AAA: a rock and a hard place

The impact of COVID-19 national restrictions on dental antibiotic dispensing trends and treatment activity in England: January 2016 to July 2021

Introduction

Reducing inappropriate antibiotic prescribing tempers the growing threat of antimicrobial resistance. We aimed to quantify the associated impact of COVID-19-related national restrictions in England on dental antibiotic dispensing and describe changes in appointments and modes of delivery of care.

Methods

Interrupted time series analyses were completed using NHS Business Service Authority (NHSBSA) ePACT2 data to measure the associated change in antibiotic dispensing in England following COVID-19-related restrictions (which began March 2020). For face-to-face dental consultations, NHS dental treatment plan (FP17) data were used. For remote consultations during the COVID-19 period, NHSBSA Compass system remote management data were used.

Results

Between January 2016 and February 2020, there was a decreasing trend in antibiotic dispensing (-0.02 per 1000 population per month, P < 0.05). In contrast, there was an increase of 0.98 per 1000 population (P < 0.05) in March. The peak in antibiotic use occurred between June 2020 and July 2020, once the restrictions were eased. At the end of the study period (July 2021), the elevated prescribing trend had not returned to pre-pandemic counterfactual levels, although exhibiting a declining trend. A stable trend in dental treatment plans was seen pre-COVID-19, with a sharp decline coinciding with the restrictions. Dental treatment plans had not yet returned to the higher pre-pandemic levels.

Conclusions

Dental antibiotic prescribing significantly increased with the national COVID-19 restrictions when service delivery was altered with the closure of dental practices and introduction of remote consultations. Teledentistry was likely associated with inappropriate antibiotic prescribing. Continued antimicrobial stewardship and prudent use of antibiotics in dentistry is important.

Reinventing Patient Support and Continuity of Care Using Innovative Physician-staffed Hotline: More than 60,000 Patients Served Across 15 Medical and Surgical Specialties During the First Wave of COVID-19 Lockdown in Qatar

Rising disease prevalence early during the COVID-19 pandemic in the State of Qatar led to stoppage of all non-emergency health care services. To maintain continuity of care and information exchanges for non-emergency patients, a physician-operated telephone hotline was set up that involved triage followed by immediate consultation with a specialized physician. We describe the initiation and evaluate the operations of the Urgent Consultation Centre (UCC) hotline manned by 150 physicians and aimed at urgent non-life-threatening consultations at Hamad Medical Corporation, the public health provider in Qatar. UCC established a hotline to triage inbound patient calls related to 15 medical and surgical specialties. For calls between April-August 2020, we describe call volume, distribution by specialty, outcomes, performance of UCC team, as well as demographics of callers. During the study period, UCC received 60229 calls (average 394 calls/day) from Qatari nationals (38%) and expatriates (62%). Maximum total daily calls peaked at 1670 calls on June 14, 2020. Call volumes were the highest from 9 AM to 2 PM. Response rate varied from 89% to 100%. After an initial telephone triage, calls were most often related to and thus directed to internal medicine (24.61%) and geriatrics (11.97%), while the least percentage of calls were for pain management and oncology/hematology (around 2% for each). By outcome of consultation, repeat prescriptions were provided for 60% of calls, new prescriptions (15%), while referrals were to outpatient department (17%), emergency department/pediatric emergency center (5%), and primary health care centres (3%). We conclude that during a pandemic, physician-staffed telephone hotline is feasible and can be employed in innovative ways to conserve medical resources, maintain continuity of care, and serve patients requiring urgent care.

Understanding the impact of COVID-19 on dental antibiotic prescribing across England: 'it was a minefield'

Introduction The COVID-19 pandemic impacted significantly on dental service delivery across England.

Objective To explore how and why the pandemic affected antibiotic prescribing by primary care dentists.

Methods Mixed-methods study: secondary analysis of routinely collected NHS dental antibiotic prescribing data from before and during the pandemic; and an online survey of dentists (NHS and private) across England's regions.

Results Dental antibiotic prescribing increased 22% in the pandemic's first year, with regional variation from a 12.1% increase in London to 29.1% in East of England. Of 159 dentists surveyed, 60% had prescribed 'many more' antibiotics. Some urgent dental centres required antibiotics before accepting referrals, irrespective of clinical appropriateness. Diagnosing remotely was hard. Antibiotics were used to delay aerosol generating procedures and fill gaps in services. Widespread frustration existed.

Discussion Maintaining access to urgent dental care during a future pandemic would include availability of high-grade personal protective equipment for dental teams. Everyone must understand the impact of restricted dental access on antibiotic overprescribing and hence antibiotic resistance.

Conclusion Reduced dental access and changes in dental service delivery because of the pandemic increased antibiotic prescribing. Ensuring uninterrupted access for all to effective urgent dental care is an important element of global efforts to tackle antibiotic resistance.

Remote management of patients during the COVID-19 pandemic resulted in increased antibiotic prescribing in each of England's regions. Most dentists were not confident managing patients with acute dental conditions remotely. Ensuring access to face-to-face dentistry is an important part of efforts to tackle antibiotic resistance.

Dentists felt frustrated about being prevented from providing the dental procedures needed to provide safe and effective care to people in pain. Many also expressed concern about the impact of increased antibiotic prescribing on antibiotic resistance and their experience of increased patient expectation that antibiotics are appropriate for toothache.

Preparedness plans for future pandemics should recognise that antibiotics are not a substitute for dental procedures and dentistry was the only part of the NHS to experience an increase in antibiotic prescribing during the COVID-19 pandemic. Planners should aim to ensure sufficient face-to-face urgent dental care provision immediately upon implementation of pandemic restrictions.

Patient-reported orofacial-dental pain severity and tele-triage decisions during COVID-19 pandemic: Does the severity of pain drive tele-triage decisions?

Background

Globally, with the COVID-19 pandemic, dental services were limited to emergency/ urgent conditions and were provided only after tele-triage referral for face-to-face management. However, no previous research explored whether the pain severity (PS) drives the tele-triage decisions. The current study examined the association between PS and tele-triage decision of whether to manage the condition remotely or refer the caller for face-to-face management.

Methods

This retrospective cross-sectional study analyzed the PS reported by hotline callers, using numerical rating scale (NRS-11), during the first wave of COVID-19 lockdown (23 March–31 August 2020) and its association with tele-triage decision controlling for age, sex, history of chronic illness, and dental discipline needed. Binomial logistic regression assessed the association between the PS (exposure) and tele-triage decision (outcome). ANOVA compared PS across tele-triage categories, dental history and tentative diagnosis.

Results

PS was significantly associated with tele-triage decisions (p < 0.05). An increase in pain score by 1 unit was associated with 1.4 times increased odds of face-face referral (95% CI: 1.26–1.54). Pediatric/ adolescent patients (9–18 years) (odds ratio (OR) = 2.07; 95% CI: 1.07–4.02), history of chronic illness (OR = 2.12; 95% CI:1.28–3.51), need for surgical specialty (OR = 1.93; 95% CI: 1.22–3.04) and orthodontic specialty (OR = 7.02; 95% CI: 3.54–13.87) were independently associated with tele-triage decision. PS was highest for the emergency triage category (8.00 ± 2.83, P < 0.0001), dental history of tooth with cavity or filling (6.65 ± 2.024, P < 0.0001), and the tentative tele-diagnosis of cellulitis (7.75 ± 2.872, P < 0.0001).

Conclusions

During COVID-19 pandemic, tele-triage decisions were significantly influenced by patient-reported PS, adjusting for a range of variables. Despite this, referral for face-to-face management was individualized and driven by the tripartite considerations of the reported pain, clinical judgement, and the high transmission characteristics of COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02340-w.

Is tele-diagnosis of dental conditions reliable during COVID-19 pandemic? Agreement between tentative diagnosis via synchronous audioconferencing and definitive clinical diagnosis

Objectives

To assess the reliability of synchronous audioconferencing teledentistry (TD) in making tentative diagnosis compared to definitive clinical face-to-face (CFTF) diagnosis; and whether agreement was influenced by dentist's experience, caller-patient relationship, and time of call.

Methods

All patients calling the TD hotline during COVID-19 pandemic, triaged as emergency/ urgent and referred for CFTF care were included (N=191). Hotline dentists triaged the calls, made tentative audio-dentistry (AD) diagnosis, while dentists at point of referral made the definitive CFTF diagnosis. Cohen's weighted kappa (κ) assessed the extent of agreement between AD vs CFTF diagnosis.

Results

There was significantly very good pair-wise agreement (κ = 0.853, P < 0.0001) between AD and CFTF diagnosis. AD diagnosis of pulpitis and periodontitis exhibited the most frequent disagreements. Tele-dentists with ≥ 20 years’ experience exhibited the highest level of agreement (κ =0.872, P < 0.0001). There was perfect agreement when mothers mediated the call (κ = 1, P < 0.0001), and very good agreement for calls received between 7 am-2 pm (κ = 0.880, P < 0.0001) compared to calls received between 2-10 pm (κ = 0.793, P < 0.0001).

Conclusions

Remote tentative diagnosis using AD is safe and reliable. Reliability was generally very good but varied by dentist's experience, caller-patient relationship, and time of call.

Clinical significance

The findings suggest that using AD in the home environment is safe and reliable, deploying providers with variable years of experience. The findings have generalizability potential to a variety of similar circumstances, healthcare settings and epi/pandemic situations.

Remote Management of Prosthodontic Emergencies in the Geriatric Population During the Pandemic Outbreak of COVID-19

The global pandemic outbreak of coronavirus disease 2019 (COVID-19) has put the world in a panic situation. It has been evident that the geriatric population is more susceptible to acquire this infection. Thus, due to this ongoing crisis, geriatric individuals cannot visit a dental operatory, and there is the possibility of their dental needs and emergencies to remain unattended. Partial or complete edentulism is very prevalent among the geriatric population, and prosthodontic management of these patients is essential for their well-being. However, the prosthesis can lead to various emergencies of the oral and its supporting structures. There are currently no available recommendations to address these prosthodontic emergencies in geriatric individuals during this pandemic period. Hence, the aims of this minireview were to discuss the common prosthodontic emergencies in the geriatric population and provide recommendations to manage these issues during the COVID-19 pandemic outbreak.