Urgent and emergency dental services are considered essential services under the new "circuit breaker" measures announced at the Multi-Ministry Taskforce (MTF) press conference on Apr. 3.

However, the fine line between what constitutes as urgent and emergency dental services and non-essential that should be deferred until after May 5 has caused some confusion.

The Ministry of Health has since provided clarifications in follow-up circulars.

Elective dental services should be deferred

In an Apr. 4 MOH circular seen by Mothership, the ministry emphasised the importance of dental practitioners being on heightened alert during this DORSCON Orange period, as infection of Covid-19 can occur concurrently with other infections.

The circular was sent out to dental clinics and registered dental practitioners.

Dental clinics have been instructed to defer elective dental services and procedures, unless otherwise instructed by MOH.

They were, however, allowed to carry out the provision of essential services and procedures.

MOH wrote:

"Essential services/procedures refer to those, if not provided or performed, would result in significant or rapid deterioration of the patient’s medical condition, and potentially threatening their health and well-being. Essential services also include operations to control the outbreak."

Subsequent circular

In another circular sent out by MOH on Apr. 12 and seen by Mothership, MOH provided updated guidance on the provision of dental care during this circuit breaker period.

In this update, MOH said that despite their directive in the first circular, reports were received regarding dental clinics and dental practitioners providing dental services and procedures deemed non-essential, non-urgent, or non-emergency treatment.

The second circular reminded dental practitioners again that they should defer all new and ongoing elective procedures, surgeries, and non-urgent or non-emergency dental care, until otherwise instructed by MOH.

The circular also listed the following examples of such care:

• Initial or periodic oral examinations and recall visits, including routine radiographs
• Routine dental cleaning and preventive therapies
• Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma) or other issues critically necessary to prevent harm to the patient
• Extraction of asymptomatic teeth
• Restorative dentistry including treatment of asymptomatic carious lesions
• Aesthetic dental procedures

Examples of urgent and emergency dental care

In the Apr. 12 circular, MOH gave the following definitions of urgent and emergency dental care:

• Urgent dental care refers to the management of conditions that requires immediate attention to relieve severe pain and/or risk of infection. These should be treated as minimally invasively as possible.
• Emergency dental care refers to the management of conditions that are potentially life-threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection.

The circular listed out the following as examples of urgent dental care:

• Severe dental pain from pulpal inflammation
• Pericoronitis or third-molar pain
• Surgical post-operative osteitis, dry socket dressing changes
• Abscess, or localized bacterial infection resulting in localized pain and swelling
• Tooth fracture resulting in pain or causing soft tissue trauma
• Dental trauma with avulsion/luxation
• Dental treatment required prior to critical medical procedures
• Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
• Extensive dental caries or defective restorations causing pain – to manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)
• Suture removal
• Denture adjustments or repairs when function impeded
• Replacing temporary filling on endo access openings in patients experiencing pain
• Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa

The following examples of emergency dental care were given:

• Uncontrolled bleeding
• Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling

  that potentially compromise the patient’s airway

• Trauma involving facial bones, potentially compromising the patient’s airway

"Dental practitioners are advised to exercise their clinical judgement in determining the patient’s need for urgent or emergency care", wrote MOH.

Failure to comply with the above may adversely impact public health and safety, and as such, will result in more stringent considerations of subsequent applications by MOH, the circular said.

Urgent and emergency care for high-risk patients

The MOH circular also included information of what should be done with high-risk patients.

These are defined as individuals with underlying medical conditions, such as a compromised immune system and/or with chronic disease, who would be at higher risk for severe illness from Covid-19 and would be more likely to be admitted into the Intensive Care Unit (ICU) if they were to become infected.

The circular called for all high-risk patients requiring urgent/emergency dental care to be either directly referred to the national dental specialty centre, stabilised by the dental practitioner before referring to either one of the national dental specialty centres for further care management, or advised to visit the A&E department at the nearest hospital to the patient for emergency dental care after office hours.

In a message by Chew Chong Lin, president of the Singapore Dental Council, which was seen by Mothership, he explained that patients at higher-risk but who do need acute dental care will be taken care of properly at the public health institutions' dental facilities:

"Patients are triaged with structured protocols at these premises and negative pressure dental rooms are also available for emergency treatment should the need arise.

This would reduce the possible risk of aerosol transmission between consecutive patients at the dental facilities as well."

He explained that patients who do not need urgent dental care should have their treatments deferred until the curve of Covid-19 infections flattens and the transmission rate of local cases decreases.

The council of the Singapore Dental Association also shared their statement with association members in a letter on Apr. 6, also seen by Mothership, explaining the importance of keeping people at home during this time:

"The guiding principle behind the "Circuit Breaker" is not about how safely we can treat patients.

Its sole purpose is to keep as many people HOME as possible, to reduce social interaction.

Many of the instances of spread are not likely to happen in the dental clinic but can happen when patients leave the safety of their home to travel to the clinic, in the transport system or when they encounter other people in the vicinity of the clinic."

Read about essential and non-essential vet services here:

Top photo by Jon Tyson on Unsplash.