What is COVID-19?
COVID-19 is caused by a novel (new) air-borne coronavirus, SARS-CoV-2, that current thinking suggests is transmitted by droplet and aerosol contamination and close contact (less than 2 metres) with an infected person or through touching contaminated surfaces.
Whilst much has been learnt about SARS-CoV-2 since it was first notified to the World Health Organisation at the end of December 2019, much remains unknown. Consequentially there is a lack of high-quality evidence of how best to protect the dental workforce and their patients. The FGDP has proposed a risk-based approach to a safe return to a suitable dental practice until new evidence emerges. This approach also supports the national objective of reducing transmission of COVID-19 in the community and takes account of those who may be at higher risk of serious infection.
The new variants of the SARS-CoV-2 virus present a particular challenge, although it is thought that the variants are not any more deadly than the earlier versions.
The overwhelming majority of pathogens in dental practice are blood-borne viruses (BBVs) such as hepatitis B, HIV, hepatitis C and vCJD. Historically there have been extremely robust infection control procedures for dealing with BBVs but much less robust procedures for airborne viruses and contact viruses. Additions to standard infection control procedures are therefore considered necessary during the COVID-19 pandemic and possibly beyond.
What is the incubation period for COVID-19?
The incubation period for COVID-19 averages 5 days and can be up to 14 days, during which time patients are thought to be infectious even though they may be asymptomatic. It is now known that around 30% of people who have the virus are asymptomatic, meaning that a significant number of patients attending a dental practice may be either asymptomatic or they may be carrying or incubating the virus. This applies equally to clinicians, team members, patients, and members of the public. There may also be individuals who choose to conceal their symptoms to access treatment.
Dental practices must therefore treat all patients as if they are infected and apply appropriately strict protocols for the protection of patients, clinicians, and team members.
In addition, all dental practice team members are advised to ‘behave as if they have COVID
What are the symptoms of COVID-19?
The three most prevalent symptoms of COVID-19 are:
Fever (a temperature over 37.8 degrees centigrade)
A new persistent cough
Loss of taste and smell
Other symptoms that are not usual to the individual and have recently started may also indicate COVID-19, even in the absence of the common symptoms listed above.
The following symptoms have been identified in patients who test positive for COVID-19 (frequency is in brackets) and if present should prompt the individual to have a test:
Loss of appetite (49-84%)
Sputum production (28-33%)
Aches and pains (11-44%)
Sore throat (11-13)
Nausea/ vomiting (5-19%)
A new skin rash/discolouration of fingers or toes (<10%)
It is well established that respiratory viruses are more prevalent in the colder months of the year and it is inevitable there will be confusion about whether symptoms are due to the common cold, influenza, or COVID-19. It is therefore imperative that everyone with any of the symptoms above has a test for COVID-19.
Which patients can and can’t be seen in general dental practices?
Only patients who are asymptomatic and whose household members are also all asymptomatic for COVID-19 can be seen.
You cannot see patients who are:
Self-isolating because they have one or more of the published symptoms of COVID-19 .
Awaiting the results of a COVID-19 test.
Are part of a household in which another member is self-isolating because they have one or more of the published symptoms of COVID-19.
Are quarantining because they have returned from a country on the UK government’s list of non-exempt countries.
Have been contacted by Test and Trace and told to self-isolate.
No treatment can be provided in dental practice for these patients until the end of the self- isolation or quarantine period.
Can I treat clinically extremely vulnerable patients?
On 4th November, the Department of Health and Social Care updated the list of patients who are clinically extremely vulnerable. These patients will again be receiving a letter from the government telling them to shield and to stay at home all the time, except for in certain specific circumstances, such as attending a medical appointment. All non-emergency dental appointments for these patients should be postponed during the lockdown. If an extremely clinically vulnerable patient is in urgent need of emergency dental treatment, they should be seen as the first patient of the day.
Clinically extremely vulnerable patients:
People with solid organ transplants
People with cancer who are undergoing active chemotherapy.
People with lung cancer who are undergoing radical radiotherapy.
People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment.
People having immunotherapy or other continuing antibody treatments for cancer
People having other targeted cancer treatments that can affect the immune system, such as protein kinase inhibitors or PARP inhibitors.
People who have had bone marrow or stem cell transplants in the last 6 months or who are still taking immunosuppression drugs.
People with severe respiratory conditions including all cystic fibrosis, severe asthma, and severe chronic obstructive pulmonary disease (COPD).
People with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).
People on immunosuppression therapies sufficient to significantly increase risk of infection.
Adults with Down’s syndrome.
Adults on dialysis or with chronic kidney disease (Stage 5).
Women who are pregnant with significant heart disease, congenital or acquired.
What risk assessments do we need to undertake?
You will need to undertake risk assessments for:
Every patient you see at your practice during the pandemic
All clinicians and all team members
To understand how to undertake risk assessments, take our CPD courses in the New Patient Journey and Risk Assessments Demystified.
What is an Aerosol Generated Exposure (AGE)?
The Faculty of General Dental Practice (UK), the FGDP guidance issued in June created the descriptor ‘aerosol generated exposure’ or AGE. An AGE is then further qualified as being a low-risk AGE (breathing, speaking, coughing, and sneezing or activating the gag reflex, some dental treatments) and a high-risk AGE (dental treatment that creates an aerosol). A high-risk AGE equates to what we have come to describe as an Aerosol Generating Procedure or AGP. This is very helpful as it stratifies risk and allows a risk-based approach to the selection of appropriate PPE. Take a look at our course here.
What are high-risk AGEs?
High-risk AGEs are procedures that include (but are not limited to) the use of:
The air turbine.
The three in one air/water syringe when use of air and water is combined.
High-speed electric handpiece operating at > 60,000 rpm.
Surgical motors with irrigant/irrigation.
Ultrasonic scalers and Piezo handpieces.
Sandblasting, air abrasion, air polishing.
Practices may also wish to consider whether there may be a risk of aerosol generation when using endosonic handpieces and rotary endodontic handpieces.
How do I transport and clean my work uniform/scrubs?
All team members must be provided with adequate surgery-only uniform/scrubs and/or reception uniform for each working day.
Surgery-only uniform/scrubs must be worn under a disposable or re-usable gown and must be changed daily and laundered daily.
Clinical team members must not travel to and from work in uniform/scrubs.
Rooms or areas should be available for team members to change into and out of uniforms or scrubs.
Uniforms/scrubs should be transported home in a pillowcase.
The scrubs and the pillowcase must be laundered immediately on return home (or at the practice if the facility is available) and separately at 60c or at a higher temperature if the fabric allows.
They must be laundered separately to other items and the washing machine must be no more than half-full. They should then be tumble-dried and/or ironed. Take a look at our course here.
Can we open the drawers in our surgery during high and low risk AGEs?
Opening drawers is a tricky one! Actually we have been advised for many, many years that we should not open drawers during treatment due to the risks associated with any droplets in the air falling on clean materials in a drawer, so this isn’t technically a new ‘requirement’. However, realistically we all know that this isn’t always followed.
COVID-19 however poses a whole new risk level, especially while there is still much to learn about how it is spread and also while it is circulating in the community. For that reason, we should keep all drawers closed during treatment, whether this is for a high-risk AGE or a low-risk AGE. The differentiation between high and low risk levels of AGEs is very important because it acknowledges that there is no such thing as ‘no AGE’ because of speaking, breathing, coughing etc. That’s the reason theatres still cannot open, and we have to wear masks in enclosed areas in public.
So, the answer is the ‘no opening drawers’ rule’ applies whatever you are doing. Take a look at our course here.
I work as a dental nurse and I have recently developed symptoms of Covid-19. Can I still attend work?
No. You must not attend work and must immediately self-isolate and get yourself a test organised. Take a look at our course here.
How do I get tested for COVID-19?
You can have a swab test to check if you have coronavirus (COVID-19). You can either:
Choose to take the test in your local area at the designated testing centres OR
Order a home test kit via this link
If you have trouble with your internet, please call 119 if you are in England, Wales or Northern Island and 0300 303 2713 if you are in Scotland. Lines are open 7 am to 11pm every day.
I am a fully private dental practice. Are my staff eligible for an NHS COVID-19 test?
Yes, the NHS COVID-19 test is available to everyone who have symptoms for coronavirus (i.e. a high temperature, a new, continuous cough or loss or change to your sense of smell or taste).
I work in a dental practice and a member of my household has got symptoms of COVID-19. They are awaiting their test results. Can I continue to go to work?
No. You should not attend work and must immediately self-isolate if you or any member of your household have symptoms.
How long should I self-Isolate for?
If you have tested positive for coronavirus or have symptoms, you will need to self-isolate for at least 10 days. You will also need to self-isolate for 10 days if:
Someone you live with has symptoms or tested positive
You have been told to self-isolate by NHS Test and Trace
Someone in your support bubble has symptoms or tested positive
Do I have to self-isolate if I was wearing a face covering or face mask?
Yes. You will have to self-isolate for 14 days if you come in close contact with someone who has symptoms or tested positive for COVID-19. The NHS Test and Trace state that:
“if you work in – or have recently visited – a setting with other people (for example, a GP surgery, a school or a workplace). The use of face masks and other forms PPE does not exclude somebody from being considered a close contact, unless they are providing direct care with patients or residents in a health and care setting”. See the guidance here.
What is NHS Test and Trace? Does it apply to private dental practices?
The NHS Test and Trace is a service:
To ensure that everyone who develops symptoms of coronavirus can be tested quickly.
To help trace close recent contacts of anyone who tests positive for coronavirus and notify them that they must self-isolate (if necessary) to stop the spread of virus.
NHS Test and Trace applies to everyone including private dental practices. See the guidance here.
What does close contact mean?
Close contact means:
having face-to-face contact with someone less than 1 metre away (this will include times where you have worn a face covering or a face mask)
spending more than 15 minutes within 2 metres of someone
travelling in a car or other small vehicle with someone (even on a short journey) or close to them on a plane
I returned to work last week after a 14-day period of self-isolation, but I have got COVID-19 symptoms again. What should I do?
If you get symptoms for coronavirus again, you must immediately self-isolate and ask for a test.
If I was previously tested positive with COVID-19, do I still need to get tested following 10 days of self-isolation?
You can return to normal activities including work if after 10 full days of self-isolation your symptoms have gone, or if the only symptoms you have are a cough or anosmia, which can last for several weeks.
If you still have a high temperature after 10 days or are otherwise unwell, stay at home and seek medical advice.
What are the symptoms of coronavirus in children?
The main symptoms of coronavirus are:
a high temperature
a new, continuous cough – this means coughing a lot, for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to sense of smell or taste – this means they cannot smell or taste anything, or things smell or taste different to normal
What to do if your child has symptoms
If your child has any of the main symptoms of coronavirus:
Get a test to check if they have coronavirus as soon as possible.
Stay at home and do not have visitors until you get the test result – only leave your home to have a test.
Anyone you live with, and anyone in your support bubble, must also stay at home until you get the result.
Can a fogger be used to reduce the fallow time in dental practices?
Appendix 2_COVID-19 infection prevention and control guidance (updated 21st January 2021) and Standard Operating Procedure for the Dental Management of Non-COVID-19 Patients in Wales advises that the use of fumigation and fogging devices with disinfection chemicals should not be used for routine cleaning and or disinfection against COVID-19 and should only be considered in healthcare settings when multi-drug resistant organisms cannot be eradicated. This must always be under specialist infection prevention and control advice. The health effects e.g. respiratory issues and long-term health implications for staff are unknown.
Can I contract COVID-19 twice?
A study by published by Public Health England on February 3rd 2021 indicated that antibodies produced following natural infection may protect most people against subsequent infection for at least 6 months. However, with the emergence of more transmissible strains of the virus, the risk of reinfection also increases. It is important for all members of the dental team to continue to adhere to the measures put in place to protect themselves and their patients.
Are lateral flow tests mandatory for all dental practices?
The Innova SARS-CoV-2 Antigen Rapid Qualitative Test has been rolled out to all patient-facing staff delivering NHS services in primary care. This is also applicable to NHS dental practices. The tests are voluntary, but staff should be encouraged to be involved in regular testing to benefit their colleagues and patients.
Do I need to self-isolate for 10 days as advised by NHS track and trace if I have had a negative PCR test and no symptoms?
It is crucial that you complete your 10-day self-isolation period if you’ve been identified as a contact, even if you get a negative test result. This is because you may have the virus, but it cannot yet be detected by a test, so you could unknowingly spread the virus if you leave the house. Other members of your household, however, do not need to remain in self-isolation.
I am a self-employed dentist who is pregnant, can I decide not to stop working?
The BDA suggests that pregnant self-employed members of the dental team are free to make their own decision as to whether they work or not. However, self-employed staff members are encouraged to work together with practice owners constructively to ensure that risks are kept to a minimum.
We have appropriate protocols in place in our dental practice. Do I need to self-isolate if a member of the dental team tests positive for COVID-19?
If members of the dental team are wearing the correct PPE in accordance with the current IPC guidance, they will not be considered as a contact for the purposes of contact tracing and isolation. They will also not be required to self-isolate for 10 days (organisations have agreed the standards for PPE specification, fit testing and regimes of use for clinical and care activities).
Can a member of staff return to work after 10 days self-isolation if a member of their household is still experiencing symptoms of COVID-19?
If you stayed at home for 10 days because you live with someone who had symptoms or tested positive for COVID-19, you can return to your usual activities including work on the 11th day as long as you have had no symptoms and have not had a positive test result. You must continue to abide by the Government’s coronavirus advice.
Can we stop following the guidance in our Standard Operating Procedures once we have had the vaccine?
No, having the vaccine greatly reduces the risk of catching Coronavirus which is great news.
However, it may take a few weeks for the vaccine to get working in your system so it’s very important to follow guidance to ensure you don’t catch the virus whilst your body is still vulnerable.
Once you have immunity, your risk of catching the virus is greatly reduced but you could potentially still spread the infection to others which is why it’s very important to continue to adhere to the guidance in your SOP’s.
Can I enforce the “No vaccine, No work” policy on my employees?
If staff refuse vaccination, employers should seriously consider the employee’s reasons and try to address any concerns and clarify any misconceptions about the vaccines. Employers in the UK currently have no statutory right to oblige an employee to be vaccinated against COVID-19 virus without their consent, but it may be theoretically possible for an employer to require vaccination through a well drafted contract of employment and policies. Legal aspects with respect to discrimination, data protection and health and safety duties must be considered as part of any changes in contractual arrangements implemented by an employer. It is important to discuss any proposed changes with a Human Resource Consultant or your indemnifier.
Can I return to work even if my GP has advised me to shield as I am clinically vulnerable?
You are strongly advised to work from home because the risk of exposure to the virus in your area may currently be higher. You may want to speak to your employer about taking on an alternative role or change your working patterns temporarily to enable you to work from home where possible. If you cannot work from home, then you should not attend work.
Support is available through the Access to Work or Coronavirus Job retention schemes for individuals who cannot work.
Can I not see a patient who refuses to wear a mask?
No. Treatment cannot be refused, but the practice may need to make reasonable adjustments to ensure both staff and patients are protected.
NHS England and the BDA offer specific advice on managing patients who do not follow the government guidance on face coverings. The advice states:
For the small number of patients who may not follow this guidance we fully support practices in ensuring that they can take all reasonable steps to identify practical working solutions with the least risk to all involved. Practices should undertake a risk assessment which should consider, for example:
Offering the patient a mask if the patient is willing to wear one
Booking the patient into a quieter appointment slot, or in a separated area
Providing care where possible via a remote appointment.
Can vaccinated members of the dental team carry out AGP’s without enhanced PPE (FFP3 mask, disposable/reusable gown, and aprons) if a patient has evidence of a negative lateral flow test undertaken immediately prior to treatment?
No. The accuracy of lateral flow tests (LFT) is heavily reliant on the test being administered correctly. LFTs are very operator-sensitive and inherently less reliable than PCR tests. They are difficult to do correctly and can provide both false positives and false negatives. If a patient has an inaccurate negative LFT result they could still be infected but asymptomatic.
The majority of my patients have now had both doses of the vaccine and can provide evidence of vaccination. The dental team are also fully vaccinated so is it still necessary to wear enhanced PPE?
Yes it is. COVID-19 vaccinations offer proven protection against serious infection, hospitalisation and death but they are not 100% effective. It is also possible to contract and/or spread the COVID-19 virus even after vaccination.
Why can’t we relax on the measures in dental practice now since things are going back to normal?
It is important to keep the current measures in place as all of the measures together keep team members and patients safe.
Although infection rates are much reduced, the virus hasn’t gone away and the Swiss Cheese Respiratory Pandemic Defence Model provides a very helpful explanation of why multiple protective measures are still needed. One protective measure on its own (e.g. vaccination) may not be enough to provide adequate protection, but all of the recommended measures together create stronger and more resilient protection against the COVID-19 virus. Dental practices should continue to implement recommended guidance to ensure they are providing a safe environment for their team members and patients and to help ensure long term success in the fight against the virus.