Level 5 Guidelines & Restrictions
SADA COVID-19 Guidelines, May 2020
Periodontology, Implantology and Oral Hygiene
Maxillofacial and Oral Surgery
During this time of national emergency, not all regular dental procedures will be performed. Please follow these guidelines for what is allowed during level 5 (High virus spread, and/or low health system readiness).
Definition
- Emergent and urgent dental procedures must be performed without delay a) if and when the patient is medically stable and b) only if the patient needs immediate treatment to avoid permanent disability or death.
- Urgent essential surgery is a surgery that must be performed in order to preserve the patient's life or limb or prevent longer-term systemic morbidity. It does not need to be performed immediately but should be generally performed within 2 weeks.
- Essential surgery or procedure is surgery scheduled in advance and where postponement of the surgery or procedure will result in the patient’s outcome or quality of life being significantly altered if extended past 2 weeks or up to 3 months.
- Semi-discretionary elective procedure cannot be done during level 5, but if it is urgent, it can be scheduled during Level 4 should the patient’s condition worsen, and pain and sepsis recur.
Dental Treatment Categories
| Category A | Category B | Category C |
| See Definition 1 | See Definition 2 | See Definition 3 |
| Emergency | Urgent conditions that can be managed with minimally invasive procedures and without aerosol generation | Urgent conditions that need to be managed with invasive and/or by AGP |
| Unstable maxillofacial fractures that can compromise the patient’s airway | Severe dental pain (>7) from pulpal inflammation that requires tooth extraction | Severe dental pain (>7) from pulpal inflammation that needs to be managed with AGPs |
| Diffuse soft-tissue bacterial infection with intra-oral or extra-oral swelling that can compromise the patient’s airway | Severe dental pain (>7) from a fractured vital tooth that can be managed without aerosol generation. | |
| Uncontrolled postoperative bleeding |
|
|
During Level 5, this table should be the standard of care to evaluate any interactions between DHCW and patient interactions. Should a Level-5 emergency be declared again, these strict measures should apply.
Antibiotics: After a proper diagnosis has been made of an acute infection or a condition that will not be resolved due to the lockdown precaution, antibiotic treatment should be the first line of defence (i.e. despite the worldwide move against the unnecessary use of antibiotics; see http://bsac.org.uk/antibiotic-prescribing-in-the-context-of-covid-19-pandemic/.)
Remote consultations: It is strongly advised to consult with patients via email, phone and/or video and by obtaining photographs of the dental emergency from the patient. Whilst this approach can be successful, it is important to closely monitor the case through regular remote consultations so that necessary steps can be taken as soon as possible if it worsens. Once lockdown is lifted, this standard of care should immediately cease.
Use of discretion: Depending on how long the lockdown continues, conditions that could not be treated under the current strict guidelines will eventually need urgent intervention. The risk of a DHCW–patient intervention should first be governed by law but should also be weighed against the best interest of the patient at the DHCW’s discretion. Should a practice be identified as a node of viral spread—whether with the help of cell phone tracking and other measures that aid the government in combatting the virus—the DHCP must be able to prove reasonable behaviour.
Special longer-term implications: Five to 7 days after a Level-5 emergency has been declared, interventions that include treatments from categories B and C can be considered, especially after failed pharmacological interventions.
Use of PPE: All patients should be treated as potentially being COVID-19 positive. The healthcare staff should use all relevant PPE—head cap, eye protection, nose and mouth protection and water-resistant gown—as discussed in detail in the SADA COVID-19 protocol document.
Remember: AGPs are severely restricted and only allowed when no other measures are possible. Below are specialty-specific guidelines.
1. General Dentistry
Clinicians must do a risk assessment of their facilities and time after emergency declarations, with the general rules in mind, to determine which of the following procedures can safely be done. Treatments that can be considered are listed below. Note that these are examples, only, and treatments are not limited to those listed.
Scope of Treatment
- Emergency root canal treatments: preparation of canals
- Re-cementation of crowns or bridges, whether temporary or permanent. If the final prosthesis has been completed and the temporary prosthesis has de-bonded, the permanent prosthesis can be placed.
- Repair of broken dentures
- Biopsy and possible excision of lesions
- Ortho follow-up where patient has a function like a rapid palatal expansion or for the replacement of worn elastics
- Atraumatic Restorative Technique (ART) restorations
- Suture removal
2. Orthodontics
The routine practice of orthodontics is fundamentally distinct from general dentistry due to its continuous and protracted nature, necessitating consistent monitoring and adjustment. It is essential that orthodontists are judicious and use their professional judgement to determine the urgency of orthodontic needs and whether in-person treatment is necessary. These essential in-person procedures should be of short duration and generally non-aerosol-generating (or could be modified to be conducted as such).
Scope of Treatment
Emergency orthodontic management.
- With careful prioritisation, orthodontic maintenance of cases currently under treatment. The rationale for maintenance is that pre-lockdown, some patients had not consulted with the orthodontist for approximately 6 weeks. After lockdown, this has added up to approximately 10 weeks or more. It is important that these patients be seen in order to circumvent any side effects.
3. Paediatric Dentistry
Paediatric dentistry focuses on the treatment of children 12 years and younger (i.e., mixed dentition).
No AGP
Use triplex syringes, where possible.
| Symptoms & Clinical Assessment | Treatment Required | Protocol (Practical Tips) |
| Emergency |
Primary teeth and permanent teeth: Facial swelling or cellulitis | - Prescription of antibiotics and/or analgesics - Extraction - Protocol to be followed for all procedures requiring access with a hand piece: For anterior permanent teeth, pulp extirpation, medicament and conventional glass ionomer (GI) cement restoration can be considered (with restricted use of hand pieces), high-volume suction, and rubber dam |
| Primary teeth: Spontaneous pain or traumatised anterior teeth with exposed pulp | - Prescription of analgesics - Extraction - For restorable posterior teeth and hand excavation,Ledermix paste sealed in with a Kalzinol restoration and prescription of analgesics could be considered |
|
| Primary teeth: Avulsion |
- No re-implantation
|
|
| Permanent teeth: Avulsion | - Re-implant and stabilise with splint | |
| Permanent teeth: Trauma to anterior tooth with pulp exposure (vital) | - Restricted use of hand pieces, pulp capping and restoration | |
| Permanent teeth: Trauma to anterior tooth with pulp exposure (non-vital/abscess) | - Restricted use of hand pieces to gain access, pulp extirpation, medicament, temporary restoration (conventional GI cement) | |
| Primary and permanent teeth: Trauma to anterior tooth (no pulp exposure) | - Smoothen rough edges - Cover with conventional GI cement for slightly bigger fractures |
|
| No pain Asymptomatic Mild symptoms Pain on eating |
Primary and permanent teeth: Fractured restorations | - Conventional GI cement restoration |
| Deep carious lesion (open cavity) | - Caries excavation (hand instruments) - Indirect pulp treatment (primary teeth)—conventional GI cement restorations (no replacement) - Indirect pulp capping (permanent teeth)—conventional GI cement restorations (need to replace at follow-up visit) |
|
| Primary and permanent teeth: Basic restorative work (no open cavities) | - Fluoride/ tooth mousse | |
| Soft-tissue infections | Primary herpetic gingivostomatitis | - Palliative management |
| Comprehensive treatment under general anaesthesia or sedation | - Not permitted due to generation of aerosols | |
| Radiographs | - Only extra-oral or panoramic |
4. Periodontology, Implantology and Oral Hygiene
The systemic dissemination of bacteria from periodontal disease is one of the potential pathways linking periodontal infection to several systemic diseases. There is an abundance of scientific data documenting the detrimental impact of periodontitis on the cardiovascular system and glycemic control in type 2 diabetes.
The benefit of periodontal therapy is well established in the literature. Following periodontal therapy, there is an improvement in both oral and systemic health, with resultant reduction in associated systemic diseases, particularly in the management of atherosclerotic cardiovascular disease and diabetes mellitus.
Specialists in oral medicine and periodontics are trained in and adhere to the highest levels of infection control protocols in their daily practice—even before the COVID-19 pandemic. These stringent infection and sterilisation standards include PPE protocols and are mandatory practice as part of our surgical discipline.
Scope of Treatment
- Recommended procedures include emergency and essential treatment to address dental or periodontal infection, sepsis and pain.
5. Endodontics
Dental practitioners should avail themselves of remote consultations (for example, by phone, WhatsApp, video or Zoom) throughout lockdown. No elective treatment or treatment that can be postponed should be attempted during Level 5. Dental treatment should be limited to emergency cases only, or if withholding immediate treatment will lead to serious complications.
COVID-19-positive patients should be treated in specialised environments such as laminar flow, HEPA filtered (H13, H14) hospital theatres, or specially designed AIIR.
All endodontic treatment should be performed under rubber dam isolation. Aerosol-creating procedures should be avoided as far as possible. If an aerosol-creating procedure is absolutely vital for performing an emergency treatment (for example, drilling though a zirconium crown to gain access to a root canal system), the procedure should be performed under rubber dam isolation with close approximation of a high-volume suction. This procedure should be completed in the shortest possible time. In addition, it is advised to douse the tooth under isolation for 30 seconds with 1% H2O2 prior to instrumentation.
Scope of Treatment
Only cases included in these criteria may be treated. Defer all other treatments.
- Emergency root canal treatment in cases presenting with irreversible pulpitis, facial swelling, acute pain and infection is allowed. If pharmacological management of these cases is possible, practitioners are advised to do so.
- Endodontic management of den ta l trauma should only be done in cases where postponement of treatment poses a risk of serious harm. The objective in the treatment should be limited to reducing the immediate pain and risk not to complete a treatment that can be postponed.
- Vital pulp therapy (for example, treatment of complicated crown fractures, pulpotomy treatment or direct pulp capping) is only advised in extreme cases where the lack of treatment will result in serious harm or complications. If it is possible to postpone treatment, practitioners are encouraged to do so.
- The obturation phase of endodontic treatment should be postponed until Level 4 or lower unless withholding such treatment will cause serious harm/ complications.
6. Prosthodontics
Prosthodontists should make themselves available for remote consultations throughout lockdown. Prosthodontic treatment should be limited to emergency and urgent care where withholding or delaying treatment will lead to life-threatening or more serious bodily complications. No elective treatment or treatment that can be postponed (without causing harm to the patient’s health) should be attempted during Level 5.
Patients should be consulted in person only if further investigation or case management is necessary or where the lack of treatment may result in harm, infection or future complications.
COVID-19-positive patients should be treated in specialised environments such as specially designed AIIR (See SADA main protocol document for guidance) or laminar flow, HEPA filtered (H13, H14) hospital theatres, and try to lessen the burden on general healthcare facilities.
Note: Appropriate PPE sterilisation and patient preparation measures must be adhered to strictly, as defined in the main SADA protocol document. All essential AGPs should be performed under a rubber dam or other isolation. The use of chlorine dioxide in dental unit waterlines is encouraged. Prior to any procedure, prosthodontic patients must use appropriate virucidal preoperative oral rinses.
Scope of Treatment
a. Fixed Prosthodontics
- The use of rubber dam or other suitable isolation is mandatory.
- The re-cementation and bonding of crowns and fixed partial dentures where there is vital pulp, and when non treatment may result in devitalisation and necessitate endodontic therapy
- Fabrication of provisional crowns and bridges where there is a vital pulp or where there is ongoing treatment which may be compromised, if not attended to.
- These include instances where an adequate coronal seal is necessary during or post endodontic therapy.
b. Removable Prosthodontics
- No rubber dam is required
- Repair and/or adaptation of prostheses where the prostheses are critical for the patient’s quality of life (QOL)
c. Implant Therapy
- The use of rubber dam isolation is mandatory when removing screw retained prostheses.
- Implant procedures related to complications where the prostheses are critical for the patients’ QOL
d. Oncology and Craniofacial Trauma
- All prosthodontic procedures that are related to the management of malignant and benign maxillofacial lesions that cannot be deferred
e. Temporomandibular Disorders (TMD)
- Pharmacological management
- Counselling
f. Endodontics
- Refer to the endodontics guidelines
7. Maxillofacial and Oral Surgery
During Level 5, maxillofacial surgery is allowed only when the patient is facing a life-threatening condition, such as severe facial trauma, uncontrollable facial sepsis and orofacial oncology and its appropriate reconstruction prior to chemo and radiotherapy.
Examine, Treat and Discharge: If the patient has a confirmed emergency, they are sent to the “Examine, treat and discharge, if possible” room in the Casualty. From there, the majority of these patients will require admission into hospital, requiring inpatient medical and maxillofacial surgical treatment. The most efficient treatment with the shortest duration should be performed. Where possible, patients who can be managed adequately with the least-invasive procedures—and through the generation of the fewest possible contacts under local anaesthesia—should be the treatment of choice and discharged rather than being treated in a hospital environment to lessen the burden on the general health care facilities.
During these severe emergency procedures, the necessary AGP is allowed, but it should be kept to a minimum. AGPs include extractions, incision and drainage of a facial or dental abscess with concomitant removal of the offending tooth/teeth, the use of power tools to place plates and screws in facial fractures and in orthopaedics for the same fracture management, use of scopes in general surgery, naso-sinus endoscopy and intubation for anaesthesia.
If there is an option to treat the patient without the need for an AGP, this should be done, but the objective should be for definitive one-stop treatment, if at all possible. For example, an extraction is much safer than first-stage endodontic treatment in terms of the aerosol risk and failure of the procedure to resolve the problem in one visit. The reason for the decision should be recorded in the patient’s notes.
Clinicians should wear the appropriate PPE as set out in the SADA protocol document.
Note: Procedures should be performed by the best qualified surgeon available. It is therefore advised that surgical extractions and impacted teeth—along with any other surgical and/or oral procedures that fall within the scope of maxillofacial and oral surgery requiring management—be referred to a maxillofacial and oral surgeon. This would ensure the shortest treatment time, along with the ability to manage any complication that arises from the procedure and, therefore, adhere to the one-stop treatment protocol. No procedure should be performed outside the scope of practice of your speciality, and reference in this regard should be made to the SADA 2016 Coding Journal.