A study in contrasts return to practice
The approach of governments in Ireland and Northern Ireland to the provision of dental care during the pandemic varied hugely
[ Words: Will Peakin ]
The experience of dental teams in Ireland and Northern Ireland during the pandemic has been a study in contrasts. While the profession as a whole debated the absolute necessity to close all practices for face-to-face care – when at the very least, urgent care could probably have been provided using appropriate personal protective equipment (PPE) – the Irish Government’s approach provoked shock and consternation amongst practitioners.
On 18 March, Dr Dympna Kavanagh, Ireland’s Chief Dental Officer, said there was no scientific evidence to justify denial of dental care to patients who do not have symptoms of the virus. In a letter to dentists, Dr Kavanagh said that the National Public Health Emergency Team (NPHET) had assessed the particular risks for the dental profession and their patients.
“Their advice is that there is no current scientific evidence to justify denial of dental care to members of the public who have neither fever nor respiratory symptoms. Neither is there scientific evidence to support the use of respirator masks for routine dental practice,” she wrote. “To be clear, at this time, the advice is that dental practices can remain open and that there is currently no need for a change in dental interventions.”
Her view prompted an outcry, with more than 500 dentists signing an open letter to the Chief Dental Officer. “The statement … is reckless beyond belief. It endangers all patients, dental workers and our wider society, as dentistry could potentially end up a substantial route of transmission of this virus. Her advice is at complete variance with that from almost every other jurisdiction.”
The Irish Dental Association (IDA) called on the Health Service Executive (HSE) to establish a regional network of designated dental emergency centres in order to adequately treat patients during the COVID-19 crisis. “The IDA respects the hard work of the Health Protection Surveillance Centre (HPSC), but our members are clearly indicating that they have a different view of the dental services which should be provided at this stage of the COVID-19 curve,” said a spokesperson at the time.
It said that the guidance should have been updated with input from the IDA, Cork Dental School and the Dublin Dental School. “We are urgently calling for the establishment of a structured, emergency care service in the form of a regional network of dedicated centres to support all patients, maximising the protection of the health of those providing it, maximising the effective and efficient use of personal protective equipment (PPE) and, very importantly, protecting the health of our patients.”
During this time, many private dentists had adapted their practices in line with international standards, limiting dental treatment for patients without symptoms to essential treatment, and ensuring patients with symptoms of COVID-19 were referred. But the vast majority of practices were limited to providing emergency treatment or had closed.
As the pandemic continued through April, the IDA accused the Government of “ignoring the effective collapse of the dental profession in Ireland”. In a letter addressed to Simon Harris, the Minister for Health, and Paschal Donohoe, Minister for Finance, the association’s Chief Executive, Fintan Hourihan, said: “I cannot overstate the sense of despair and panic in the dental profession at present.
“In normal times, 83 per cent of spending on dentistry is out of pocket rather than paid for by the State – now, dentists’ incomes are down by over 90 per cent on average during the COVID-19 pandemic as routine dentistry has been prohibited and emergency care cannot be provided in many cases due to unavailable or overly expensive PPE and other requirements.”
Hourihan said it was disappointing that dentists had not received a similar level of support given to the medical and pharmaceutical professions, especially given dentists receive no capitation funding from the state. “Medics and pharmacists have, quite rightly, been offered extensive support from the Government in order to continue to operate in such challenging circumstances. However, dentists have been left utterly isolated.”
There was a meeting between the IDA and Simon Harris in May, but it came to nothing and last month the association accused the minister of a “dereliction of duty” saying that the neglect of oral health would have “huge consequences” for Irish people in the months and years ahead”. By then, more than 700 dentists had registered for PPE promised by the Government, but by mid-June, it had not been provided.
In Northern Ireland, practices remained open during the pandemic to provide limited face-to-face care to patients with an urgent dental care need. Around three-quarters of practices saw more than 2,000 a week, supporting provision of emergency dental care alongside five Urgent Dental Care Centres (UDCCs).
“The pandemic has changed the way so many of our health and social care services are being delivered and dental practices have been particularly impacted,” said Michael Donaldson, acting Chief Dental Officer for Northern Ireland.
“I recognise this has been a difficult time for dentists, some of whom have lost income as a result of the restrictions placed on their services and I’m also aware of the frustrations of those who have had to live with dental pain during lockdown.
“Our role at the Health and Social Care Board (HSCB) has been to try and manage that delicate balance between preventing virus infection, looking after the oral health needs of the population and ensuring dental practices remain financially viable.”
Working with the five health and social care trusts, the HSCB established a network of UDCCs to ensure that dental care was available to those with the greatest needs. Practices played an essential role in dealing with patients’ dental problems during the pandemic. Dentists in all practices have been available to receive telephone calls to provide advice or see patients, if they felt it was safe.
During lockdown, 2,000 patients continued to be seen weekly in dental practices and a further 250 patients were seen at the urgent dental care centres. Dentists continue to staff the centres, the associated triage hub, and to provide support to care homes and other parts of the health and social care system as required. “I’m very thankful for the cooperation of dentists and practice staff for stepping up to the plate when required,” said Donaldson.
“Practices face not only shortages but crippling increases in costs for vital protective kit”Richard Graham
As part of the phased reopening of dental services, from 8 June practices could reopen to offer face-to-face urgent dental care while referring more complex care to the centres which have been able to carry out limited aerosol generating procedures (AGPs) where appropriate.
Phase two, beginning on 29 June, saw practices offering non-urgent care, but without AGPs.
It was anticipated that this would increase the number of dental patients being seen from around 2,200 patients a week to an estimated 38,000. Permitted procedures from then included extractions, removing dental decay and placing temporary fillings and making dentures.
It is hoped that practices would be able to return to routine care on 20 July, including the use of AGPs. Practices were also being given the option of fast tracking a full return to routine care by the beginning of July, providing key conditions around infection and prevention control are met.
“We are doing everything we can to ensure that we continue to provide safe, quality care to those in the most need, guided by the scientific and public health evidence,” said Donaldson. “A working group has been established with representation from the profession, the trusts, the board and the Department of Health. This working group has produced guidance for practices on how to prepare for increased patient numbers while protecting patients and staff.”
Two further working groups have been established, one looking at the immediate and longer-term oral health needs of the population and the other looking at developing solutions for the large numbers of children on Trust waiting lists for extractions under general anaesthetic.
Donaldson added: “I would like to pay tribute to all dentists and staff who, throughout the pandemic, have gone the extra mile to ensure that patients in urgent need were able to receive the care that they required in very challenging circumstances.”
Speaking on 18 June, Richard Graham, Chair of the BDA’s Northern Ireland Dental Practice Committee said: “We finally have a timetable. Dentists need time to prepare, but PPE remains the elephant in the room. Practices face not only shortages but crippling increases in costs for vital protective kit. We can put out the welcome mat, but without access to government supply chains, we will be in no position to treat patients.
“But we will need help to survive the new normal. Without long term support, sky-high overheads and fewer patents could be the final nail in the coffin for the service in NI. We trust the Department will step up to the plate.”