Ant-Man and the Wasp are subatomic comic book superheroes who fight unseen enemies and, once victorious, return to normal size. Unfortunately, our dentists, hygienists and dental nurses are not superheroes (although some of us do wear a lot of spandex) and are amongst the most susceptible health workers to Covid-191. Dentists have to be near the patient’s mouth. Dental instruments increase the risk of virus transmission.
Dentists know about viruses and use some of the best infection-control measures around. We prevent transmission of blood-borne diseases such as hepatitis B and C, AIDS and prions (infectious protein particles). Dentists employ single-use instrumentation and sterilising techniques of a higher level than a general hospital's operating theatre. Respiratory infections such as tuberculosis are well-recognised and our medical screening process allows us to identify at-risk patients and treat them accordingly. The dental surgery is one of the safest places on earth. And, yes, I know that some people don't necessarily feel that way.
Teeth are hard. Drills cause friction. Many patients don't like having burns in their mouths. So we reduce heating with a flow of cooling water. Water hits the drill, and an aerosol is produced. Inevitably, this spray or splatter incorporates saliva and other material in the oral cavity. Dental nurses working alongside the dentist or hygienist use high volume aspirators (aerosol vacuum cleaners) which remove the spray. Most - but probably not all - of the aerosol/spray produced is removed. The research is not strong here and most was done back in the nineties and noughties. Furthermore, to make teeth look dazzlingly bright again, hygienists use an ultrasonic scaler to remove calcified deposits that stick to the teeth. That also becomes an aerosol.
These aerosol generating procedures raise the potential for the virus to enter. We know that it can be detected in saliva and that there is a risk of transmission to other patients who are treated in our surgeries. It would be quite nice if dentists were protected too. How risky is it? There is little to no research. We do have the best infection-control measures in healthcare, but we don't know if they are sufficient.? That's why dental surgeries were told to suspend routine care during lockdown, with care restricted to a smattering of urgent dental care hubs around the country. Patients may be relieved not to hear the drill but they're also not keen on the other options open to us such as extraction.
Ant-Man and the Wasp are superheroes. But, unlike them, dentists are real. We need the best personal protective equipment (PPE) available. We have to avoid aerosols. In between patients, surgeries need downtime to remove the virus from both the air and surfaces. This slows down dentistry and limits our treatment choices - mostly to emergency treatment such as the extraction of teeth for the relief of pain.
So, can we move forward? And how do we restart routine dentistry?
We really want to prevent virus transmission in the surgery. Therefore, an extreme approach to barrier infection control is applied. Social distancing? Prior to treatment perhaps, but not where both dentist and nurse are working in and around a patient’s mouth. The type of PPE required, such as a facemask, has come under close scrutiny: the research base just isn't there yet. As dentistry restarts there is an enormous demand for PPE and the supply is not infinite. Any economist can tell you what that will do to prices.
How do we prevent aerosols? By not using them or minimising their use. That doesn't bode well for routine dentistry in the long term.
How long do we wait between appointments for any aerosol to settle down and leave the air? Our best available evidence is around 30 minutes but the research base is not strong here. There is a common research theme developing here! Far fewer patients will be able to be seen. Pre-Covid-19, a dentist would normally see 30 patients a day which included check-ups and other procedures. Now the standard operating procedures manuals from the office of the Chief Dental Officer will reduce that figure to (maybe) six to seven patients per day. There will be a lot of extractions. Any other procedure that may help retain the tooth will involve aerosols and therefore is best avoided. These aerosol generating procedures can only be performed if the surgery has high-level PPE, such as respiratory masks and fluid resistant gowns. These are hard to come by, the respiratory masks have to be individually fitted by a certified trainer, and costs have gone through the roof. No routine dentistry means simple problems will become major procedures. Huge demand for dentistry and limited supply. Is there an economist in the house?
Dentistry is linked inextricably with health and well-being. Having a good smile is attractive and helps increase self-esteem. “A healthy smile can truly transform our visual appearance, the positivity of our mind-set, as well as improving the health of not only our mouth but our body too.”2 Depressingly, Covid19-era dentistry is reduced to pain relief with extraction of the tooth being the end result. Anything more is, to put it frankly, “too risky”, and certainly cannot be done without the highest level of PPE. Dentists are highly regulated and do not wish to incur the wrath of their governing bodies. However, the perceived peril is paralysing dentistry. Whilst before we prided ourselves on our infection control, now we are stuck behind Covid19.
I, personally, would like to see dentistry survive and patients’ self-confidence in their teeth restored and these are issues that will need to be addressed as dentistry is gradually adjusting to a ‘new normal’, for now at least. In other countries, the assessment of risk is different and some normalisation of dentistry has resumed, although the infection control is at a high level. In the UK, we need urgent research aimed at mitigating the risk. This will allow patients to enjoy the benefits of high-quality dentistry. Sensible risk-assessment should be combined with strong leadership. We must move forward at a quicker pace whilst keeping the safeguards in place. Like Ant-Man and the Wasp, dentists and their staff are also superheroes, and we do want UK dentistry to return to being the best in the world. Because, honestly, it really is marvel-lous.
1 World Economic Forum - These are the occupations with the highest COVID-19 risk (Accessed June 2020)
2 Oral Health Foundation - The importance of a healthy smile (Accessed June 2020)