Measures taken to tackle Covid-19 have dramatically changed how dental care is provided, says Helen O’Callaghan
When HSE dentist Kathy Fox gets home from work these days, she throws the clothes she wore that day into the washing machine, then jumps straight into the shower. “I wash the day out of my hair, my skin,” she says.
Like many dentists, Fox is doing emergency procedures only — and on a very selective basis. The advent of Covid-19 means the options to do safe dentistry are severely limited. In March, after the Government introduced restrictive measures, the Irish Dental Association confirmed that the vast majority of dental practices are limited to emergency treatment or had closed. It warned that social distancing guidelines of at least 2m between people are “unworkable in a dental setting”.
“Dental work is conducted in very, very close range,” says Fox, pointing to the other major factor that has scuppered much of dental work: aerosol-generating procedures involving many of the dentist’s top tools — the drill, the three-in-one syringe used to dry/rinse a patient’s mouth, and the ultrasonic scaler that removes plaque from teeth — are dangerous in a Covid-19 scenario.
“They generate sprays that fly directly up into the dentist’s and nurse’s faces. These sprays linger in the air — above staff, patient and dental chair — before falling back down on surrounding work surfaces. If the patient’s infected with Covid-19 or is an asymptomatic carrier, the virus is carried in the aerosol spray. The nurse and dentist are inhaling this and, because it’s in the atmosphere or on surfaces, patients coming in afterwards could potentially become infected.”
The result, says Cork City-based dentist Michael McCarthy, is that 80% of the dentist’s job “has gone out the window”. Like many dentists, he’s providing a tele-dentistry service, where he advises and prescribes over the phone. “We’re limited to treating pain and swelling.”
He finds patients are glad he’s there to talk to and to be reassured: “I’m able to take out their chart and say ‘oh, I’ve given you this antibiotic before’. I phone the prescription to their local chemist, so they don’t have to travel. I’ve been lucky so far that there haven’t been any serious emergencies.”
Phone consults allow dentists to assess whether a problem can wait or whether it constitutes an emergency and, if so, whether benefit of treatment outweighs potential risk of Covid-19. “Most patients are very accepting and see the benefit in delaying treatment provided they’re not in pain,” says Dr Carmel Curtin of Corabbey Dental and Orthodontics in Midleton, Co Cork.
“Chipped teeth that are asymptomatic just have to wait for now. In reality, even in normal times, many patients delay fixing broken teeth that aren’t causing pain because of busy schedules — often, when we see them, a tooth or filling has been chipped for four to six weeks. For patients with good brushing habits and a low-sugar diet, these teeth usually have a good outcome.”
These days, when Curtin picks up the phone, she finds patients most commonly ringing about throbbing pain.
“If it’s an abscess, it’s easy to treat short-term — you can prescribe antibiotics over the phone to control the infection. But you’re just holding things. In normal [times], you’d bring the patient in once they’d finished the antibiotics, usually after five to seven days, and do root canal treatment or extraction. But root canal treatment requires use of the drill and extractions can too — without the drill, it’s like the dentist has lost their right arm.”
Curtin explains however that if the abscess doesn’t respond to antibiotics, it can develop into sepsis and potentially be life-threatening — and this is an emergency requiring urgent care, even in Covid-19 times.
But not all dentists or dental teams are in a position to provide emergency care, points out Irish Dental Association vice-president Kieran O’Connor: “If they’ve got a medical condition, have compromised immunity or are pregnant, they may have to stay home.
Dentists are probably able to manage many situations through advice and prescription but may be able to refer some situations to A&E.
The association has called on the Government to establish designated centres around Ireland for patients to receive emergency dental care during the coronavirus crisis. And they’ve asked that these be provided to all patients, not just those with medical cards. “It would be a safety net because, currently, emergency care mightn’t be accessible everywhere,” says O’Connor.
With personal protective equipment (PPE) difficult to source even for frontline healthcare workers, it goes without saying that dentists don’t have PPE. “No dentist, public or private, has hospital-grade PPE to my knowledge,” says Fox. And yet, in the era of Covid-19, it’s essential.
Last week, the Dental Council of Ireland issued a statement, emphasising that “aerosol-generating procedures should only be undertaken with an appropriate level of PPE, which includes a respirator mask to a minimum standard of FFP2” — a rating which refers to the percentage of particles the mask will filter out.
Curtin, in her local DIY store, found helmets with visors. “I bought 10 of them. They offer great protection worn with our safety goggles and surgical masks. But they’re heavy to wear. And now it has been announced that we need to wear respirator masks.”
Practising dentistry in the current climate is very stressful, says Fox, whose cohort is mainly primary school children. “If you have to bring them in, you’re keeping the contact minimal, the appointment as short as possible and you’re minimising time spent bending over the patient. But — while a parent might truthfully have said their child doesn’t have Covid-19 — children can be silent, asymptomatic carriers, so you’re quite exposed.
“In normal times, when a patient presents with a problem, you’d be thinking of the problem only. Now, if you’re doing an extraction, you’re hoping the tooth will come out easily. The thought is there: ‘what if it breaks, what if there’s a complication, if there’s bleeding and the child’s upset’. This would elongate the appointment, and risk of infection increases if the child’s a silent carrier.”
And then there’s the financial strain. With 3,283 active dentists on the Dental Council of Ireland’s register, the Irish Dental Association warned in mid-March that the dental profession in Ireland is on the brink of collapse, and that urgent direction is needed from the Government if it’s to survive the Covid-19 crisis. In a survey of 358 private dentists around Ireland, which outlined the scale of the crisis, nearly half estimated a drop of at least 90% in practice income in the medium to long term as a result of Covid-19.
“Running a dental practice is akin to running a mini-hospital,” says Curtin, explaining that, unlike GP practices, dental practices don’t receive State funding. “So for dentists to have to close their practices has been very upsetting. Just like other small businesses, for every week we’re closed we’re going further into debt — any loan or lease repayments for dental chairs (which cost about €40,000), x-ray machines, sterilisers (sterilisation could cost at least €20,000) that have been put on hold will still have to be paid at a later date. Rent still has to be paid. Rates have to be paid.”
O’Connor says patients stopped phoning for appointments three or four weeks ago. “It really shows they’ve got the key keep-away message around social distancing — which is good because dentists want to do their bit to see the curve flattened too.”
Dentists are trying to do the best, and the right thing, by their country and by their patients. And if you have a dental concern, the safest advice is to ring your own dentist, recommends Curtin. “They have access to your records, to your x-rays. They know your mouth.”
Since the Dental Council of Ireland announced the requirement for respirator masks, Curtin has been working to source N95 masks — they cover nose and mouth and help protect the wearer from breathing in hazardous substances. “We’re busy behind the scenes sourcing these, as well as PPE, which will be needed in dentistry for some time even after restrictions are lifted.”
She sounds a note of optimism, saying it’s not all doom and gloom: “In the grand scheme of things, it’s only a couple of months. Dentists would hope that within eight to 10 weeks they’ll be providing more routine treatment again. Meanwhile, they will make sure that patients’ dental health is kept stable.”