State of the Dentistry under COVID19

Summary of this announcement

As of 26/Mar/2020 The Australian Dental Association (ADA) met and received information from the Australian Health Protection Principal Committee (AHPPC), comprised of all state and territory Chief Health Officers and chaired by the Australian Chief Medical Officer.

All dental surgeries will now be operating at Level 3 restrictions. All elective surgeries will be suspended until the pandemic is under control.

Our surgeries will still be open for emergency and urgent dental treatments.
Emergency examples: any swelling or uncontrolled facial or dental infections
Urgent examples: toothache, trauma

The ADA has spoken with the Federal Government and we are deemed as part of the essential health services. Therefore even in the event of a lock down we will still be open for the community.

Note: as the situation is fluid I will try my best to update and add to this post. The changelog of any edits will be posted here with a timestamp.

Version 1 (2PM 27/March/2020): Original post

Version 2 (9:30PM 27/March/2020): AHPPC has officially posted the statement for all those whom are sceptical whether it is government endorsed or not.

Version 3 (6PM 28/03/2020): Dental Council of NSW (governmental body) officially endorses the stance of ADA for Level 3 restrictions. The situation has made it to the mainstream media such as ABC NEWS:

Version 4 (5PM 30/03/2020) AHPRA (Dental Board) officially endorses what the ADA and AHPPC has outlined.

History of events (Australian context)

  • On 23 January, biosecurity officials began screening arrivals on the three weekly flights to Sydney from Wuhan. Passengers were given an information sheet and asked to present themselves if they had a fever or suspect they might have the disease (wiki-timeline)

  • On 25 January, the first case of a SARS-CoV-2 infection was reported, that of a Chinese citizen who arrived from Guangzhou on 19 January. The patient received treatment in Melbourne.[1][2] On the same day, three other patients tested positive in Sydney after returning from Wuhan (wiki-timeline)

  • At around early February 2020, there has been a shortage of personal protective equipment and masks for the dental context. At that stage even though there are cases growing the government response has indicated that things are under control with no known community transmission.

  • Up to this stage including up to Mid-March 2020 there has been no directive at this stage to start restricting practices and elective treatments. The ADA at this time has been talking with colleagues at the UK and elsewhere to get more information regarding COVID19 and dental practices

  • 18th March 2020, The Federal Health Minister’s office has confirmed that essential health services including dental will continue to operate as normal. There is no current advice or mandate from the Federal Government, AHPRA, or the Dental Board that suggests dental services should be limited or ceased.  

  • 22nd March 2020, non essential services has been closed by the government. No changes to the restrictions of practice or changes needed to be made.

  • 23rd March 2020, Level 2 restrictions has been announced for dental practices

  • 26th March 2020 4pm: Confirmed once more level 2 restrictions still in place in line with the second version of the restriction document

  • 26th March 2020 6:30pm: Level 3 restrictions have commenced. All elective surgeries must be halted.

What does this mean as a dentist?

This is what level 3 restrictions look like in the ADA document:

You can download the reference documents as follows:

Simply put:

The key message: do not do any treatments which will generate aerosols (that is pretty much 80% of dentistry -it’s like telling a surgeon that you can’t use scalpel to do surgery), if you have to do it limit that by using alternative tools or limit it by placement of rubber dam. This means we cannot, by governmental mandate, do this anymore:

  • All elective surgeries
    • General check up and clean
    • aesthetics and cosmetic dentistry (crowns and bridges, whitening, veneers)
    • Simple preventative fillings that won’t cause pain or infection within the next 4-6 months
    • Taking teeth out without any symptoms
    • Clicking/grinding of jaw joints and related pain or discomfort
    • Broken or chipped tooth -> looking further as an example, you can do it as long as it is under rubber dam with reduced use of aerosol.
    • Bleeding or sore gums, bad breath

Essentially: If the patient is not in pain and does not have an infection or dental concern with serious medical
implications, then they can be seen in several months when the pandemic has been controlled

We can still see you if you need any urgent or emergency treatments. So if you have anything that causes you pain (toothache, infections or ulcers) or emergencies such as uncontrolled infections or facial swelling. WE CAN STILL SEE YOU DESPITE LOCKDOWN.

Why aerosols?

In dentistry there are 3 levels of possible transmissions:

  1. Droplet transmission
  2. Contact transmission
  3. Aerosol transmission (or airborne in this case)
Source from the International Journal of Oral Science:

Droplet: – small and usually wet particles that stay in the air for a short period of time. Contamination usually occurs in the presence of the host. Particle size > 5 μm. (wiki)

Contact can be either:

  • direct – touching an infected individual, including sexual contact
  • indirect – usually by touching a contaminated surface

Aerosol/Airbourne: really small dry and wet particles that stay in the air for long periods of time allowing airborne contamination even after the departure of the host. Particle size < 5 μm

This is how we dentists protect ourselves, staff and you (cross-infection control) against this:

  • Droplet: by wearing gloves, safety glasses and face masks +/- face shields
  • Contact: by wearing gloves, good practice to separate treating areas and non-treating areas, good hand hygiene, sterilisation and disinfection of instruments, disinfection of hard surfaces
  • Aerosol/airborne: vaccinations, limit usage, negative pressure rooms, N95/P2 masks, full hazmat gowns.

Do you see the problem with aerosols now? The main problem is that aerosols require even more precautions than the usual dental context, his is made more complicated there is a worldwide shortage in personal, protective equipment.

Plus the fact according to the New England Journal of Medicine, the SARS-CoV-2 (which causes COVID19) will survive in the air for 3 hours.

We cannot source N95/P2 masks even as dentists as well, infact those masks are hardly used in the dental context and mainly used for infectious disease doctors and nurses in intensive care units.

The same with hazmat gowns and negative pressure rooms.

This leaves us with vaccinations and limit usage.

As of this post there are no known cures and vaccines for COVID19.

This is the main reason why dental clinics either must limit aerosol usage, or, in some cases, suspend and close their practice.

What does this mean for me as a patient?

You can still see us dentists for any urgent and emergency treatments, but please do not be mad and be patient as we all go through this pandemic together.

Unfortunately we cannot see you regular for the usual things due to the governmental mandate of restrictions.

The limit on the use of aerosols has severely limited 80-90% of our treatments effectively and treat you safely.

We will endeavour to keep you updated from our side as much as possible, once the storm has calmed down, we shall recommence normal treatments.

We will be able to go through this, nothing will trump human endeavour. Stay safe.