Dentists and dental surgery guidance

Who does this guidance apply to and scope

These guidelines are intended to support dentists and dental services to manage risk of infection in the context of the current COVID-19 climate.     

Since 1 June 2020 dental services in the community have been allowed to operate but have been restricted to emergency and necessary treatments only.

At level 2 of the safe exit framework dentists can resume urgent and routine dental care, in a way that is safe, operationally deliverable and allows dental practices flexibility to do what is best for patients and their teams. Progression to the full range of dental care should be risk-managed by the individual practice and can include aerosol-generating procedures (AGPs), subject to following the necessary IPC and PPE requirements.

Confirmed or suspected cases of COVID-19 should not be treated and those requiring emergency and urgent care should be referred to the Urgent Treatment Centre and Covid-19 helpline at the hospital. If antibody testing is undertaken it should be remembered that a negative IgM does not exclude infection and that we have insufficient information to declare that an IgG positive cannot be an asymptomatic carrier.

The following public health guidelines are intended for use as a minimum requirement and in addition to standard precautions in keeping with General Dental Council (GDC) guidance.

Principles for the extension of community dental care services at Level 2 

This guidance is in addition to the general advice for all businesses and workplaces during COVID-19. This covers risk assessments, general hygiene, looking after your staff and physical distancing, amongst other things.

Physical distancing

You should have a strategy in place to support physical distancing between everyone on your premises including staff, patients and any other permitted visitors or carers accompanying a patient when not delivering treatment.

Measures to do this will depend on your practice operations but may include:

• reviewing the use of the building including lifts, staircases and car parks and other users of the building to support physical distancing and decontamination 
• avoid walk in situations as much as possible, use signage and ensure that all access is by scheduled appointment
• appointment timings being staggered to allow for physical distancing, decontamination and preparing of treatment. Consider longer opening hours, staggering rest breaks and weekend opening to support physical distancing
• avoid patients waiting in the waiting room at the same time and ideally being in the practice at the same time
• minimise non-essential interaction (especially physical contact) between staff members and patients and between staff members. Family members that are non-guardians or caretakers should not attend appointments with patients. Essential family members and carers should be asked to stay in the waiting room, during treatment (except parents / carers accompanying children’s treatment or with patients with complex needs)
• minimising furniture or chairs spaced apart in the waiting room
• consider floor markings to demonstrate minimum requirement for physical distancing
• all physical distancing and hygiene measures must apply to all elements of the premises and
  operation, for example stock rooms, staff areas, locker rooms and delivery points
• use physical barriers to reduce exposure to the COVID-19 virus, such as glass or plastic windows at receptions area and where screening is taking place
• consider contactless or card payment for treatment 

Hygiene and sanitising for community dental care services at Level 2

Business as usual hygiene measures should be enhanced throughout the Safe Exit Framework to ensure reduced risk of COVID-19 transmission. As well as the measures outlined in this guidance, the advice given by General Dental Council should also be considered.

Where practical, identify a specific person to take a leadership role for infection prevention
and control (IPC)and support them with training and some protected time for this role.

They will also monitor supplies of materials required for good infection prevention and control practice including supplies required to support hand hygiene and supplies of PPE.

Observe strict adherence to the Infection Prevention and Control protocols and Decontamination in primary care dental practices (HTM 01-05):

• remove magazines / leaflets / toothpaste samples / unnecessary items from waiting rooms
• minimise touch points
• promote hand hygiene at reception (signage, verbal reminders and provide alcohol hand rub)
• promote respiratory hygiene and cough etiquette (signage, provide tissue and enclosed bins)
• encourage use of facemasks by patients and accompanying persons at all times in the waiting room
• toilets should be cleaned at least twice per day and should be checked regularly and cleaned whenever visibly dirty 

In the surgery

Remove all non-necessary items from exposed surfaces – prescription pads / pens should be kept in a cupboard and only filled in after the patient has left the surgery and after hand washing. 

Before the patient arrives in the surgery (which would already have been decontaminated)

Ensure all instruments, equipment and materials required for the procedure are set up and available, and ensure PPE is correctly fitted.

After the patient leaves the surgery

Remove instruments for sterilisation using standard protocol; close the door and allow the droplets to settle for 20 minutes. This fallow period is the time required for clearance of infectious aerosols after a particular procedure, before decontamination of the surgery can begin.

A fallow period of up to 60 minutes is required for high risk Aerosol Generating Exposures (AGE). This should be timed from the cessation of aerosol generation. A practitioner can choose to adjust this time if, after carrying out a thorough risk assessment, it is considered that the risk from an AGE can be modified. For example by natural and / or mechanical ventilation to support the change of air in the room (further guidance on air change rates can be found in the Infection Prevention and Control protocols). 

Following the fallow period, decontaminate all work surfaces, chair, computer keyboard / laptop, switches, door handles other touch surfaces and any areas that may additionally have been contaminated with droplets and finally the surgery floor. (NB ensure that an environmental cleaning protocol is available so that appropriate cleaning and decontamination takes place with routine disinfectants, such as detergent or detergent with hypochlorite or alcohol as appropriate and is sufficient. The use of plastic aprons and household gloves is generally appropriate for cleaning).

Also ensure:

• dental prostheses and moulds should be safely packaged and appropriately labelled for transportation to laboratory. They should be appropriately cleaned and disinfected before being sent to the laboratory, and after laboratory work prior to placing in the patient’s mouth
• handwashing should be maintained and enhanced, particularly between seeing patients and between changing gloves
• all clinical waste should be double bagged in yellow clinical waste bags and tied with a cable tie and disposed of in line with the routine clinical waste disposal regimes
• dental scrubs should be washed on site or at a laundry service. They should not be taken home

In addition to the above precautions, please also consider:

• limiting personnel in the treatment room to the minimum required and ensure that the door remains closed throughout
• only allowing one patient in the actual treatment room at any time      
• increase ventilation to help to disperse aerosols generated. Increased ventilation may be achieved naturally (for example opening a window where practical) or by mechanical ventilation 

Risk assessments for community dental care services at Level 2

Risk assessment of all staff coming into / returning to work – for wellness / temperature check and vulnerability should be done. Risk assessment for patients can be done by screening and triaging as follows: 

Screening and triaging

Whenever possible patients should be assessed by phone / telemedicine before being seen for face-to-face consultation as follows: 

• ask patients for current / recent symptoms using a COVID-19 triage questionnaire based on the symptoms of COVID 19. If a prospective patient is suspected to have COVID 19 infection, then defer treatment by 14 days or refer to the Urgent Treatment Centre (UTC) and COVID-19 helpline
• patients who have travelled into Jersey recently are asked to schedule an appointment for 2weeks after return to allow for self-isolation; if the patient has an emergency case, consider referral to the UTC
• screen patients for severe vulnerability and risk assess necessity of treatment to ensure balance of risks is considered before treatment. If treatment is deemed necessary, vulnerable patients should be seen at the start of any session (definition of vulnerability to COVID-19)
• where appropriate, patient history should be taken ahead of any appointment to reduce contact time. On arrival for the face to face consultation at the reception:
• request patients to complete and sign a pre-treatment questionnaire either electronically before arrival or on arrival reconfirming a negative COVID-19 history (sample) and obtain a consent for treatment
• check patient temperature using a no-touch thermometer. If the patient has a raised temperature, use clinical judgement to assess if the rise in temperature is due to dental infection or suspected COVID 19 infection. If temperature increase due to dental infection is ruled out, refer her / him to the UTC; inform the patient that this procedure is in place before arrival 
• accurate record keeping for contact tracing should this be required
• notifiable disease recording and reporting via appropriate channels if testing is performed and positive cases are identified (Notifiable diseases notification form)
• ensure patients decontaminate hands upon arrival to the surgery with either access to hand washing facilities or alcohol hand rub
• the use of masks and visors by all reception staff should be considered 

Considerations for vulnerable groups

Children: Where identified as necessary, parents / carers should be allowed inside the treatment room but should be at 2 metres distance from the dental chair and should be encouraged to wear facemasks and follow hand washing and respiratory etiquette.

Higher risk patients (older people or those with underlying health conditions): dentists and other healthcare staff should be extra cautious while treating people in older age groups and / or with underlying medical needs. Appointments for these patients should be at the quietest times of the day and limiting use of the waiting room- ideally at the start of the morning list.

Personal protective equipment (PPE)

PPE to include gloves, plastic apron, surgical mask (FRSM) and eye protection like visors to be used when performing routine low risk procedures.

If aerosol generating procedures (AGPs) must take place, then enhanced protective equipment is recommended. This equipment includes surgical FFP2/N95 masks, visors, water-resistant long-sleeved gowns and gloves. FFP2/N95 masks must be fit tested. 

Further guidance on the use of personal protective equipment in healthcare settings is available and where relevant will be up-dated.

Staff should change at work and not wear clinical clothing to or from work. If staff cannot shower at work before leaving they should do so as soon as they get home.

Aerosol Generating Procedures

The risk from aerosol exposure applies to all people in the room when an AGP is performed. Where there is a practical and equally effective alternative to AGPs, it is appropriate to use the alternative.

It is strongly recommended to use a rubber dam with high volume suction during aerosol generating procedures to reduce aerosol generation.

Aerosols can also be minimised through use of suction, cotton rolls and damp gauze.    

Advice for display

Information to be displayed in practices