Letter to SDCEP Regarding Ventilation

13th August 2020

Professor Jan Clarkson (Chairperson)

Scottish Dental Clinical Effectiveness Programme (SDCEP)

Dundee Dental Education Centre
Frankland Building
Small’s Wynd
Dundee
DD1 4HN

 

Dear Professor Clarkson,

Re: NSS document on Ventilation, Water and Environmental Cleaning in Dental Surgeries.

https://www.scottishdental.org/ventilation-water-and-environmental-cleaning-in-dental-surgeries-relating-to-covid-19/

We eagerly anticipate the SDCEP guidelines on the provision of aerosol generating procedures (AGPs) in a dental setting and the consideration of Post AGP Fallow Time (PAGPFT) in relation to this.

Our interim committee has considered the above document, with the following observations:

  • General Dental Practitioners (GDPs) or bodies representative of GDPs were not included within the submissions by the working group panel. General dental practice is where the significant majority of dental procedures are carried out, therefore input from GDPs would have been appropriate.
  • Dentists and their staff are those most at risk regarding all occupational aerosol hazards, yet no evidence of increased infection rates in dental staff is noted.
  • The practical challenges of multi-chair clinics in dental hospitals, Public Dental Service (PDS) settings and dental surgeries in buildings/retail units that are difficult to convert make ventilation suggestions outlined in the report impossible to achieve. A resultant drop in suitable premises for dental treatment provision will negatively impact the profession and access for patients.
  • Routine measures including High Volume Evacuation (HVE), Personal Protective Equipment (PPE) and rubber dam are more significant than ventilation when considering bio-aerosol contaminant levels.
  • Surgery air changes post-AGP are a sensible but only a theoretical consideration given the NSS report has provided no evidence regarding the minimum contaminant levels of bio-aerosol required to sustain a human infection with SARS-CoV-2. As such, this is indicative of the NSS’ preamble statement that “it is not intended as specific formal guidance in itself.”
  • The economic and environmental impact of AGP and fallow time regulation of dental surgeries is not considered in the report. This has to be balanced with the overall risk versus benefit to members of the dental team and patients.
  • Many of the studies quoted in the report are artificial simulations with inadequate sample sizes. Much of this data is also not representative of a multifactorial dental setting.

Current Measures:

  • Enhanced Personal Protective Equipment standards have been embraced by the profession- including FFP3 respirator masks, full gown, visor, and gloves for any AGP under rubber dam where possible. Many Scottish dental practices, at their own expense, have staff who have been fit tested for respirator masks for privately provided treatments. There is some NHS provision for fit testing of one dentist and one dental nurse per practice in order to provide emergency NHS AGPs from the 17th of August 2020.
  • Combined measures including rubber dam, visor and HVE have shown evidence of a 0.4% contamination difference between standard type IIR surgical masks and the FFP3 respirator masks. If rubber dam is not used, this difference increases to 7%.

https://www.nationalelfservice.net/dentistry/dental-workforce/how-much-extra-protection-does-an-ffp3-mask-offer-in-the-dental-surgery/

  • There is wider evidence supporting the significance of long-established universal protocols in general dental practice. This limits cross infection and trained dental staff are well placed to mitigate the contamination risks.
  • There is a hugely significant increase in plastic waste from disposed PPE which has a negative impact on the environment now and for future generations. A sensible approach overall is required to mitigate these factors.

The risk assessment of performing routine dental treatment should be calculated with consideration given to all of the above and additional notice given to:

  • The current SARS-CoV-2 infection level within the local population.
  • The local replication numbers.
  • Improved pre-appointment triage with appropriate deferral/referral of symptomatic patients.

Statistical information supplied by bodies such as National Records Scotland and the Scottish Government can be used to influence these decisions.

SDCEP guidance is a valuable tool for dental professionals. The Advice, Analgesic and Antibiotic (AAA) protocols recommended during lockdown were followed, though this conflicted with previous guidance aiming to treat acute oral and dental pain directly without a reliance on antibiotics. This may have been a compromise given the limitations during lockdown though we are keen to avoid such scenarios going forward with reliable evidence-based protocols.

We are concerned by the difficulties faced by dental professionals in trying to navigate a path through the COVID-19 crisis. We all want to provide an optimum level of care for our patients in a safe environment. This, however, has to be balanced with the real-world economic, environmental and practical considerations in order for these goals to be realistic.

Dentists have always looked to SDCEP for evidence-based guidance though we realise that reputable evidence on this subject is difficult to come by in the present situation. The SDA interim committee are happy to contribute to any further discussions to progress Scottish dentistry.

Yours sincerely,

 

The Scottish Dental Association Interim Committee

hello@thescottishdentalassociation.co.uk

 

 

 

More Posts from The Scottish Dental Association

The SDA Summit

The SDA Summit We are delighted to announce our first SDA event on Tuesday 16th of March from 12.00 – 2.30 on webinarjam. This webinar aims to inform and stimulate discussion around the promised changes to the post-pandemic SDR. If you are a dental professional and you have questions or ideas then please get in touch and book the event here. The Chief Dental Officer (CDO) has stated that he wishes to engage widely with the profession. This is a new dynamic and presents a unique opportunity for the majority of the dental profession to have a role in this

Read More »

“Scottish Dental Students Forced to repeat a year” BBC News

Scottish dental students forced to repeat a year – BBC News A massive blow to the profession as VTs repeat a year, no new graduates, EU dentists heading home and the difficulty taking on dentists out with Scotland. It doesn’t matter how long qualified you are if you have never had a Scottish NHS list number you will be offered COVID support along the same lines as the recently qualified vocational trainees. As we all know the only way NHS dentistry has survived this long is through volume of work and COVID has put a complete halt on this. We

Read More »

Consultation on SDR Reform

As you will be aware the SDR and general dental services are to be fundamentally changed. This will directly effect each one of us and our patients‘ future care. Tom Ferris (CDO Scotland) has said that there will be consultation with the profession and the SDA will ensure that we present all of your views coherently. The survey is being conducted via Scottish Dental Network. See link below. Initial SDA Consultation on SDR Reform – Scottish Dental Network

Read More »

NHS Lothian COVID-19 Update No 22 – 27th October 2020

Angus Walls, Director Edinburgh Dental Institute 4th Floor Lauriston Building Lauriston Place Edinburgh EH3 9HA Content of this update PCA and SDR 148 Patient Communication National SoP IPC guidance PPE stock and usage SARS CoV2 vaccination program   Dear Colleagues, I am sending you the most recent PCA from CDO in association with this letter, I must apologise, this should have come to you yesterday. As I am sure you are aware there was an announcement in Parliament recently that a full range of dental care would be available through NHS dental practices from the 1st November. This PCA underpins

Read More »

Agenda for Change

The eagerly anticipated “Agenda for Change” (within the NHS) highlights once more just how far Scottish NHS dentists have fallen. The Doctors and Dentists Review Body (DDRB) amply demonstrates how they feel about dentistry and the professionals showing no improved recognition over the last two decades and no peer acknowledgement. https://www.nhsemployers.org/pay-pensions-and-reward/agenda-for-change We can never aspire to this but who works for nothing and how far are we prepared to be left behind? The question must be asked in relation to the act of NHS dental Items of Service (IOS) treatment because they impact hugely on everything that we and our

Read More »

SDR Recommendations

6 October 2020 Scottish Dental Association Working Group on new SDR proposals   Preamble The Scottish Dental Association (SDA) recognises, along with almost the entire profession and the current CDO, that the pre COVID SDR is not fit for purpose for the likely future situation we face. It should be noted anecdotal evidence suggests most practitioners have felt the previous SDR was not fit for purpose for several years. To propose potential new solutions the SDA has formed a working group to briefly formulate potential new SDR options. The SDA welcomes feedback from all sectors within Scottish dentistry on this

Read More »

General Dental Services Budget Letter to Joe FitzPatrick MSP

Mr Joe FitzPatrick MSP Minister for Health St Andrew’s House Edinburgh October 4th 2020 Dear Mr Joe FitzPatrick MSP, General Dental Services (GDS) Budget On behalf of the Scottish Dental Association (SDA) and following your letter (ref: 202000055870) to Mr Graham Smith in relation to the Public Dental Service budget, we would be grateful for the following information to assist us in consideration of a realistic proposal for the new Statement of Dental Remuneration (SDR): Please detail the predicted positive or negative impact of ‘COVID support’ for General Dental Practitioners (GDPs) on GDS payments in this financial year. A breakdown

Read More »