Worldwide COVID-19 responses: Looking over the garden fence.

By Damien McNee BDS MSc PGCert (Law and Ethics)

Sunday 22nd March 2020 is a day that will resonate deeply with UK dental practitioners far many

years to come. This of course was the day that the BDA, having looked at guidance from the various

UK authorities, recommended complete cessation of AGPs on any dental patient (without

appropriately fitting FFP3 masks, protective equipment and protocols). The aforementioned

‘appropriate protective equipment and protocols’ are still to be established. The viral agent, that

such equipment is required to offer protection from, is relatively poorly understood. Research into

the SARS-CoV-2 virus and its pathogenicity is in its infancy and it may be quite some time before the

medical world has fully, factually, established what appropriate PPE and supportive measures

actually are.

This article is aimed at comparatively detailing worldwide responses for information purposes only.

The task of response comparison is made all the more challenging by the differing ways dentistry is

funded and accessed. This is compounded further by the very individual legal and social ideologies

held in any particular region or country. Population demography is a huge variable when analysing

statistics, particularly when considering the general health of a population and the associated risk

factors for contracting COVID-19. These risk factors, as we know, are pertinent to those who have a

reduced immune response, such as sufferers of diabetes or cancer. The article is intended as a

snapshot, so that dental practitioners as well as those in positions of authority in the dental sector in

the UK (PHE, NHSE, CQC, GDC, Dental Indemnifiers and the OCDO ) can pay reference to the steps

taken elsewhere, and use this as part of their decision making process moving forwards.

1) Australia

Relevant statistics:

Approx. 75% of dental services are on a privately funded basis

COVID cases to date (30/4/20) 6746 confirmed: 90 deaths

Population density: 3.1/km2

Population 24.99 million

57.7 dentists per 100,000 population (reference)

Dental response to date:

26th March 2020- Australian Dental Association- dental services considered essential.

Immediate restriction to non-AGPs. Level 3 restrictions.

This still allowed dentists to see patients on an emergency basis, and importantly, to offer

extirpations and extractions where causing dental pain. In addition, management of

damaged front teeth (under RD), where damaged occurred due to trauma. (full scope can be

found here)

21st of April 2020- move back to Level 2 restrictions. Key considerations of these restrictions

may be that orthodontics is now re-introduced, surgical extractions to be referred out.

Further delay to implant provision.

Financial support for Dentists/ Dental Practices

The Australian Chamber of Commerce and Industry implemented financial support packages to

include dental practices. More information on these can be found here. These financial support

packages are all found on the ADA website.

Summary

The response in Australia, to an outsider looking in, seems incredibly measured and well thought

out. From the outset there was an abundance of clear protocols available electronically, offering

support documents and resources to practitioners. The lead on guidance for dentists has been

channelled unilaterally through the ADA, who work closely with national government acting directly

as an advisory body. In addition, the ADA acted as a source for procuring PPE at cost from

government stockpiles. The abundance of supportive and easy to access documentation is

staggering- for example the ‘Which mask and when?’ document.

It is difficult not to form a strong correlation between the influence of the ADA upon government led

decision making and the rapid, structured re introduction of ‘essential’ dental services.

2) China

Relevant statistics

Population density 153/Km2

Confirmed cases 84,369, Deaths 4,643

Predominantly provided in public sector at 48 hospital sites in 35 cities. This accounts for

over 80% of patient volume in China (reference)

20% patient volume in private clinics.

Population 1.4 billion

8 dentists per 100,000 population (Reference)

Dental Response

As the vast majority of dental care provision is in the public sector, the restriction of dental

service provision was rapid and whole scale. All hospitals (100%) suspended general

dentistry, whilst the same number provided emergency care. (Reference here)

Interestingly, 68% of these hospitals provided online professional consultations to determine

if presenting condition was an emergency.

Emergencies included acute toothaches, abscesses, trauma.

Care was continued throughout COVID-19 with endodontic access carried out under rubber

dam. Techniques involved slow speed access/ hand instrumentation and appropriate pulpal

dressings placed.

As dental care provision is largely within the hospital setting, rigorous infection control measures can

be employed as standard. Within the School and Hospital of Stomatology, Wuhan University, during

the COVID outbreak, the clinics were segregated like this. Triage staff wore, disposable masks, caps

and normal work attire. Categorised low risk patients were treated in designated surgeries using

disposable N95 masks, gloves, gowns, caps, goggles/face shields. These areas were disinfected twice

per day. Isolation clinics for suspected COVID-19 patients were operated using additional but

unspecified PPE. However it can be deduced from the article that this PPE is much in line with that

used for patients with cholera or the plague.

Interestingly this article highlights how emergency pulpitis cases were triaged and treated

throughout COVID-19 using the above segregation procedures. Pulpitis was continued to be treated

using endodontic access, without any obviously jurisdiction placed on tooth removal. Non carious

pulpal exposure was treated using high speed access as the last patients of the day. All treatment

was carried out under rubber dam isolation and high volume aspiration.

Summary

On 29th January, China imposed a ‘Cordon Sanitaire’ around the Hubei Province, which prevented

anyone from entering or leaving the region following recognition of the virility of the COVID-19 virus.

A publication from the WHO (found here) highlights the rapid response to prevention of viral

transmission, including a full scale lockdown. The social ideologies of the Chinese population ensure

that this lockdown was incredibly well adhered to as reported in this document.

From a dental perspective, the way dentistry is provided in China allows almost complete control

from high level government very quickly. The rapid adoption of clinic segregation, no apparent

shortage of PPE, and large clinical settings promoted a continuation of emergency dental care

provision. The early adoption of methods enabling ‘teledentistry’ promoted appropriate triaging of

patients in advance. This will undoubtedly have reduced patient exposure to unprotected

environments during transport to and from hospitals unnecessarily. At no point did endodontic

access cease nor did there appear to be any cessation of AGPs. Instead a mindful approach to their

use, which of course could be recorded and monitored appropriately given the settings in which

dentistry is provided.

The most recent reports suggest an easing of the lockdown in early April 2020, but restrictions

remain. There are reports suggesting people require a smartphone app to record public transport

use, as well as visits to restaurants and hotels. This essentially acts as contact tracing in a way that

would be viewed as an invasion of basic civil liberties in many areas of the world.

3) Germany

COVID-19 Relevant Statistics

Confirmed cases 162,000

Deaths 6,518

Population Density 232/Km2

One country that is often looked towards in terms of fiscal stability and crisis management is

Germany. 86% of the German population pay into a statutory health insurance scheme ensuring a

minimum legally prescribed standard oral healthcare package. The remainder of the population have

the option of fully private funding for their oral healthcare.

The response to COVID-19 in Germany has been managed at a regional level, without an overriding

order for closure of dental practices. The German Dental Chambers provide the guidance and are the

body who provide licences to practice in Germany. The equivalent of the British Dental

Association(link) recommend the following as of 21/04/2020:

Generalised recognition that standard cross infection procedures protect from virulent

organisms on a daily basis.

ALL dental team members to wear masks at all times.

2m social distancing between staff members when not treating patients

specifically highlight the lack of evidence of dental aerosol transmission, whilst also

promoting a four-handed approach to high volume aspiration.

Suspected low risk patients- PPE as follows- goggles, visors, masks (FFP2), gloves, and

possibly protective gowns (if possible).

Rubber dam where possible

Dentist led assessment on treatment need depending on risk to the individual and

procedure complexity.

It is recommended that patients displaying COVID-19 positive signs delay treatment until

symptoms have resolved.

Additional PPE and measures for COVID-19 positive patients- patient separation from

symptom free patients, use of surgical gowns (must be worn), head and foot coverage.

Very Importantly- The chambers highlight the evidence coming out of Wuhan, Italy and

South Korea, that there is no evidence to suggest that dental teams are at a higher risk of

transmission in any way.

Financial aid for dentists

There is a comprehensive financial package in place for small enterprises in all sectors, not only the

businesses themselves but also the self employed. The businesses are entitled to 9,000 Euros (one

off payment) if up to 5 employees for a 3-month period, and up to 15000 Euros (one off payment)

for between 5-10 employees.

There is also additionally a tax deferral option, loan deferrals, short term work allowances,

simplified access to basic financial security, tenancy protection and suspension of the insolvency

process.

This can all be found here if you are fluent in German or have limitless time to copy and paste into

your chosen language translation site.

Summary

It appears that the German professional bodies have taken a stance which allows for each individual

practice to determine levels of treatment provision. They have assessed the evidence available and

feel there is a relatively low transmission risk to the dental team during the COVID-19 pandemic.

4) France

COVID-19 Relevant Statistics

Confirmed cases 130,000

Deaths 24,376

Population Density- 117/Km2

Funding of dental Services

Basic dental care- such as examinations, routine cons and extractions are state funded

More complex/indirect treatments are self-funded with or without personal insurance

schemes.

COVID Response

The National Council of Dental Surgeons shut down all dental practices on the 16th of March, setting

up a centralised emergency service which could be accessed following telephone triage. There are

formal plans in place to re-open practices on May 11th. The main regulatory body for French dentists

have sourced enough FFP2 masks to allow French dentists to resume clinical practice. (Link). The

French Dentists protested vehemently about the lack of PPE and the French government responded

by promising to provide 4 FFP2 masks per day or the equivalent of 24 per week. Any additional PPE

deemed necessary will need to be self-sourced.

Re-introduction of dental care

Pre-informing patients, patient triage/ risks assessment, practice re-organisation, postponing

certain treatments.

Patients must attend wearing a mask, and if not then shall be provided with one.

Anti-splash protectors on reception.

Advocate use of air filtration systems

15 minute rest period post AGP

Work clothes should not leave the surgeries or be taken home

FFP2 masks for AGPs and if not visibly soiled or wet, can be used for half a day.

For non-blood splatter procedures- a plastic apron will suffice. Gowns for surgical

procedures.

No use of spittoons

Red/ blue ring contra-angle use over an air turbine as a preference/ where possible

Summary

It appears the French Dentists are heading back to work on May 11th with the above protocols in

place. Low risk, asymptomatic patients will have full range of access to both urgent and non-

urgent treatments. Patients who display no symptoms or have no history of COVID-19 but could

be seriously ill they contracted it, can access emergency care, and possibly routine care. These

appointments should be clustered with patients of the same category. Finally, patients who are

in close contact with a COVID positive patient or indeed display the symptoms thereof can

access emergency only care but still within the general practice setting.

Financial assistance for dentists

Non reported specifically for dentists, however there are some basic social security payments

and tax relief measures.

6) Italy

COVID-19 Relevant Statistics

Confirmed cases 205,000

Deaths 27,967

Population density 206/Km2

Funding of dental services

There exists very little public funding for oral health maintenance in Italy with the vast

majority being provided on a private basis (out of pocket or OOP). Vulnerable groups and

children can access dental care on a basic level which is state funded. (reference)

COVID-19 Response (Awaiting Translation)

Italy have very similar COVID-19 figures to the UK, and have now released an SOP in place for Phase

2 released by the AIO (Italian Dental Council) published on 28/04/2020. What is clear is that dental

practices were advised to cease all routine care but to remain open to treat emergencies only. Some

reports (link) suggest the current lockdown period will be in place until May the 2nd when it will be

reviewed. It is at this stage that ‘Phase 2’ may be initiated.

Italian policy document can be found here

This document appears to accept that there is a general risk of transmission from normal social

interaction, not limited to clinical settings.

Summary of Italian SOP when entering Phase 2

Triage, temperature, reduce risk of waiting room crowding

All patients must be given masks

Patients must wear disposable shoe coverings

Place any of the patients external clothing in a clothes bag

Scrupulous cleaning of waiting room area

Surface items on surgery surfaces

Cover surfaces with polyethylene film

Avoid opening drawers

Limit to treatment to necessary interventions

Pre-tx gargle with povidone iodine 1% or Hydrogen peroxide 1%

Rubber dam where possible and double surgical suction

FFP2/FFP3 masks without valve

Visors/ suitable eye protection

Gowns/caps/boot covers

15 minute set down period prior to cleaning

No treatment for suspected COVID-19 +ve patients- these should have real time PCR test

carried out ASAP. Avoid treatment on those with symptoms, or have been in close contact

with symptomatic or positive family members/ friends.

Financial Assistance for Dentists

Dentists can access up to 1000Euros per month for up to 3 months as part of wide social security

measures for pensioners and self-employed. More information on this is found here.

7) Sweden

COVID-19 relevant statistics

Confirmed cases 21,092

Deaths 2,586

A large percentage of dental care provision is state funded but there is access to a growing

private market.

Population density 25/Km2

COVID-19 response

The following document here is by the National Board of Health and Welfare. This document

updated on the 08/04/2020 outlines the uncertainty and lack of evidence surrounding aerosol

generating procedures. It does however outline what they consider to be ‘at risk’ aerosol generating

procedures, and what they do not.

The document tabulates various procedures cross checked against various research papers and SOPs

of various advisory health boards including the WHO, The Swedish Intensive Care society and Public

Health England.

For example they consider endotracheal intubation as high risk, as well as endoscopy and

tracheotomies. However, they do not consider ‘Dental care- High speed drill use’ to be an at risk

procedure. In fact of the seven evidence sources considered, only Public Health England considers

this to be an at risk intervention.

The Swedish Health Authorities have also considered the advice from the European Centre for

Disease Control and Prevention of which they state the UK as a target audience. This article sites the

following research papers which do not consider AGPs to be a risk here and here A word of caution

here would be that the fist paper looks solely at medical procedures, not specifically dental, and the

second paper again looks at critically ill ICU patients, who you wouldn’t expect to receiving dental

specific interventions. Additionally this document again uses the following paper here as a resource,

however this is again considering more medical, rather than dental interventions.

The health board do however consider Triaging of patients vital and appropriate risk categorisation.

The health board do not feel in a position to provide an overriding order on which procedures are

able to be carried out, presumably due to a lack of scientific evidence. It is accepted that procedures

including routine procedures can continue as normal (with additional PPE precautions) for low risk

groups who are symptom free. Those more at risk, due to complex medical conditions, can access

emergency care only, with social distancing from other patient groups.

It seems that the Swedish heath authorities are supportive of dentists providing a good level of oral

healthcare in their communities, highlighting the importance of their roles.

8) Canada

Relevant Statistics

Confirmed cases- 55000

Deaths 3391

Circa 90% privately funded – OOP/private insurance schemes.

Population density 4/Km2

In a similar response to Germany, the Canadian Dental Association has recommended that there is a

Provincial/ territory led response depending upon how each region has been affected. On May 4th

the provinces will allow incorporation of urgent care in addition to emergency care.

Alberta- 17/03/20- advice given to cease routine care immediately but still able to provide

emergency care. Pre-screening through triage if possible. The Albertan Dental Association highlight

the need for emergency care that could result in further patient deterioration and a further burden

on healthcare resources. Dental Emergency protocol can be found here.

The specified urgent cases are defined separately from Emergency cases and can be found here.

Managing active orthodontic cases is considered urgent. This list seems comprehensive and well

considered. Rubber Dam encouraged and Silver Diamine Fluoride.

British Columbia (Vancouver) 16/03/20 advice given to cease all non-urgent Dentistry. The protocols

seem a little more stringent here in terms of more active promotion of specific urgent dental care

centres. Still only urgent treatment only. Interestingly- no differentiation between emergency/

urgent as with Alberta. More specific management pathways which can be viewed here

Manitoba- Urgent and Emergency from May 4th. Very similar SOP to Alberta. here

New Brunswick – 16/03/20- advised to cease all non-emergency treatments. Conditions still apply.

Requires login to see SOPs

Newfoundland 18/03/20- advised to cease routine care. Very interesting advice here on SOP. This

remote province has 260 cases and 3 registered deaths. Appears less stringent than those above.

PPE requirements would now be considered ‘usual’ however does recommend procedure specific

mask usage.

Northwest Territories information packs emailed to dentists- not able to view publicly

Nova-Scotia No date on cessation of dental care. All urgent care sent to emergency dental clinics

Triaged by dentists. Appears very similar to UK

Nunavut – Coupled with Northwest territories- see above.

Ontario- 15/03/20- notice to cease all routine dentistry. Emergency AND urgent treatment to

continue. Clear segregation of urgent and emergency care. Government of Ontario consider health

professional as essential businesses. Orthodontics not included here- (see Alberta’s definition of

this.) Also interesting to note that final crown cementation is viewed as urgent if temp off/ causing

irritation. See here. Note also the 3 hour set down period post AGP with or without COVID-19

symptoms here

Prince Edward Island – full closure order on dental practices from unspecified date (suspected

similar dates to above provinces). Referral of all cases post triage to emergency dental care clinics.

Phased re-introduction detailed- May 22nd practices to re-open for Emergency care. June 12th re-

opening for urgent care.

Quebec 18/03/2020- routine care ceased but practices still open for emergencies. SOPs not

available.

Saskatchewan advice to cease non urgent care but instructed to act as contact points for

emergencies. Emergencies triaged locally and emergency clinics used for treatments. Unspecified

date but presumably similar early March dates as above. Phased re-introduction to provision of

urgent care in practices. Excellent standard SOP document can be found here. Examinations can be

carried out, but emergency care must be prioritised. Interestingly recommending a 2-hour set down

period post AGP.

Yukon – not publicly available.

Summary

Thirteen individual provinces exist in Canada and have been entrusted with managing their response

individually for their specific region. These decisions are most likely to be down to basic geography,

population density and demography. Canada is a vast country and has highly populated areas such

as Vancouver where you may expect stricter approaches to dental care provision. Of note is the level

of variance between the provinces and their approach to SOPs. Many of the themes are now familiar

and adopted worldwide, but the documentation and clarity of Saskatchewan province is

extraordinary.

9) Denmark

Relevant Statistics

Confirmed cases- 9563

Deaths- 484

Population density 134/Km2

40% of cost of treatment for adults funded by the state.

COVID-19 Response

The National Board of Health Denmark issues an order for dental practices to cease routine dental

treatments from 17/03/2020. The practices were instructed to continue to see emergency patients.

As of the 22/04/2020, Danish dentists have been invited to begin providing dental care much in line

with what was offered pre COVID-19. The health board specify minimising risk of spread of infective

agents and using video consultations where possible. The document can be found here.

Some measures are expected to be considered such as:

Deciding is a procedure can be delayed without risk of increasing morbidity

Measures in placed to encourage social distancing

Reducing daily patient flow

Suspected COVID patients refer to hospital

Pre treatment triaging for any suspected symptoms

****Promotion of in surgery SARS-CoV2 testing prior to elective AGPs****

Manage treatment depending on result of above test.

If test result negative then enhanced PPE worn in any case and room to be ‘briefly’

ventilated post procedure.

Gowns with all AGPs, but if supply issues then plastic aprons with neck coverage acceptable

If no apron, then change clinic clothes after this patient. These should not be laundered at

home

Normal loupes ok if have adequate eye protection features

High risk groups should not be treated in rooms that have just had an AGP carried out.

Summary of Danish response

The approach in Denmark was to ensure emergency access maintained locally within dental

practices. This has since moved on to perhaps the most rapid re introduction of ‘routine’ dentistry

anywhere in the world. Denmark is the only country (out of those considered here) to introduce pre-

treatment testing before AGPs carried out. In terms of set down time post AGP, the SOP was

translated as ‘briefly’ and not time specific.

OVERALL RESULTS

12 out of 17 countries/ regions considered, allowed to remain open for emergency

treatments since the beginning of the pandemic.

5 out of 8 (Canada considered as a single unit here given all provinces will have staged re-

opening) are undertaking a staged re-opening plan.

3 out of 8 (Sweden/ Denmark/ France) are encouraged to consider routine procedures on

low risk patients.

How the UK response compares to the response of other countries considered worldwide.

1) Notable time lag between Live OCDO releases and publication of ‘current advice’ from

professional representative organisations.

2) Australia, Germany, France, Italy, Sweden, Denmark and Canada (majority of provinces) in

addition to 15 out of 31 European countries all given the green light to manage dental emergencies

locally with stipulated additional PPE requirements.

3) Early adoption of AAA approach, which is not definitively described in any of the other SOPs

examined. This approach is also re-iterated on the SOP for UDCs.

4) Orthodontic management considered urgent in other areas of the world but not UK.

5) The Third Preparedness letter from the OCDO is specific in its detailing of how primary care

practices are expected to function from 25/03, however lacks specificity in other areas. For example,

the SOPs for the UDCs advise ‘use of high-speed handpieces should be avoided where possible. This

can be compared to once Canadian SOP:

Urgent endodontic procedures – AGP with Dental Dam in Aerosol Controlled

Environment utilizing Aerosol Protective Measures and N95 respirator

Urgent restorative procedures - AGP with Dental Dam in Aerosol Controlled

Environment utilizing Aerosol Protective Measures and N95 respirator

Urgent paediatric restorative procedures - AGP with Dental Dam in Aerosol

Controlled Environment utilizing Aerosol Protective Measures and N95 respirator

5) UK SOP recommends a 1-hour vacancy period post AGP. This compares to 15 minutes in France

and Italy, and 2-3 hours depending on the province of Canada.

Executive summary

Undoubtedly, the emergence of SARS-CoV-2, acted like a ‘stun gun’ to many of the civil liberties

which we have taken for granted all our lives. There was no blueprint for this specific event,

although pandemic risk has occurred historically with viruses such as SARS and MERS. The rapidity

with which this virus spread, and the factors that mitigated this spread, will undoubtedly be subject

to many public enquiries in the future.

However, from a dental perspective, what is clear is that although the infective agent remained the

same, the response to it varied wildly. For a profession which prides itself on evidence-based

decision making, it was evidently un-nerving to be required to make such challenging decisions

without any evidence base at all.

Some countries were better placed geographically to contain the virus, Australia and Canada for

instance. The population density is so low in these countries that social distancing is enforced

naturally. Interestingly, these countries allowed regions and provinces to decide how to manage

dental provision specific to their region.

It cannot be disputed that lockdown and social distancing were an essential component of the UKs

fight to halt the spread of SARS-CoV-2. Undoubtedly, cessation of routine dental care was pivotal in

promoting social distancing and preservation of PPE. What could be raised as discussion point would

be the speed and efficiency of the UDCs and supply of PPE to these institutions. The consequence of

these failings has been a vastly reduced emergency service to patients throughout the country, and

without doubt in some cases this has led to a deterioration in their overall and general health.

Many countries took the stance from the outset, that dentistry is an essential service, there to

prevent patients from overburdening secondary care. The UK did not take this stance, and instead

adopted a recommendation for AAA approach only in primary care. This has been flawed and vastly

insufficient in many cases.

One theme that resonated through my research was a clear synergy between government health

departments and dental associations/councils in many countries. The government set the strategy

and allowed dentistry to self-govern its approach, resulting in clear directives from the outset. This

information was then disseminated on one portal. Take Australia for example- all protocols, patient

information posters and financial aid packages all accessible on the same webpage. This is not the

case in the UK. Information is presented on multiple platforms with variable accessibility, adding to

the confusion felt amongst practitioners. In the UK, the response to SARS-CoV-2 was varied

between Wales, Scotland and England, leading to a period of confusion, delay and heightened

transmission risk.

There has been much confusion within England specifically, about the roles of Public health England,

the CDO, CQC, GDC and indemnity organisations. It is still an area of confusion about under which

circumstances a practice may be able to provide face to face emergency patient management.

The mixed messages, and statements have created a scenario where all dental practices have been

forced to offer telephone triage only resulting in patients being left vastly under resourced for

emergency care. This is now a time to consider specifically defined SOPs and requirements to allow

dental practices, particularly those in the private sector to introduce a phased re -opening, as has

been the case in many countries around the world.

There is no evidence of SARS-CoV-2 transmission between dental professionals and patients. The

most up to date study from Wuhan found here suggests no reported deaths from the provision of

dental care to COVID-19 positive patients. Studies such as this highlight the role of rubber dam in

prevention of micro-organism spread, and consequently need serious consideration. This has been

adopted by many countries as a reason to keep the profession providing a much-valued service. The

UK has created a situation where dental practices have closed, without any scientific evidence

supporting these decisions, risking patient health in the process. The financial impacts of this is

beyond the scope of this article, the reality is, however, dire for many practices nationwide. Many of

these practices have the required PPE in place to provide a non-AGP emergency service from

tomorrow, instantly easing the workload of UDCs. The Financial impacts upon practices acting as a

UDC have not gone unnoticed in the national press in recent days, as well as reports of inadequate

PPE provision.