Sam & Richard Snoad: dentistry during lockdown

Sam Snoad, managing director at the Castle Street Dental Practice, and her husband, Richard Snoad, a specialist dentist at the practice and its co-director, talk to Neasa MacErlean about the effect of coronavirus on dentists; and what patients can expect as Lockdown ends. As the NHS was ring-fenced, dental patients were left way outside. But dentistry is one of the most high-tech areas of medicine and dentists have successfully been using sophisticated barrier procedures to prevent HIV cross-infection since the 1980s.

What happened to the dozen or so dental practices in the Canterbury area when Lockdown took place?
RS: On 25 March a letter from the Chief Dental Officer for NHS England (CDO England) instructed that all face-to-face dentistry should cease. We were not able to see patients face-to-face under any circumstances and, therefore, I have been providing “the three As” (Advice, Analgesia and Antimicrobials) remotely on a seven-days-per-week basis for patients (completely free of charge). I phoned Boots immediately at their HQ in Nottingham, to check the procedure for emailing prescriptions to pharmacies. It was arranged that this would be done with the local Boots at Whitefriars in Canterbury. In contrast, German dentists have been allowed to see their patients face-to-face for emergency appointments only, throughout their Lockdown.

Urgent Dental Centres (UDCs) were set up by the NHS in Ashford, Maidstone and Chatham. They are part of the NHS’s wider pandemic plan which was about: closing general practice face-to-face dentistry; and creating centres to treat very tightly defined emergencies (and separate centres were set up for Covid-19-symptomatic patients). These defined emergencies were for instance; trauma, potentially life-threatening dental conditions and for patients with systemic illnesses or those at risk of these.  The triage systems [deciding which patients were eligible to go to the UDCs] were to be carried out remotely — first by dental practices and then repeated after referral by the UDCs themselves. The sites for the UDCs were identified very early in the planning but these services took time to set up due in part to a lack of the necessary Personal Protective Equipment (PPE).  (Source: Interview by CDO England).

Were there difficulties dealing with the national dental hierarchy?
RS: The CDO England was redeployed in January to help manage the acquisition of PPE for the NHS. It may be that some focus on dentistry was lessened. There is an emerging consensus from dentists in England that there has been a lack of leadership and guidance from the office of the CDO England.
SS: We are a completely private practice and although the CDO England sets out the conditions of practice for NHS dentistry in England, all dentists have to comply with these national guidelines (NHS and Private). There is no guidance specifically just for the private dentistry sector which accounts for 60 per cent of all dentistry provision nationally.
RS: We are looking closely at what is happening in Germany, Wuhan, the People’s Republic of China and other locations. In the Irish government’s road map out of the Lockdown, dentists have been put into the same later re-opening phase as tattoo parlours and hairdressers.
SS: We are obviously part of the medical profession but suddenly we have been deemed High Street businesses. Scientific advice is given to the Department of Health through the SAGE [Scientific Advisory Group for Emergencies] committee. There are more than 50 people on that committee who have allowed their names to be published and among these there are no experts in primary dental care (and there are two SAGE members who have maintained their anonymity).

How will dentistry be different as we come out of the crisis?
SS: We are still waiting for guidance. It’s likely to be about the aerosol-generating procedures (AGPs) —small water droplets — that we produce when drilling and scaling teeth with mechanical devices. [The guidance is due this week — week commencing 25 May 2020.]  We are planning for possible limited reopening on 1 June but we must wait for official guidance on that [through Standard Operating Procedures from Public Health England and the Department of Health, promulgated by the CDO England).
RS: There have been a number of academic papers published recently, in particular on-line, from Wuhan and the US, but many have not been peer-reviewed. There is, as yet, no clear picture as to whether dentistry-produced aerosols are a risk or not. There is no scientific evidence that dentistry has been a problem in this way in the past and any aerosols generated by AGPs are reduced at least 90 per cent by the routine procedures we already use.

What differences will your patients notice when they return?
SS: A member of staff will call them 24 hours before an appointment, asking them if they have Covid19 symptoms. If they are free of the recognised symptoms, we will ask them to arrive punctually (not early) and alone (if possible). A member of staff wearing PPE will take their temperature from a distance on arrival, give them a new face mask and hand sanitiser. Appointments will be staggered. There will be no paperwork (this will be done online or over the phone). For AGPs the dentist, dental nurse and, if applicable, the dental hygienist will be wearing enhanced PPE. Patients will be asked to rinse with an anti-viral mouth rinse for 60 seconds before any dentistry is carried out.
RS: During and in-between appointments, we will be using medical-grade air filters to reduce the dentally-produced aerosols in each surgery. We expect it to take approximately five minutes after each AGP to eliminate any airborne aerosol. We have bought two new HEPA [High Efficiency Particulate Air] air filters made by Philips which have an anti-virus mode. The barrier methods we already use reduce the aerosols and any that escape into the air in the surgery will be trapped by the HEPA filters.  Between appointments we will use a microfibre cloth with an anti-virus disinfectant to clean the surfaces and we will use a separate similar protocol to clean the floor.

Which procedures produce aerosol?
RS: There are two main AGPs. The water-cooled high speed drill (the air turbine) that is used for fillings, crown preparations and root treatments; and the ultrasonic scaler used by dental hygienists. We will use a rubber dam to catch over 90 per cent of the aerosols in the first three examples. This dam isolates teeth from the mouth leaving just the teeth being treated exposed. (This cannot be used during scaling but high-volume suction removes up to 90 per cent of dentally-produced aerosol anyway).

How confident are you that infection will not pass in your surgeries or in other practices?
SS: Very. Extra equipment was installed and new procedures and PPE used in all dental surgeries from the 1980s onwards because of HIV. For instance, from that time dentists and their staff have routinely been wearing disposable masks, gloves and glasses and processing all suitable non-single use instruments in autoclaves which sterilize these items in a dedicated decontamination room in the practice.[st]. Worldwide there are no authenticated cases of HIV transmission from the dental surgery.
RS: We also had to take steps to protect against infection from Hepatitis B and C. There have also been no cases of patients being infected with Hepatitis B and C because of dentistry, the reason being that our ‘Universal Cross-Infection Procedures’ are so effective (and are very closely regulated). Sars-Cov-2 [Covid-19] spreads through respiratory aerosols (coughing) and fomite [surface contamination of inanimate objects and surfaces] transmission. We are already exceptional at eliminating potential fomite transmission. You can kill the virus in the dental environment if you have the right kit. We have that. The HEPA air filters take in the air from the surgery, filter out 99.97per cent of airborne particles which will include any aerosol water droplets having virus particles attached. These are permanently trapped in the HEPA filter and any virus dies inside. These machines have an LED screen with 12 levels on it, showing the state of the air quality. If they wish, patients can look at the display when they enter each surgery and they will be able to see that it registers 1 [the cleanest air] before they are treated. After a HEPA filter has been used air quality is probably better than at the top of the Matterhorn.

What effect will there be on your pricing?
RS: It’s difficult to estimate, but there will be significant additional overheads (for instance the two HEPA filters cost £400 each). There will be greatly increased costs due to buying PPE.
SS: The FFP [Filtering Face Piece] Masks are expensive (if they can be obtained at all and require professional fit-testing at additional cost). The FFP2 masks are £5 each and although we are trying to source them at a lower price, if you speak to any private dentist, you find that they think fees will have to go up. There will be fewer patients per day due to the increased time taken to don and doff PPE. There will be extra PPE costs. It was already very expensive to run a dental practice and most dentists run on tight margins anyway.
RS: Margins are much tighter than people think. When I qualified in 1980, the overheads of a dental practice were about 50 per cent of gross income. Now they are about 80 to 85 per cent. That is because the cost of dental materials is high and all dentists wish to provide the best service for patients by using the highest quality equipment and materials which are inevitably more costly. As a consequence of this pandemic there could be other expenses and procedures we have not factored in. For instance: will we require proof from a patient who has not had symptoms in the form of an authenticated negative antigen test or a positive antibody test?

How long will this last?
RS: I am, of course, speculating but this will be temporary if we get a vaccine and the news seems to be promising on that. If everyone is immune either because they have had Covid-19 and have antibodies or, better still, because worldwide we are all vaccinated, there will eventually be no need for social distancing or the other measures. Under these conditions dentistry could return to something like its pre-pandemic protocols. Roche [the Swiss pharmaceuticals company] is confident about its antibody test and says it will potentially indicate three years of immunity (though this has yet to be independently verified), and the University of Oxford is also encouraging about the prospects from its work on a vaccine.

Castle Street Dental Practice has been eligible for no government support during the crisis other than the Job Retention Scheme. It has furloughed all its staff on full pay.

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