A year in practice
From stealth masks to red bands - no fallow times, no compulsory FFP3, and a significant reduction in patients waiting for treatment
In July 2020 we started carrying out AGPs using our newly acquired, face fitted Stealth masks. Having failed to get the Stealth masks endorsed by our health board our next step was to check with our defence union about their use. Having received a positive response we were happy to press ahead knowing full well that they were being used safely in other parts of the UK on a private basis.
The NHS alternative around that time was the limited supply of expired 3M1863 masks that the BDA had advised us not to use. Three of the staff, including one of the associates, failed the face fitting on the Stealth masks but passed on the 3M series, my nurse being one of them. The hard plastic grey straps of the 3M6000 were not as comfortable as the fabric straps of the Stealth and I would watch her don the mask with a sense of guilt that we did not have a real alternative for her.
The AGPs were always allocated a minimum of 60 minutes which allowed for donning and doffing, and the surgery preparation needed to avoid opening any drawers mid-treatment. We would get to the 40-minute mark and my nurse would look at me with eyes that said: “I’ve had enough,” and I would try to wrap things up. She never moaned once, even when we were working weekends
to try and ensure all the associates during the week had two surgeries each to operate in to allow for the lengthy fallow times.
My surgery has south-facing French doors which lead out into the practice garden, and these were fully open during that Summer, but even with the blinds down all day, the washable plastic gowns, respirator masks, visors and head covers were intolerable at times. I hadn’t signed up for this way of working 25 years ago and I could only imagine how difficult it must have been for medical colleagues wearing full PPE for whole shifts.
January 2021, and we finally had enough FFP3 masks – and the face fittings – to make a start on NHS routine treatment. My lockdown 23 March 2020 spreadsheet of outstanding patient treatment still ran to several pages and starting to see a small number of patients for examinations from Spring was only adding to the backlog. Fallow times and cleaning spaces limited us to five AGPs a day and whilst we were all working, we were working reduced sessions.
Two or three dentists working each day out of the six of us and opening seven days a week so that we could see as many patients as possible. Social distancing between the staff and between our patients arriving and leaving were some of our biggest barriers to how many patients could be seen. By May we were all feeling demoralised as there seemed no way anything was going to change before the end of 2021 even with the increasing numbers of patients being vaccinated.
With no holidays to look forward to, a welcome break came along in the form of a summer school at the Edinburgh Dental Institute. My second year of a master’s degree in restorative dentistry was coming to a close. It was a much-needed distraction from running a practice during a pandemic and it was during this week that we were shown a short presentation on red band handpieces by one of our tutors, Krishnakant Bhatia. Using water dye and lasers you could see the difference between the aerosol generated by an air turbine and that produced by a red band handpiece. This difference was especially seen when high volume suction was introduced. Here was real clinical evidence that was instantly relatable, and I travelled home that evening knowing full well that if the EDI was using them on their open clinics, then so could we. We bought three red band handpieces the following day.
Back at work, my nurse and I donned our enhanced PPE and I clipped on one of the new handpieces to my Adec 500 micromotor. I turned off the chip air and picked up a new coarse diamond bur and started my first red band handpiece filling. I hadn’t discussed what I was doing with my nurse until I was sure it was going to work. Later that morning, a patient attended to have two anterior crowns replaced on the NHS. She had been waiting since 2019 and I wanted to see her treatment completed. As I cut easily through the porcelain and metal, I realised that this new way of working had real potential. Speaking to the patient at the end of the treatment I explained that I was using a new electric handpiece and that I now felt confident it was going to mean a real shift back to how we used to do things pre pandemic.
Several months later and the reception team are booking patients into normal treatment slots. They no longer have to worry about fallow times and extended cleaning spaces. All red band handpiece treatments are carried out using full length disposable aprons, disposable gloves, type IIR masks and face visors. Everyone still has the option of wearing FFP3 masks and the gowns if they want to. Through July and August, it was a relief not having to wear the full gowns in the heat.
No fallow times, no compulsory FFP3 wearing, no wasted time donning and doffing, and more importantly a significant reduction in the number of patients waiting for treatment. Patients have commented on the reduced noise levels from handpieces compared with the air turbine handpieces.
We have changed to each dentist in turn being the emergency dentist for the day, which enables the other dentists who are in to get on with their day undisturbed. It is so much better being able to lift a drill and get that filling done, get a tooth accessed, there and then, instead of having to schedule an AGP. More emergency patients can be seen each day using red band handpieces.
We have four or five dentists in each day currently and again it is the two-metre social distancing within the practice that remains the barrier to all six dentists in at the same time.
Has the red band handpiece way of working come along too late for the profession? We have a growing recruitment crisis and the uncertainty and the changes in day to day working need to be resolved by the Scottish Government.
In a recent poll (end of September) by the Scottish Dental Practice Owners group, 92 per cent of respondents were “not optimistic about the future of NHS based dental practice in Scotland” and 89 per cent were “unwilling to return to the pre-pandemic low fee, high-output model of NHS care delivery.”
What we need is the new IPC guidance that was promised to us by the end of September, by our CDO, back in July.
There is plenty of evidence out there. Meethil et al, 20211, have characterised the type and source of the microorganisms in dental AGPs finding that is the irrigant fluid that “contributes to the majority of the bio load” and that the patient’s saliva is diluted between 20 and 200 times. The main source of “microorganisms in aerosols” being the dental equipment itself, not the patient.
Dudding et al, 20212, describes the “unlikely event” of an aerosol interacting with and then being large enough to carry the virus, avoiding being diluted by the irrigant and then proceeding to interact with a susceptible host (patient or dentist/DCP).
Let’s move forward with real evidence, definitive protocols and regulations so all practices are clear in the way that we will need to be working. It’s over to Scottish Government for a new model of care for NHS dentistry or I fear it will be too late for a number of NHS committed practices.
References:
1Meethil, A.P. & Chaudhary, Prem Prashant & Dabdoub, Shareef & Kumar, Purnima. (2021). Sources of SARS-CoV-2 and Other Microorganisms in Dental Aerosols. Journal of Dental Research.
2A clinical observational analysis of aerosol emissions from dental procedures. T. Dudding, S. Sheikh, F. Gregson, J. Haworth, S. Haworth, B.G. Main, A.J. Shrimpton, F.W. Hamilton, A.J. Ireland, N.A. Maskell, J.P. Reid, B.R. Bzdek, M. Gormley
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