Neobook — clinical reference

Preamble

Purpose, Guidelines and Standards

Emergency Protocol Level

Introduction

General Implications of the Pandemic on Public Health and Dentistry

Clinical Implications of a Return to Routine Dentistry

Community-based Dentistry Activity

In Closing

Preamble

These guidelines were in effect during the Covid-19 pandemic in line with FDI, WHO, and RSA Government guidelines. As of 5 May 2023, the WHO has declared that Covid-19 is no longer a Public Health Emergency of International Concern, but still considers the outbreak as a pandemic. During this time, it is recommended that doctors and nurses follow the WHO/FDI standard.

South African OHC providers must address the challenges of providing care during and after the COVID-19 pandemic. OHC has been identified as one of the occupations at highest risk for contracting the virus and/or becoming a node of transmission.

Purpose, Guidelines and Standards

The purpose of this clinical document is to guide OHC workers in South Africa by providing clinical and decontamination guidelines for daily procedures in response to the COVID-19 pandemic. The goal is to help reduce the opportunity for uncontrolled virus spread and the guidelines have been created with this sole purpose in mind.

Patients have differing levels of required dental care, and it is unrealistic to expect that all patients will need the same level of dental care during the COVID-19 pandemic. However, patients do have the right to expect that the level of care they receive is in line with the evidence of good practice and within their available resources (Steel, 2001). Clinical guidelines are systematically developed statements to assist dental practitioners and patients about appropriate healthcare for specific circumstances (Field and Lohr, 1990). Guidelines also provide recommendations in the management of clinical conditions where variations in practices occur and where effective care may not be delivered uniformly (https://www.fgdp.org.uk/SiD/1-introduction-second-edition). Standards are definable measures by which existing structures, processes and outcomes can be compared (Health Information and Quality Authority, 2011) and are used to describe the specific elements of care that need to be correct in order to optimise patient outcomes. In this document, we aim to provide the reader the most up-to-date (1 May 2020) clinical protocols (Aspirational), which may not be achievable by every practitioner; therefore, we will aim to provide the minimum standard of care in any OHC facility in South Africa.

Emergency Protocol Levels

The South African population is highly susceptible to this virus due to the high incidence of respiratory or immunocompromised comorbidities, such as HIV, TB, drug-resistant TB, and the elderly. In addition, many such patients have cardiovascular comorbidities and are malnourished.

Level 1- COVID-19 South African regulations will eventually end this emergency protocol, but our OHC environment will be irreversibly changed, requiring a change in our treatment protocols. There is a need for clear guidelines to define each level as announced by our president until we go back to a post-COVID-19 OHC service.

Some OHC workers in South Africa appear to lack the extensive knowledge needed to manage their practices during these extremely trying times. There is also a lack of advanced knowledge of aseptic procedures and sterility practices dealing with the scourge.

Some practitioners have mistakenly been using or are seeking to use protocols that have not been scientifically tested or devices that have not been accredited, as no well-defined South African document exists on how dentistry should respond to the COVID-19 pandemic. This has led to some OHC workers providing unsanctioned treatment against the law. Unscrupulous traders and business entities are also using this lack of guidance for monetary gain.

Many communications are not only lacking in professionalism but are leading to a dangerous and harmful arena of unproven claims. Therefore, there is an urgent need for a set of South African guidelines for the safety, both physical and financial, of dentistry professionals until a vaccine is available to achieve herd immunity.

The abundance of unscientific as well as inflammatory claims could damage the profession. It leads to poor choices like the purchase of unnecessary and expensive equipment, or implementation of protocols that are not scientifically based, in the pursuit of safety for our patients and staff.

The suggested guidelines should be suitable for reference and seen as the standard of care in dentistry in South Africa. This guideline will ultimately benefit our patients and our country. Many similar documents exist, and we should consult and refer to these when possible with the goal of sharing valuable information on practising dentistry safely in South Africa.

The general mode of transmission is via droplet spread, but in an area where AGP are routinely carried out, the possibility of airborne spread may be high. Under normal working conditions, AGP could lead to a vastly increased viral load per unit of air volume. This could increase the likelihood of aerosol transmission. At this stage, there is no scientific data to the contrary; therefore, it is imperative that maximum preventive measures be applied. The normal running of a dental practice should thus adhere to the recommendations for each level, as announced and published by our government.

The SADA guidelines for proper dental health care facility decontamination and sterilisation protocols, as before COVID-19, must now be expanded to include the full-office environment. Non-clinical office procedures, such as oral communications, payment of accounts, etc., should be treated with vigilance and care.

It is imperative that clear guidelines are put in place for each level as prescribed by the government, which will help identify risk factors and present clear clinical protocols in line with the COVID-19 laws. The (80:20) rule will apply (Protocol: DHC worker professional judgement). In other words, it is expected that about 80% measures and methods will be guided by the defined protocols, and about 20% are expected to be drawn from the health practitioner’s professional skills, experience and judgement. The DHC worker has an important role in following and advocating these rules; if we do so, we will contribute to a culture of resilience that is characterised by altruism and pragmatism.

National lockdown measures are well defined. The related OHC document (SADA) defines the application of these measures in dentistry: It must be noted that these levels be considered in relationship to the appropriate national level announcement, as this might differ by region. These measurements can be expected to be applicable for an extended time. A realistic estimated timeframe for national Level 1 to be reached is May 2021 to November 2023, should herd immunisation not be achieved earlier). Complacency must be guarded against during easing measures, as this does not indicate lesser risk.

Level 5: High virus spread, and/or low health system readiness.
Dentistry implication: Only life-threatening and severe emergency procedures and necessary AGP allowed.

Level 4: Moderate to high virus spread, with moderate readiness:
Dentistry implication: A slight easing of measures and a larger scope of work but still only essential AGP allowed, with recognition of additional safety to avoid spread of any droplet/vapour.

Level 3: Moderate virus spread, with moderate readiness
Dentistry implication: AGP allowed with recognition of additional safety measures as per SADA recommendation protocol document to avoid spread of any droplet/vapour.

Level 2: Moderate virus spread, with high readiness
Dentistry implication: The standard of OHC facility decontamination and sterilisation practices, occupational safety, including infection prevention and control, as part of the minimum standard of dental care in South Africa, should put these two categories at the same level, and DHCWs should be able to operate normally under the new realm of post-COVID-19 preparedness.

Level 1: Low virus spread, high health system readiness

Introduction

The governmental alert levels in response to the COVID-19 pandemic were announced in order to balance the economic and health risks. They are not designed to guide health policies and protocols.

Health care services include dental care and are allowable at all alert levels. What is not addressed is whether a dental visit constitutes unnecessary risk to the individual or the community. Taking public transport to the dental oral healthcare facility and waiting in a crowded waiting room already increase the risk of infection. This is further exacerbated when dental treatment encompasses aerosol generation.

What is important is that the epidemiologists recognise the prevalence (number of existing cases) and the population incidence (rate of new cases appearing) of COVID-19, which ranges from low to very high. This influences the probability that a patient walking into a dental clinic may be infectious. Although this does not radically influence our dental protocols, it does influence the availability of PPEs, infection control protocols and ventilation controls within our environment.

It must be noted that this is not a new problem for dentistry. Subclinical infected cases of TB, HBV and HIV have forced us to establish rigorous cross-infection control standards in dentistry, many years ago. This means we have to recognise every patient as a potential infected case, for whom all precautions must be in place before we do any treatment. If this protocol is ignored, it could invite litigation and ethical challenges. Although this is not something new, it does create an extra burden.

What is new with the COVID-19 pandemic is the potential for cross-infection and contamination via droplet spread and possible aerosols associated with AGPs generally performed by DHC workers that we have not faced before. We will need to address and alter our protocols where necessary to manage this new threat.

What is also new is the complicating factors of often encountered disease—comorbidities that increase the risk of death, therefore making adjustment of our protocols even more important.

Any new COVID-19 Dentistry protocol can really ignore the alert levels, but it should define what dentistry can do in two stages of the pandemic:

The first is the social risk to patients when attending a dental clinic or simply going into a public space, whilst COVID-19 incidence rates are still high. The treatment need has to be substantial to justify such a visit and probably constitutes a clear emergency case. This is probably what we are doing at Level 5.
When the epidemic rates of COVID-19 occurrence have subsided enough to allow reasonably safe access to dental facilities, the members of the community (including practising good social distancing, etc.), then routine dentistry might resume. However, this is only legally and ethically permissible if adequate conditions for its safe practice are in place. The safety of the patient and clinical staff must be ensured using evidence-based clinical protocols throughout. This is the focus of the document being prepared here.

General Implications of the Pandemic on Public Health and Dentistry

The recognition that COVID-19 spreads quickly via droplets between people in proximity has led to various strategies, from mask-wearing and education to lockdown regulations, all designed to increase social distancing. Decanting all health sector waiting rooms and queues was one such measure. This was based on the assumption that sick people come to clinics and hospitals and therefore health care centres are high-risk sites for contagion to spread. The advice to “phone your doctor; do not visit them” is still prominent in the media. Making appointments ahead of time still remains good advice for dentistry and medicine to sustain adequate social distancing.

In the private sector, patient volumes were already lower and more controlled by appointments, and this was further reduced to address only emergencies in the lockdown period (ironically, this early period will probably later be regarded as the lowest risk period of the pandemic).

In the public sector, where walk-in patients are the majority, patient flow was radically reduced to minimise waiting room volumes and also to reduce the consumption of precious PPE that was in short supply. A limited appointment-making process exists, which would need to be enhanced in the future.

Clinical Implications of a Return to Routine Dentistry

At Academic Oral Health Centres, we have a group continuously reviewing and discussing the current evidence to determine what is necessary to enable safe return to "routine" general and specialised dentistry and the news is not good (May 2020).

The gist of it is that there is a two-fold risk, since all dentistry procedures involve a proximity of 15-25 cm between operator and patient, and, of course, 80%+ also involve aerosols. Any clinical area/zone where this is happening is de facto an aerosol risk area for patients, clinician and clinical assistants working there. Before COVID-19, the general distribution of procedures was mixed e.g. Aerosol procedure on one patient, immediately followed with e.g. a non-aerosol procedure. No grouping of procedures is practised in most private dental practices.

The implications are that N95 masks or equivalent, respirator and full PPE is required for anyone entering/working as well as patients, in that specific area, as long as there is a significant probability that a patient there might be COVID-19 positive. This needs to change for every patient.

Aerosol containment systems must also be in place, in addition to obligatory recommended pre-procedural mouth rinse, HVE and rubber dam use in every case, where it is feasible. This is required for every AGP in dental care.

One of the major problems in dental surgery is ventilation or air-conditioning systems. Each facility should be evaluated, and the risk profile known. Some could be very harmful whilst others have quite a few benefits.

The COVID-19 prevalence is expected to climb for some time, along with patient and clinician exposure risk. It is important to note, supported by COVID-19 publications, that a patient is infective and spreads SARS-CoV-2 two days prior to showing any symptoms. Additionally, some COVID-19 patients show no symptoms at all. This emphasises the urgency for the appropriate disinfection protocols; PPE and engineering controls should be in place for every DHC facility.

Advising elderly patients and those with comorbidities to postpone all clinical dentistry except real emergencies can also mitigate their risk.

Community-based Dentistry Activity

Whilst policy, protocol and health informatics may well continue, community dental surveys, outreach, brushing, varnish, sealant and educational programmes, which are the substance of dental public health at the community level, clearly cannot resume at this time.

Any community clinical activity must clearly adhere to the same guidelines indicated for general dentistry elsewhere in this document.

Any other community-based activity sadly has to remain suspended for now until community prevalence levels of COVID-19 have dropped too much lower levels, and even then, must meet the requirements of safe social distancing and personal hygiene practices.

In Closing

This means that we probably cannot restart "normal" dentistry until we can ensure all these safety requirements are in place, for now, Level 4, emergency care only can be offered, by DHC worker doing non-aerosol-generating procedures, but all must still be gowned and PPE protected, with N95 (or equivalent respirator), face shields, caps, gowns, goggles and gloves.

The risk factor of dental clinician proximity has perhaps not been adequately considered in previous PPE discussions. It has turned out to be critical, according to several studies.

Makes a return to "normal" dentistry look very remote indeed.