June 20th 2020

Framework of patient care for Prosthodontists during COVID-19

  

Dear AANZP Colleagues,

I hope that this communication finds you all well, safe and navigating these difficult times with good spirits. Over the past few weeks, I have been approached by an increasing number of AANZP members to help interpret guidance on how to manage patients during the COVID-19 pandemic. The AANZP executive convened an Ad hoc COVID-19 Committee: Danielle Layton (chair), Gordon Burt, John Cho, Cos Maiolo and Simon Wylie. To help explain the AANZP position, please find our official preamble below. 

Background

On 23rd April 2020, the Dental Board of Australia stated: “Professional bodies and associations, such as the Australian Dental Association (ADA), have a different but crucial role to play in supporting dental practitioners. The role of associations is to represent the profession by promoting it, developing good practice guidance and policy and advocating to government in support of their members. We would expect the associations to suggest practice guides for the AHPPC to adopt in a public health crisis. While the Managing COVID-19 guidelines published by the ADA are not Board-approved guidelines, the Board expects all dental practitioners, including oral health therapists, dental therapists, dental hygienists, dental prosthetists and dentists, to follow the AHPPC’s recommendation and apply its advice in their practice setting.” 

The document we are directed to, “Managing COVID-19 Guidelines”, produced by the ADA is tailored towards provision of dental care in the general dental practice – it has been written by general dentists, for the regulation of general dentistry and has been endorsed by the AHPPC. The dental board has requested that clinicians seek guidance for their scope of restricted practice from their affiliated associations. For the prosthodontic community, the peak association is the AANZP and it is our responsibility to provide guidelines specific to the prosthodontic speciality. We believe this will acknowledge the complex nature of providing care for a referral-based practice. This inevitably places the onus of providing patient care by practising consistent with the guidelines, squarely on the shoulders of the prosthodontist. 

Prosthodontists are registered dental specialists, having completed an accredited higher degree, gaining expertise in assessment, diagnosis and provision of evidence-based appropriate care for patients with complex dental needs. The peak body for prosthodontists in Australia and New Zealand is the Academy of Australian and New Zealand Prosthodontists – AANZP. It is the AANZP that should be providing guidance to Prosthodontists in relation to patient care during this pandemic.

We believe the AANZP guidelines are consistent with the AHPPC endorsed- ADA guidelines (Levels 1 to 5) however they are written with specific reference to, and knowledge of, the challenges in the provision of specialist prosthodontic care during the upcoming level 2 phase.

On the basis of this background, the AANZP Ad hoc COVID-19 Committee is producing the AANZP Position Paper on patient care for prosthodontists during COVID-19. 

Aims and Charges

The AANZP Position Paper aims to provide Prosthodontists with guidance on how to provide appropriate patient care, based on our expertise in understanding the complex needs of patients in a prosthodontic practice, whilst working within the combined frameworks of government mandates and recognised professional guidelines for dentistry.

The ‘terms of reference’ of the AANZP Ad Hoc COVID-19 committee has were the following: 

1. Draft the “AANZP Position Paper” on patient care for Prosthodontists during COVID-19, as an iterative document, appropriate to use as a framework to seek feedback from stakeholders and initiate advocacy. (Completed).

2. Circulate the draft AANZP Position Paper across AANZP executive and AANZP Council, for assent/dissent and comment; followed by an update. The method utilized resembles a Delphi Method. The Delphi Method is used to identify consensus of opinion, often in the absence of a published evidence based. (Completed).

3. Circulate the AANZP Position Paper to the AANZP membership, to assist Members with further guidance when providing patient care as a Prosthodontist during COVID-19. (Attached).

4. Continue to review and update of the AANZP Position Paper, as an iterative process, seeking feedback from multiple sources. Feedback will be officially sought from the Australian & New Zealand Council of Dental Specialists (ANZCDS), before and during a planned ANZCDS meeting, Wednesday 6th May 2020; followed by re-circulation of the AANZP Position Paper to the membership if guidance evolves.

5. Continue to review and update of the AANZP Position Paper, as indicated.

6. Submission of the AANZP Position Paper to government-based stakeholders, including the AHPCC and The Australian Dental Board. 

7. Submission of the AANZP Position Paper to professional dental associations, including specialist dental associations and the ADA.

8. Facilitate and support the NZ membership of the AANZP to utilise the AANZP Position Paper, as necessary for the NZ prosthodontic community.

Throughout this process, it is likely that the AANZP Position Paper guidance will evolve, as further evidence comes to light, and as important feedback is provided. When this occurs, we will circulate updates, including the updated AANZP Position Paper. It is important to understand that the AANZP has already sought and integrated important feedback from our internal review to strengthen the external utility of our Paper; and is now in the process of further strengthening our position, and hence the support we can then provide to our membership, by undertaking a robust external review and advocacy process.

It is also important to note that the process outlined above is a recognised methodology for construction of guidance and guidelines, especially when evidence-based outcomes are lacking. The AANZP is cognisant that the ADA has had guidance endorsed by the AHPPC, and that the AANZP has not. However, the ADA’s guidance also had its inception as a type of position paper, which was then endorsed over time; and as it stands, it is the AANZP opinion that we need to provide suitable guidance specific for the specialist Prosthodontist. 

The AANZP has also clearly outlined how the AANZP Position Paper sits within the authoritative framework at this point in time and expects our membership to exercise due professional judgement when utilizing this guidance in clinical practice.

The AANZP Position Paper: Framework on patient care for Prosthodontists during COVID-19

In summary, the attached AANZP Position Paper delineates the AANZP guidance for provision of patient care by Prosthodontists during the COVID-19 pandemic. The AANZP framework of care is a framework for the provision of appropriate patient care; not a framework of restrictions. Within the Paper, the ethical stalwarts of beneficence, non-maleficence, justice and autonomy are paramount. It highlights that care for patients being treated by a Prosthodontist can be considered across the following categories: (1) all care, unrestricted, (2) care where there is risk of detrimental deterioration, (3) care for urgent needs, (4) care for emergency needs, (5) care for “oral health-related quality of life” needs, and (6) care for “oral health-related medical health” needs.

The membership is invited to provide feedback to the AANZP Ad Hoc COVID-19 committee on the AANZP Position Paper; as stated, this is an iterative and living document and may adapt as new evidence and expert advice comes to light.

Kind Regards,

Simon Wylie (Hon President, AANZP)

Danielle Layton (Chair, Ad Hoc COVID-19 Committee)  




AANZP Position Paper:

Framework of patient care for Prosthodontists during COVID-19

Prosthodontists are registered dental specialists, having completed an accredited higher degree, gaining expertise in assessment, diagnosis and provision of evidence-based appropriate care for patients with complex dental needs. The peak body for Prosthodontists in Australia and New Zealand is the Academy of Australian and New Zealand Prosthodontists – AANZP.

This position paper delineates the AANZP guidance for provision of patient care by Prosthodontists during the COVID-19 pandemic. It highlights that care for patients being treated by a Prosthodontist can be considered across the following categories: (1) all care, unrestricted, (2) care where there is risk of detrimental deterioration, (3) care for urgent needs, (4) care for emergency needs, (5) care for “oral health-related quality of life” needs, and (6) care for “oral health-related medical health” needs. 

The position paper also respects that patient care by Prosthodontists can be completed: without generation of saliva-aerosol because of the nature of the care; with substantially reduced saliva-aerosol generation because it is feasible to implement aerosol-precautions (e.g. rubber dam); with generation of saliva-aerosol because it is not feasible to implement aerosol-precautions; and with generation of both saliva- and sinus-aerosols because it is not feasible to implement aerosol-precautions. The AANZP refers Prosthodontists to “The Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC)” for further information on transmission-based precautions.

AANZP accepts the position of the Dental Board of Australia, that “The Board expects all dental practitioners, including oral health therapists, dental therapists, dental hygienists, dental prosthetists and dentists, to follow the AHPPC’s recommendation and apply it in their practice setting.” (2nd April 2020). AANZP acknowledges that the AHPPC has recommended adopting the Managing COVID-19 Guidelines published by the ADA. (27th March 2020). AANZP also accepts that the Dental Board of Australia states, “We would expect the associations to suggest practice guides for the AHPPC to adopt in a public health crisis.” (23rd April 2020).

The documents produced by the ADA, including “Managing COVID-19 Guidelines” are tailored towards provision of dental care in the most common practice setting, the general dental practice. 

It is the AANZP position that dental care in specialist prosthodontic practice differs from dental care in other dental settings, such as general dental practice. By definition, no care provided by specialist Prosthodontists is routine. Patients seen by Prosthodontists have complex presentations and complex needs. They are referred or self-present because their care needs cannot or should not be managed in general practice. They may present with social, psychological and biological risk factors that can have substantial and serious impacts on function, quality of life, medical health and overall well-being. Prosthodontists facilitate care to ensure that patient’s care needs are met and risk factors are managed so to prevent further deterioration of their oral health, oral health-related quality of life or oral health-related medical health. For prosthodontic care, the Prosthodontist is the most qualified practitioner to manage individual patient care in relation to “oral health”, “oral health-related quality of life” and “oral health-related medical health” (sic. “medically necessary dental care”). 

The Prosthodontist may also accept a referral from a medical practitioner to support patient care in relation to “oral health-related quality of life” and “oral health-related medical health”, and can choose to provide direct patient care or facilitate care in an alternative way.

Given this understanding of patient care needs when being treated by a Prosthodontist, the AANZP position on managing and facilitating patient care during an infective transmission risk pandemic such as COVID-19 is outlined below. For ease of understanding, the AANZP position has been presented within the ADA-proposed 1- to 5- level restriction framework. 

General principles

· The AANZP framework of care is a framework for the provision of appropriate patient care; not a framework of restrictions. The ethical stalwarts of beneficence, non-maleficence, justice and autonomy are paramount. 

· Undertaking care for patients is considered on an individual case-by-case basis by Prosthodontists exercising their professional judgement and expertise. 

· Prosthodontists will apply their expert knowledge of evidence-based outcomes, including patient-related outcome to consider the patient’s reported symptoms, clinical signs (if a physical examination is undertaken), biological care needs, oral-medical health interactions and oral health-related quality of life care needs when offering or facilitating care for patients.

· Prosthodontists may decide to not treat patients in their practice, and to facilitate care requirements in alternative ways.

· Care provided by Prosthodontists is not routine.

The dental profession is entering Level 2 patient care on Monday 27th April 2020. The ADA guidance advises aerosol transmission precautions for “elective” care needs (with specific procedure examples provided); and aerosol transmission precautions for undertaking this care is endorsed by the AANZP. However, the ADA guidance is silent on the management of patients under Level 2 who present with urgent and emergency care needs. In the absence of guidance, the AANZP advises “only treatments that generate aerosols where aerosol generation is limited to urgent and emergency care”, as per Level 3; where aerosol transmission precautions are utilised if feasible. In addition, under Level 2 the AANZP advises that, where the clinical presentation to the Prosthodontist necessitates care for those at risk of detrimental deterioration (category 2), with urgent needs (category 3), with emergency needs (category 4), with “oral health-related quality of life” needs (category 5), and with “oral health-related medical health” needs (category 6), such care is considered to qualify under the broad categories of Urgent and Emergency. 

Level 1, patient care 

· Referral of patients who require aerosol-related care, who meet epidemiological or clinical risk factors for COVID-19 infection transmissions to a facility that is equipped to provide such care.

· Provision of any patient care (category 1), for patients who do not meet epidemiological or clinical risk factors for COVID-19 infection transmissions, where it is deemed necessary by the Prosthodontist, without restriction on generation of aerosols.

Level 2, patient care

· Referral of patients who require aerosol-related care, who meet epidemiological or clinical risk factors for COVID-19 infection transmissions to a facility that is equipped to provide such care.

· Provision of definitive care, where it is deemed necessary by the Prosthodontist, for patients: at risk of detrimental deterioration (category 2), with urgent needs (category 3), with emergency needs (category 4), with “oral health-related quality of life” needs (category 5), and with “oral health-related medical health” needs (category 6), with generation of saliva-aerosols if necessary.

· Provision of definitive care, for any reason other than listed above, where it is deemed necessary by the Prosthodontist, if it is feasible to implement precautions to substantially reduce saliva-sinus-aerosol generation.

· Provision of any patient care, where it is deemed necessary by the Prosthodontist, if it is feasible to complete without generation of saliva- sinus-aerosols.

Level 3, patient care

· Referral of patients who require aerosol-related care, who meet epidemiological or clinical risk factors for COVID-19 infection transmissions to a facility that is equipped to provide such care.

· Provision of care, where it is deemed necessary by the Prosthodontist, for: urgent (category 3), emergency (category 4), “oral health-related quality of life”  (category 5), and “oral health-related medical health” needs (category 6) with generation of saliva-aerosols if necessary, and use of precautions to substantially reduce aerosol generation if feasible. Those requiring aerosol-related care can have care completed in a definitive manner, but a principle consideration is to stabilise in a way where necessary generation of aerosols is minimised

· Provision of any patient care, where it is deemed necessary by the Prosthodontist, if it is feasible to complete without generation of saliva- sinus-aerosols.

Level 4, patient care

· Referral of patients who require aerosol-related care, who meet epidemiological or clinical risk factors for COVID-19 infection transmissions to a facility that is equipped to provide such care.

· Provision of care, where it is deemed necessary by the Prosthodontist, for: emergency (category 4), and “oral health-related medical health” needs (category 6) with generation of saliva-aerosols if necessary, and use of precautions to substantially reduce aerosol generation if feasible. Those requiring aerosol-related care can have care completed in a definitive manner, but a principle consideration is to stabilise in a way where necessary generation of aerosols is minimised

· Provision of any patient care, where it is deemed necessary by the prosthodontist, if it is feasible to complete without generation of saliva- sinus-aerosols.

Level 5, patient care

· Referral of all patients who require aerosol-related care, whether or not they meet epidemiological or clinical risk factors for COVID-19 infection transmissions to a facility that is equipped to provide such care. This guidance is based on the principle that those presenting have a high chance of 

· Provision of any patient care, where it is deemed necessary by the Prosthodontist, if it is feasible to complete without generation of saliva- sinus-aerosols.

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