The CDO for England's letter of 1 June set out the "next steps" for IPC in dental practices following the COVID-19 pandemic. The BDA sought clarification on a number of points, and we can now confirm that practices – having completed their own risk assessment – must now make their own decisions about how and when the patients are treated and what PPE might be required.
Facemasks – no longer mandatory
Patients with respiratory symptoms who are required to attend for emergency treatment should wear a facemask/covering, if able to do so, they may be offered one on arrival;
All other patients are not required to wear a facemask unless this is a personal preference;
Health staff are not required to wear facemasks in non-clinical areas (eg. reception areas, offices and staff rooms), unless this is their personal preference or there are specific issues raised by the risk assessment.
Screening – at pre-covid levels
The UK Health Security Agency (UKHSA) has said "defined COVID screening questions are no longer required" and that "routine, pre-attendance screening of all patients is no longer an expectation".
However, the public health messaging of "do not attend or call in advance if you have respiratory symptoms or feel unwell" remains.
Practices should be familiar with the pre-COVID approach, which asked unwell patients to contact the practice, to discuss their symptoms. This allows the practice to determine the priority and urgency for care and balance of risks.
Practices should return to messaging and raising awareness of this amongst their patients; (eg. using the practice website, comments on the appointment cards or reminder text messages).
When patients present for care with obvious signs/symptoms of a respiratory illness, the published dental framework suggests that practices draw up a protocol for individual triaging and patient expectation management.
Practice risk assessment - the "Dental Framework"
The way forward is based very much on common sense and informed risk, together with professional judgement. Completing risk assessments is an important part of this.
The CDO's letter included a template risk assessment for dental practices, which is designed to "offer a useful handrail"; it is a structured and methodical approach to recording the practice's risk assessments.
It is not mandatory to follow the framework and this risk assessment is not a rigid set of rules. It has been designed to support the implementation of the current national guidance. It is a summary of generic prompts and, as such, not all the examples suggested will be applicable in every dental practice.
There is a risk assessment for the whole practice, with others for communal and care areas and these should be complemented with individual staff risk assessments.
How risk assessments help
Providers are already expected to demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment. It is something local IPC leads (and the CQC) would be looking for if they were to visit a practice, especially one which had been highlighted as being of concern.
To help with this process, risk assessments are employed. These tend to have five main elements – elimination, substitution, engineering, administrative controls, and PPE. The more risk mitigation and controls can be established further up the "hierarchy of control" – such as elimination/engineering controls – the less will be required lower down the system, such as PPE.
If the risks cannot be managed through a combination of these higher controls – such as elimination (for example, the patient is triaged and the oral health needs require urgent dental care and patient cannot be deferred so they must attend) and engineering (for example, increase a poorly ventilated clinical area), then further risk mitigation will be required for all those encountering the patient.
These mitigations might include increasing any distancing and additional PPE and rescheduling the patient to a less busy time; this reduces the numbers of staff and patients who come into contact with them.
In addition, for those actively involved in treating the patient, depending on the intervention and duration, then the level of PPE will need to be considered.
Fundamentally, it is the reality of clinical dentistry that, due to the risk of blood/body fluid splashing during care, some form of PPE will always be required.