13th August 2020
Dear Mr Joe Fitzpatrick MSP, Minister for Public Health, Sport and Wellbeing,
Re: NSS document on Ventilation, Water and Environmental Cleaning in Dental Surgeries.
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 and Public Dental Service 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.
- 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%
- 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 deselection and onward 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.
We note the BDA letter of 6 August 2020 detailing four case studies which involve dental practices suffering monthly losses of £10,000/£14,200/£21,000/£30,000 per calendar month. The prevention and treatment of oral and dental disease is a fundamental health requirement. The SDA wish to mitigate the future losses of GDPs and to express the opinion that regular patient treatment may therefore be imperative for both the profession and patients alike.
The SDA interim committee raises the following points:
- We seek to support GDPs whose business it is to manage the oral health of their patients. Practices performing AGPs with increased fallow times without extra financial support, will make the business of dentistry unsustainable and irrevocably result in the demise of their patients’ oral health.
- We recommend that the Scottish Government (SG) urgently underwrites the provision of adequate ventilation for every dental practice. Furthermore, the provision of NHS AGP’s is not financially viable if fallow times are to be followed and the current payment structure is not enhanced.
- We request detail through the Chief Dental Officer (CDO) discussions with the Scottish Dental Practice Committee (SDPC) on the Scottish Government’s Oral Health Plan including a now urgent proposal for the amended Statement of Dental Remuneration (SDR) and how the profession can be involved in its restructuring.
- The SDA also notes the lack of evidence in relation to SARS-CoV-2 cross infection within dental practice setting; further the impossible dichotomy of stringent adherence to unevidenced restriction on dental treatments versus job retention.
- Dentistry is a highly regulated industry that is well versed in following appropriate cross-infection measures to protect dental staff and their patients, more so than many other business sectors.
- There are a large number of dental staff who have been deskilled since mid-March 2020. Furthermore, there are extremely limited job prospects for dental students and newly qualified dentists in the current set up. It is the opinion of the SDA interim committee that the disregard of patient care, the ongoing lack of professional engagement and the questionable prospects of staff retention must now be addressed.
We request that the Scottish Government address the above issues with particular attention to the urgent issue of dental surgery ventilation and the financial considerations of a revised SDR.
The Interim Committee, Scottish Dental Association.