Moving on from AAA: the 3Ps and 3Rs protocol for remote management of dental patients

Introduction

As the crisis caused by the coronavirus disease 2019 (COVID-19) pandemic dramatically took effect on society in early 2020, the Chief Dental Officer of England announced on the 25th March 2020, that all face-to-face management of dental patients should cease with immediate effect.¹ The aims of this intervention were to respect lockdown and prevent people from leaving their homes, as well as to protect patients and staff from potentially hazardous clinical environments.

The announcement led to an immediate scurry of re-writing of standard operating procedures, as dental professionals improvised to manage their patients as best as they could. Remote management was initially considered, simply to deflect patients who contacted the non-operational practices from seeking face-to-face attention. Dentists were instructed to give relevant advice over the phone, manage patients with analgesics and prescribe them antibiotics. The guidance was in line with that produced by the Scottish Dental Clinical Effectiveness Programme on Emergency Dental Care,² and the acronym AAA was born. Since dental services started to re-open on 8th June 2020, the profession has become accustomed to a new way of practising. Working from home is a concept that could not previously have been fathomed by most in clinical dentistry, but it is likely that a place will remain for the remote management of dental patients in some instances for a number of possible reasons:

The AAA protocol is, however, problematic in many respects.

Advice

On listening to the patient's concerns, dental professionals proceed to advise on how patients could self-manage the presenting problem. The advice is largely generic, presenting patients with information relevant to their condition. Prior to the pandemic, dentists would generally manage a patient in the clinical setting by taking a thorough history of the presenting complaint and a medical, dental and social history, followed by a relevant extra-oral and intra-oral examination with investigations, such as radiographs when necessary. Having gathered this information, a diagnosis would be made and presented to the patient with suggestions on how the complaint can be managed. The patient and the dentist would then agree on how to proceed, and treatment would follow. Following the first lockdown, remote management became equivalent to taking a brief history, which may not have been as thorough as one traditionally taken in the clinical setting, without performing any examination or investigation. The dentist was then expected to offer the patient adequare care, having gathered this very limited level of information. This approach may risk inappropriate advice being given, potentially leading to unsuccessful management outcomes, or at worst, unnoticed and delayed presentation of oral carcinoma.

Analgesics

The advice to manage patients with analgesics implies that the only dental diseases worthy of management were those that manifested with pain. A number of other relatively painless conditions could have therefore been left unaddressed. From gingival and periodontal diseases, to viral and fungal infections and other hard and soft tissue conditions, active oral and dental conditions could have remained untreated. Gingivitis, for example, may be appropriately left for treatment at a later date, but oral carcinoma left without treatment is inappropriate and life-threatening. Thus, the dental concerns most likely to be managed were often limited to pulpitis or cellulitis only.

Antibiotics

Although dentists can readily prescribe antimicrobial medication to manage oral and dental infections, the benefits are limited by potential problems such as side-effects, allergic reactions, toxicity and the development of resistant strains of microbes.³ Indiscriminate antibiotic prescribing within dentistry is a phenomenon that has previously contributed greatly to the worldwide problem of antimicrobial resistance, constituting a major threat to public health.⁴ Having made progress in changing prescribing cultures in line with evidence-based best practice, the current situation now risks reversing such advances and contributing to further resistance to antimicrobial medication.

In relation to the Faculty of General Dental Practice (FGDP) guidelines on antimicrobial prescribing,³ managing patients with antibiotics during these unprecedented circumstances has remained appropriate. The guidelines advised three indications for antimicrobial prescribing in primary care:

It is the latter reason that justifies prescribing antimicrobial medication under the current circumstances. However, with current remote management practices, the clinical assessment of the patient to ascertain a true indication is, at best, limited, and at worst, inappropriate.

Given the variation in the clinical presentation of dental patients, a single management protocol applied to all clinical conditions may be considered inappropriate. As the urgent dental care centres prepared and opened for service, followed by the gradual re-opening of general dental practices, a limited provision of clinical dental services has become available; however, there remains a need to manage patients remotely, and only call on face-to-face clinical care if necessary.

We, therefore, suggest an improved, patient-centred protocol to help dental professionals manage patients remotely with personalized healthcare: the 3Ps and 3Rs – phone, photo, prescription and record, refer, review.

Phone

As an alternative to face-to-face management of patients, telecommunications with patients is an essential tool. As previously suggested, clinical dental staff must remain readily available during working hours to receive phone calls and speak to patients to take a thorough history and offer appropriate advice. However, beyond simple telephone calls, we suggest the use of videoconferencing applications to add that element of face-to-face management of patients, limited though this may be. There is much to be gained from seeing facial expressions when managing patients and the tone of their voices and emotions are largely enhanced during a video call. The element of empathy that a face-to-face call offers is a significant advancement from the voice-only phone call. In addition to enhancing the level of communication during history taking, the use of video conferencing can also be useful for some further levels of patient management, oral hygiene instruction being an example (Figure 1). Applications such as FaceTime (Apple, Inc, Cupertino, USA), Skype (Microsoft, Inc, Redmond, USA), Zoom (Zoom Video Communications, Inc, San Jose, USA), Google Meet (Alphabet, Inc, Mountain View, USA) and Microsoft Teams (Microsoft, Inc, Redmond, USA), are readily available on smartphones.

Clinicians must first confirm the identity of the patient and remind them that they should be sitting in a surrounding where they are satisfied that the conversation they are about to have is acceptable to them. If the patient is a child, then they should be accompanied on the call by an adult who identifies themself as the parent or legal guardian. Now facing a patient with an enhanced level of communication, dentists can proceed to take an accurate medical, dental and social history, gathering information in much the same way as if the interaction was in the clinical environment. Face-to-face management would be re-established, albeit remotely.

Dental practices should have use of a smartphone or tablet, and an independent subscription to a phone contract and number. A professional using his or her private number is not advisable.

Careful attention must be given to maintaining the confidentiality of patients during video calls. It may be appropriate for the dental professional to be having the conversation outside the clinical premises, and even from home. Thus, we advise that the responsible clinician sits alone in a room in the premises, with their backs to a wall and wearing an earpiece rather than using the speaker (Figure 2). This would minimize the risk of breaching the patient's confidentiality by other members of the household hearing the conversation or seeing the patient's face. Using a computer-generated false background is not advisable so that the patient can be reassured of the true background to where the dentist is sitting. In the clinical dental setting, a patient would be in a position to make their own assessments of the surroundings and, therefore, the level of confidentiality they are being offered; however, during a video call, their ability to do so is limited. The surroundings must therefore be carefully explained to the patient and they must constantly and continually be reassured that their confidentiality is being respected at all times.

Photo

Smartphones are capable of capturing high-quality photos and, with a little professional guidance and the assistance of a member of their household, patients may be able to take clinical photos to assist clinicians in gathering further information to aid diagnosis. Photos in natural lighting may produce an image with enough clarity for the required purposes of information gathering.

Extra-oral presentations are easily gathered using a front-facing photo or even a ‘selfie’. This could be particularly useful for facial swellings and cellulitis, or lip lesions (Figure 3a). A photo of the tongue can be taken with protrusion and lateral positioning (Figure 3b). Holding the tongue with a dry tissue or cloth will help maximize protrusion. The anterior labial area is relatively easily captured by asking the patient to retract their own lips with their index and middle fingers, as another member of their household takes the photo. Photos in both centric occlusion and in slight opening may be useful (Figure 3c and d). Photographs of occlusal surfaces are a little challenging, but entirely possible by the patient opening as wide as possible and the camera being placed in a suitable position (Figure 3e and f). The posterior buccal segment is slightly more challenging, but achievable by the patient retracting one side of their lips only, using the index and middle fingers while a photo is taken. The limitations to how far posteriorly an image may be captured are dependent on how far the lip can be stretched by the patient (Figure 3g and h). Placing the camera very close to the mouth may affect focus as well as causing steaming of the lens as the patient breathes out. Placing the camera at a slight distance then using the zoom function often helps resolve this problem.

Transfer of photographs for perusal by the dentist can be performed by email, text or other messaging applications, ideally through an encrypted platform. The patient must understand the mechanism of transfer and not be persuaded to use any system they could be potentially unhappy with.

In addition to photography illustrating the clinical appearance, new patients may have access to previous X-rays that may aid dental assessment. If this is the case, they could potentially be forwarded to the dentist. Photographs may be an inadequate form of examination, but at least add an additional level of information that may assist in clinical management.

Prescribe

The current AAA protocol implies that analgesics and antimicrobial medication are the only medicaments of use for remote management. They may well be the most commonly used medications, but clinicians must be reminded that prescription of other drugs may also be appropriate. Mouthwashes for a number of gingival, mucosal and dental conditions; fluoride-containing toothpaste for symptoms of sensitivity; antiviral topical medication for viral lesions; and anti-fungal creams for oral candidiasis are all part of the medical armamentarium.⁵ Prescriptions may only need to be verbal for over-the-counter medications, or written for accuracy and specificity. Written prescriptions can be sent by post or email, either to the patient or to a nominated pharmacy. Alternatively, with the thus far unfortunate unavailability of an electronic prescription mechanism for dentists and pharmacists to use directly, a willing general medical practitioner may be in a position to assist. This remains an area in which further policy and procedural development is warranted within dentistry.

In addition to prescribing medication, a clinician may advise or even prescribe the use of adjuncts for the temporary management of dental disease. Temporary restorative materials are available for patients to self-apply to teeth (Figure 4). Dental professionals may not be familiar with such products as self-treatment has rarely been a treatment pathway to pursue, so familiarisation in the available products and techniques of use would be prudent to assist the patient.

Record

If remote management is being performed while the clinician is at the clinic, then all record-keeping protocols must be adhered to in the same way as if the patient was also present. Notes must be recorded contemporaneously in an accurate, clear, logical and concise way, to be understood by any reader.⁶

Careful consideration must be given to how record-keeping procedures are performed if the clinician is not at the workplace, in order to not compromise any aspect of patient care and legislative rights. If the dental team has subscribed to patient record software that allows for remote access, then this can be accessed from home with the appropriate password-protected and encrypted methods. Care must be taken to not allow anyone except the responsible clinician view of the records. A computer must be strategically placed so that nobody in the surrounding area can view the screen.

Where there is no remote access to the dental software, then the clinician must take reasonable steps to be innovative in recording notes then subsequently transferring them to the records software in the most appropriate way. The following is a suggestion that could be potentially deployed given the challenging circumstances. It is by no means a suggested method to practice under normal circumstances, but merely a technique worth considering when other methods prove impossible. Remote access to make contemporaneous notes must, however, remain the gold standard to replicate what would occur in face-to-face consultations.

If immediate access to the practice's notes system is not possible, then, while at the remote position and using a secure email account, such as NHSmail, contemporaneous notes can be written into an email but not sent, rather saved in the ‘draft folder’ instead. On return to the practice, the draft folder could then be opened and the notes cut and pasted directly into the patient notes software. Ideally, if there is someone at the practice who also has a secure email account, then the notes can be emailed to them for immediate cutting and pasting into the notes. The main point for consideration is that, in much the same way as it is common practice to transfer sensitive patient data through secure pathways when sending referrals, remotely recorded contemporaneous notes must be treated with the same level of security, using the same methods. Any photographs or images that have been sent by the patient form part of the records and will also need to be saved and safely stored for the requisite legal time. Patients should be made aware of this and provide their consent for the storage of any material.

Some video-calling applications have a recording function and, if agreeable to both the clinician and patient, this could be used and indeed then form part of the record by being saved and stored in the notes.

The suggested note-keeping technique is far from ideal, but we suggest that it is innovation in patients' best interests to cater to the current unprecedented need. Any adjustment of protocol must not in any way compromise the responsibilities of the dental team in relation to data protection. The patient must be informed of the suggested technique and agree to the mechanism.

Refer

While lockdown and social distancing measures remain of importance to the control of the spread of the disease within the population, limitations in access to healthcare is itself a risk to patients. If clinicians are in any doubt that the patient requires attention in a clinical facility, and are unable to see them in their own facility, then they must refer appropriately. There are a number of urgent dental care centres or operational practices that are in a position to receive patients, as well as the limited number of hospital departments and community dental centres. At the time of writing, dental practices remain open for face-to-face management, despite the spike in cases. The authors believe that another closure of routine dental services would be extremely unlikely, but there are a number of reasons where face-to-face management may prove impossible, perhaps due to staffing issues or infrastructure limitations that affect capacity at the practice. Patients must not be expected to tolerate uncontrollable pain or infections and may require urgent intervention.

Oral carcinoma and an acute spreading infection, with or without systemic involvement, remain of particular concern when managing patients remotely. There have been reports of such cases being missed during the remote management of patients.⁷ While there may be limitations in this novel protocol, such life-threatening concerns are less likely to be missed than if the AAA protocol remained in use.

If there is any doubt that the patient is presenting with any urgent or life-threatening condition, then immediate referral to a secondary care setting is necessary.

Review

Given the limitations of remote patient management, every attempt should be made to not only review the patient, but also review the application of the process. The following should be considered:

Ultimately, the clinician should be following up processes to ensure that patient management has been optimized, and the patient should also be reminded that, given there is a substantial deviation from traditional operating procedures, they should make contact with the clinical team if they have any concerns.

Limitations

As with all novel clinical interventions, objective evidence is required before declaring an intervention meaningful to clinical outcomes. Additionally, teledentistry carries limitations that may hamper patient satisfaction with clinical care.⁸ Moreover, with some patients, remote management may be unachievable, such as those unable to access or use smartphones in the suggested way. Finally, with all teledental management, there remains a risk that patients who warrant urgent face-to-face management may be missed.

Conclusions

As society has been forced to innovate and improvise during the COVID-19 pandemic, novel approaches to patient management have become a new normal, and we must strive to continually improve our operating procedures. While not novel, there is likely to be a place in healthcare for the increased use of remote management protocols and it is likely that an element of teledentistry will become part of our normal clinical practice.⁸

The AAA management plan in dental care may be considered insufficient and the 3Ps and 3Rs protocol (Table 1) could be valuable. While we consider the suggested 3Ps and 3Rs protocol an improvement on the AAA protocol, we acknowledge that it is by no means flawless and further updates to practising protocols for remote management of dental patients are likely to be required in the future.