All information about the
European Commission's Coronavirus response can be found on this website. They have also created a factsheet called
Testing kits for COVID-19: What is the EU doing?.
The European Commission, together with several global partners including the World Health Organisation, has started a worldwide pledging marathon known as the
Coronavirus Global Response. The aim is to get governments around the world to commit money toward developing vaccines, medicine and diagnostics against the new coronavirus. The EC hopes to raise €7.5 billion in initial funding to kick-start the global cooperation.
World Dental Federation (FDI)
The FDI has provided a
summary list of guidance documents for oral health professionals
In response to the COVID-19 outbreak, CEN and CENELEC have made available a series of European standards for medical devices and personal protective equipment used (in the context of the pandemic) to help prevent contagion. The
full list available can be found in the press release here.
Other sources of statistical information on COVID-10 (non-dental)
National response to the coronavirus pandemic
Coronavirus testing in Europe by country
Worldometer: Coronavirus pandemic
Chair of International Affairs Committee, BDA
Principal Executive Committee member, BDA