FGDP Dean Ian Mills says Urgent Dental Care centres may provide an excellent service, but they do not have the capacity to meet the need, and the number of dental practices involved needs to be rapidly increased to prevent the backlog of worsening cases becoming unmanageable.
It is now more than three weeks since we closed our practice, and it looks like it will be at least another three until we open our doors again, if not longer. The days have flown by, and I’m sure like many of you, I find it difficult to keep track of the day with the loss of any normal routine. My new norm is emails, phone calls, Skype meetings, and more emails; interspersed with cups of coffee, grunts at the family, and the odd fix on Twitter.
Despite the hours spent sitting in front of a computer, inquisitively staring at my colleagues’ surroundings and admiring their increasingly dishevelled appearance, I do occasionally manage to escape from my office and have a change of scenery. You can probably imagine my excitement when I was able to swap my home computer for my surgery computer when it was my turn to triage emergency calls at the practice last week. It was a fairly typical day, by all accounts, with ten calls received and four patients provided with compromised care based on the 3As. All four would have benefitted from urgent care, but sadly at that stage no urgent dental care centres were operating within my area.
As it turns out, I had a fairly uneventful day, as my colleagues on subsequent days had much greater challenges to deal with, including a 16-year-old with irreversible pulpitis of seven days duration. His mother had been on the phone three times over the previous week, he had been seen in the local Oral-Maxfac unit, but sadly was still unable to access the appropriate care. A sad indictment on the current situation within the South West, and one which led to a 32-week pregnant lady making a 160-mile round trip to have a tooth extracted in Birmingham, which subsequently made national news, and another patient removing his own lower molar! The picture of the intact extracted tooth would indicate that he has a potential future as an oral surgeon – he certainly seems to have the surgical skills and the attitude!
We need to acknowledge that these are unprecedented times, and our primary focus must be on safety and limiting transmission of the virus. I also appreciate the demands on the NHS supply chain and the challenges in accessing supplies of appropriate PPE. And I completely accept the pressures which Local Area Teams are under and the difficulties which they are facing. However, I am not sure everyone appreciates just how debilitating severe toothache is; or how inadequate the 3As are in dealing with irreversible pulpitis; or how potentially dangerous the lack of urgent dental facilities are for patients with an acute dental abscess. Sadly, this was once again illustrated in the South West last weekend with a patient admitted to the local hospital with an acute facial swelling and trismus having been unable to access care over the Easter Bank Holiday weekend, despite repeated requests via NHS 111 by both the patient and the dentist.
I am delighted that many areas across the UK have now managed to get operational UDC facilities in place, and I have huge respect and admiration for the dedicated dental teams providing desperately needed care in such challenging circumstances. However, it is extremely disappointing to hear of so many other areas where no such provision has yet been made available. This is not just about availability of PPE, this is about organisational capability, leadership and communication, which I have referred to in my previous blogs.
I am in regular contact with colleagues in Scotland and I have been hugely impressed with the level of organisation and foresight which some have shown in obtaining supplies of PPE and setting up well organised hubs delivering high standards of patient care. I had the opportunity to speak with one of the Clinical Directors who is leading the way in Scotland, and I was reliably informed that emergency hubs have been operating successfully for several weeks. It is evident that early recognition of the impending crisis and implementation of a decisive action plan ensured that urgent dental care facilities were operating at an early stage, and this has meant that some are well ahead of the game, compared to others. This proactive approach allowed access to supplies of PPE, recruitment and training of staff, establishment of an effective triage system and prevention of unnecessary pain and suffering for patients.
Two specific aspects of my conversation with the Clinical Director intrigued me; firstly, he reported that after initial concerns about the use of standard PPE for non AGP treatments, there had been a gradual acceptance that this was a sensible approach, so long as a high standard of cross infection control was maintained. Any AGP was undertaken in a separate surgery with appropriate gown and FFP3 mask. A risk-based approach had been adopted, reflecting the updated guidance from PHE, and this seemed to have been accepted.
For a number of dentists this will be seen as a common sense approach, which may allow practices to gradually re-open and start to treat patients, albeit for non-AGPs only. However, for some a move towards treating patients face-to-face without level 3 PPE is seen as entirely inappropriate, and considered an unacceptable level of risk. Alarmingly, during a separate meeting involving colleagues from Wales and Northern Ireland, dentists indicated underlying concerns about safety and expressed the view that they felt coerced into undertaking non-AGP treatments with standard PPE.
As a profession, we are familiar with receiving conflicting views and opinions, interpreting the evidence and subsequently making a decision based on research, clinical experience and patient preference. On this particular issue we seem to be struggling to reach consensus, and I fear that opinions on this will continue to differ for some time yet.
We have limited evidence available on COVID-19, we have minimal experience of dealing with such a crisis, and we have disparate views on what is a sensible approach based on our own attitudes, values and beliefs. We are being deluged with information, advice and opinions which is highly confusing and has the potential to feed our existing confirmation bias, which is undoubtedly underpinned by our individual circumstances. It is therefore unsurprising that polarised opinions have emerged; at one extreme we have dentists who want to get back to normal as quickly as possible, and at the other end, we have colleagues who are unwilling to see a patient without the highest level of personal protective equipment. So, who is right, and who is wrong?
In my personal opinion they are both right. “What a cop out”, I hear you say! Let me try to explain…
I think the issue is all about risk, both real and perceived; and more importantly our approach to the risks confronting us as healthcare workers, as employers, as responsible individuals and as business owners.
What is the level of risk? What level of risk is acceptable? And how can we minimise the risk to ourselves, our staff, our patients and the wider community?
Unfortunately, many of these questions remain unanswered, but even if we had additional information, the answers may still be different for each of us. What does seem to be clear, is that at the present time there would appear to be an elevated risk in view of the current transmission rates in the UK, the lack of testing being conducted, and our professional exposure due to our working distance from the patient’s airway.
In view of this elevated risk, I would agree with the current approach of the CDOs that urgent dental care should continue to be provided in dedicated centres which have appropriate facilities, training and equipment. The issue of transmission is more than just PPE, it is about adherence to strict cross infection protocols carried out by trained staff in a suitable facility.
Many general dental practices, whether NHS, private or mixed, have suitable facilities and highly trained staff, and there is no reason why urgent dental care should not be provided from such locations. Indeed, a small number of practices have already been turned into such centres, and I would suggest that without a significant effort to rapidly increase the number of dental practices providing urgent care, the backlog of worsening cases with nowhere to go will quickly become unmanageable.
We also need to be planning now for a return to more routine dentistry in future. Safety must continue to be our key priority, and realistically this means a resumption will only happen through a gradual rollout, which should hopefully allow a number of things to happen. We should have a better understanding of the risks based on the knowledge and experience of our colleagues in other countries. The peak of the virus should have passed. Testing, and appropriate PPE, should be increasingly available. Improved evidence should beget greater confidence in the available guidance within the profession. A range of questions on the minds of dentists, such as on the safety of specific interventions, should also have been answered to a more satisfactory level of detail, and the FGDP (UK) is looking to work with others to ensure that the profession is able to make an informed judgment about the risks of returning to surgery.
Unfortunately, a gradual return to work would do little to help the financial position of mixed and private practices, indeed it is likely to make their position all the more precarious. This issue needs to be addressed urgently, and the FGDP (UK) is supportive of the approach taken by the BDA, and the newly formed British Association of Private Dentistry, in lobbying Government for a range of measures to support mixed and private practices. Separate financial measures need to be put in place to protect all practices, and I plan to discuss this in a future blog.
The second comment which the Clinical Director from Scotland made, was again in relation to the provision of urgent dental care, and was both insightful and alarming. Three weeks in, the hubs are beginning to see increasing numbers of patients presenting at the UDCs who had previously been through the 3As triage system. Patients who had been prescribed analgesics, but no definitive treatment, were presenting with increasing pain or infection; patients who had been prescribed antibiotics were returning with pain or further swelling as the cause of the problem had not been dealt with appropriately in the first place. The reasons for this will be clear to all, the 3As are simply “field dentistry” and a method of buying time until definitive treatment can be provided. That is fine if the delay is a few days, it is a potential problem if we are looking at weeks or months.
If that is the case, we are in danger of creating a massive issue which will cause untold problems for our patients, our practices, the UDCs and ultimately secondary care. We may need to accept a level of compromised care, but we cannot ignore the increasing numbers of patients developing irreversible pulpitis or acute peri-apical abscesses. These patients must be seen and provided with the appropriate treatment if we wish to avoid a dental crisis over the next few weeks and months, not to mention the problems which arise from inappropriate prescribing of antimicrobials.
The UDCs, which are currently operating, may provide an excellent service, but they do not have the capacity to deal with the current need, let alone the likely demand over the coming weeks. We desperately need to expand the service and it would make sense to use the existing network of practices and dental staff who have already indicated their willingness to help. Availability of appropriate PPE is vitally important but we must not allow the lack of supplies to be an excuse for a failure to identify sites, prepare facilities and train staff. We have facilities, equipment and staff on standby with the necessary skills and we must take advantage of this to treat patients who are in desperate need.
I would therefore support a further roll out of centres providing urgent dental care, through utilisation of existing practices. Safety is paramount and we must do everything we can to minimise the risk of transmission to staff, patients, and the wider community. This will undoubtedly mean reduced chair occupancy, longer treatment times and higher standards of cross infection control. A controlled approach will allow dental staff to gradually return to work, adapt to new ways of operating and provide a much needed service for patients, but we need to address the shortage of PPE before we rush ahead opening multiple centres that are inadequately equipped, putting staff and patients at risk.
We cannot eliminate risk in the dental surgery, we can only reduce it to an acceptable level. What is “acceptable” will be different for each individual, based on their own personal circumstances and their attitude to risk. I am confident this will change with time and we will eventually return to some semblance of normality. In the meantime, we need to focus on three things; staying safe, ensuring access for patients in need, and supporting each other through this extremely difficult time.
Keep well and stay safe.
Read more posts by Ian at www.fgdp.org.uk/deans-blog.