Multiplying risk

24 August, 2020 / insider
 Arthur Dent  

We need to find a way to get back to caring for our patients, quickly.

I was talking to my son about Fortnite and he needs 2FA to be able to enter competitions which could have prize money.

If the last sentence makes no sense; bear with me. I didn’t know what he was talking about when he mentioned 2FA, so, like all senseless parents, I Googled it. It means two-factor authentication. You all think I’m an idiot because you already know this because your banking app does it. However, I managed to try to explain this to my son, pointing out that by using multiple layers of protection it makes it much harder to get hacked.

You see where I’m going with this, right? Multiple processes don’t just add protection; they multiply it. The chances of your password being ‘password’ and your second code being ‘12345’ are very small. I am not a statistician or even very good at maths. However, I can see that by using layers of protection our chances of getting hacked are massively reduced.

In Scotland, at the time of writing, there are around seven cases of COVID-19 per 100,000. This means a dentist with a list of 2,500 patients is likely to see 0.175 patients with COVID-19. Now, anyone who is mathematical is about to shout at me. It’s not that simple. For a start, how do you see 0.175 of a patient? You might see some people more than once in a year. You won’t see all 2,500 patients; only about 65 per cent of registered patients come every two years. If someone is sick; you hope they don’t come, but many are asymptomatic. Your screening questions and temperature check might pick up a case or two. In time, we may even be testing patients prior to appointments.

So, the risk of seeing someone at the moment is low but that is only one factor. We are protected with PPE (at whatever level), we are reducing our flow, we are socially distancing patients and staff, we are using more stringent cleaning protocols with slightly different materials. If we were to do AGPs, we would do so with constant, high volume aspiration and mitigating methods, such as a rubber dam. The vast majority of these elements we do daily as a matter of course. These methods not only reduce our risk but multiply the layers of protection. I cannot calculate the level of risk with these layers, maybe someone can, but we should recognise they exist.

Currently, I only see debate about one measure or another. FFP3 or surgical mask. AGP or not. Screening or not. Surely the combination of our regular protective measures plus enhanced options makes the risk for patients and staff very low? Maybe I’m wrong? What I am sure of is that in our profession, there is always risk. Being a surgical professional carries risk to ourselves, our staff and our patients. COVID-19 is not going away and we have to accept a degree of risk. Our job cannot be risk free.

While we wait for SDCEP to tell us what the risk of an AGP is, patients are not being cared for. Many are taking great care. Many are doing the wrong thing. I guarantee, whatever disease there is, it is getting worse. What might have been a filling is ever closer to a root treatment. The root treatment is heading to an extraction and peoples’ quality of life is diminishing. It may not be apparent right now, but I am certain things are getting worse.

Day-by-day, the level of care we have built over years is being eroded. We will have to pick up the pieces and the collateral damage of COVID-19 could be significantly greater than the disease itself. Are we letting our patients down? Is the profession heading for a crisis of confidence in our ability to care? So far, people have been very understanding about us not doing our jobs. How long can that goodwill last? How long can the profession sustain the inevitable losses?

I have another worry. This one is much more ‘niche’, but I want to talk about it. VDPs coming to the end of the year are lacking in experience. No shock there. PSD have decided that anyone being taken on for an existing list is unlikely to do what the previous associate did and not get paid the same. Anyone starting a new list won’t get anything at all. Even if you do work, we’re on a zero-rated SDR so working all the hours God sends won’t increase your income. There is a significant risk that this year’s VDPs might not get jobs. If this goes on for another few months, or six months, then they won’t have been in work for months and won’t have done much or any treatment for nearly a year. Who will employ a de-skilled, inexperienced dentist? There is a risk that about 150 VDPs might never make it into GDS.

In addition, I think there will be an increase in (early) retirement. I think anyone who was considering it will have experienced the reduction in work and will struggle to go back. Once the hamster wheel starts again, we may have significantly fewer hamsters. At least significantly fewer full-time hamsters.

If you combine these factors and add the increase in demand from the lack of care; we may have an even larger multiplication of risk. A population with unchecked oral problems and a reduced workforce to care for them in future. Regardless of the level of risk of COVID-19, the fallout, the collateral damage, could set back dental care by a decade or more. We need to get a handle on risk. We need to multiply our protection and divide our harm. We need to find a way to get back to caring for our patients, quickly.

Arthur Dent is a practising NHS dentist in Scotland. Got a comment or question for Arthur? Email

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