key: cord-0915567-1mpy6xba
authors: Pajpani, Meera; Patel, Kishan; Bendkowski, Anthony; Stenhouse, Philip
title: Rapid Response: Activity from a hospital based Urgent Dental Care Centre during the COVID-19 pandemic
date: 2020-07-09
journal: Br J Oral Maxillofac Surg
DOI: 10.1016/j.bjoms.2020.07.004
sha: 74b0f2ffcb3e4b0399a042a5a23250f73179ff25
doc_id: 915567
cord_uid: 1mpy6xba

Abstract Aim On 23rd March, the UK Government announced a nationwide lockdown in response to the COVID-19 pandemic, resulting in the unequivocal and absolute cessation of all elective dental treatment. With much conflicting evidence on best practice to deliver safe treatment comprising of emergency dento-alveolar surgery, this paper describes the protocols which were undertaken to successfully set up a novel Urgent Dental Care Centre (UDCC) service within a short timeframe. We present patient data from referral through to treatment for the entire ten-week period of operation. Method A UDCC was established at Queen Mary’s Hospital, Sidcup within 10 days of this announcement. Through an iterative process with minor stakeholders and in collaboration with our Local Dental Committee, a comprehensive urgent dental service was established. Results Our UDCC received 1,311 referrals within a 10-week period, with 884 patients being accepted for treatment. The majority of treatment delivered in this emergency setting was surgical dento-alveolar procedures (84%). 16% of patients attended for trauma, first stage restorative treatment for teeth and post-operative complications. Both aerosol and non-aerosol generating procedures were available to patients. Conclusion Preventing acute hospital admissions relies on the ability to provide safe dento-alveolar surgery. Our results advocate that our unique UDCC is efficient and provides appropriate patient access and outcomes for those most in need of urgent dental treatment in the face of a pandemic.

On 23 rd March 2020, a nationwide lockdown was announced in the United Kingdom resulting in the cessation of all primary, secondary and tertiary dental care due to the coronavirus pandemic. Failure to successfully manage patients using the 'AAA' protocol On week commencing 20 th April, the government announced the phased opening of UDCCs in community care settings with referrals via the NHS-111 team. On 28 th of April, the government announced that primary care dental practices could re-open with appropriate risk assessments, protocols and PPE for non-aerosol generating procedures within the London region and for all procedures nationally.

Given the proximity that dental and oral surgeons operate to the mucosal membranes of the mouth, nose and eyes, as well as the use of droplet and aerosol generating procedures makes the provision of dento-alveolar surgery a potential risk for the transmission of the coronavirus. However, it must be emphasised that current evidence is equivocal on whether AGPs may produce aerosol particles capable of holding and suspending the coronavirus in the air in a clinical setting 4 . This article describes our UDCC and presents patient referral and outcome data for much of the period where all elective dental procedures throughout the country was prohibited in light of the COVID-19 pandemic (3 rd April 2020 to 12 th June 2020).

Through liaising with the chair of the Local Dental Committee (LDC) of Bexley, Bromley and Greenwich (London), a pathway was established between local GDPs and our UDCC, following referral guidance as established by Office of the Chief Dental Officer 5. No specific J o u r n a l P r e -p r o o f tariffs for payment were set for the UDCC; this allowed prompt delivery of emergency care to fulfil the needs of the local population. A trust-wide hospital response to the coronavirus pandemic included a reversion to a block contract for payment as opposed to a 'payment by results' system. This was established from April-October 2020 with the aim of review after this time. The service was staffed by Dental Core Trainees (DCTs) and staff grade surgeons The aim of the service was to make every contact count, with patients being advised at triage that their visit will provide definitive treatment for their condition to prevent reattendance and inevitable re-exposure for all parties. For those patients with lifethreatening dento-alveolar infection, referral was made to our OMFS team at a different trust site with in-patient admission rights and access to an emergency CEPOD theatre list.

This on-call service provided emergency provision on weekends and outside of our operating hours.

Each patient referred was triaged via phone and booked in for treatment either on the day of referral or the next working day, if their presenting condition truly warranted treatment in a UDCC (Box 1). Early intervention through definitive dento-alveolar surgery was J o u r n a l P r e -p r o o f imperative to prevent attendances to Emergency Departments and minimise hospital admissions for dental sepsis and thereby reducing the burden on in-patient hospital care.

Treatment slots were booked for 45 minutes, followed by a 30-minute fallow period and subsequent 60-minute surgery disinfection. This was based on 11-12 air changes per hour (ACH), per surgery, with the 30-minute fallow period considered pragmatic given the ACH.

Through a rotation of 5 teams working across 12 individual surgeries, a daily capacity of 32 treatment slots were available. Specific slots were reserved for patients who were deemed vulnerable in relation to the coronavirus virus at the beginning of the day to prevent unnecessary waiting in the reception. Table 1 indicates the minor oral surgery (MOS) and dental procedures (DPs) which were offered to patients depending on their presentation categorised as either an aerosol generating procedure (AGP) or a non-aerosol generating procedure (nAGP). DPs include the management of acute dental trauma and tooth extirpation. All treatment provided was under local anaesthetic only. Follow-up care for MOS procedures was organised as a telephone review, whilst follow-up care for DPs was delegated to the patient's GDP with an appropriate discharge letter.

This section discusses the results of the referral and triage process, as well as service delivery from 3 rd April -12 th June 2020. This includes the initial period of government enforced lockdown, when the key message was for the public to 'stay home' and then to J o u r n a l P r e -p r o o f 'stay alert' when lockdown restrictions began to ease. The last week of data presented saw GDPs resuming activity on 8 th June.

Within this ten-week period, a total of 1,311 referrals were received. Of these, 884 were accepted for treatment, with 438 being rejected. The acceptance rate of referrals received increased from an average of 32% in the first full week of opening the UDCC, to 63% by the end of the ten-week period, as a running average from inception ( Figure 1 ).

Of the patients referred into the service:  1,075 (70%) patients were referred with 'Pain' as the primary indicator for referral.

Of these, 65% were seen by our service.

 285 (18%) patients were referred with 'Swelling' as the primary indicator for referral.

Of these, 75% were seen by our service.

 9% of patients were referred with 'Dental trauma' as the primary indicator. Of these, 55% were seen by our service.

 2% of patient were referred with 'Trauma' as the primary indicator. Of these, 43%

were seen by our service.

 <1% of patients were referred with 'Bleeding' as the primary indication of referral.

Of these, 50% were seen by our service.

Of the referrals sent to our service, 47% of patients had pre-existing medical conditions. Of the patient cohort treated within our service:

 56% were female and 44% were male.

 A range of age groups were treated, including:

 5% under 20  61% aged 21-50  26% aged 51-70  8% over 71  98% of all patients treated were asymptomatic with regards to coronavirus  2% were symptomatic (but not confirmed with having coronavirus)  81% were not considered to be vulnerable  17% were considered to be vulnerable  2% were considered to be extremely vulnerable Of the 880 patients accepted for treatment, 96% attended, 3% did not attend and 1% cancelled their appointment. Of those who attended our service, 82% had dental extractions and 18% had other treatments carried out, including 8% having only an assessment, 5% having extirpations, 2% with trauma, 2% having restorations (including those related to dental trauma) and 1% with post-operative pain.

84% of all procedures carried out within the UDCC were nAGPs, whilst 16% were AGPs. Table 1 shows the type of procedure performed in respect of aerosol production and their count value. 61% of cases were treated by OMFS DCTs and SGs, 31% by Orthodontic staff J o u r n a l P r e -p r o o f and 6% by GDPs, with the remaining 2% being joint cases shared by different specialties. Figure 3 shows the level of treating clinician by grade. 6% of patients were sent home with oral antibiotics, whilst 3% had an incision and drainage performed. 10% of these patients were given a 'Stat' dose of intravenous antibiotics. This is compared to 6% in the first week of operation.

The continued increase in referral acceptance rate ( Figure 1) This collaborative service between primary and secondary care supports the notion of a continued journey; a path was established from the referring GDP who undertakes regular patient care to the triaging clinician and finally the operating clinical team within the UDCC.

This alliance facilitated numerous patient-clinician conversations relating to the delivery of care, minimising the likelihood of incorrect treatment being undertaken, as well as the provision of patient care rapidly within an appropriate setting. The utilisation of a secondary triaging team within a local practice for patients without a GDP to carry out 'AAA' also J o u r n a l P r e -p r o o f functioned effectively and served to take pressure away from the UDCC to allow focus on service delivery. This also allowed the UDCC to maintain a rapid response time: patients were contacted the same day or the next working day of referral receipt.

The highest acceptance rate for patients triaged was for those with swelling, where 75% of patients were accepted. This reflects the fact that a swelling is likely to be easier to objectively assess by the GDP, with many using photographs to aid in diagnosis, as well as its ability to cause rapid and significant threat to life if left untreated. Pain is highly subjective and this is reflected by the lower acceptance rate of 65% for those patients referred with pain. A patients' medical status did not preclude them having treatment with us, with almost half of our patient cohort reporting pre-existing medical conditions. A secondary care setting is well equipped and has active communication channels to liaise with other medical specialties which was extremely useful for a small number of compromised patients.

Attendance rates were generally high, with an average 'failure-to-attend' rate of 3% in ten weeks. This may be reflective of the anxiety response associated with dental procedures for some patients, especially in a climate with no provision for adjunctive sedation facilities. 8% of patients attended and were examined only with no treatment provided. Reasons for this included the need to be admitted for intravenous antibiotics with onwards referral to our sister OMFS site, the patient deciding that they did not want treatment, or there not J o u r n a l P r e -p r o o f being a clear cause for the pain. This only represents a small number of patients however, and reinforces the notion that pain is subjective.

The majority of patients attending for exodontia had nAGP XLAs (89%). Although well over half of all treatment provided in the UDCC was carried out by DCT or specialty doctors in OMFS, the low level for MOS AGPs was due to a high supervision rate of an experienced oral surgical team who could prevent the procedure from becoming an AGP where possible. By providing patients with incision and drainage and a 'stat' dose of intravenous antibiotics where necessary, progressive infection requiring inpatient care was prevented.

Patients were assessed and offered the most predictable outcome to resolve their symptoms. Extirpations of teeth were offered to the patients where teeth were considered reliably restorable, as per British Endodontic Society COVID-19 guidelines 6 . Most patients were in pain for a considerable amount of time with no access to primary care facilities and often the added time line for response to 'AAA', by which point they opted for extraction.

We found that traumatised anterior teeth and those with historical restorations in patients with otherwise low treatment need were deemed more suitable for extirpation. Figure 4 demonstrates that utilisation of capacity gradually increased over the period that the UDCC was operational. This continued to follow the trend irrespective of the different sanctions enforced by the Government on peoples' movement. This trend continued even once general dental services resumed face-to-face activity. This was highly publicised on national news platforms and may have created a surge of people contacting their own GDP, resulting in increased referrals to our UDCC. However, limitations on individual practices' J o u r n a l P r e -p r o o f ability to provide AGPs in primary care was still restricted and the need for existing UDCCs to maintain operational was imperative in continuing the timely delivery of care. Access to our UDCC was maintained throughout the duration of the COVID-19 UK wide lockdown restrictions. Figure 2 , which shows that our service has catered for patients as far reaching as from Oxford to Folkestone. These patients were accepted as their clinical need dictated urgent treatment and patients stated they were unable to access UDCCs in their area.

The coronavirus pandemic has changed the landscape of dentistry for the foreseeable future and UDCCs such as this one may still need to be operational in some capacity.

Although the maximum capacity of this UDCC was based on 12 self-contained surgeries where procedures could be performed, this does not necessarily translate to similar OMFS units around the country, especially those based in teaching hospitals. The basic principles and tenets used to establish this UDCC however, can be translated into other settings. This could be especially important to consider as hospital services re-establish themselves as providers of specialist care and this model can be considered when paving the way for primary care services, either in selected dental surgeries or within Community Dental Service settings.

Dento-alveolar surgery demonstrates a potential risk of coronavirus transmission due to the nature of its aerosol generation. With the potential of causing life threatening illness requiring emergency hospital admission, the early and appropriate management of acute dental infections is imperative and this relies on the ability to provide safe dento-alveolar J o u r n a l P r e -p r o o f 13 surgery in the face of a pandemic. By working in collaboration with our neighbouring LDC's, we established a service which has demonstrated a successful ten-week period of urgent dental care delivery for a large volume of our local patient population. Our results indicate an effective use of resources for the patient group in need of access to emergency dental services.

The authors have no conflict of interest in submitting this article for publication. There has been no source of funding for this article.

 Life-threating spreading head and neck infection which is dento-alveolar in origin, e.g. airway restriction or breathing/swallowing difficulties due to facial swelling  Trauma including facial/oral soft tissues injuries, and/or dento-alveolar injuries, e.g. avulsion of permanent tooth  Oro-facial swelling which is significant and worsening  Inadequate referral from practitioner lacking enough detail to process  Patient not in pain: either through effective AAA or inappropriate referral from GDP  Patient not on routine analgesia, even if in pain  Patient not had a course of antimicrobials and is clinically indicated  Unable to offer paediatric patient treatment without sedation: poor patient compliance  Any dental condition that does not meet our acceptance criteria: e.g. lost crown, non-suspicious oral lesions

 Patient declined two appointment slots  Patient unwilling to accept that dental extraction may be the only suitable treatment option pending a clinical assessment  Patient unwilling to have treatment without sedation or GA 

Emergency Dental Care, Dental Clinical Guidance

British Association of Oral Surgeons. Covid-19 Updates

Covid-19 Personal Protective Equipment (PPE)

Modes of transmission of virus causing COVID-19: Implications for IPC precaution recommendations

Preparedness letter for primary dental care -25

Diagnosis and Management of Endodontic Emergencies, a British Endodontic Society Position Paper for Primary Dental Care and other healthcare providers during the COVID-19 pandemic

The authors would like to acknowledge Rupert Jefferson for his hard work and dedication of the IT support during the establishment and operation of this UDCC.J o u r n a l P r e -p r o o f