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​​​​​​Recommendations and Expectations for Clinical Care in the COVID-19 Pandemic

March 29, 2020

Dear members of the dental team,

Every health professional is being asked to play an important front-line role to contain the spread of the COVID-19 virus and provide essential health services. On March 26, the provincial government announced additional measures being taken under the Emergency Program Act, and included dentists on the list of essential direct-to-public health services during the COVID-19 pandemic. The Provincial Health Officer and Minister Dix have also said that the health of workers in the healthcare system is paramount, and you will see this reflected in their calls to the public to keep healthcare workers safe and in the detailed guidance on the BCCDC website.

Everyone at CDSBC knows this is a difficult position at a stressful time for all oral health practitioners, especially as you are being asked to make unprecedented changes to the way you run your practice.

Over the last weeks, the COVID-19 response has been evolving and changing. We understand gathering information and applying it in the context of oral health care has been extremely challenging. As such, we have been liaising with the Ministry of Health, the Office of the Provincial Health Officer, professional associations and other regulators to help determine the level of information we provide.

Expert advice on the clinical aspects of COVID-19 should and will continue to come from federal and provincial health and other governmental authorities, including the BC Centre for Disease Control. We, as the regulator, cannot create that advice; our role will be — and must be — ​limited to providing clear signposting to all the current guidance provided by those higher authorities.

CDSBC does not expect any dental professional to provide treatment unless, in your professional opinion, it is safe to do so for both patients and the dental team. For our part, we will expect dental professionals to be aware of current guidance and to make decisions informed by it but we won’t be looking to second guess your clinical judgments made on that basis.

We understand the stresses you feel at a time where your businesses cannot function as usual, with the need for dental practices to be operating in a very different way. The recommendations and expectations that follow are intended to assist you in your decision-making.

We are all functioning differently, all of us are adjusting the way we work and live in this unfamiliar situation. It is a new experience for everyone. As Dr. Henry said yesterday, "we must be united in this, and 100% committed until we flatten this curve."

Recommendations & Expectations for Clinical Care in the COVID-19 Pandemic

March 29, 2020 (note: these replace the March 16, 2020 recommendations that were sent to registrants and posted on our website.)

Context
Novel coronavirus (COVID-19) is a new and emerging infectious disease threat. There is still much uncertainty around its clinical presentation, but the spectrum of disease may range from mild to moderate illness to pneumonia or severe acute respiratory infection.

Symptoms may include:
  • fever
  • tiredness (fatigue)
  • dry cough
  • more infrequently, patients may have aches and pains, nasal congestion, runny nose, sore throat, diarrhea or may show no symptoms at all
Modes of transmission of COVID-19 are:
  • droplet spread
  • interpersonal contact (e.g. direct or indirect contact with human fluids)
  • contact with contaminated surfaces (COVID-19 can persist on certain surfaces from a few hours up to several days depending on the surface and ambient conditions)
Infectivity of symptomatic and COVID-19 positive patients:
  • the science around durations and intensity of infectivity is still evolving
  • the milder the symptoms, the less infectious the patient appears to be
  • patients are most infectious at day 4 of symptoms and should remain in isolation for 10 days after the resolution of symptoms
  • it appears patients who have been positive for the disease will develop immunity for at least a few months post-infection

Below are CDSBC's expectations regarding the provision of dental care during the COVID-19 pandemic:

  1. CDSBC continues to strongly recommend all elective and non-essential dental services involving direct physical contact be reduced to minimal levels.

  2. Management of time sensitive treatment and essential and emergent concerns by registrants that helps avert or avoid negative patient outcomes will continue and be as minimally invasive as possible. The oral health care provider can determine the best place and manner in which the care can be delivered safely and appropriately. Management may include referral to an appropriate facility.

  3. Protocols for management of time sensitive treatment and essential and emergent concerns should follow current expert peer-reviewed guidelines and recommendations.

  4. Where possible, telephone and other forms of virtual technology are encouraged and should be used for triaging patient concerns. All dental offices should have an appropriate voicemail, email out-of-office, and email and telephone that are monitored daily.

  5. All patients will be assessed and screened for symptoms of COVID-19 prior to any treatment considerations. If the patient has suspected or confirmed COVID-19 disease, and if the appropriate treatment requires direct physical contact, appropriate personal protective equipment (PPE) and infection prevention and control practices must be used.

  6. Health professionals are in the best position to determine what is essential for their patient's well-being and these choices should be guided by principles of proportionality, harm reduction, fairness and reciprocity.

  7. If the determined care requires physical contact, all registrants will perform a thorough pre-treatment risk assessment that includes risk to the patient, to the oral heath care provider and to the greater community before any treatment is undertaken. If risks are identified that cannot be immediately or sufficiently mitigated, the determined care must be postponed or referred to an appropriate provider.

  8. If the determined care requires physical contact, the facility and staff will be compliant with expert authoritative opinion and existing CDSBC standards and guidance. Part A, Section 7 of CDSBC's Infection Prevention and Control Guidelines requires additional precautions in cases where patients are known or suspected of having an infection that can be transmitted by respiratory droplets. Additional precautions include enhanced appropriate personal protective equipment (PPE) for staff and patient, required patient hand hygiene and isolation, and capacity for social distancing.

    Recommendations for appropriate PPE can be found through BCCDC, Health Canada, authoritative health agencies and governmental bodies and expert opinion.

    Capacity to provide appropriate PPE for all oral healthcare providers must be assessed before treatment can be initiated. If appropriate PPE cannot be provided, the care must be postponed or referred to an appropriate provider.

  9. Following remote or virtual triage, when considering management options, registrants will receive full informed consent from the patient before moving forward with definitive treatment decisions including transfer to another facility.

  10. Advice, comments and care provided by registrants will be in keeping with current evidence provided by the scientific community. Registrants will not prescribe or recommend unproven treatments or medications for COVID-19.

  11. Registrants will stay up to date with federal and provincial laws and with expectations of federal and provincial public health agencies to keep patients, staff and themselves safe. Registrants will comply with orders, recommendations, expectations and updates from the Office of the Provincial Health Officer.
References and Resources:


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