WHO Press conference Covid19 & Dental care 11 August 2020

Good morning everyone.

This is Tariq from WHO hope you can all hear me well and see me well.

Thank you for coming for this WHO press briefing.

I will just give you a little bit of introduction and context and then I will give the floor to our expert, Benoit Varian, who is with us today.

I would just like before that to thank our colleagues from, from Munich for technically supporting this briefing and those who would like to ask questions after introduction by our experts, just please raise your hand so briefly.

You know, and we were saying this all along, that impact of COVID-19 extends beyond the, the, the, the, the direct toll on people who get infected.

It has a negative impact on the capacity of health systems to deliver.

And you listen to what Doctor Mike Ryan said on 3rd of August, and I would really like to quote him.

A WHO survey with responses from 103 countries between mid-May and early July found that 3/4 of our Member States reported partial or complete disruption of immunisation services, rehabilitation services and dental services.

2/3 reported a partial or complete disruption of non communicable diseases, chronic diseases, diagnosis and treatment, family planning, treatment of mental health disorders.

Over half reported disruption of malaria treatment campaigns, distribution of Nets, antenatal care, cancer diagnosis and treatment, palliative care services and services for sick children.

So, while services are impacted, COVID-19 is also affecting the demand for them.

People are afraid to visit health facilities in areas of transmission.

Equally, the economic impact of the crisis means that some people are having to make tough choices between accessing healthcare and other pressing needs.

All this implies that more people may suffer and die from other diseases that in many cases are treatable and curable.

We need to act with urgency to reinforce health services and increase investment in a resilient public health system worldwide.

WTO is issuing guidance on on maintaining social health services during COVID-19 as well as immunisation, blood supply and oral health services.

So today we will speak about this particular point, but just I wanted to put it in a context that providing oral health services is part of a wider context of providing health services that has been disrupted by, by COVID-19.

So as you have seen in our media advisory, we we, we are issuing the guidance on oral health provisional for oral health during COVID-19.

And today we will hear more about that, about guidance itself and about what we are recommending to health professionals in this area as as well as to ministries of health and others involved in provision of oral health.

I'll give a floor to Doctor Benoit Bargain who will give us more details on all of this.

Just to remind everyone that we will need to finish this press briefing by 10:00.

So once we get to questions, hope we will go have a short questions.

Benoit, the floor is yours for opening remarks.

[Other language spoken]

Thank you, Tariq, and good morning to all those attending this press briefing and thanks for giving the opportunity as to present this new guidance document that is part, as you mentioned, Tariq, of a series of documents which aim to support countries to maintain essential health services during COVID.

So I'm leading Oral F programme and I'm working with the NCD team department in Headquarters Geneva as part of the management of NCD unit.

So just to introduce the topic of the day, as I guess that some of you are not familiar with oral health issue, I would like to raise 2 important facts.

Firstly, that oral disease represent a major neglected health burden in many countries around the world.

Oral disease affect people throughout the entire life causing pain, social isolation, distress and even death.

As we are considering oral cancer and some specific oral facial gangrene called Noma, we know that oral disease are kind of social marker in in in a number of of society at global level.

Last estimates that are available show that 3 billion and half people are affected by oral disease.

And important to mention of course that untreated dental caries in permanent teeth.

So it means in adults and young is the most common health condition in human beings.

We also know that more than 500 million children are suffer from untreated dental carry in primary teeth or milk teeth.

Another so important aspect just to to give you a kind of context of oral health is that oral disease disproportionately affect the poorest population and that inequalities in access to oral services are huge within and across countries and region.

Secondly, the second fact that I would like to to introduce to you, of course, and as Tariq mentioned, yeah, with The Who survey, it's that COVID-19 has affected and still affect dental service around the world in really unprecedented ways.

So Tariq already mentioned Doctor Ryan Coat and it's true that 75% of WHO member state who responded to to this survey mentioned that dental services have been completely or partially descripted during the the pandemic.

So this is either than for any other tip type of essential health services.

And of course this is for public and private dental service that have been suspended.

And so it concerned dental school temporarily closed in the context of lockdown measures introduced to contain the the pandemic.

So now quickly how can we explain this really **** level of service disruption?

I think we can mention three or four major explanation as it is described in the in the guidance document.

The main reason is linked to the to the nature of the work provided by the oral healthcare personnel.

As you know dentist, the dental nurses, hygienist and dental assistant work in close contact with with patient and are exposed to saliva and blood.

And so they are using what we call spray generating equipment such as ultrasonic, scalar, **** speed devices.

All this equipment that maybe you have experienced during your last dental visit and all this equipment are generating what we call airborne particles or aerosol.

So all this to, to to mention that oral healthcare providers are thus at **** risk of being infected with COVID-19 or passing the infection to the patient.

Another likely reason of service disruption is certainly the the lack of preparedness and the response of the oral healthcare services and providers to such an outbreak.

As you know, a number of countries where, for example, confronted to a critical shortage of personal protective equipment.

We also know that oral health staff in some countries have been deployed or redeployed to provide COVID-19 relief.

Finally, I think it's so important to to say that unfortunately oral services continue to be quite wrongly perceived as non essential health services by health authorities.

So it's in in this context.

The Debejo guidance recommends in case of community transmission to give priority to urgent or emergency oral cases to avoid or minimise procedures that may generate aerosol and pre authorise a set of clinical intervention that are performed using end instrument and of course to to daily routine non essential oral health care.

This means oral checkup, dental cleaning, preventive care and certainly also some aesthetic dental treatment.

The guidance also suggests applying several measures to prevent and reduce and reduce, of course, the risk of transmission during dental visit.

This measure including remote screening and or triaging of patient and a set of of infection prevention and control procedures before and during treatment, but also between patients.

So just before moving to the question and answer session.

So I would like to to mention some thoughts on what, what are the next step or the, the way forward at this point of time.

As you know, dental service are reopening or have already reopened for example in Europe for one or two months depending of of the countries, but mostly with significant adaptation of service and work arrangements.

And we know that such adaptation and arrangement will require time and investment to implement in low resource seating.

And of course, all this will depend of of support providing by by government and and partners.

We think that the most pressing issue is related to the availability of essential personal protective equipment, PPE for all healthcare personnel and taking or assisting of course in the clinical procedures.

This should be accompanied by training programme or DRF workforce on IPC on the same time looks very important.

Communicating about all people can protect themselves and others during dental care.

I think it's so time to draw a lesson, learn and improve preparedness and respond for the future.

And WHO is working with a network of international HealthPartners and so global Chief Dental Officer on DBG operative centres network to gather data and review national guidelines, recommendation and policy directive related to dental services and COVID-19.

I will stop here and we'll be happy to answer your your question.

[Other language spoken]

Thank you very much, Doctor Benoit again.

So I will now open the floor to questions and I see some hands raised.

So this time I learned how to do it.

Last time I didn't know really how to how to get to know who is asking questions.

So we'll start with Peter Kenny, followed by Lisa Schlein.

Peter, thank you for taking my question.

Tarek, I would like to ask Doctor Baron why he thinks that the dental services are not considered essential in many aspects of the health sphere.

[Other language spoken]

Thank you, Peter.

[Other language spoken]

Not easy one, but I think we we can explain that by maybe giving some information about the history of of oral health care system and also training.

As you may know, you know, in more or less all the countries around the world, dentists are train in in dental school.

You know that are separate with with medical school.

Usually even you could have one of first year at the beginning join with with medical schools.

And so it's, it means that for from the beginning, you know of, of the training of dentist and hygienist.

You know, it's a kind of of organisation in isolation with, with let's say the, the, the other medical aspect or, or medical school, for example.

And of course as a consequences, of course, after the, the dentist I saw are opening are working in in private or public and sometime in hospital.

But again, we have the this feeling that oral health services are considered as a specific, you know, specialised services and not really part of of the, the, the health system.

This is definitely true.

You know, there are also some specialised of course representative organisation of the dentist that are not part of the of the medical side.

So there is a number of organisation through from the the the beginning, the training and so of course after that in terms of provision that are definitely in parallel with the health system.

So I think this could explain a bit this situation and I think we are working in in a in a global RF report now and we hope to to release this in a couple of months.

And it's part of this analysis that we are trying to do and to explore all to make you know or NF system more integrated into the the health system.

Thank you very much, Doctor Bagan.

[Other language spoken]

Good morning, Tarek, nice to see you.

[Other language spoken]

Yes, Doctor, I would like to have a have a couple of questions please.

First, I don't really quite understand what is it that people must do in order to protect themselves from getting infected with COVID-19 if they do go for a dental care.

And you seem to indicate that there were some services like perhaps the six month dental cleaning that can be delayed until things get better.

Is that right?

And if so, how long can you, can you delay this sort of treatment and, and then continuing on this, what sort of private or home care should people take if they're unable to have the, the cleaning and the tartar removed and so on and so forth?

What can people do in order to protect themselves to help themselves from getting cavities and other problems that might arise and might need dental services?

And I may have a follow up afterwards.

[Other language spoken]

Thank you, Lisa for for the question.

I think it's so quite important one, maybe just to clarify that of course, the, the, the guidance, the WTO guidance propose in fact different strategies and of course this strategy are to put in place to implement according to, to the level of transmission of COVID-19 in the country.

So this, I think this is important.

So it means that for example, most of the countries I mentioned that now are reopening, you know, the dental care are no longer, you know, exposed to a community transmission scenario.

And in this case, of course they can apply in case they have of course all the resources, you know, adequate ICP procedures and etcetera.

I think the, the guidance also suggests that in case of community transmission in, in the country or at local level, it could be in, in the city, for example, of course that they just suggest to, to postpone routine dental care.

You, you mentioned, of course, cleaning and preventive care because of course, we think that the priority should be given to urgent and emergency cases.

And again, in, in, in such context, of course, DBHO definitely suggests to to avoid or to minimise the, you know, all these dental care procedures generating irosol because as you may know, you know, of course, even the the likelihood of COVID-19 being transmitted through aerosol micro and particles or airborne particles is well, today, I think is unknown, is open to question at least.

And this thing that more research is needed is needed.

But in any case, the aim of this guidance is just to to, to share information available and to reduce and, and, and prevent of course, the the transmission.

So for the patient who who has to go to the dentist, you will see so that we we propose a number of of of procedures and action to to be taken that definitely could help again to prevent and reduce the transmission.

The second part of the question, of course, is related to all to all.

The people could of course maybe reinforce, you know, usual oral health hygiene using, for example, of course toothpaste and brushing their teeth.

But so they have a so to to take care about the nutrition aspect.

Sugar of course, should be a void or at least should be followed by toothbrushing.

So there are a number of risk factors of course, related to oral disease.

And we have, of course, this nutrition aspect and sugar, but we have also, as you may know, alcohol and tobacco that are part of risk factors of oral disease.

Lisa, you said you had a follow up, so why don't you go immediately with a follow up for Doctor Ragan?

[Other language spoken]

First, could you be a little bit specific about you said that were the people who have to go to for dental services that there there are are certain measures that they should take to protect themselves if you would be specific about what those measures are?

And then just a quick follow up on an issue you dealt with earlier.

That is the survey that was conducted.

Where was it conducted in?

In many countries around the world.

And did you find, as I expect, that oral health problems were most prominent in developing countries in Africa and elsewhere?

Is that correct?

And what sort of recommendations do you have for these people who probably have far more difficulty getting the health services they need then we in the more developed countries do?

[Other language spoken]

So in terms of, of more specific well procedures or action that that patient could take before during the dental care, I think it's more or less the the same with, you know, other seating means physical distancing, frequent and correct and hygiene wear mask of course, indoor and during the well when they are going to to the oral facility.

And this is definitely a mention after that, of course, the the the the oral team or so should apply a number of of procedures in the waiting area.

The the best thing, if available, of course, it's to call before of course, going to to the dentist and to call the dentist and explain exactly the the need in terms of dental care.

This I think it's kind of remote screening of of people that would be very useful.

So to ensure again that in case of again, community transmission, you know that the the the service will just pre authorise urgent cases.

In addition, concerning the the question about the the survey, we know that 103 member states responded to to the survey.

I don't have the the details of you know, which countries responded compared with others, but we can just mention that for sure in Europe or in France, Switzerland and other European countries, DRL services have been definitely closed suspending between at least two or three months and only remote assessment have been provided in in such countries.

So this this issue is definitely not an issue that only low and middle income countries have been faced, but definitely a number or so of **** income countries.

Thank you very much, Doctor Rogan.

Hope this answers questions from Lisa.

[Other language spoken]

Sorry, I missed a little bit one of your answers, but I was interested, Doctor Vahan, in what you said about there's still an open question about transmission and some of these aerosol procedures.

I wonder if who has any data at all on, you know, confirming transmission in such procedures, What sort of level and also the level of infection among oral healthcare workers if you have any data in?

Terms of the on a, on a general issue of transmission, I think this has been dealt with at press conferences, but I will look really to see if there is anything specific on evidence regarding aerosol transmission.

But we were saying that there is a risk for all the respiratory viruses of, of transmission in a healthcare facilities where aerosol generating procedures are being carried.

And maybe Doctor Vagan can say something about infection among the true oral health.

[Other language spoken]

No, it's, it's definitely a very important aspect.

And again, as I have mentioned before, you know, we definitely did more, more research and I know that there are some teams working on, on reviewing the existing data.

And so we're performing some, some Advanced Research to, to understand a bit more, you know, the, the, the risk of, of transmission through this very small droplet.

And again, there is quite uncertainty about the, this likelihood of, of being transmitted by through this strong debt.

I can just add that of course a number and most of the dental care procedures, you know can produce this this aerosol and and we know that this aerosol stays suspending in the hair for a long period of time.

And of course, we know that if such procedures are conducted in, you know, in people infected with COVID-19 in dental facilities, this aerosol can contain the COVID-19 virus.

Now we, we don't know exactly again the the risk of transmission from this, but of course this aerosol could be annihilated with others if they are not rearing appropriate personnel protective equipment.

So it's definitely essential that oral health team perform such procedures, take specific airborne protection measures.

And in the guidance we'll have you can find some some details about what it means in terms of of ICP measure.

And of course I saw a number of other measure like visitors or accompanying person should not be permitted, you know, to enter into into treatment area where such procedures are performed.

So there is quite a many again procedures or intervention that could be applied and should be now implement in in a dental sitting.

It's also the reason that we develop a specific paragraph on ventilation, you know, because all these droplets were suspending in in droplet and very small particle could be suspending in the air.

So we need adequate ventilation of the operating room.

And this we have also developed some specific option according to to the context.

Thank you very much.

I would just maybe refer Stephanie to the scientific brief that has been published on July 9th regarding the transmission of Star Scope 2.

So, so you can, you can see there were, I think there are some references to some, some articles there I've seen before that Nick, Nick wanted to ask questions, but his hand is down.

Oh, Nick, you are there again.

So Nick from New York Times.

[Other language spoken]

Just to follow up a little bit on Stephanie's question, and that is to ask what evidence there is of transmission among all, you know, dental healthcare workers.

Have we seen many of them succumbing to this virus?

If not, is that because so many dental services have as you say been suspended and if so, where are the main areas that we're seeing that happen?

[Other language spoken]

Sorry, it's true that haven't responding to the second part of of Stephanie concerning the well the, the if we have some some data regarding the the number of health workers and of course oral health providers that would have been infected by by COVID.

I think Doctor Ryan also mentioned a couple of days ago that there is an alarming number of healthcare workers infected by COVID.

And so I think it's mentioned that globally, the estimates are around 10% of cases are among healthcare workers, 10% of all cases of COVID-19 are among healthcare workers.

Unfortunately, we have no data regarding particularly oral healthcare providers.

I know that some partners, the Word Dental Federation and the so the American Dental Association are now working on some evaluation and survey to, to try to, to, to get some numbers because it, it would be definitely important to, to have this estimate.

And how I definitely hope so that in maybe the, the next weeks or months, we could provide some, some data about the number of percentage of oral healthcare portfolio that been infected by COVID-19.

[Other language spoken]

Thank you very much, Doctor Benoit.

I see that Lisa has one more follow up.

[Other language spoken]

Well, first I was wondering, are you able to send us the, the guidance or do you have a press release on this issue?

That's yeah, one thing.

And then the question is, are there some people whose health conditions or age is such that they should never go to a dental, a dentist, even if they have some, some problems that need attending to?

I, I, I I don't know, sounds like they may be caught in a a real bind.

Just quickly on on guidance itself, it has been already posted.

We will send it to you immediately after this press briefing.

And then also we will send it to the globalist.

But maybe you know, we will send it to you first so you have it.

So I'll make sure that it gets to you as soon as as we are finished.

And I'll let's say Doctor Wagen, answer the the the second question.

Yes, I'm not sure to to capture the the question, please.

[Other language spoken]

I asked whether there were some people who, because of their health condition or their age, might, should perhaps never go to A to a dentist or a dental provider.

[Other language spoken]

They might, they might have to make a serious choice between which is, which is worse.

You know, they may have serious dental problems, but they may be caught in a bad situation.

Yes, thank you for for this question.

It's true that, and this is something that it will so refer to to to different scenario or question or or seating.

Because of course, I think that the question that that any person of course that are maybe a part of older people or living with underlying condition could should ask it's do I really need to go of course to see my my dentist again?

I think this question is definitely relevant in case of community transmission, because I definitely think that in case the the situation at local or national level is low rate of transmission.

And if of course, the the dentist that you are that these people are, are visiting, of course could apply the, the measure in terms of personal protective equipment and all these ICP measures, I think there is no reason to to avoid dental care.

But again, it depends of each people to make, of course this decision.

And so I think that something important during such pandemic is it's also the oral F care professional that should use the professional judgement, you know, in determining each patient need for urgent care or not.

And so I think the there is a need for, for discussion or so between the, the patient and, and, and the dentist.

And this of course, could be made by by phone or virtual technology.

Thank you very much.

I see one more question and that would probably be the last one as we have to finish by by 10:00.

Agence France.

[Other language spoken]

Just a question about the the measures that the dentists can take to protect themselves because in many cases, they will already be wearing masks and gloves.

They would, they would do that sort of thing anyway.

So are there are there further things that they could do?

And secondly, are there could you be specific about the dental procedures that do and do not produce aerosol?

So like a routine inspection, an extraction filling?

Yeah, if you could just spell them out for us.

[Other language spoken]

Thank you, Robin.

The first part of the question is kind of ICP infection prevention and control measures and PPE personal protective equipment.

So in the guidance, I think we David Joe gives a number of specific response to to your question.

So according to, to the type of intervention, according again to the, the context of the pandemic at local and national level, you, you can, the dentist could adjust of course the the measures and the and the procedures.

The second part of the question is definitely important because for Debbie Joe, it was kind of opportunity, you know, to to mention that a number of intervention should be provided, you know, without using AGP aerosol generating procedures.

And this we well we call this in the, in the guidance we, we promote that we should promote an essential oral F service concept.

And this is based on the on the number of of interventions could be to to manage infections, swelling, so simple extraction, but so dental caries using only dental instrument.

So in the in the guidance.

So we'll find a list of of intervention that could quite easily perform without using, you know, **** speed, **** speed devices and the solar Trasonic scaling and all this very common today.

But we think that it's important because of course a number of countries, you know, around the world have not access to this **** technology and we damage your things and promote this non invasive, you know, intervention or dentistry because we that maybe sometime, you know, the using this **** technology will not really cost effective.

And as I mentioned quickly in the introduction, dental care is unfortunately very expensive and it means that.

Quite important part of the population again in low middle and **** income countries have no access to to dental care because the dental treatment now is definitely costly and out of pocket for patient.

It becomes a really big issue and so far in most of the countries, so dental care are not part of universal F coverage and it's something that thanks to for your question because we hope so to to promote better integration of essential F care as part of UHC in in countries.

[Other language spoken]

Thank you very much.

We have 3 minutes left for Lisa for her last follow up.

[Other language spoken]

OK, It'll be less than that.

[Other language spoken]

I know that sugar is bad for teeth, but I eat a lot of fruit.

Is the sugar in the fruit OK or is that also problematic in terms of of teeth?

[Other language spoken]

It that's, that's a good question, Doctor Megan yes, yes, thank you for for this question.

Unfortunately, my colleague in charge of nutrition and things are not here.

But what we know, of course, is definitely sugar is it's not good for, for teeth.

We know that the fruits, of course, contain some sugar and sugar containing fructose, like for example, fructose are not good for, for teeth.

But we also know that it's definitely better to to eat fruit than pressing and, and drink the, the juice.

So yes, all the, all the, the, the sugar sugars are will have an impact of on dental caries, but we also know that some kind of sugars and the way that you are eating or drinking will change.

So the, the risk of, of, of well having this impact on dental calories.

Thank you very much, Doctor Vagan and I thank everyone for being with us this morning.

As I said, we, we will be sending you the guidance that has already been posted.

And as you will see, it's been dated August 4, but it has been, it has been posted recently and this is the first time that we publicly speak about it.

So, So with that, I also want to thank our colleagues from the eunuch for supporting us from the technical side.

And I'm going to see you in 1/2 an hour for our press conference.

Thank you everyone and have a have a lovely day.

[Other language spoken]